There are many factors that contribute to Erectile Dysfunction (ED). Men with diabetes suffer with ED more frequently and at a younger age than those without diabetes. There are two kinds of medical specialists that should be included on your medical team if you suffer from ED. One is your endocrinologist (to discuss if there is a hormonal problem). The other specialist is an urologist (a doctor that specializes in the urinary tract of men and women and the reproductive system of men) (1). Know that ED is a very common problem in men who have diabetes. To get the proper diagnosis and treatment, ED must be discussed. This article contains possible causes and therapies for ED. Discussion will include hormones, medications, devices and surgery. Questions to ask your physician will be included to help you become comfortable in talking about ED with your medical team.

According to the National Kidney and Urologic Diseases Information Clearinghouse, ED is often caused by a physical disease or injury. (2) As mentioned in Part 1 of this series, potential reasons can also include side effects from medication. In men with diabetes the cause of ED can be complicated.  Side effects from diabetes can include problems with nerves, blood vessels and muscle function which can contribute to ED.(3) Hormonal imbalances also need to be addressed.

The steps involved in treatment for ED may include filling out a screening form to gather information about your history and problems. The doctor most likely will want to perform a physical examination. Blood may be drawn to test for abnormal hormone levels as well as systemic diseases. Your doctor may also want to know if you have erections that occur during sleep and discuss any psychological reasons that may be contributing to ED.(2)

5 Questions for Your Doctor about ED:

Question 1: Could my ED be a hormonal problem? Do I have low testosterone, high prolactin, a problem with my thyroid or any other hormonal imbalances involved?

Altered levels of many hormones may contribute to ED. Testosterone, prolactin and thyroid hormone are among the hormones that may be involved.

It is thought that low levels of testosterone without other risk factors affects less than five percent of men but it can contribute to ED in men with other risk factors.(4) Testosterone levels in many individuals decline with age.

The Endocrine Society’s Clinical Guidelines (2010) recommends offering testosterone therapy to men who have low levels and ED after evaluating for causes of ED and consideration of established therapies. There are some men in which testosterone therapy is not recommended even if testosterone is low. These include men with high hematocrit values, heart failure, untreated sleep apnea and those with high risk of prostate cancer as well as other conditions.(5)

According to the American Diabetes Association, men with type 2 diabetes are twice as likely to have a deficiency of testosterone as men without diabetes.(6) The Urology Care Foundation estimates that 50 percent of men with diabetes will develop low testosterone levels.(7) When testosterone therapy is needed and prescribed in men with type 2 diabetes, it may help with ED and studies also show insulin sensitivity is increased and resistance is lowered by as much as 25 percent.(8) Not all men with ED and diabetes that take testosterone will become functional.(9) Please consult with your physician to see if testosterone is a possibility for you. Do not forget to discuss benefits as well as potential side effects of taking this hormone.

Prolactin is a hormone that is made in the pituitary gland of both males and females. It is thought to have more than 300 functions in the human body.(10) High levels of prolactin are sometimes found in men with low testosterone levels. In men, the most common symptom of prolactinoma (high prolactin levels) is erectile dysfunction.(11) Ask if there is a problem with your body making too much prolactin.

Thyroid Hormones
Studies have shown that ED is very common with both hyperthyroidism and hypothyroidism, which can be a problem with too much thyroid hormone or too little thyroid hormone. It is suggested that if there is a thyroid dysfunction, this should be treated before undergoing any specific treatment for ED. Normalizing thyroid hormones, if abnormal, may be appropriate treatment needed for ED. (12)

Question 2: Would a medication advertised for ED such as  Cialis, Viagra, Levitra, Staxyn, or Stendra help me with sexual function or would there be a potential problem if I was prescribed one of these medications?

Oral medication may be part of an ED treatment plan for men with diabetes that is under control. The drugs that are currently available include; Cialis, Viagra, Levitra, Staxyn, and Stendra. Using one of these drugs as prescribed by ones physician may help approximately 50-60 percent of men with diabetes.(13) Not everyone with diabetes should use these medications. Please be careful and use a reputable pharmacy to obtain your order. If you get your medications from a pharmacy online, make sure that it is certified by the National Association of Boards of Pharmacy. Go to the Verified Internet Pharmacy Practice Sites (VIPPS) program here to check on your pharmacy provider. This is to make sure you are getting the correct medication and it is not counterfeit. If you are in a country where one or more of these medications do not need a prescription, make sure you have permission to use the medication from your physician, review what would be a safe dose and when you can safely use it. Discuss how the medication may react with other medications and food. Please discuss with your doctor and pharmacist any contraindications you may have to these medications.

