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Psychological causes (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) Decreased appearance and volume of ejaculate. Chronic prostatitis, normal aging process, obstruction of ejaculatory duct(s), retrograde ejaculation.

Chronic fatigue syndrome, hypogonadism, hypothyroidism, psychological conditions. Impaired quality and timing of orgasm, including anorgasmia. Alcohol abuse, Cushing syndrome, hyper- or hypothyroidism, medications (e.g., antihistamines, antipsychotics, beta blockers, selective serotonin reuptake inhibitors, thiazides, tricyclic antidepressants), psychological causes, surgery of the pelvis or prostate. History of sexual abuse, genital piercings, sexually transmitted infections (e.g., genital herpes) Assessment of body habitus for central obesity. Cushing syndrome, diabetes mellitus, metabolic syndrome. Cauda equina syndrome, spinal stenosis, surgery of the pelvis or prostate, trauma. Atherosclerotic vascular disease, cerebrovascular disease.

Peyronie disease, ruptured corpora cavernosum, venous leakage. Anxiety, hyperthyroidism, stimulant abuse, underlying cardiovascular disease.

Epididymitis, hypogonadism, testicular cancer, varicocele. Psychological causes (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) Decreased appearance and volume of ejaculate.

Chronic prostatitis, normal aging process, obstruction of ejaculatory duct(s), retrograde ejaculation. Chronic fatigue syndrome, hypogonadism, hypothyroidism, psychological conditions. Impaired quality and timing of orgasm, including anorgasmia. Alcohol abuse, Cushing syndrome, hyper- or hypothyroidism, medications (e.g., antihistamines, antipsychotics, beta blockers, selective serotonin reuptake inhibitors, thiazides, tricyclic antidepressants), psychological causes, surgery of the pelvis or prostate. History of sexual abuse, genital piercings, sexually transmitted infections (e.g., genital herpes) Assessment of body habitus for central obesity. Cushing syndrome, diabetes mellitus, metabolic syndrome.

Cauda equina syndrome, spinal stenosis, surgery of the pelvis or prostate, trauma.

Atherosclerotic vascular disease, cerebrovascular disease.

Peyronie disease, ruptured corpora cavernosum, venous leakage.

Anxiety, hyperthyroidism, stimulant abuse, underlying cardiovascular disease. Epididymitis, hypogonadism, testicular cancer, varicocele. Phosphodiesterase type 5 (PDE5) inhibitors are the most effective oral drugs in the treatment of ED,9 , 12 and should be considered first-line therapy.8 , 14 , 17 Retail sales of sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) approached $1.48 billion in 2007.18 Sildenafil has been found to be effective and safe in cases of ED associated with diabetes mellitus17 , 19 and spinal cord injury,20 and in men with sexual dysfunction secondary to antidepressant therapy.21 Compared with placebo, sildenafil has been shown to improve erections (74 versus 21 percent; number needed to treat [NNT] = 2)22 and results in more frequent intercourse attempts (57 versus 21 percent; NNT = 3).23 Approximately one third of men with ED do not respond to therapy with PDE5 inhibitors.

These agents are not effective for improving libido.24.

The three PDE5 inhibitors are considered to be relatively similar in effectiveness, but there are differences in dosing, onset of action, and duration of therapeutic effect ( Table 6 ).25 There are no rigorous data to suggest that one PDE5 inhibitor is superior to another. An open-label trial found that patients preferred tadalafil and vardenafil over sildenafil,26 yet most evidence supports equal effectiveness between sildenafil and vardenafil.27 PDE5 inhibitors are generally well tolerated, with mild transient adverse effects of headache, flushing, dyspepsia, rhinitis, and abnormal vision.

Headache is the most commonly reported adverse effect, occurring in approximately 10 percent of patients. Rare but important adverse effects include dizziness, syncope, and nonarteritic anterior optic neuropathy (predominantly from crossover phosphodiesterase type 6 inhibition).

