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Dr M H Cummings MD FRCP, Consultant Physician
Honorary Reader in Diabetes and Endocrinology
Member of the Advisory Panel for the Impotence Association
Many men with diabetes feel isolated if they develop impotence (or erectile dysfunction, as it is termed by the medical profession). Impotence is certainly not an isolated problem, however, as we now know that approximately one third to one half of diabetic men suffer from this problem.
Ten years ago impotence was a taboo subject. Patients and health care professionals were embarrassed to talk about the subject. Health care professionals were uncertain how to treat the problem and the easiest way out was to reassure the patient that the problem would get better with time. However, if a man with diabetes develops impotence there is less than a one in ten chance that the problem will improve spontaneously.
Who can you turn to for help?There have fortunately been considerable advances in our understanding of why impotence develops and how to treat it. Health care professionals are far more aware of the problem and if they cannot treat you themselves they will know to whom to refer you for further advice.
Most general practitioners have an understanding of the problem for their diabetic patients and usually can initiate treat-ment themselves. Alternatively, many hospital diabetes centres now offer an impotence service for men with diabetes, or work closely with urology teams who can help. There should always be a health care professional with experience in the treatment of impotence who can advise you.
What causes impotence?Many factors can contribute to the problem. 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 else damage to the nerves or muscles themselves can therefore result in impo-tence. 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.
Seeking medical adviceWhen 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 may help. There is no benefit, however, from using testosterone if your blood testosterone levels are normal. And indeed, this approach can be dangerous. More commonly, the problem is likely to be due to abnormalities of the blood vessels, nerves or muscles of the penis. Extensive investigations to determine which of these factors is the most important are not necessary since they are very unlikely to influence the treat-ment offered to you.
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Treatments availableThere 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. Having heart disease does not preclude you from treatment but it is important that this is stabilised first. As a rough rule of thumb, the physical activity associated with sexual intercourse is equivalent to that of a brisk walk for twenty minutes on the flat.
Oral therapyMany diabetic men 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. Apomorphine (Uprima) is a newer alternative and is placed under the tongue. It works differently to Viagra. Overall, Uprima can work a little quicker than Viagra but may not be as effective for some 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 benefit.
Penile injectionsIf oral therapy does not work or cannot be taken, many other effective treatments exist. The most effective of these is injecting a drug into the penis (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 would be taught to you by the 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 dis-pelled 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.
MUSEAn 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. Prolonged erections are virtually unheard of and side effects can include some discomfort for a little while after insertion of the pellet.
Vacuum devicesFor men not keen on using drug treatment to restore erections, vacuum devices may be an acceptable alternative. 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. Some couples find these devices a little intrusive although others report the opposite, with effective erections being obtained within a few minutes. It is best to go to a recognised company manufacturing vacuum pumps (for example, Erecaid and Genesis devices). These latter ones cost from £100 upwards but most companies give you a limited time/money-back guarantee if you are not satisfied with the device.
Pleasingly, these devices can now be prescribed under the NHS.
S t a y i n g w e l l u n t i l a c u r e i S f o u n D . . .
CounsellingIf 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.
Surgical treatmentSurgical treatment for impotence is available but is rarely needed. Penile implants are usual y reserved for diabetic men 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.
Research continuesFortunately, there have been considerable advances in our understanding of why impotence develops and how to treat it. Health care professionals are far more aware of the problem and, if they cannot treat you themselves, they will know to whom to refer you for further advice. If your general practitioner is unfamiliar with how to treat the problem, many hospital diabetes centres now offer an impotence service for men, or work closely with urology teams who can help. There should always be a health care professional with experience in the treatment of impotence who can advise you. Recently, and in the next few years we are likely to see many more treatments emerging for the treatment of impotence, as research continues.
Further advice for both men and women:Sexual Dysfunction Association Helpline: 0870 7743571 Web: www.sda.uk.net E-mail: firstname.lastname@example.org
British Association for Sexual and Relationship Therapy (BASRT) Tel: 0208 543 2707, Web: www.basrt.org.uk
SPOD (an information service for disabled people with sex and relationship problems) Tel: 0207 607 8851 Tues & Thurs (10.30-1.30), & Wed (1.30-4.30).
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