Sexual Dysfunction and Hypogonadism in Men With Diabetes

Diabetes Canada Clinical Practice Guidelines Expert Committee

Richard Bebb MD, ABIM, FRCPC, Adam Millar MD, MScCH, FRCPC, Gerald Brock MD, FRCSC

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

Key Messages Regarding Sexual Dysfunction in Men with Diabetes

  • Erectile dysfunction affects approximately 34% to 45% of adult men with diabetes. It has been demonstrated to negatively impact quality of life among those affected across all age strata and may be an early clinical indication of cardiovascular disease.

  • All adult men with diabetes should be regularly screened for erectile dysfunction with a sexual function history.

  • The current mainstay of therapy for erectile dysfunction 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 erectile dysfunction.

Key Messages Regarding Hypogonadism in Men with Diabetes

  • Hypogonadotropic hypogonadism is common in men with type 2 diabetes, with a prevalence of up to 40%.

  • Hypogonadal men with diabetes have a higher risk for cardiovascular mortality than eugonadal men with diabetes.

  • Screening for symptomatic hypogonadism in men with type 2 diabetes is recommended.

  • Evidence is conflicted as to whether treatment of hypogonadism in men with diabetes can increase quality of life, improve body composition, weight loss and glycemic control.

  • Observational studies assessing the impact of testosterone use on cardiovascular health in hypogonadal men have produced mixed results. Randomized, placebo-controlled studies have been too small or short in duration to adequately answer this question.

Key Messages for Men with Diabetes

  • Low testosterone is common in men with type 2 diabetes.

  • Symptoms of low testosterone can include: diminished interest in sex, erectile dysfunction, reduced lean body mass, depressed mood and lack of energy.

  • If you are experiencing symptoms of low testosterone, you should talk with your health-care provider.

Erectile Dysfunction

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 (1), with a greater impact on those with permanent—rather than intermittent—ED (2,3). Recent reports describe up to one-third of newly diagnosed men with diabetes have ED at presentation (4), with upward of 50% of men 6 years after diagnosis (5,6). In addition, studies indicate that 40% of men with diabetes greater than 60 years of age have complete ED (7–15).

Recent studies have reported that alteration of the cyclic guanosine monophosphate (cGMP)/nitric oxide (NO) pathway among men with diabetes with impaired vascular relaxation is related to endothelial dysfunction (16–18). Among men with diabetes, risk factors include increasing age, duration of diabetes, poor glycemic control, cigarette smoking, hypertension, dyslipidemia, androgen-deficiency states (19) and cardiovascular disease (CVD) (6,11,12,20–24).

ED as a marker of potential cardiovascular (CV) events has been reported by numerous investigators (25–34). In fact, ED has been shown to be significantly associated with all-cause mortality and CV events (35–37). Diabetic retinopathy has been shown to correlate with the presence of ED (11,13,38). Organic causes of ED include microvascular and CV 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, it is often neglected by clinicians treating men with diabetes (39).

Compared with the general population, multiple studies have reported that men with diabetes have higher rates of hypogonadism (19,40–44). One report described a correlation between glycemic control and testosterone levels (45). Importantly, phosphodiesterase type 5 (PDE5) inhibitors appear to be less effective in men with diabetes with hypogonadism (41,43,46,47). In this population, 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 certain antihypertensives and antidepressants. Obstructive sleep apnea (OSA) is commonly associated with ED and, like diabetes, is an independent risk factor for the presence of ED (48). Screening for OSA in men with obesity with type 2 diabetes and ED should be considered.

Figure 1
Diagnostic workup of hypogonadism (TDS) (modified from reference [91]).

BAT, calculated bioavailable testosterone; CBC, complete blood count; COPD; chronic obstructive pulmonary disease; FT, free testosterone; FSH, follicle stimulating hormone; LH, luteinizing hormone; PSA, prostate specific antigen; SHBG, sex hormone-binding globulin; TSH, thyroid stimulating hormone.

Screening for Erectile Dysfunction

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 (49,50) or Sexual Health Inventory for Men) (51) have been shown to be both sensitive and specific in determining the presence of ED and providing a means of assessing response to therapy (24). Men with diabetes and ED should be further investigated for hypogonadism (Figure 1).