PDE5 inhibitors should not be taken concomitantly with nitrates because this may lead to a synergistic effect, resulting in a potentially serious, even fatal, decrease in blood pressure. PDE5 inhibitors are metabolized by the cytochrome P450 3A4 and may affect metabolism of protease inhibitors and antifungal medications. Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction. *— Maximum recommended dose per 24 hours is the maximum strength dose for each agent . † — Duration during which successful erections may be achieved following a dose of medication .

Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction.

*— Maximum recommended dose per 24 hours is the maximum strength dose for each agent . † — Duration during which successful erections may be achieved following a dose of medication . Intracavernosal pressure and PDE5 activity are androgen-dependent.

The prevalence of hypogonadism (defined as a morning serum total testosterone level less than 300 ng per dL [10.41 nmol per L]) in men with ED is estimated to be 5 to 10 percent.13 , 28 In men with hypogonadism, testosterone supplementation is superior to placebo in improving erections and sexual function. Response rates are higher in primary versus secondary testicular failure, and with transdermal versus oral or intramuscular testosterone.13 Supplementation is also associated with improved satisfaction with erectile function and sexual desire.29 Men with hypogonadism who failed a trial of sildenafil were found to have significant improvement in erectile function with the addition of testosterone supplementation.30 Testosterone supplementation may result in erythrocytosis, elevated serum trans-aminase levels, exacerbation of untreated sleep apnea, benign prostatic hyperplasia, and an increased risk of adenocarcinoma of the prostate.

Men receiving testosterone supplementation require more frequent monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels, and prostate examinations.31.

Alprostadil (Caverject) is a viable second-line therapeutic option for the treatment of ED. It should initially be administered in the physician's office at the lowest dose and sequentially titrated to an adequate erectile response while monitoring for syncope. The physicians should also provide education on self-administration.8 Intra-cavernosal alprostadil is more effective, better tolerated, and preferred by men over the intraurethral form.32 Common adverse effects of intraurethral alprostadil include local penile pain, urethral bleeding, dizziness, and dysuria.

Common adverse effects of intracavernosal alprostadil include penile pain, edema and hematoma, palpable nodules or plaques, and priapism.

Patients should be informed about the potential for occurrence of prolonged erections and should seek emergent medical evaluation for rigid erections lasting longer than four hours. Priapism is most commonly treated with aspiration of blood from the corpus cavernosum under local anesthetic.

If this treatment is insufficient, then intra-cavernosal injections of phenylephrine should be performed with hemodynamic monitoring to watch for severe hypertension, tachycardia, or arrhythmia. Vacuum pump devices are a noninvasive second-line option ( Figure 2 ) . They are contraindicated in men with sickle

cell

If used properly, adverse effects and potential risks are negligible, yet there may be a substantial learning curve. When first- and second-line therapies have failed, surgical implantation of an inflatable penile prosthesis can be considered in consultation with a urologist ( Figure 3 ) .

Patients should be counseled regarding risks, benefits, and expectations of this procedure. The AUA does not endorse penile venous reconstructive surgery or surgeries to limit venous outflow from the penis. Penile arterial reconstructive surgery is controversial and more rigorous trials are needed to prove short- and long-term effectiveness.16. If you are a man with diabetes, we’ve got good news and bad news about your sex life.

The bad news: Men with diabetes are three times more likely to report having problems with sex than non-diabetic men. The most common sexual problem is Erectile Dysfunction, or ED, sometimes called impotence.

Even worse, because ED is such a private issue, many men feel embarrassed to discuss the problem with their doctor, or even their partner, so the problem is never addressed.

The good news: ED is one of the most treatable complications of diabetes.

In fact, over 95 percent of cases can be successfully treated. With proven treatments available, diabetic men with ED have options. It isn’t something you—or your partner—should have to live with. What ED Is—and What It Isn’t ED means the repeated inability to achieve or sustain an erection sufficient for sexual intercourse. Although sexual vigor generally declines with age, a man who is healthy, physically and emotionally, should be able to produce erections, and enjoy sexual intercourse, regardless of his age. ED does not mean: • An occasional failure to achieve an erection. The adage is true: It really does happen to everyone.

