Diabetes and Erectile Dysfunction (ED) go hand in hand like lovers walking down the street.  Both are different conditions with their own symptoms and characteristics.  However, as a male, if you have diabetes, you are 2 to 3 times more likely to develop ED.  So, what comes first?  Much like the egg and chicken debate, research has focused on whether ED is a symptom of some much broader health conditions.  For example, could the loss of erection function indicate some underlying health concern? 

The connection between diabetes and ED is related to blood circulation and the nervous system.  Both are essential in maintaining an erection, and both are susceptible to damage due to diabetes.

At a high level, what is diabetes?

The purpose of this post is not to give a detailed explanation of diabetes.  However, suppose you are interested in learning more about the condition.  In that case, I recommend going to the Diabetes Australia website for more information.

So at a high level, with diabetes, your body struggles to maintain healthy blood glucose levels.  We eat food which is then broken down into glucose.  This glucose moves into the bloodstream to assist with cell growth and energy.  For glucose to be used by the body for energy, it needs to be converted.  This conversion happens due to the release of insulin by the body.  People with diabetes produce little or no insulin, or you may have heard the term ‘insulin resistant.’ This is because insulin no longer works in their body.  The ability to turn glucose into energy cannot occur.  Therefore, the glucose level in their blood (blood sugar levels) can rise and harm the body.

This damage to your body is often called the ‘silent’ killer.  The high blood sugar levels and high levels of insulin released to combat it start to damage your body long before you’re diagnosed with diabetes.  Damage occurs to nerves, blood vessels, and organs. 

Your penis is not exempt from this.

The silent damage to the penis

Diabetes education focuses heavily on how it affects your heart and the whole circulatory system.  This includes small blood vessels in your penis and the nerves in this area.  When we have systemic high blood sugar and insulin levels, our body must work extremely hard to correct these levels.  Still, over time the ability to do so breaks down.  Over time this can cause inflammation of the blood vessels, allowing harmful cells to enter the inner lining, ultimately leading to damaged endothelium.  Reduced endothelial function is the number one reason for ED.

Nerve damage is another complication of extended high blood sugar levels.  This damage can result in interrupted neural pathways, specifically between the brain and the penis, affecting arousal and erection function.  Autonomic neuropathy can often appear asymptomatic in the early stage.  For example, suppose you have read or listened to my videos regarding the erection function.  In that case, the autonomic nervous system controls the muscle relaxation necessary for the corpus cavernosum to fill with blood resulting in an erection.  In other words, controls the vascular dilation required for penile erection.  It also is responsible for stimulating prostate secretions and smooth muscle contractions of the vas deferens during ejaculation.  On top of this, neural pathways can be damaged, interrupting the flow of information through the body, for example, the path that controls the sexual organs from S2-S4 that reaches the sex organs via the pelvic nerves.  

So it is straightforward to see why diabetes is considered a cause of ED or ED as a symptom of diabetes.

Do I treat diabetes, or do I treat the ED?

In short, you do both.

Managing your blood sugar levels will ultimately benefit your ED and prevent further damage to the blood vessels and nerves.  Therefore, the following lifestyle changes will help not only your diabetes but also your ED:

• Eat a diabetes-friendly diet to control your blood sugar levels appropriately
• Reduce alcohol consumption
• Stop smoking
• Increasing your activity will assist with improving circulation, lower stress levels, and improve energy levels
• Get more sleep
• Reduce stress

Your next steps for treatment should be worked out with your healthcare professional.  Ideally, a comprehensive medical and psychosexual history is taken.  In addition, an assessment can be done on blood flow in the penile area via an echo doppler.  As well as a penile biothesiometry test which determines the nerve sensitivity and function in your penis.

From here, the Urological Society of Australia and New Zealand (USANZ) and the Australiasian Chapter of Sexual Health and Medicine (AChSHM) for the Royal Australiasian College of Physicians (RACP) have released clinical practice guidelines for the management of ED.  Lifestyle changes listed above are the first line of treatment, followed by the introduction of oral phosphodiesterase type 5 inhibitors (PDE5i), i.e., viagra. 

Many men have mixed results with PDE5i inhibitors or say the side effects outweigh the benefits.  Still, there are a couple of things to be mindful of when starting these medications.  Firstly, viagra is only one of the PDE5i inhibitors on the market.  Its active ingredient is Silandefil.  If you find no response on viagra, there are other PDE5i inhibitors to try.  Secondly, your healthcare professional may start you on a low dose and work towards titrating your dose according to effect.  This may take some time.  Alternatively, some may start you out on the max dose and titrate down depending on the side effects experienced.  Just be aware it’s never as simple as swallowing a pill, and you have an instant erection.  Finding the correct type of PDE5i and the right dose for you may take some time.

How you take the medication is another consideration.  For example, PDE5i inhibitors should be taken at least 30-45 mins before sexual intimacy to allow absorption of the drug.  In addition, taking the medication on a high-fat meal can interrupt the drug’s absorption level.  Therefore, it is recommended that you take it on an empty stomach or at least ensure your meal is not too high in fat.

Viagra is just not working for me……what now?

Suppose you’ve done all the above and still are not seeing the effects needed from PDE5i inhibitors.  In that case, the next step is combination therapy.  Combination therapy involves using PDE5i inhibitors with intracavernosal injections or vacuum erection devices.  Penile prosthesis implants may be considered for men who cannot tolerate the side effects of medical therapy or see no results from medication.

What’s the take-home message?

Rather than get caught up in the chicken or egg debate on which comes first.  Diabetes can be a cause of ED, or ED can be a sign of diabetes, and you may have diabetes first, then get ED, or you may have ED without knowing you have diabetes.  Either way, both conditions need to be managed concurrently.  Your work to manage your diabetes will ultimately benefit your erectile dysfunction.  Likewise, some lifestyle changes recommended for managing diabetes will help your erectile function.

The clinical practice guidelines for managing ED show that ED is no longer seen as a symptom of underlying health conditions but requires management in its own entity.  This shared care model for the treatment of ED will hopefully lead to better outcomes for the 20-30% of men that currently have ED.