Silent and neglected
DR. VIJAY VISWANATHAN
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Erectile dysfunction is a complication arising from diabetes but is often ignored.
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THERE has been a revolution in the understanding of erectile dysfunction (ED) and its management. It is now accepted ED occurs because of changes in small blood vessels and in the nerves called the autonomic nerves.
Erection occurs because the penile vasculature has increased blood flow. This is mediated by the nervous system as well as nitric oxide. There are theoretical grounds to believe that ED might be an early marker and an important risk factor for cardiovascular disease.
Causes
Other factors in diabetes that contribute to ED are poor control of diabetes, smoking, hypertension, large vessel disease and medication like atenolol used for hypertension. ED probably affects around 35 per cent of all diabetic men over the age of 18. Diabetic men who smoke had a fourfold increase in ED.
An impotent male will take a long time before discussing the problem with his physician. The key aspect is that the onset is usually gradual and erections do not last long enough for satisfactory intercourse.
The investigation for ED includes serum testosterone if the patient is over 50 years and if there has been loss of libido. An ECG for cardiovascular status and glycolated haemoglobin are the other routine tests. Doppler duplex ultrasound for vascular disease and advanced neurological testing are some of the other investigations in patients who require these tests.
Treatment
The treatment for diabetic men with ED includes oral agents, intracavernosal injection and vaccum therapy among others. While getting the history, the doctor should check if the patient is on nitrates. This is one of the major contraindications for oral treatment, as there may be an alarming decrease in blood pressure. However in the absence of any major cardiac disease, the oral agents can be given safely, as they have not been associated with any significant adverse effect. The oral agent that has revolutionised management of ED is sildenafil citrate (viagra). The success rate has been reported to be between 56 and 59 per cent. Common adverse effects are headache, indigestion, flushing and abnormal vision. Other drugs like tadalafil and vardenafil have similar mode of action.
Another method is injecting a vasodilating agent into the penis. The disadvantages are that it is painful and produced fibrosis at the site of injection. It also causes priapism (painful prolonged erection), which has to be treated immediately.
Transurethral administration of prostaglandin (MUSE) has also been used and 60 per cent have reported success. The most common side effect was pain but priapism and penile fibrosis were not reported.
Vaccum therapy consists of a transparent tube placed over the penis and attached to a vaccum pump. Air is pumped out and the negative pressure draws blood into the erectile tissue causing tumescence. A constricting band present at the base of the tube is slipped off to remain at the base of the penis to maintain the erection and the tube is removed.
The success rate is 70 per cent in both diabetics and non-diabetic men. It is safe and effective and can be used in men who cannot use oral agents. Surgery has a limited role and the options are insertion of penile prosthesis.
Complete assessment
ED is usually managed in a dedicated ED clinical. A complete assessment of the patient is made along with psychological evaluation if required. Hormonal, vascular and neurological assessments are also done.
The treatment options are explained to the patient and, depending on his condition and needs, the treatment is modified to suit individual needs.
The writer is the Joint Director, M.V. Hospital for Diabetes, Chennai.
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