All men experience occasional difficulties with erection, usually related to fatigue, illness, alcohol or drug use, or stress. ED occurs when a man is interested in sex, but still cannot achieve or maintain an erection. Many men with diabetes also experience a decreased sex drive, often as a result of hormone imbalances or depression.

Decreased sex drive is quite treatable, but it is treated differently from ED.

Such problems often indicate a structural problem with the penis.

How Diabetes Causes ED Human sexual response requires several different body functions to work properly and together: nerves, blood vessels, hormones, and psyche.

Unfortunately, diabetes—and even the treatment for diabetes—can affect many of these functions.

• Nerves: One of the most common complications of diabetes is neuropathy, or nerve damage.

Erection is a function of the parasympathetic nervous system, but orgasm and ejaculation are controlled by the sympathetic system. • Blood Vessels: Diabetes damages blood vessels, especially the smallest blood vessels such as those in the penis. Diabetes can also cause heart disease and other circulatory problems.

Proper blood flow is absolutely crucial to achieving erection. “Erection is a hydraulic phenomenon that occurs involuntarily,” says Arturo Rolla, MD, of Harvard University School of Medicine. “Nobody can will an erection!” Anything that limits or impairs blood flow can interfere with the ability to achieve an erection, no matter how strong one’s sexual desire.

• Hormones: Diabetes often causes kidney disease, and kidney disease, in turn, can cause chemical changes in the type and amount of hormones one’s body secretes, including the hormones involved in sexual response.

• Psyche: Psychological issues can cause a diminished sex drive, but they can also lead to ED even when sex drive is fine.

ED can follow major life changes, stressful events, relationship difficulties, or even the fear of ED itself. The physiological changes associated with fear can themselves cause ED! • Medications: About 25 percent of ED cases are caused by drugs. Many medications, including common medicines prescribed for diabetes and its complications, can cause ED.

The most common offenders are blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug). In addition, over-the-counter medications, including certain eye drops and nose drops, have been associated with ED. That does not mean you should stop taking these medications! Rather, you should discuss them with your doctor to determine whether a different dosage, an alternate medicine, or additional treatments will resolve the ED. Treatments for ED ED is easily and successfully treated! If your sex drive is unaffected, but you experience problems achieving or sustaining erection for a period of four to five weeks, you may have ED. Don’t delay—erectile dysfunction doesn’t “just go away!” Additionally, ED could be a sign of a serious, even life-threatening complication, such as congestive heart failure or kidney disease.

Ignoring your ED because it’s embarrassing could jeopardize your health.

Most men seek treatment from their family doctor, who may or may not be familiar with the range of treatment options.

Specialists include urologists and doctors practicing at ED treatment centers.

A thorough physical exam and medical history, along with certain laboratory tests, can help your doctor determine what is causing ED, and then choose an appropriate treatment. The most common treatments for ED fall into four categories: medications, external mechanical devices, counseling, and surgery. Medications: Oral medicines: The best known ED medications are the Big Three: Viagra (sildenafil citrate, made by Pfizer, Inc.), Levitra (vardenafil HCl, made by Bayer and GlaxoSmithKline), and Cialis (tadalafil,

made

The three are chemically very similar, and all have proven very effective.

Because they are effective, convenient, and relatively inexpensive (about nine dollars per pill), these medicines have become the treatment of choice for most men experiencing ED. The main difference among the three is in how long they last.

Viagra is supposed to work for between 30 minutes and four hours; Levitra for 30 minutes to two hours, and Cialis for up to 36 hours. In addition, Viagra is slightly less effective if taken with food; Viagra can also cause temporary abnormalities of color vision. In some cases, however, these drugs may be unsuitable for patients with heart disease.

If you are considering one of these drugs and you have heart disease, as many diabetics do, be sure to tell your doctor. In rare cases, the pills may create “priapism,” a prolonged and painful erection lasting six hours or more (although reversible with prompt medical attention). Topical medicines: When the problem is insufficient blood flow, vasodilators (such as nitroglycerine ointment) can be applied to the penis to increase penile blood flow and improve erections.

The main side effect of nitroglycerine ointment is that it may give the partner headaches.

