Erectile Dysfunction

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Gerald Brock MD, FRCSC William Harper MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Erectile dysfunction (ED) affects approximately 34% to 45% of adult men with diabetes, has been demonstrated to negatively impact quality of life among those affected across all age strata and may be the earliest sign of cardiovascular disease.
  • All adult men with diabetes should be regularly screened for ED with a sexual function history. Those with ED should be investigated for hypogonadism.
  • The current mainstay of therapy is phosphodiesterase type 5 inhibitors. They have been shown to have major impacts on erectile function and quality of life, with a low reported side effect profile, and should be offered as first-line therapy to men with diabetes wishing treatment for ED.


Erectile dysfunction (ED) affects approximately 34% to 45% of men with diabetes and has been demonstrated to negatively impact quality of life among those affected across all age strata, with a greater likelihood among men with diabetes that their ED is permanent (1). Recent reports describe up to one-third of newly diagnosed men with diabetes have ED at presentation (2), with upward of 50% of men having ED by year 6 after diagnosis (3). Furthermore, studies indicate that 40% of men with diabetes >60 years of age have complete ED (4–12). Recent studies have reported that alteration of the cyclic guanosine monophosphate (cGMP(/nitric acid (NO) pathway among men with diabetes with impaired vascular relaxation is related to endothelial dysfunction (13–15). Among the population with diabetes, risk factors include increasing age, duration of diabetes, poor glycemic control, cigarette smoking, hypertension, dyslipidemia, androgen deficiency states (16) and cardiovascular (CV) disease (8,10,17,18). ED as a marker of potential CV events has been reported by numerous investigators (19–26). In fact, ED has been shown to be significantly associated with all-cause mortality and CV events (27,28). Diabetic retinopathy has been shown to correlate with the presence of ED (8,10,29). Organic causes of ED include microvascular and macrovascular disease, and neuropathy. In addition, psychological or situational factors may cause or contribute to ED.

In spite of the overwhelming amount of data linking ED and diabetes, this remains a subject often neglected by clinicians treating the population with diabetes (30).

Compared with the general population, multiple studies have reported men with diabetes having higher rates of hypogonadism (16,31–34). Interestingly, a recent report describes a correlation between glycemic control and testosterone levels (35). Importantly, phosphodiesterase type 5 (PDE5) inhibitors appear to be less effective in hypogonadal states (32,34,36), where treatment of nonresponders to PDE5 inhibitors with testosterone replacement is successful in roughly 50% of individuals. In addition, ED is a side effect of many drugs commonly prescribed to men with diabetes, such as some antihypertensives and antidepressants.


All adult men with diabetes should be regularly screened for ED with a sexual function history. Screening for ED in men with type 2 diabetes should begin at diagnosis of diabetes. Validated questionnaires (e.g. International Index of Erectile Function (37,38) or Sexual Health Inventory for Men (39) ) have been shown to be both sensitive and specific in determining the presence of ED and providing a means of assessing response to therapy. Men with diabetes and ED should be further investigated for hypogonadism. The Androgen Deficiency in Aging Males (ADAM) instrument is the most widely accepted screening questionnaire, and, while bioavailable testosterone is recognized as the gold standard for biochemistry confirmation, total testosterone is an acceptable alternative if bioavailable testosterone is unavailable or unaffordable (40).


While no randomized clinical trials have demonstrated that interventions that improve glycemic control also reduce the incidence and progression of ED, the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive glycemic control was effective for primary prevention of and secondary intervention for neuropathy, a condition that can impair sensory feedback from the penis, leading to reduced erectile function (41–43). The current data are controversial as it relates to diet, glycemic control and ED, with both positive and negative studies (28,44–46). Based on these conflicting data, a prudent physician should encourage tight glycemic control as a potential factor in maintaining erectile function (28).

The current mainstay of treatment for ED is therapy with PDE5 inhibitors. They have been reported to have a major impact on erectile function and quality of life, and should be offered as first-line therapy to men with diabetes wishing treatment for ED (47–52). Evidence for scheduled daily therapy is effective within the population with diabetes and ED (53,54), and may improve efficacy with lower rates of side effects, may impact lower urinary tract symptoms and has the potential for endothelial benefits (55). Additionally, among PDE5 inhibitor failure patients, use of a vacuum constriction device may salvage a significant percentage of erectile function and should be considered (56).

Contraindications for the use of PDE5 inhibitors include unstable angina or untreated cardiac ischemia and concomitant use of nitrates (3,57,58). Interestingly, men with diabetes appear to have lower rates of side effects with PDE5 inhibitors than the general population. This is believed to be a result of altered vasomotor tone or other factors (59).

Referral to a specialist in ED should be offered to men who do not respond to PDE5 inhibitors or for whom the use of PDE5 inhibitors is contraindicated. Second-line therapies (e.g. vacuum constriction devices, intracorporal injection therapy with prostaglandin E1 [PGE1] alone or in combination with papaverine and phentolamine [triple therapy], or intraurethral therapy using PGE1) or third-line therapy (penile prosthesis) may be considered for these men (60).

Ejaculatory Disorders

Ejaculatory disorders are a common disorder of sexual function in men with diabetes, occurring in 32–67% of that population (61). They range in scope from retrograde ejaculation, usually secondary to autonomic neuropathy with incomplete closure of the bladder neck during ejaculation, to premature or retarded ejaculation. Their recognition as an important component in sexual quality of life makes inquiry about ejaculatory function important.


  1. 1.All adult men with diabetes should be regularly screened for ED with a sexual function history [Grade D, Consensus].
  2. 2.Men with diabetes and ED should be investigated for hypogonadism [Grade D, Level 4 (16,31,32,34)].
  3. 3.A PDE5 inhibitor, if there are no contraindications to its use, should be offered as first-line therapy to men with diabetes and ED in either an on-demand [Grade A, Level 1A (47-53)] or scheduled-use [Grade B, Level 2 (53,54)] dosing regimen.
  4. 4.Referral to a specialist in ED should be considered for eugonadal men who do not respond to PDE5 inhibitors or for whom the use of PDE5 inhibitors is contraindicated [Grade D, Consensus].
  5. 5.Men with diabetes and ejaculatory dysfunction who are interested in fertility should be referred to a healthcare professional experienced in the treatment of ejaculatory dysfunction [Grade D, Consensus].

ED, erectile dysfunction; PDE5, phosphodiesterase type 5.


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