Evaluation and treatment of erectile dysfunction in men with diabetes mellitus

Diabetic men have a more than 3-fold increased prevalence of erectile dysfunction (ED) compared with nondiabetic men. Erectile function is primarily a vascular phenomenon, triggered by neurologic controls and facilitated by appropriate hormonal and psychological components. Recent advances in the understanding of the physiology of penile vasculature and its role in male sexual performance have influenced the clinical approach to ED. The pathophysiological alterations leading to impotence in diabetic men include vasculogenic, neurogenic, and hormonal etiologies. A clinical work-up, including a thorough history and physical examination, is an important aspect of ED management. Biochemical evaluations to rule out secondary causes like hypogonadism and thyroid abnormalities are suggested. Oral medications acting through phosphodiesterase inhibition in penile vasculature have revolutionized treatment of impotence in diabetic men. Because of a high success rate in treating ED of various etiologies, these agents are the treatment of choice for most patients. Safety and efficacy of vacuum-constriction devices, intraurethral suppositories, intracavernosal injections, and other therapies are discussed. A clinical algorithm for the evaluation and management of ED is provided for use in the primary care setting.