Penile Injection Medication: This is just what it sounds like.

Injected at home directly into the penis, the medication alprostadil produces erection by relaxing certain muscles, increasing blood flow into the penis and restricting outflow. Although some sources report an 80 percent success rate, the therapy has disadvantages, such as risks of infection, pain, and scarring—fibrosis—in the penis, and it may also cause priapism.

A popular version of this medication is Upjohn Corporation’s Caverject. The MUSE System, by VIVUS, involves the same medicine (a pellet of alprostadil) applied with an eye-dropper-like applicator, directly into the urethra. External Mechanical Devices: This category of treatments includes external vacuum therapies: devices that go around the penis and produce erections by increasing the flow of blood in, while constricting the flow out.

Such devices imitate a natural erection, and do not interfere with orgasm. External vacuum therapy mechanisms are approximately 95 percent successful in causing and sustaining an erection.

All are portable, and costs range between $200-$500, covered under most insurance plans and Medicare Part B. The vacuum constriction device consists of a vacuum cylinder, various sizes of tension rings, and a vacuum pump, either hand-operated or electric. The penis is placed in a cylinder to which a tension ring is attached.

Air is evacuated from the cylinder by means of the pump, creating a vacuum, which produces the erection. The

cylinder

You must use the correct-size tension ring and remove it, to prevent penile bruising, after sustaining the erection for 30 minutes.

Such devices may be unsuitable for men with certain bleeding disorders. In general, vacuum constriction devices are successful in management of long-term ED.

“Rejoyn” is an inexpensive, nonprescription alternative to the vacuum-actuated devices. Described by its manufacturer as a “support sleeve,” it does not “cause” an erection, but

rather

Counseling: The great majority of ED cases in diabetic men have a physical cause, such as neuropathy or circulatory problems. In some cases, however, the cause of ED is psychological, including depression, guilt, or anxiety.

With a thorough exam, the doctor should be able to determine whether the ED is psychological or physical in nature. If the cause is psychological, your doctor may refer you to a psychiatrist, psychologist, sex therapist, or marital counselor. Most psychologically-based ED is easily and successfully treated.

Surgery: There are two kinds of surgery for ED: one involves implantation of a penile prosthesis; the other attempts vascular reconstruction. Expert opinion about surgical implants has changed during recent years; today, surgery is no longer so widely recommended. There are many less-invasive and less-expensive options, and surgery should be considered only as a last resort.

The obvious risks are the same that accompany any surgery: infection, pain, bleeding, and scarring. If for some reason the prosthesis or parts become damaged or dislocated, surgical removal may be necessary.

With a general success rate of about 90 percent, any of the devices will restore erections, but they will not affect sexual desire, ejaculation, or orgasm. Prostheses: Many different types of penile prostheses are available, in three categories: rods, inflatable prostheses, and self-contained prostheses.

Semi-rigid or malleable rods are the simplest and least expensive of all. Their main disadvantage is that the penis remains constantly erect, which may cause problems with concealment. Inflatable prostheses are complex mechanical devices that imitate the natural process of erection.

Parts are inserted surgically into the penis and scrotum, and activated by squeezing. When erection is no longer desired, a valve on the pump is pressed, and the penis becomes flaccid.

Self-contained single-unit prostheses are similar to the inflatable types, but more compact. When erection is desired, the unit is activated by either squeezing or bending, depending on which of the two types of self-contained prostheses is used.

Vascular Reconstructive Surgery corrects defects in penile blood vessels. The surgeon may reconstruct the arterial blood supply, or remove veins when the cause is due to leakage. Less than five percent of men with ED may benefit from vascular surgery.

Preventing ED Like all diabetic complications, ED can occur even when you have followed your doctor’s advice and carefully managed your diabetes. Also like all diabetes complications, ED is less likely to occur with good blood sugar control.

Poorly controlled diabetes and high cholesterol increase the chances of vascular complications, which may lead to ED or other circulatory problems.

In addition, regular smoking and alcohol use can contribute to ED. You are not alone; others have faced these difficulties.