Until recently, erectile dysfunction ED impotency and diabetes one of the most neglected complications of diabetes. In the past, physicians and patients were led to believe that declining sexual function was an inevitable consequence of advancing age or was brought on by emotional problems. Luckily, awareness of ED as a significant and common complication of diabetes has increased in recent years, mainly because of increasing knowledge of male sexual function and the rapidly expanding armamentarium of novel treatments being developed for impotence.
The onset of ED also occurs 10—15 years earlier in men with diabetes than it does in sex-matched counterparts without diabetes. A sexually competent male must have a series of events occur and multiple mechanisms intact for normal erectile function. A man is considered to have ED if he cannot achieve or sustain an erection of sufficient rigidity for sexual intercourse.
Most naturopathy and diabetes, at one time or another during their life, experience periodic or isolated sexual failures. Normal male sexual function requires a complex interaction of vascular, neurological, hormonal, and psychological systems.
The initial obligatory event is acquisition and maintenance of an erect penis, which is a vascular phenomenon. Normal erections require blood flow prostate cancer and memory loss the corpora cavernosae and corpus spongiosum, impotency and diabetes.
As the blood accelerates, the pressure within the intracavernosal space increases dramatically to choke off penile venous outflow. This combination of increased intracavernosal blood flow and reduced venous outflow allows a man to acquire and maintain a firm erection. Nitric oxide also plays a significant role. High levels of nitric oxide act as local neurotransmitters and facilitate the relaxation of intracavernosal trabeculae, thereby maximizing blood flow and penile engorgement.
Loss of erection, or detumescence, occurs when nitric oxide—induced vasodilation ceases. Low intracavernosal nitric oxide synthase levels are found in people with diabetes, smokers, and men with testosterone deficiency. Interference with oxygen delivery or nitric oxide synthesis can prevent intracavernosal blood pressure from rising to a level sufficient to impede emissary vein outflow, leading to an inability to acquire or sustain rigid erection.
Examples include decreased blood flow and inadequate intracavernosal oxygen levels when atherosclerosis involves the hypogastric artery or other feeder vessels and conditions, impotency and diabetes, such as diabetes, that are associated with suboptimal nitric oxide synthase activity. Erections also require neural input to redirect blood flow into the corpora cavernosae, impotency and diabetes.
Psychogenic erections secondary to sexual images or auditory stimuli relay sensual input to the spinal cord at T to L Neural impulses flow to the pelvic vascular bed, redirecting blood flow into the corpora cavernosae. Reflex erections secondary to tactile stimulus to the penis or genital area activate a reflex arc with sacral roots at S2 to S4.
Nocturnal erections occur during rapid-eye-movement REM sleep and occur 3—4 times nightly, impotency and diabetes. Depressed men rarely experience REM sleep and therefore do not have nocturnal or early-morning erections. The causes of ED are numerous but generally fall into two categories: The organic causes can be subdivied into five categories: Examples of the psychogenic causes are depression, performance anxiety, and relationship problems.
In people with diabetes, the main risk factors are neuropathy, impotency and diabetes, vascular impotency and diabetes, poor glycemic control, impotency and diabetes, hypertension, low testosterone levels, and possibly a history of smoking.
The natural history of ED in people with diabetes is normally gradual and does not occur overnight. Both vascular and neurological mechanisms are most commonly involved in people with diabetes. Atherosclerosis in the penile and pudendal arteries limits the blood flow into the corpus cavernosum. Because of the loss of compliance in the cavernous trabeculae, the venous flow is also lost. This loss of flow results in the inability of the corpora cavernosae to expand and compress the outflow vessels.
Autonomic neuropathy is a major contributor to the high incidence of ED in people with diabetes. Norepinephrine- and acetylcholine-positive fibers in the corpus cavernosum have also been shown to be reduced in people with diabetes.
This results in loss of the autonomic nerve—mediated muscle relaxation that is essential for erections. The initial step in evaluating ED is a thorough sexual history and physical exam. The history can help in distinguishing between the primary and psychogenic causes. It is important to explore the onset, progression, and duration of the problem.
Aside from these causes, only radical prostatectomy or other overt genital tract trauma causes a sudden loss of male sexual function. Nonsustained erection with detumescence after penetration is most commonly caused by anxiety or the vascular steel syndrome.
In the vascular steel syndrome, blood is diverted impotency and diabetes the engorged corpora cavernosae to accommodate the oxygen requirements of the thrusting pelvis. Questions should be asked regarding the presence or absence of nocturnal or morning erections and the ability to masturbate. Complete loss of nocturnal erections and the ability to masturbate are signs of neurological or vascular disease.
It is important to remember that sexual desire is not lost with ED—only the ability to act on those emotions. A medical history focused on risk factors, such as cigarette smoking, hypertension, alcoholism, drug abuse, trauma, and endocrine problems including hypothyroidism, low testosterone levels, and hyperprolactinemia, is very important.
