Warning: This article contains language of an adult nature and is not recommended for our young readers.

Erectile dysfunction (ED), the inability to have or maintain an erect penis, may be one of the more embarrassing topics for a man to discuss—even with his healthcare provider.

For every man too embarrassed to talk to his doctor about ED, however, Aaron Vinik, MD, PhD, has this to say:

"To prevent ED is to prevent a heart attack!"

What Is ED, and Why Do Guys With Diabetes Get It?

Statements from the National Institutes of Diabetes and Digestive and Kidney Disorders (NIDDK) stress that ED is treatable in all age groups and that "more men have been seeking help and returning to near-normal sexual activity because of improved, successful treatments" for ED.

An erection requires a sequence of events, and ED can occur when any of those events is disrupted. Any disorder that impairs blood flow in the penis has the potential to cause ED.

The NIDDK reports that diseases—including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis (narrowing of the arteries) and vascular disease—account for about 70 percent of cases of ED.

Vinik, who is director of the Diabetes Research Institute at Eastern Virginia Medical School in Norfolk, Virginia, notes that there are many reasons why a man with diabetes might get ED. However, neuropathy—a nerve disorder common in people with diabetes, especially when their diabetes is poorly controlled—appears to be a primary culprit.

Although Vinik singles out neuropathy as "no doubt the major contributor," he suggests that "neurovascular dysfunction" would be a better description.

"By this, I mean impaired function of the small nerve fibers important for altering function of the lining of the blood vessels to the corpora cavernosa—the smooth muscle that contracts or relaxes, depending on sexual arousal, to cause an erection."

Vinik states that a necessary ingredient in getting an erection is the formation and release of the powerful vasodilator nitric oxide, whose bioavailability is reduced in people with diabetes.

Vivian Fonseca, MD, professor of medicine and pharmacology and holder of the Tullis Tulane Alumni Chair in Diabetes at Tulane University in New Orleans, Louisiana, has extensively researched and lectured on the topic of diabetes and erectile dysfunction. He explains that dysfunction of the endothelium (the lining of the blood vessel) is another major factor in men with diabetes developing ED.

A Common Problem That Increases With Age and Diabetes Duration

German researchers presenting data at this past summer's American Diabetes Association Scientific Sessions in San Francisco, California, concluded that the prevalence of ED is high in men with type 1 and 2 diabetes and that it increases with age and the duration of illness.

Analyzing data that was obtained between 1992 and 2000 from 15,770 men with diabetes, the researchers discovered that, at the time of diagnosis, 22 percent of men with type 2 diabetes already had ED.

Further, they presented these statistics:

• Among men who have had type 2 for one to five years, 33 percent have ED.
• Among men who have had diabetes for five to 10 years, 37 percent of those with type 2 have ED, compared to 7 percent of those who have type 1.
• Among men who have had diabetes for 10 to 20 years, 50 percent of men with type 2 have ED, compared to 13 percent of men with type 1.

Another study, conducted by researchers from the Department of Nutrition at Harvard School of Public Health in Boston, Massachusetts, also found that in men over the age of 50, increasing duration of type 2 diabetes is positively associated with increased risk of ED.

According to this research, published in the August 2002 issue of Diabetes Care, men with diabetes had an age-adjusted relative risk 1.32 times that of men without diabetes for having ED.

In another study, published in the February 2002 issue of Diabetes Care, Italian researchers discovered that ED is extremely common among men with type 2 diabetes. In data collected from 1,460 men with type 2, 34 percent reported frequent erectile problems, 24 percent reported occasional problems and 42 percent reported no erectile problems.

What the Doctor Ordered

For men with ED, treatments do exist.

Fonseca recommends Viagra (sildenafil) as first-line therapy for men with ED. He does not use other treatments unless the patient cannot tolerate or respond to Viagra.

Many of Vinik's patients have been referred to him when Viagra has failed and they are wondering about other options. Some patients believe that penile-injection therapy is the answer. But Vinik stresses that injection of a vasodilator into a man's penis will produce an erection only if the valves in the veins draining the penis are functioning normally.

"If there is no response, then the person is a candidate for an external vacuum therapy device with a constriction ring," says Vinik. "If there is a response, it means that the problem is either neurovascular, macrovascular or psychological. A careful history will usually establish the difference."

Why Are Some ED Treatments Prescription Only?

Because of rules established by the U.S. Food and Drug Administration, some of the medications that are used to treat ED do require prescriptions.

"This ensures physician supervision," explains Fonseca, "which is important because of drug interactions."

Vinik notes that Viagra has certain side effects that require care, "as would injections and, of course, surgery." In contrast, a vacuum device, which does not require a prescription, "rarely causes trouble if the directions are followed."

Vinik feels that good old-fashioned blood-glucose control is the best remedy for ED for men who do not have insurance and cannot afford Viagra or a vacuum therapy device.

"Your best shot is to be sure to control your blood glucose and lipids as well as possible and to do an exercise program to improve blood flow and psychological state."

He also stresses that eating a high-fiber diet low in saturated fats and trans fatty acids may be the best preventive measure.

Fonseca adds that exercise, weight loss and quitting smoking are low-cost ways to help improve endothelial function.

Treatment Options for ED

Counseling: A qualified counselor or therapist can often help.

Hormonal Therapy: No hormone therapy should be started unless a low blood-testosterone level has been found.

Medications:

Viagra (sildenafil): Viagra is the number one prescribed medication for erectile dysfunction. Do not take Viagra if you are also taking nitroglycerine.

Trental (pentoxifylline): Trental works by improving blood-flow characteristics. Desyrel (trazodone) Originally an anti-depression medication, Desyrel can help nondepressed men maintain an erection.

Penile Injection Therapy: With this technique, a man injects medications directly into his penis.

Intraurethal Pellet Therapy ("MUSE"): This technique involves painlessly placing a very small, medicated pellet inside the tip of the penis. As the pellet dissolves, it releases the medication and causes rigidity in about five to 10 minutes.

External Vacuum Therapy: This is a mechanical, nonsurgical method of producing penile engorgement and rigidity. It is based on the principle that placing the penis in a vacuum chamber or cylinder that draws blood into the erection bodies can produce an erection.

Surgical Treatment (Penile Prosthetic Implants): If simpler treatments are unsuccessful, 15 different models of penile prostheses are currently available.

Source: Stephen W. Leslie, MD, FACS, Assistant Clinical Professor, Department of Urology, Medical College of Ohio, School of Medicine, Toledo, Ohio.