Treatment of ED

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 (52–54). The current data are controversial as they relate to diet, glycemic control and ED, with both positive and negative studies (36,55–57). Based on these conflicting data, a prudent clinician should encourage optimal glycemic control as a potential factor in maintaining erectile function (36,58,59).

Dyslipidemia and hypertension are also risk factors for ED. A meta-analysis of statin use in older men, many of whom had diabetes, suggests a benefit from statin treatment on erectile function. Diabetes-specific data are lacking (60). A small study of losartan in combination with tadalafil in men with type 2 diabetes showed an improved ED response rate compared to tadalafil monotherapy (61).

The current mainstay of treatment for ED in men with diabetes is therapy with PDE5 inhibitors (62–64). 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 (65–70) (see Figure 2). There is evidence that scheduled daily therapy is effective within the population with diabetes and ED (71,72), and may improve efficacy with lower rates of side effects, may reduce lower urinary tract symptoms and has the potential for endothelial benefits (73). Additionally, among PDE5 inhibitor failure patients, use of a vacuum constriction device may salvage a significant percentage of men with erectile function and should be considered (74,75).

Contraindications for the use of PDE5 inhibitors include unstable angina or untreated cardiac ischemia and concomitant use of nitrates (5,76,77). 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 (78).

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 (see Figure 2). Second-line therapies (e.g. vacuum constriction devices [79], 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 (80,81).

Ejaculatory Disorders

Ejaculatory disorders are a common disorder of sexual function in men with diabetes, occurring in 32%–67% of that population (82,83). 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.

Figure 2
Management of erectile dysfunction in men with diabetes. PDE5, phosphodiesterase type 5.


Hypogonadotropic hypogonadism has a reported prevalence of 30% to 40% in men with type 2 diabetes (84–86). One study noted a prevalence of 30% in men with prediabetes, compared to 13.6% of age-matched controls (87). In contrast to type 2 diabetes, the prevalence of hypogonadism in men with type 1 diabetes is similar to the general male population (88,89). Although the pathophysiology may be related to numerous factors, including age, insulin resistance, glycemic control, concomitant sleep apnea and obesity, the most significant predictor is theorized to be the degree of central or visceral obesity (84,86,89,90). Insulin resistance is correlated with a reduction of sex hormone-binding globulin (SHBG). Measurement of total testosterone may be affected by low SHBG levels, giving the false impression of biochemical hypogonadism when bioavailable or free testosterone levels are still normal.

Biochemical testing should be by analysis of total testosterone levels drawn before 11 am or within 3 hours of awakening (91). Due to the natural variability of serum testosterone levels, repeat testing is often helpful to clarify the diagnosis. In men with diabetes with symptoms of hypogonadism but with total testosterone levels still in the lower normal range, measurement of bioavailable testosterone may be helpful.

Common symptoms of hypogonadism include fatigue, muscle weakness or muscle cramps, loss of sleep-related erections, low libido, night sweats or mood changes, such as depressive affect or irritability. A recent systematic review of male hypogonadism provides a more detailed discussion regarding diagnosis and treatment of testosterone deficiency (91).

Many men with type 2 diabetes and hypogonadism are asymptomatic, and treatment should be reserved for those who are biochemically hypogonadal and symptomatic. Some causes of secondary hypogonadism are potentially reversible, such as sleep apnea and obesity. Significant weight reduction is generally associated with an increase in testosterone in hypogonadal men with diabetes (92,93). In some instances, this can restore the eugonadal state without the need for testosterone replacement (92,93).

Conflicting evidence suggests that testosterone therapy in hypogonadal men with type 2 diabetes may increase quality of life or improve sexual function (44,94–98). Studies assessing whether testosterone treatment in hypogonadal men with diabetes can reduce glycated hemoglobin (A1C) values have also produced mixed results (93,94,99–104). A nonrandomized, ongoing, observational study of testosterone-treated men with hypogonadism with (40%) or without diabetes showed reductions in weight, visceral obesity, abdominal circumference, as well as decreased hypertension and insulin resistance over a 5-year study interval (105,106).

