Erectile dysfunction is a common multi-factorial complication of diabetes mellitus. Newer medications, like the so-called PDE-5 inhibitors result in enhancement of penile erection. The introduction of sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), have altered the management of erectile dysfunction. In this review we assessed the effect of these agents on erectile dysfunction in diabetic people. Eight studies with 976 men randomised to PDE-5 inhibitor therapy and a duration of mainly 12 weeks were evaluated. Compared to placebo treatment, these agents showed favourable effects in scores estimating sexual life, with an increased rate of adverse effects like headache and flushing after PDE-inhibitor therapy. Mortality was not reported in any of the included trials. Quality of life, with the exception of scores for sexual life, was not relevantly affected. If taken as prescribed, PDE-5 inhibitors comprise a valuable treatment option for erectile dysfunction in men with diabetes.
A meta-analysis of 36 744 men with ED in 12 prospective cohort studies found that the presence of ED significantly increased the risk of CVD, CAD, stroke and all-cause mortality, and the presence of ED was an independent risk factor for CVD. Ponholzer et al found that men with moderate to severe ED had a 65% increased relative risk for developing symptomatic CAD compared with men who did not have ED.26
Assessment of erectile dysfunction provides the opportunity to identify numerous comorbidities that are associated with erectile dysfunction. Some of these more common conditions, and the unique role of the GP in their assessment, are further discussed. However, many other conditions, including cancer or chronic diseases, can be associated with erectile dysfunction,11,12 but their unique features are outside the scope of this review. Table 2 provides a stepwise approach to erectile dysfunction management and treatment by the GP.

If any types of reversible causes are identified in the assessment, these should be treated initially. Typical reversible causes include hormonal imbalance (eg low testosterone), medication-induced erectile dysfunction and psychogenic erectile dysfunction. Modifiable risk factors, such as diabetes, hypertension, smoking and dyslipidaemia, should be optimised as well. Lifestyle modifications, risk factor optimisation, pharmacological and psychological treatments are not mutually exclusive, and patients are often better served by an integrative approach. For example, combining psychological treatment with a phosphodiesterase type 5 (PDE5) inhibitor may optimise the treatment response in patients with psychogenic erectile dysfunction.9


While studies are limited, it has been shown that male sexual dysfunction can also negatively impact the sexual function of female partners. A study comparing the sexual function of women with partners with erectile dysfunction to those without showed that sexual arousal, lubrication, orgasm, satisfaction, pain and total score were significantly lower in those who had partners with erectile dysfunction. Later in that study, a large proportion of the men with erectile dysfunction underwent treatment. Following treatment, sexual arousal, lubrication, orgasm, satisfaction and pain were all significantly increased. It was concluded that female sexual function is impacted by male erection status, which may improve following treatment of male sexual dysfunction.

Dr. Liou says that some men come to him after getting a prescription from their primary care doctors, claiming that the drug doesn't work. Sometimes it's because they used it incorrectly. "The biggest misconception is that these drugs are an on/off switch for erections," Dr. Liou says. But the drugs don't work well without sexual stimulation. "During that time, you need to be with your partner and have foreplay," Dr. Liou says. "Don't take it, do the taxes or the dishes, and then meet at the bedroom thinking you'll be ready to go. It's not like that."
Illegal online ‘pharmacies’ typically provide no physical contact information, often do not provide the name of the pharmacist who supposedly prescribes the medication, and do not require prescriptions to supply prescription-only medicines. A European study reported that 94% of online pharmacy websites surveyed did not name a pharmacist, 90% did not require a prescription and 85% had no physical address.
Taking one of these tablets will not automatically produce an erection. Sexual stimulation is needed first to cause the release of nitric oxide from your penile nerves. These medications amplify that signal, allowing some men to function normally. Oral erectile dysfunction medications are not aphrodisiacs, will not cause excitement and are not needed in men who get normal erections.
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