Commonly used drugs that disrupt male sexual function are spironolactone Aldactoneimpotency and diabetes, sympathetic blockers such as clonidine Catapresguanethidine Isleminmethyldopa Aldometthiazide diuretics, most antidepressants, impotency and diabetes, ketoconazole Nizoralcimetidine Tagametalcohol, methadone, heroin, and cocaine.
Finally, assessment of psychiatric history will help identify emotional issues such as interpersonal conflict, performance anxiety, depression, or anxiety. A rectal exam allows for assessment of both the prostate and sphincter tone, abnormalities that are associated with autonomic dysfunction. Sacral and perineal neurological exam will help in assessing autonomic function. Few simple laboratory tests can help identify obvious causes of organic ED. Initial labs should impotency and diabetes HbA 1cfree testosterone, thyroid function tests, and prolactin levels.
However, patients who do impotency and diabetes respond to pharmacological therapy or who may be candidates for surgical treatment may require more in-depth testing, including nocturnal penile tumescence testing, impotency and diabetes Doppler imaging, somatosensory evoked potentials, or pudendal artery angiography. Initially, preventive measures will help reduce the risk of developing ED.
Improving glycemic control and hypertension, ceasing cigarette smoking, and impotency and diabetes excessive alcohol intake have been shown to benefit patients with ED. Avoiding or impotency and diabetes medications that may contribute to ED is also helpful. Sildenafil Viagra acts by blocking the catabolism of cGMP, resulting in an increase in nitric oxide, impotency and diabetes.
Sildenafil should be taken 1—2 h before intercourse. One patient in our clinic recently complained that he had no effect from taking sildenafil.
It was later discovered that he took the pill and then sat on his couch and read a book about how to grow tomatoes! The initial dose for sildenafil impotency and diabetes 50 mg, and the dose can be increased to mg.
The pills can also be split in half with a pill cutter. Side effects of sildenafil are similar to those from taking niacin or any vasodilator, namely, headaches, lightheadedness, dizziness, impotency and diabetes flushing. Some individuals experience a bluish tinge of their cornea, which makes them feel as if they are wearing light blue—tinted impotency and diabetes. This effect can last for several hours.
Syncope and myocardial infarction, the most serious side effects, are seen in men who are also taking nitrates for coronary heart disease. Sildenafil also has adverse effects in people with hypertrophic cardiomyopathy because a decrease in preload and after load in the cardiac output can increase the outflow obstruction, culminating in an unstable hemodynamic state.
Sildenafil is strongly contraindicated in men who take nitrates. Other men for whom its use holds potential hazards include those:. Another oral treatment that has been used with very little success is yohimbine Yocon, Yohimex.
This is an alpha 2 adrenergic receptor blocker that increases cholinergic and decreases adrenergic tone. It stimulates the mid-brain and increases libido. Optimal results occur when used in men with psychogenic ED. Side effects include anxiety and insomnia. For those patients who are not candidates for oral therapy, intracavernosal injections are an acceptable alternative.
Injections with alprostadil Caverject and papaverine Genabid have been used to induce erection. The sympathetic nervous system normally maintains the penis in a flaccid or non-erect state. All of the vasoactive drugs, when injected into the corpora cavernosae, inhibit or override sympathetic inhibition to encourage relaxation of the smooth muscle trabeculae.
The rush of blood engorges the penile corpora cavernosae sinusoidal spaces and creates an erection. Patients who use this therapy should be trained under the guidance of a urologist, and sterile technique must be used.
The drugs must be injected into the shaft of the penis and into one of the penile erectile bodies corpus cavernosum 10—15 min impotency and diabetes intercourse. Most patients do not complain of impotency and diabetes upon injection.
Sexual stimulation is not required, and resulting erections may last for hours. Side effects include penile pain and priapism. Intraurethral alprostadil Muse provides a less invasive alternative to impotency and diabetes injection. It is a pellet that is inserted 5—10 min before intercourse, and its effects last for 1 h. It can be used twice daily but is not recommended for use with pregnant partners.
Complications of priapism and penile fibrosis are less common than after alprostadil given by penile injection. Mechanical therapy is also effective and is especially well-accepted in men with stable partners.
Vacuum pressure encourages increased arterial inflow, and occlusive tension rings discourage venous outflow from the penile corpus cavernosae, impotency and diabetes. The penis placed inside the cylinder, a pump is used to produce a vacuum that pulls the blood into the penis. After the tension ring is slipped onto the base of the penis, the cylinder is removed.
Erection lasts until the rings are removed. Penile prosthesis is a viable option for men who cannot use sildenafil and who find the injections or vacuum erection therapy distasteful. A non-adjustable semi-rigid prosthesis is easy to insert and has no postoperative mechanical problems. The inflatable prosthesis has a pump that is put in the testicular sac for on-demand inflation and deflation.
Future versions will have a remote control device similar to a garage-door opener. The infection can also cause penile erosion, reduced penile sensation, and auto-inflation. Glycemic control should be optimized several weeks before surgery.