Hypogonadism has been associated both with risk factors of CVD, including carotid intimal medial changes in men with type 2 diabetes (107), and an increased risk of myocardial infarction (MI) and increased CV mortality (108,109). A 3-year randomized, placebo-controlled study of testosterone use in men with hypogonadism age 60 years or older showed no significant change in either carotid artery intimal medial thickness or coronary artery calcium scores. However, only 15% of this cohort had diabetes (110). Hypogonadism also predicted an increased CV risk in men (27% of whom had type 2 diabetes) with known coronary artery disease (CAD) (111). Several nonrandomized, observational studies have produced conflicting results in regards to cardiac risk vs. benefit from testosterone replacement (101,109,112).

As men with type 2 diabetes are high risk for CV events, any positive or negative impact could, therefore, potentially have a very significant clinical impact due to the high CVD event rate in this population. Until future studies clarify the effect of testosterone on CVD, it is prudent to discuss the issue with men with diabetes prior to initiating testosterone treatment.

To date, no large, randomized, placebo-controlled study has shown an increased risk of prostate cancer in men treated with testosterone. Monitoring for prostate cancer both prior to initiation of testosterone therapy and while on therapy is recommended.

Evaluation of hypogonadal symptoms

Biochemical testing is recommended in men with diabetes who are symptomatic. In the absence of symptoms of hypogonadism, biochemical testing is not indicated. OSA is very common in people with type 2 diabetes and obesity (113). Increasing age and obesity are risk factors (113). When hypogonadotrophic hypogonadism is diagnosed in men with type 2 diabetes, the presence of underlying OSA should be considered.

Treatment of hypogonadism

There is no evidence that 1 preparation of testosterone is superior to another in the relief of hypogonadal symptoms or the prevention of hypogonadism-related complications. The selection of a testosterone preparation should consider the benefits and risks of testosterone therapy in addition to patient preference. Monitoring the effects of testosterone should be done in accordance with national guidelines, such as those recommended by the Endocrine Society or the Diagnosis and management of testosterone deficiency syndrome in men: Clinical Practice Guideline (91).


  1. All adult men with diabetes should be regularly screened for ED with a sexual function history [Grade D, Consensus].
  2. A PDE5 inhibitor should be offered as first-line therapy to men with diabetes and ED in either an on-demand [Grade A, Level 1A (65–71)] or daily-use [Grade B, Level 2 (71,72)] dosing regimen.
  3. Men with diabetes and ED who do not respond to PDE5 inhibitors should be investigated for hypogonadism with measurement of a morning serum total testosterone level drawn before 11 am [Grade D, Level 4 (19,40,41,43)].
  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. Men with diabetes and ejaculatory dysfunction who are interested in fertility should be referred to a health-care professional experienced in the treatment of ejaculatory dysfunction [Grade D, Consensus].


A1C, glycated hemoglobin; CV, cardiovascular; CVD, cardiovascular disease; CAD, coronary artery disease; ED, erectile dysfunction; NO, nitrous oxide; PDE5, phosphodiesterase type 5; OSA, obstructive sleep apnea; SHBG, sex hormone-binding globulin.

Literature Review Flow Diagram for Chapter 33: Sexual Dysfunction and Hypogonadism in Men with Diabetes

*Excluded based on: population, intervention/exposure, comparator/control or study design.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097 (114).

For more information, visit

Author Disclosures

Dr. Brock reports personal fees from Lilly, Pfizer, Astellas, Ferring, Boston Scientific, and Paladin, outside the submitted work. No other author has anything to disclose.