- Click here for more information on Cialis
- Click here for more information on Viagra
- Click here for more information on Levitra
- Click here for more information on Staxyn
- Click here for more information on Stendra

Question 3: Are there injection treatments for ED?

When oral medications do not work, sometimes Alprostadil,   which is approved by the Food and Drug Administration (FDA), can be used. This medication is injected with a small needle. A man will need to be able to do this or the man’s partner will need to be trained. An auto-injector is also available to make injection easier. Instruction needs to take place under your physician’s guidance. This medication may also be prescribed using a devise that inserts the medication into the urethral opening instead of using a needle. For more information on Alprostadil, click here.

Question 4: Are there any devices, pumps or vibrators that are recommended?

Devices that use vacuum pressure to aid with erection are an option for some men. There are some devices that are FDA approved which limit the amounts of pressure allowed to help prevent possible injury. It is not recommended to acquire a device without discussing the options and being counseled by your physician. Be wary of companies that sell devices that are not FDA approved as these could potentially cause bodily harm. Pumps come in both manually and battery operated versions. FDA approved devices have a safety feature to limit pressures inside of the chamber used. For more information, click here.

The FDA has also approved the use of a battery-operated device called the “Viberect.” This device, which is available only through prescription from your doctor, uses vibration to help develop an erection. For more information, click here.

Question 5: Am I a candidate for surgery to help resolve my ED? If so can you review my options and tell me the benefits and risks?

There are different types of surgery for ED that may be possibilities for some men:

Penile Prostheses
Penile prostheses devises are implanted in the body by a surgeon usually in the hospital. There are two kinds to discuss with your doctor: 

- The first kind consists usually of flexible cylinders that are inflated with fluid to get an erection. Fluid can be removed and stored in an abdominal reservoir.

- The second is a malleable prosthesis. This type of prostheses is always rigid. It can be placed in the proper position for body functions such as intercourse and urination.Infections are noted in approximately one-third of surgical procedures for ED. For more information on Penile prostheses, click here.

Vascular Reconstructive Surgery
When an artery is blocked for proper erectile function to happen, this type of surgery may be suggested. The surgeon takes an artery from the abdomen to bypass the blockage that inhibits blood flow. This surgery has a success rate in younger men with a single blockage of 50-75 percent, but unfortunately in older men results is only successful five percent of the time. For more information, click here.

Vein Ligation Surgery
This procedure is considered when veins leak and erections are not maintained. Veins are blocked surgically to aid in function. This procedure is not considered successful long-term and is not widely available in the United States. For more information, click here.
There are many herbs and supplements that promise to help with ED. Remember not to take any supplements or herbs without first discussing possible adverse effects with your physician. Some substances may have dangerous side-effects and may also interfere with prescribed medications. An article from the University of Maryland discusses problems with some of the supplements including Yohimbe, Viramax, Gamma-Butyrolactone, L-arginine, DHEA and Spanish Fly. Click here to review this information.

The American Urological Society (AUS) also has statements and recommendations about herbs and supplements for ED. They do not recommend the use of herbal supplements. According to AUS, the only supplement identified so far that may potentially be of benefit for ED is Korean Red Ginseng. While promising, the efficacy of this supplement still needs to be validated by large clinical trials. Due to the lack of these trials and insufficient data available, not even this supplement is recommended.(14)

As you can see there are many kinds of therapies available to help with erectile dysfunction. Please do not be afraid to talk about this very important issue with your physician. We at hope the information provided in our ED series will benefit you in discussions with your doctor and healthcare team.
If you missed Part 1 of this series, “Erectile Dysfunction with Diabetes - 9 Healthy Habits to Help Prevent and Control Erectile Dysfunction,” click here.

Article Referenced Links by Number:

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Written and reviewed by Clara Schneider MS, RD, RN, CDE, LDN - 09/13