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Canadian Pharmacists Association
Canadian Pharmacists Association
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Chapter 33: Erectile Dysfunction

Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

Introduction
  • Erectile dysfunction (ED) affects approximately 34% to 45% of men with diabetes and has been demonstrated to negatively impact quality of life among those affected.
  • Men who have diabetes are more likely to have permanent ED.
  • Up to one-third of newly diagnosed men with diabetes have ED at presentation, with upward of 50% of men having ED by year 6 after diagnosis.
  • Studies indicate that 40% of men with diabetes >60 years of age have complete ED.
  • Risk factors for the development of ED in men with diabetes include increasing age, duration of diabetes, poor glycemic control, cigarette smoking, hypertension, dyslipidemia, androgen deficiency states and cardiovascular (CV) disease.
  • ED has been shown to be significantly associated with all-cause mortality and CV events. Diabetic retinopathy has been shown to correlate with the presence of ED. Organic causes of ED include microvascular and macrovascular disease, and neuropathy. In addition, psychological or situational factors may cause or contribute to ED.
  • Despite the overwhelming amount of data linking ED and diabetes, this remains a subject often neglected by clinicians treating the population with diabetes.
Screening
  • All adult men with diabetes should be regularly screened for ED with a sexual function history [Grade D, Consensus].
    • Screening for ED in men with type 2 diabetes should begin at diagnosis of diabetes.
    • Validated questionnaires (e.g. International Index of Erectile Function or Sexual Health Inventory for Men) have been shown to be both sensitive and specific in determining the presence of ED and providing a means of assessing response to therapy.
  • Men with diabetes and ED should be investigated for hypogonadism [Grade D, Level 4].
    • The Androgen Deficiency in Aging Males (ADAM) instrument is the most widely accepted screening questionnaire.
    • A confirmation test using bioavailable testosterone is recognized as the gold standard, but total testosterone may be measured if a test for bioavailable testosterone is unavailable or unaffordable.
Treatment
  • The Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive glycemic control was effective for primary prevention of and secondary intervention for neuropathy, a condition that can impair sensory feedback from the penis, leading to reduced erectile function.
  • The current data are controversial as it relates to diet, glycemic control and ED, with both positive and negative studies. Based on these conflicting data, a prudent physician should encourage tight glycemic control as a potential factor in maintaining erectile function.
  • A PDE5 inhibitor, if there are no contraindications to its use, should be offered as first-line therapy to men with diabetes and ED in either an on-demand [Grade A, Level 1A] or scheduled-use [Grade B, Level 2] dosing regimen.
    • PDE5 inhibitors have been reported to have a major impact on erectile function and quality of life.
    • Scheduled daily therapy may improve efficacy with lower rates of side effects, may impact lower urinary tract symptoms and has the potential for endothelial benefits.
  • Referral to a specialist in ED should be considered for eugonadal men who do not respond to PDE5 inhibitors or for whom the use of PDE5 inhibitors is contraindicated [Grade D, Consensus].
    • Contraindications for the use of PDE5 inhibitors include unstable angina or untreated cardiac ischemia and concomitant use of nitrates.
    • Second-line therapies (e.g. vacuum constriction devices, intracorporal injection therapy with prostaglandin E1 [PGE1] alone or in combination with papaverine and phentolamine [triple therapy], or intraurethral therapy using PGE1) or third-line therapy (penile prosthesis) may be considered for these men.
Ejaculatory Disorders
  • Ejaculatory disorders are a common disorder of sexual function in men with diabetes, occurring in 32–67% of that population.
  • They range from retrograde ejaculation, usually secondary to autonomic neuropathy with incomplete closure of the bladder neck during ejaculation, to premature or retarded ejaculation.
  • Men with diabetes and ejaculatory dysfunction who are interested in fertility should be referred to a healthcare professional experienced in the treatment of ejaculatory dysfunction [Grade D, Consensus].
Other Relevant Guidelines

For definitions of the levels of evidence cited in this chapter, please refer to the Guideline Recommendations: Levels of Evidence.

If you would like more details on this topic, please visit the Canadian Diabetes Association Clinical Practice Guidelines: Chapter 33.