  1. M.I.MaiorinoG.BellastellaE.Della VolpeErectile dysfunction in young men with type 1 diabetesInt J Impot Res2920171722
  2. I.EardleyW.FisherR.C.RosenThe multinational Men's Attitudes to Life Events and Sexuality study: The influence of diabetes on self-reported erectile function, attitudes and treatment-seeking patterns in men with erectile dysfunctionInt J Clin Pract61200714461453
  3. G.CoronaC.B.GiordaD.CucinottaThe SUBITO-DE study: Sexual dysfunction in newly diagnosed type 2 diabetes male patientsJ Endocrinol Invest362013864868
  4. A.Al-HunayanM.Al-MutarE.O.KehindeThe prevalence and predictors of erectile dysfunction in men with newly diagnosed with type 2 diabetes mellitusBJU Int992007130134
  5. A.AversaR.BruzzichesC.VitaleChronic sildenafil in men with diabetes and erectile dysfunctionExpert Opin Drug Metab Toxicol32007451464
  6. G.DerosaD.RomanoC.TinelliPrevalence and associations of erectile dysfunction in a sample of Italian males with type 2 diabetesDiabetes Res Clin Pract1082015329335
  7. K.K.ChewC.M.EarleB.G.StuckeyErectile dysfunction in general medicine practice: Prevalence and clinical correlatesInt J Impot Res1220004145
  8. T.J.MaatmanD.K.MontagueL.M.MartinErectile dysfunction in men with diabetes mellitusUrology291987589592
  9. A.RubinD.BabbottImpotence and diabetes mellitusJ Am Med Assoc1681958498500
  10. R.C.KolodnyC.B.KahnH.H.GoldsteinSexual dysfunction in diabetic menDiabetes231974306309
  11. D.K.McCullochI.W.CampbellWuF.C.The prevalence of diabetic impotenceDiabetologia181980279283
  12. P.ZemelSexual dysfunction in the diabetic patient with hypertensionAm J Cardiol61198827h33h
  13. D.K.McCullochR.J.YoungR.J.PrescottThe natural history of impotence in diabetic menDiabetologia261984437440
  14. C.G.BaconHuF.B.E.GiovannucciAssociation of type and duration of diabetes with erectile dysfunction in a large cohort of menDiabetes Care25200214581463
  15. G.De BerardisF.PellegriniM.FranciosiIdentifying patients with type 2 diabetes with a higher likelihood of erectile dysfunction: The role of the interaction between clinical and psychological factorsJ Urol169200314221428
  16. J.AnguloP.CuevasA.FernandezEnhanced thromboxane receptor-mediated responses and impaired endothelium-dependent relaxation in human corpus cavernosum from diabetic impotent men: Role of protein kinase C activityJ Pharmacol Exp Ther3192006783789
  17. J.AnguloC.PeiroP.CuevasThe novel antioxidant, AC3056 (2,6-di-t-butyl-4-((dimethyl-4-methoxyphenylsilyl)methyloxy)phenol), reverses erectile dysfunction in diabetic rats and improves NO-mediated responses in penile tissue from diabetic menJ Sex Med62009373387
  18. J.AnguloR.Gonzalez-CorrochanoP.CuevasDiabetes exacerbates the functional deficiency of NO/cGMP pathway associated with erectile dysfunction in human corpus cavernosum and penile arteriesJ Sex Med72010758768
  19. O.AlexopoulouJ.JamartD.MaiterErectile dysfunction and lower androgenicity in type 1 diabetic patientsDiabetes Metab272001329336
  20. B.D.NaliboffM.RosenthalEffects of age on complications in adult onset diabetesJ Am Geriatr Soc371989838842
  21. H.A.FeldmanI.GoldsteinD.G.HatzichristouImpotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging StudyJ Urol15119945461
  22. R.RamirezJ.Pedro-BotetM.GarciaErectile dysfunction and cardiovascular risk factors in a Mediterranean diet cohortIntern Med J4620165256
  23. S.GlavašL.ValenčićN.TrbojevićErectile function in cardiovascular patients: Its significance and a quick assessment using a visual-scale questionnaireActa Cardiol702015712719
  24. P.PallangyoP.NicholausP.KisengeA community-based study on prevalence and correlates of erectile dysfunction among Kinondoni District Residents, Dar es Salaam, TanzaniaReprod Health132016140
  25. S.A.GroverI.LowensteynM.KaouacheThe prevalence of erectile dysfunction in the primary care setting: Importance of risk factors for diabetes and vascular diseaseArch Intern Med1662006213219
