Diabetes and erectile dysfunction

Diabetes is one of the strongest and most common causes of erectile dysfunction. In men with diabetes, erectile dysfunction appears both at a younger age and in a more severe form; it is also often one of the first noticeable signs of diabetes. That is why checking fasting blood glucose or HbA1c is routine when erectile problems first appear.

Why is the link so strong?

An erection requires healthy small blood vessels and healthy nerves — every link in the chain described in penile blood flow depends on these two structures. High blood sugar quietly wears down exactly these two structures over the years. The same mechanism behind diabetes’ effects on the eyes (retinopathy), kidneys (nephropathy) and feet (neuropathy) is also at work in penile circulation.

Four mechanisms

How do symptoms progress?

In diabetes the picture usually develops slowly and insidiously: first erections become shorter, then full rigidity is not reached, and then morning erections decrease. A sudden onset is more often a sign of psychological causes or a change in medication. This slow progression leads many men to get used to the situation and put off seeing a doctor for years.

How much can blood sugar control restore?

Keeping blood sugar on target is clearly effective at slowing the progression of damage. However, expecting nerve and vessel damage caused by many years of high blood sugar to reverse completely is not realistic. The approach therefore works on two fronts: halting progression (metabolic control) and supporting existing function (treatment options).

Why are pills less effective in diabetes?

PDE5 inhibitors work by prolonging a relaxation that has already been started via nitric oxide. In diabetes, both nitric oxide production (endothelial damage) and signal transmission (neuropathy) are impaired, so there may not be enough of a response to prolong. This is why response rates to pills are lower in men with diabetes than in the general population, and they fall further the longer the disease has lasted.

Why does the vacuum device stand out for this group?

• It does not rely on nerve or endothelial response. It draws blood in through a pressure difference, so it works even with neuropathy.
• No drug interactions. An important advantage for diabetic patients taking multiple medications.
• No extra load on the kidneys or heart. No substance enters the systemic circulation.
• No recurring costs. While medication costs add up in the management of a chronic disease, the device is a one-time purchase.
• It keeps the tissue supplied with blood. Regular use helps limit the long-term effect of reduced blood flow on the tissue.

For how the device works and how to choose a ring, see penile vacuum device; for a consistent routine, see vacuum erection therapy. The original texts of peer-reviewed publications on the method — including a study of 41 men with diabetes who had not responded to oral medication — are available with translations on the clinical research page.

Practical tips for users with diabetes

• Check your skin. Wounds heal slowly in diabetes; inspect the skin before and after each session and take a break if there is irritation.
• Build up the vacuum gradually. This reduces the risk of bruising; it matters even more if you take blood thinners.
• If sensation is reduced, pay closer attention to time. Neuropathy weakens the pain warning; use a timer to keep to the 30-minute limit.
• Inspect the area after removing the ring. If there is persistent discolouration or a sore, see your doctor.
• Keep things clean to prevent infection. Wash the parts with lukewarm water and mild soap after every use and let them dry.

Recommended check-ups

1. HbA1c and fasting blood glucose — the level of metabolic control.
2. Blood pressure and lipid profile — accompanying vascular risk.
3. Morning total testosterone — especially if desire has decreased.
4. Kidney function and urinalysis.
5. Urological assessment — to plan treatment options for the individual.

For all causes of erectile dysfunction and the steps of treatment, see erectile dysfunction.