Professor M H Cummings MD FRCP, Consultant Physician
Honorary Professor in Diabetes and Endocrinology
What is sexual dysfunction in men? Ten years ago sexual dysfunction in men and impotence, was a taboo subject. But it's important to address because, if a man with diabetes develops impotence there is less than a one in ten chance that the problem will improve spontaneously so it is important to seek help. It is now known that one third to one half of men with diabetes suffer from it. Symptoms Many factors can contribute to impotence. In order to achieve an erection, the blood vessels in the penis, under the control of their nerve supply, have to enlarge to allow sufficient blood flow to the penis. At the same time, the muscles in the penis relax so they can allow perhaps ten times the amount of blood to be stored, resulting in penile enlargement.
Changes in the calibre or the function of the blood vessels or damage to the nerves or muscles themselves can therefore result in impotence.
The nerves and blood vessels also depend on stimulatory signals from the brain (often referred to as the 'libido'), which in turn depends on psychological factors and adequate circulating levels of certain hormones particularly testosterone. Any of these factors individually or in combination, can cause impotence.
In addition, the problem may be compounded by some treatments used for men with diabetes - such as treatments for blood pressure or cholesterol-lowering medication.
Getting help
When seeking medical advice you are usually encouraged to attend with your partner (for the purpose of making a choice acceptable to both partners). The health care professional will normally take a medical history and examine you, as this can give a clue to the cause of your impotence and can also influence the choice of treatments.
Simple approaches such as a change in medication (where possible) or treatment of hormone imbalances (testosterone deficiency is more common in diabetes) may help. Also in many cases, the problem is likely to be due to abnormalities of the blood vessels, nerves or muscles of the penis.
It should also be recognised that impotence may herald underlying circulatory conditions such as heart disease, another reason for seeking professional guidance. Treatments available There are now many treatments available for impotence. Most health care professionals will discuss the options and allow you to make a choice of treatment, unless there is a clear reason why one form of treatment may not work or be unsuitable in your case. Oral therapy Many men with diabetes are opting for sildenafil (Viagra) as their first choice. It is very effective in perhaps two thirds of cases, and works by enhancing the blood flow to the penis when sexually aroused. There are no proven benefits in men with normal sexual function.
Concerns about Viagra causing heart disease have not been substantiated although caution is expressed by the manufacturers regarding men with heart disease; and it should not be used if the patient is taking certain forms of heart medication.
Tadalafil (Cialis) and Vardenafil (Levitra) work similarly to Viagra and appear to be just as effective. Studies have suggested that there may be some additional benefits, for instance the effects of Cialis may last up to 24 hours and do not seem to be impaired by the intake of food or alcohol. It is important that whatever treatment you take, it is tried several times (at least 4) to determine whether there is any clear benefit to using the treatment. It is also important to understand how the treatment works and optimum conditions for success (as with all treatment). Penile injections If oral therapy does not work or cannot be taken, many other effective treatments exist including injecting a drug into the penis. See Figure 1. (Caverject is an example of this type of treatment). The drug causes the blood vessels to enlarge and the dose can be altered to allow the penis to stay erect for up to one hour.
The overwhelming majority of patients notice just a little tingling on injection,rather than actual discomfort. The technique is taught by a health care professional who would often get you to do a practice injection there and then. Concerns over prolonged erections (termed 'priapism') have been largely dispelled with the use of newer drugs for injections and the finding that this problem is very rare with careful and gradual alterations of the injected dose. MUSE An alternative approach to the problem is the use of a pellet called MUSE which is inserted into the urethra, the tube that expels urine. It uses the same drug as the injection treatment, and works once the pellet has been absorbed into the penis across the lining of the urethra. Although it is less effective than injection treatment, some men prefer this approach. Overall, MUSE appears to work in about two thirds of patients, while injections are effective in over four fifths of cases. Side effects can include some discomfort for a little while after insertion of the pellet. Vacuum devices For men not keen on using drug treatment to restore erections, vacuum devices may be an acceptable alternative. See Figure 2. This involves placing a cylinder over the penis and, with a pump device, removing air from the cylinder. This results in the penis, enlarging. The cylinder is removed once a band is placed around the base of the penis to keep it erect by preventing blood from escaping. The band can be left in place for up to 30 minutes. These devices can now be prescribed under the NHS. Counselling If it is clear that there is a strong psychological contribution to the problem, then seeing a psychosexual counsellor can be very rewarding. Some men do not like the (imagined) stigma attached to seeing a counsellor and would rather try one of the physical approaches as previously discussed. This is perfectly acceptable and, for a number of men, once they have achieved an erection they are able to stop taking the drug as spontaneous erections return. Figure 1 If oral therapy does not work or cannot be taken, Figure 2For men not keen on using drug treatment to many other effective treatments exist including injecting a restore erections, vacuum devices may be an acceptable
Staying well until a cure iS found. Surgical treatment Surgical treatment for impotence is available but is rarely needed. Penile implants are usually reserved for men with diabetes who do not respond to the measures outlined above. The simpler forms of implants result in a semi- permanent erection and the more complex implants are prone to malfunctioning. Rarely, specialised procedures to the blood vessels may be performed, but these techniques are carried out in only a few centres and their success rates are disappointingly low. Top tips to help manage sexual dysfunction • Get help if you have this problem, there are very effective treatments available • Involving your partner at consultations is more likely to achieve a successful outcome • Make sure that your blood glucose and cholesterol levels, and blood pressure are well controlled which will
reduce your chances of developing impotence. Impotence may be a sign of underlying heart disease
• Don't smoke Further advice for both men and women: Sexual Advice Association Helpline: 0207 486 7262 Web: www.sexualadviceassociation.co.uk Email: info@sexualadviceassociation.co.uk College of Sexual and Relationship Therapists (COSRT) Tel: 0208 543 2707 Web: www.cosrt.org.uk Email: info@cosrt.org.uk www.drwf.org.uk
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Staying Well Until a Cure is found.
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V2.0 published: September 2011 Due for review: September 2012
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All details correct at time of print.
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Professor M H Cummings MD FRCP, Consultant Physician
Honorary Professor in Diabetes and Endocrinology
What is sexual dysfunction in men?
Tadalafil (Cialis) and Vardenafil (Levitra) work similarly to Viagra and appear to be just as effective. Studies have suggested that there may be some additional benefits, for instance the effects of Cialis may last up to 24 hours and do not seem to be impaired by the intake of food or alcohol. It is important that whatever treatment you take, it is tried several times (at least 4) to determine whether there is any clear benefit to using the treatment. It is also important to understand how the treatment works and optimum conditions for success (as with all treatment).
Staying well until a cure iS found.