  26. E.Barrett-ConnorCardiovascular risk stratification and cardiovascular risk factors associated with erectile dysfunction: Assessing cardiovascular risk in men with erectile dysfunctionClin Cardiol272004I813
  27. K.L.BillupsErectile dysfunction as an early sign of cardiovascular diseaseInt J Impot Res17Suppl. 12005S19S24
  28. I.M.ThompsonC.M.TangenP.J.GoodmanErectile dysfunction and subsequent cardiovascular diseaseJAMA294200529963002
  29. C.GazzarusoErectile dysfunction and coronary atherothrombosis in diabetic patients: Pathophysiology, clinical features and treatmentExpert Rev Cardiovasc Ther42006173180
  30. E.Barrett-ConnorHeart disease risk factors predict erectile dysfunction 25 years later (the Rancho Bernardo Study)Am J Cardiol9620053m7m
  31. MinJ.K.K.A.WilliamsT.M.OkwuosaPrediction of coronary heart disease by erectile dysfunction in men referred for nuclear stress testingArch Intern Med1662006201206
  32. E.ChiurliaR.D'AmicoC.RattiSubclinical coronary artery atherosclerosis in patients with erectile dysfunctionJ Am Coll Cardiol46200515031506
  33. D.DjordjevicI.VukovicD.Milenkovic PetronicErectile dysfunction as a predictor of advanced vascular ageAndrology3201511251131
  34. G.GandagliaA.SaloniaN.PassoniErectile dysfunction as a cardiovascular risk factor in patients with diabetesEndocrine432013285292
  35. A.B.AraujoT.G.TravisonP.GanzErectile dysfunction and mortalityJ Sex Med6200924452454
  36. F.GiuglianoM.I.MaiorinoG.BellastellaAdherence to Mediterranean diet and erectile dysfunction in men with type 2 diabetesJ Sex Med7201019111917
  37. T.YamadaK.HaraH.UmematsuErectile dysfunction and cardiovascular events in diabetic men: A meta-analysis of observational studiesPLoS ONE72012e43673
  38. R.KleinB.E.KleinK.E.LeePrevalence of self-reported erectile dysfunction in people with long-term IDDMDiabetes Care191996135141
  39. P.S.GrantD.LipscombHow often do we ask about erectile dysfunction in the diabetes review clinic? Development of a neuropathy screening toolActa Diabetol462009285290
  40. S.DhindsaS.PrabhakarM.SethiFrequent occurrence of hypogonadotropic hypogonadism in type 2 diabetesJ Clin Endocrinol Metab89200454625468
  41. M.A.BoyanovZ.BonevaV.G.ChristovTestosterone supplementation in men with type 2 diabetes, visceral obesity and partial androgen deficiencyAging Male6200317
  42. R.ShabsighJ.RajferA.AversaThe evolving role of testosterone in the treatment of erectile dysfunctionInt J Clin Pract60200610871092
  43. R.ShabsighJ.M.KaufmanC.SteidleRandomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil aloneJ Urol1722004658663
  44. R.MazzilliJ.EliaM.DelfinoPrevalence of Diabetes Mellitus (DM) in a population of men affected by Erectile Dysfunction (ED)Clin Ter1662015e317e320
  45. A.I.El-SakkaH.M.SayedK.A.TayebAndrogen pattern in patients with type 2 diabetes-associated erectile dysfunction: Impact of metabolic controlUrology742009552559
  46. S.Y.KalinchenkoG.I.KozlovN.P.GontcharovOral testosterone undecanoate reverses erectile dysfunction associated with diabetes mellitus in patients failing on sildenafil citrate therapy aloneAging Male620039499
  47. N.N.HadeedI.A.ThanoonS.B.Al-MukhtarTotal testosterone levels and the effect of sildenafil on type 2 diabetics with erectile dysfunctionOman Med J2920144650
  48. W.H.LoFuS.N.C.K.WongPrevalence, correlates, attitude and treatment seeking of erectile dysfunction among type 2 diabetic Chinese men attending primary care outpatient clinicsAsian J Androl162014755760
  49. R.C.RosenA.RileyG.WagnerThe international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunctionUrology491997822830
  50. J.C.CappelleriR.C.RosenM.D.SmithDiagnostic evaluation of the erectile function domain of the International Index of Erectile FunctionUrology541999346351
  51. R.RamanathanJ.MulhallRaoS.Predictive correlation between the International Index of Erectile Function (IIEF) and Sexual Health Inventory for Men (SHIM): Implications for calculating a derived SHIM for clinical useJ Sex Med4200713361344
