Diabetes mellitus Erectile dysfunction management options

Oral treatment

Sildenafil 

This is an oral phosphodiasterase inhibitor suitable for treatment of Erectile Dysfunction in diabetic patients.

It is likely to be considered first line in most patients. Absolute contraindications are listed below and guidelines on its use in diabetic patients with known IHD or with known risk factors for IHD. It should be remembered that silent ischaemia occurs in a substantial proportion of diabetic men so that cardiovascular risk factors should be assessed and applied to the graded risk management algorithm.

Contraindications

• · Treatment with nitrate (including Nicorandil) 
• · Severe Hepatic impairment 
• · BP <90/50mmHg 
• · Recent history of MI (within 3 months) 
• · Recent history of CABG (within 3 months) 
• · Recent history of CVA (within 3 months) 
• · Unstable angina

Dosage

• · A starting dose of 50mg is recommended - adjusted up to a maximum of 100mg or down to 25mg depending on how the drug is tolerated. 
• · The drug should be taken 1 hour before planned sexual activity and requires sexual stimulation to work. A maximum dose of 1 tablet per day is advised.

Guidelines for Sildenafil use in Diabetic patients 

Assessment of Cardiovascular Risk and suitability for OP treatment of Erectile Dysfunction with Sildenafil. Taken from a Consensus Statement J.Clin Practice, Vol 53, No. 6 1999.

1. If patient has known cardiovascular disease
   • · Establish baseline measure of type of activities, frequency and level of physical exertion a person normally undertakes.
   • · Grade cardiovascular risk
   • · The majority of patients with low or intermediate cardiac risk can have their Erectile Dysfunction effectively managed in primary care.
2. If patient has no history of cardiovascular disease
   • · Take into account cardiovascular risk factors and apply to graded risk management algorithm.
   • The majority of patients with low or intermediate cardiac risk can have their Erectile Dysfunction effectively managed in primary care.

Intraurethral preparations

MUSE (Medical Urethral System for Erection) 

PGE1, delivered in pellet form into the urethra.

Administration instructions 

This is preferably taught by a specialist. An instruction video is also available.

• Micturate 
• Stem of MUSE device inserted frilly into the urethra so that tip is at least 3cm proximal to the meatus.
• Depress button on end of device to eject pellet into the urethra Massage penis for several minutes to help disperse pellet 
• Avoid lying down for 10-15 minutes 
• Try dose of 125mg initially and titrate up to an effective level (125mg, 250mg, 500mg, 1000mg) 
• In responders the erection develops within 15 minutes and typically lasts for 30-60 mins. 
• The strength of the erection can be improved in some men by use of a constriction ring (applied around base of penis prior to administration of MUSE pellet - ATIS)

Side Effects

• Urethral pain (33%) 
• Urethral trauma (5%) 
• Dizziness (2%)

Avoid use in patients whose partners are pregnant.

Intracorporial injection 

PGE1 Caverject Viridal

Teaching a patient to self-inject

This should be supervised by a Consultant Diabetologist, Erectile Dysfunction Nurse or Urologist.

Recommended test dose of PGE1

• · If psychogenic ED Start at 5mcg - increase in 5mcg increments
•  · In neurogenic ED Start at 2.5mcg - increase in 2.5mcg increments 
• · In vasculogenic ED Start at l0mcg - increase in 5-10mcg increments

Consider combination with Papaverine or Phentolamine if 40mcg fails.

NOTE: Injection should be given no more than 3 times per week or once every 2 days.

Side Effects

• · Priapism : If erection lasts >4 hours seek urgent medical attention 
• · Penile pain 
• · Tolerance 
• · Bruising 
• · Hypotension 
• · Flushing 
• · Corporal fibrosis

Vacuum erection devices

• Relatively simple to use.
• Like injections, vacuum devices are suitable for patients who have failed oral therapy.
• In the UK devices currently cost over £300.00 and are not available on prescription.
• Some manufacturers allow patients to return the device within 3 months if they are dissatisfied with them
• Most Erectile Dysifinction specialist services have devices for loan together with instruction manual and video

Surgery

Indications 

• Corporal Fibrosis 
  • Post inject fibrosis 
  • Previous surgery 
  • Priapism 
  • Peyronies Disease 
• Failure of other treatments 
  • Vasculogenic ED 
  • Psychogenic ED
• Patient preference 
  • Unwilling to consider alternative treatment

Refer for assessment by Consultant Urologist

• Mr Powell - Freeman Hospital
• Mr Thomas - Wansbeck Hosp.

Source: Northumbria NHS Health Care Trust diabetes protocol

• Brad Cheek: last updated Dec 2006
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