Diabetes and ED Treatment: What to Discuss With Your GP

Erectile dysfunction is among the most common complications of diabetes in men, and among the least raised in appointments. It tends to appear earlier and be more persistent than in men without diabetes, because diabetes affects several of the systems an erection depends on at once.

That makes the consultation slightly different from a standard one. Treating the symptom without addressing the diabetes leaves most of the problem in place.

Why diabetes affects erectile function

Three mechanisms, usually overlapping:

• Blood vessels. Sustained high blood glucose damages the endothelium — the lining of blood vessels — impairing the vessel relaxation that allows blood flow into the penis.
• Nerves. Diabetic neuropathy affects the nerve signalling involved in arousal and erection, and can also reduce sensation.
• Hormones. Lower testosterone is more common in men with type 2 diabetes, and affects libido as well as erectile function.

Because nerve damage is involved, diabetes-related ED can be less responsive to some treatments than ED from other causes. That is worth knowing in advance so expectations are realistic.

The most important conversation is about the diabetes

Glycaemic control is not a side topic here. Improving it slows the vascular and nerve damage that drive the problem, and protects eyes, kidneys and feet at the same time.

Bring to the appointment:

• Your recent HbA1c results and how they have trended.
• Your current diabetes medicines, including insulin.
• Whether you have known complications — retinopathy, neuropathy, kidney disease or foot problems.
• Your blood pressure and cholesterol results.
• Whether you have had a recent diabetes cycle of care review.

If your ED has appeared or worsened recently, it may be a signal that control has slipped, which is useful clinical information in itself.

The other conditions that travel with it

Men with type 2 diabetes commonly also have high blood pressure, high cholesterol, excess weight and sometimes sleep apnoea. Each of these independently affects erectile function, and each is treatable. Untreated obstructive sleep apnoea in particular is worth asking about if you snore heavily or wake unrefreshed.

Medicines and interactions

Several points to raise:

• Kidney function. Diabetic kidney disease affects how some medicines are cleared, and your prescriber will take this into account.
• Blood pressure medicines. Additive blood pressure lowering effects matter, and alpha-blockers require particular care.
• Nitrates are an absolute contraindication. This is especially relevant because coronary artery disease is common in diabetes, and nitrate sprays are often carried for angina. Recreational nitrites are included in this.
• Testosterone. If low testosterone is suspected, it is assessed separately with blood tests, usually in the morning, and managed on its own terms.

Diabetes complications that change the assessment

Tell your GP if you have had any sudden vision loss, or a diagnosis such as non-arteritic anterior ischaemic optic neuropathy — this is directly relevant to this class of medicine. Mention any retinal disease, cardiac history, or peripheral vascular disease.

What the appointment might include

Expect a review of your diabetes, a blood pressure check, and blood tests that may include HbA1c, lipids, kidney function and testosterone. A physical examination is sometimes appropriate. Depending on findings, you may be referred to an endocrinologist, urologist, diabetes educator or psychologist.

Not every consultation ends with a prescription, and that is not a failure of the appointment. Sildenafil, tadalafil, vardenafil and dapoxetine are Schedule 4 prescription-only medicines in Australia requiring a valid prescription from a registered Australian prescriber, precisely so this assessment happens first.

Lifestyle changes that do double duty

The measures that help glycaemic control also support erectile function, which makes them unusually good value:

• Regular physical activity, including both aerobic exercise and resistance work.
• Weight reduction where relevant, which improves insulin sensitivity and testosterone.
• Stopping smoking, which is among the most significant single vascular interventions available.
• Moderating alcohol.
• Treating sleep apnoea if present.

None of these are quick, and it is fair to say so plainly. They are, however, the interventions that address the cause rather than the symptom.

The psychological side

A diabetes diagnosis, the daily management burden and the arrival of a complication like ED can all affect mood, and depression is more common in people with diabetes. Antidepressants can themselves affect sexual function. This is all discussable, and worth discussing rather than absorbing.

Urgent signs

Seek immediate care for chest pain or breathlessness during or after sexual activity, an erection lasting more than four hours, or sudden loss of vision or hearing.

Raising it

If you find the topic difficult, one sentence is enough: I have been having trouble with erections and I want to know whether it is related to my diabetes. GPs managing diabetes expect this question — Healthdirect Australia and Diabetes Australia both publish general information for people who want to read up first.

This article is general health information, not medical advice. Discuss your diabetes management and any treatment with your doctor or pharmacist.