  52. L.ValiquetteF.MontorsiS.AuerbachFirst-dose success with vardenafil in men with erectile dysfunction and associated comorbidities: RELY-IInt J Clin Pract60200613781385
  53. The Diabetes Control and Complications Trial Research GroupThe effect of intensive diabetes therapy on the development and progression of neuropathyAnn Intern Med1221995561568
  54. The Diabetes Control and Complications Trial Research GroupThe effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitusN Engl J Med3291993977986
  55. UK Prospective Diabetes Study (UKPDS) GroupIntensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)Lancet3521998837853
  56. N.AzadN.V.EmanueleC.AbrairaThe effects of intensive glycemic control on neuropathy in the VA cooperative study on type II diabetes mellitus (VA CSDM)J Diabetes Complications131999307313
  57. A.I.El-SakkaH.M.HassobaH.M.SayedPattern of endocrinal changes in patients with sexual dysfunctionJ Sex Med22005551558
  58. V.A.GiagulliM.D.CarboneM.I.RamunniAdding liraglutide to lifestyle changes, metformin and testosterone therapy boosts erectile function in diabetic obese men with overt hypogonadismAndrology3201510941103
  59. L.WongChenH.M.LaiS.Q.Effects of sulfonylurea as initial treatment on testosterone of middle-aged men with type 2 diabetes: A 16-week, pilot studyJ Diabetes Investig62015454459
  60. J.B.KostisJ.M.DobrzynskiThe effect of statins on erectile dysfunction: A meta-analysis of randomized trialsJ Sex Med11201416261635
  61. ChenY.CuiS.LinH.Losartan improves erectile dysfunction in diabetic patients: A clinical trialInt J Impot Res242012217220
  62. Y.P.BalharaS.SarkarR.GuptaPhosphodiesterase-5 inhibitors for erectile dysfunction in patients with diabetes mellitus: A systematic review and meta-analysis of randomized controlled trialsIndian J Endocrinol Metab192015451461
  63. T.J.WalshJ.M.HotalingA.SmithMen with diabetes may require more aggressive treatment for erectile dysfunctionInt J Impot Res262014112115
  64. D.SantiA.R.GranataA.GuidiSix months of daily treatment with vardenafil improves parameters of endothelial inflammation and of hypogonadism in male patients with type 2 diabetes and erectile dysfunction: A randomized, double-blind, prospective trialEur J Endocrinol1742016513522
  65. V.FonsecaA.SeftelJ.DenneImpact of diabetes mellitus on the severity of erectile dysfunction and response to treatment: Analysis of data from tadalafil clinical trialsDiabetologia47200419141923
  66. M.S.RendellJ.RajferP.A.WickerSildenafil for treatment of erectile dysfunction in men with diabetes: A randomized controlled trialJAMA2811999421426
  67. A.J.BoultonJ.L.SelamM.SweeneySildenafil citrate for the treatment of erectile dysfunction in men with type II diabetes mellitusDiabetologia44200112961301
  68. I.GoldsteinJ.M.YoungJ.FischerVardenafil, a new phosphodiesterase type 5 inhibitor, in the treatment of erectile dysfunction in men with diabetes: A multicenter double-blind placebo-controlled fixed-dose studyDiabetes Care262003777783
  69. I.Sáenz de TejadaG.AnglinJ.R.KnightEffects of tadalafil on erectile dysfunction in men with diabetesDiabetes Care25200221592164
  70. C.C.CarsonT.F.LuePhosphodiesterase type 5 inhibitors for erectile dysfunctionBJU Int962005257280
  71. D.HatzichristouM.GamblaE.Rubio-AuriolesEfficacy of tadalafil once daily in men with diabetes mellitus and erectile dysfunctionDiabet Med252008138146
  72. J.BuvatH.van AhlenH.SchmittEfficacy and safety of two dosing regimens of tadalafil and patterns of sexual activity in men with diabetes mellitus and erectile dysfunction: Scheduled use vs. on-demand regimen evaluation (SURE) study in 14 European countriesJ Sex Med32006512520
  73. A.KonstantinopoulosK.GiannitsasA.AthanasopoulosThe impact of daily sildenafil on levels of soluble molecular markers of endothelial function in plasma in patients with erectile dysfunctionExpert Opin Pharmacother102009155160
