Diabetes-induced erectile dysfunction: epidemiology, pathophysiology and management

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Abstract

Erectile dysfunction (ED) is defined as the inability of the male to attain and maintain erection of penis sufficient to permit satisfactory sexual intercourse. Prevalence of impotence in diabetic men is ≥50%. The pathophysiology of diabetes-induced erectile dysfunction (DIED) is multifactorial and no single etiology is at the forefront. The proposed mechanisms of erectile dysfunction in diabetic patients includes elevated advanced glycation end-products, increased levels of oxygen free radicals, impaired nitric oxide synthesis, increased endothelin B receptor binding sites and up-regulated RhoA/Rho-kinase pathway, neuropathic damage and impaired cyclic guanosine monophosphate (cGMP)-dependent protein kinase-1. The treatment of DIED is multimodal. Treatment of the underlying hyperglycemia and comorbidities is of utmost importance to prevent or halt the progression of disease. Oral medications are considered as the first line therapy for management of DIED. If oral agents cannot be used or have insufficient efficacy despite appropriate dosing and education, second-line treatments should be addressed. When there is lack of efficacy or when there is dissatisfaction with other modalities, penile prostheses are often the best alternative for ED and are considered as the third line therapy for DIED. Future strategies in the evolution of the treatment of DIED are aimed at correcting or treating the underlying mechanisms of DIED.

Introduction

Diabetes mellitus is categorized as a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. As a result, the amount of glucose in the blood increases while the cells are starved of energy (Kumar, Cotran, & Robbins, 2004). It is predicted that by 2030, India, China and the United States will have the largest number of people with diabetes (Wild, Roglic, Green, Sicree, & King, 2004).

Sustained higher levels of blood glucose cause damage to nerves and blood vessels, leading to complications such as heart disease and stroke, the leading causes of death among people with diabetes. Uncontrolled diabetes can eventually lead to other health problems as well, such as vision loss, nephropathy, neuropathy and sexual dysfunction. Uncontrolled high blood glucose level for long time may develop depression, foot or leg amputation and skin complications (Haslett et al., 2002).

Impotency in males, which is also referred as erectile dysfunction (ED), is defined as the inability to achieve and/or maintain an erection sufficient to permit satisfactory sexual intercourse. Normal penile erection is a hemodynamic process that is dependent upon corporal smooth muscle relaxation mediated by parasympathetic neurotransmission, nitric oxide (NO), electrophysiologic events and possibly other regulatory factors (Arie et al., 2003).

An association between diabetes mellitus (DM) and the development of erectile dysfunction has been documented in the literature since 1798 (McCulloch, Campbell, Wu, Prescott, & Clarke, 1980). Generally 25–75% of men with Type 2 diabetes complain of erectile dysfunction (Klein, Klein, Lee, Moss, & Cruickshanks, 1996). In numerous epidemiological studies the odd ratio of having erectile dysfunction if a man is diabetic is 1.9–4 times greater than a population without diabetes, making diabetes one of the greatest risk factors for erectile dysfunction (Lewis, 1996).

Section snippets

Significance of sexual health

Sexuality is an integral part of a human life and well-being. Sexuality in health and illness includes a wide spectrum of excitations and activities, which are a source of different drives, affects impulses like pleasure, anxiety, feelings of shame, disgust, etc., throughout the lifespan (Laumann, Paik, & Rosen, 1999). Proper sexual functioning is one of the most important components of quality of life and of maintaining a satisfying intimate relationship (Rosen et al., 2000). When sexual

Epidemiology of DIED

The increasing worldwide incidence of DM in adults constitutes a global public health burden (Fig. 1) (Hilary, Ronald, & William 1998). ED is a worldwide problem as its prevalence is projected to increase in all continents (Fig. 2) (Ayta, McKinlay, & Krane, 1999).

ED has been reported to occur in ≥50% of men with DM worldwide. It is usually present within 10 years of diagnosis of DM. The incidence of ED was reported to be higher in men with DM than for men without DM and up to 12% of men who

Pathophysiology of DIED

The pathophysiology of diabetic impotency is multifactorial and no single etiology is at the forefront. Following are the proposed mechanisms of ED in diabetic patients (Moore & Run, 2006).

The therapeutic approach and strategies for the management of DIED

Despite considerable progress, the treatment of erectile dysfunction is often difficult due to its multifactorial etiology. Consequently, a global approach, requiring not one but several treatment modalities is needed for management of ED, instead of an approach localized to the organ. Oral medications are considered as the first line therapy for the management of DIED (Gerald, 2002). If oral agents cannot be used or have insufficient efficacy despite appropriate dosing and education,

Future prospects in management of DIED

Based on the more extensive knowledge and understanding of physiological mechanisms regulating male erectile function, orally delivered drugs have been established as a logical and straightforward pharmacological approach for treating male DIED. Increased public awareness in this field will undoubtedly promote the identification of new compounds that might be effective in the treatment of such sexual disorder. Due to the unending charge to conceive a first-line treatment more advanced than the

Conclusion

Prevalence of ED in diabetic patients is increasing day by day. The pathophysiology of diabetes induced erectile dysfunction is multi factorial and no single etiology is at the forefront. However, in the past few years, our knowledge on the pathophysiology of ED and on male sexual problems in general has expanded enormously. However, there are still many unanswered questions that need to be addressed and more efforts need to be made in order to improve drug design and therapy. Treatment ranging

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