  74. O.CanguvenJ.BailenW.FredrikssonCombination of vacuum erection device and PDE5 inhibitors as salvage therapy in PDE5 inhibitor nonresponders with erectile dysfunctionJ Sex Med6200925612567
  75. B.PajovicA.DimitrovskiN.FaticVacuum erection device in treatment of organic erectile dysfunction and penile vascular differences between patients with DM type I and DM type IIAging Male201615
  76. A.BrigantiA.SaloniaA.GallinaDrug Insight: Oral phosphodiesterase type 5 inhibitors for erectile dysfunctionNat Clin Pract Urol22005239247
  77. R.DeBuskY.DroryI.GoldsteinManagement of sexual dysfunction in patients with cardiovascular disease: Recommendations of The Princeton Consensus PanelAm J Cardiol862000175181
  78. G.BrockS.GlinaI.MoncadaLikelihood of tadalafil-associated adverse events in integrated multiclinical trial database: Classification tree analysis in men with erectile dysfunctionUrology732009756761
  79. SunL.PengF.L.YuZ.L.Combined sildenafil with vacuum erection device therapy in the management of diabetic men with erectile dysfunction after failure of first-line sildenafil monotherapyInt J Urol21201412631267
  80. C.C.CarsonJ.J.MulcahyF.E.GovierEfficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: Results of a long-term multicenter study. AMS 700CX Study GroupJ Urol1642000376380
  81. G.P.RedrowC.M.ThompsonWangR.Treatment strategies for diabetic patients suffering from erectile dysfunction: An updateExpert Opin Pharmacother15201418271836
  82. M.L.IsidroSexual dysfunction in men with type 2 diabetesPostgrad Med J882012152159
  83. J.FedderM.D.KaspersenI.BrandslundRetrograde ejaculation and sexual dysfunction in men with diabetes mellitus: A prospective, controlled studyAndrology12013602606
  84. C.H.HoF.S.JawWuC.C.The prevalence and the risk factors of testosterone deficiency in newly diagnosed and previously known type 2 diabetic menJ Sex Med122015389397
  85. G.HackettM.KirbyA.J.SinclairTestosterone deficiency, cardiac health, and older menInt J Endocrinol20142014143763
  86. LiuR.T.M.S.ChungWangP.W.The prevalence and predictors of androgen deficiency in Taiwanese men with type 2 diabetesUrology822013124129
  87. M.RabijewskiL.PapierskaP.PiatkiewiczLate-onset hypogonadism among old and middle-aged males with prediabetes in Polish populationAging Male1820151621
  88. S.K.HoltN.LopushnyanJ.HotalingPrevalence of low testosterone and predisposing risk factors in men with type 1 diabetes mellitus: Findings from the DCCT/EDICJ Clin Endocrinol Metab992014E1655E1660
  89. M.Ng Tang FuiR.HoermannA.S.CheungObesity and age as dominant correlates of low testosterone in men irrespective of diabetes statusAndrology12013906912
  90. S.A.Saboor AftabS.KumarT.M.BarberThe role of obesity and type 2 diabetes mellitus in the development of male obesity-associated secondary hypogonadismClin Endocrinol (Oxf)782013330337
  91. A.MoralesR.A.BebbP.ManjooDiagnosis and management of testosterone deficiency syndrome in men: Clinical practice guidelineCMAJ187201513691377
  92. M.GrossmannLow testosterone in men with type 2 diabetes: Significance and treatmentJ Clin Endocrinol Metab96201123412353
  93. G.CoronaG.RastrelliM.MonamiBody weight loss reverts obesity-associated hypogonadotropic hypogonadism: A systematic review and meta-analysisEur J Endocrinol1682013829843
  94. G.HackettN.ColeM.BhartiaTestosterone replacement therapy improves metabolic parameters in hypogonadal men with type 2 diabetes but not in men with coexisting depression: The BLAST studyJ Sex Med112014840856
  95. E.J.GianattiP.DupuisR.HoermannEffect of testosterone treatment on constitutional and sexual symptoms in men with type 2 diabetes in a randomized, placebo-controlled clinical trialJ Clin Endocrinol Metab99201438213828
  96. G.HackettN.ColeM.BhartiaTestosterone replacement therapy with long-acting testosterone undecanoate improves sexual function and quality-of-life parameters vs. placebo in a population of men with type 2 diabetesJ Sex Med10201316121627
  97. G.HackettN.ColeM.BhartiaThe response to testosterone undecanoate in men with type 2 diabetes is dependent on achieving threshold serum levels (the BLAST study)Int J Clin Pract682014203215
  98. J.C.BrookeD.J.WalterD.KapoorTestosterone deficiency and severity of erectile dysfunction are independently associated with reduced quality of life in men with type 2 diabetesAndrology22014205211
  99. CaiX.TianY.WuT.Metabolic effects of testosterone replacement therapy on hypogonadal men with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trialsAsian J Androl162014146152
  100. M.GrossmannR.HoermannG.WittertEffects of testosterone treatment on glucose metabolism and symptoms in men with type 2 diabetes and the metabolic syndrome: A systematic review and meta-analysis of randomized controlled clinical trialsClin Endocrinol (Oxf)832015344351
  101. G.CoronaG.RastrelliM.MaggiDiagnosis and treatment of late-onset hypogonadism: Systematic review and meta-analysis of TRT outcomesBest Pract Res Clin Endocrinol Metab272013557579
  102. S.R.TaylorL.M.MeadowcraftB.WilliamsonPrevalence, pathophysiology, and management of androgen deficiency in men with metabolic syndrome, type 2 diabetes mellitus, or bothPharmacotherapy352015780792
  103. E.J.GianattiP.DupuisR.HoermannEffect of testosterone treatment on glucose metabolism in men with type 2 diabetes: A randomized controlled trialDiabetes Care37201420982107
  104. A.HaiderA.YassinG.DorosEffects of long-term testosterone therapy on patients with “diabesity”: Results of observational studies of pooled analyses in obese hypogonadal men with type 2 diabetesInt J Endocrinol20142014683515
  105. A.HaiderF.SaadG.DorosHypogonadal obese men with and without diabetes mellitus type 2 lose weight and show improvement in cardiovascular risk factors when treated with testosterone: An observational studyObes Res Clin Pract82014e339e349
  106. F.SaadA.YassinG.DorosEffects of long-term treatment with testosterone on weight and waist size in 411 hypogonadal men with obesity classes I-III: Observational data from two registry studiesInt J Obes402016162170
  107. J.M.FariasM.TinettiM.KhouryLow testosterone concentration and atherosclerotic disease markers in male patients with type 2 diabetesJ Clin Endocrinol Metab99201446984703
  108. B.DakaR.D.LangerC.A.LarssonLow concentrations of serum testosterone predict acute myocardial infarction in men with type 2 diabetes mellitusBMC Endocr Disord152015
  109. V.MuraleedharanT.H.JonesTestosterone and mortalityClin Endocrinol (Oxf)812014477487
  110. S.BasariaS.M.HarmanT.G.TravisonEffects of testosterone administration for 3 years on subclinical atherosclerosis progression in older men with low or low-normal testosterone levels: A randomized clinical trialJAMA3142015570581
  111. A.ChmielK.Mizia-StecJ.Wierzbicka-ChmielLow testosterone and sexual symptoms in men with acute coronary syndrome can be used to predict major adverse cardiovascular events during long-term follow-upAndrology3201511131118
  112. V.MuraleedharanH.MarshD.KapoorTestosterone deficiency is associated with increased risk of mortality and testosterone replacement improves survival in men with type 2 diabetesEur J Endocrinol1692013725733
  113. G.D.FosterM.H.SandersR.MillmanObstructive sleep apnea among obese patients with type 2 diabetesDiabetes Care32200910171019
  114. D.MoherA.LiberatiJ.TetzlaffPreferred reporting items for systematic reviews and meta-analyses: The PRISMA statementPLoS Med62009e1000097
Reproduced with permission from Canadian Journal of Diabetes © 2018 Canadian Diabetes Association. To cite this article, please refer to For citation.

*The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. All content on, CPG Apps and in our online store remains exactly the same. For questions, contact