The risk of men developing erectile dysfunction increases with age. Diabetes mellitus can further increase the risk of erectile dysfunction. In a study of 351 men who had recently been diagnosed with diabetes mellitus, scientists from the German Diabetes Center (DDZ) in Düsseldorf found that erectile dysfunction also occurred in men who had just developed diabetes and that the prevalence erectile dysfunction varied between diabetes subtypes. Medscape spoke with study author Haifa Maalmi, MD, a research associate at DDZ, about the study results and what they mean for clinical practice.

Medscape: Erectile dysfunction usually affects older men who have had diabetes for many years, whose blood sugar levels are poorly managed, or who have additional conditions, such as high blood pressure or high cholesterol. However, diabetes was recently diagnosed in the men in your study. Is the high proportion of erectile dysfunction surprising given the short duration of the disease? And do the results mean that the onset of erectile dysfunction is independent of how long a person has diabetes?

Malmi: The relatively high prevalence (23%) of erectile dysfunction in men within one year of their diagnosis of diabetes that was observed in our study did not surprise us.

First, a diabetic metabolism is often present months or years before the actual diagnosis; and although the German Diabetes Study includes people with known duration of diabetes for less than a year, the exact duration of diabetes is unknown.

Second, most diabetes complications (including erectile dysfunction) develop during the prediabetic phase, when hyperglycemia is above normal but still below the diabetes threshold. Early penile artery damage may even have developed during the prediabetes phase and lead to erectile dysfunction soon after diagnosis.

Third, the prevalence of erectile dysfunction determined in our study was consistent with the prevalence determined in previous studies in men in whom diabetes had only recently developed (20% to 37%).

In this context, it should also be noted that the prevalence of erectile dysfunction in newly diagnosed diabetics, as in our study, is much lower than in men with a longer duration of diabetes (prevalence between 35% and 90% ). However, considering that our study subjects are relatively young (mean age, 49 years), a prevalence of 23% can still be considered high.

Medscape: Men between the ages of 18 and 69 were included in the study. Were there age-related differences in the severity of erectile dysfunction? That is, were older men more commonly affected, and if so, was erectile dysfunction more severe?

Malmi: Yes, there was a correlation between age and a worse erection (recognizable by lower values ​​in the international index of erection function). This correlation is known and was confirmed in our study.

Medscape: What do you think: Is the extent of erectile dysfunction with type 2 diabetes generally underestimated?

Malmi: We believe that erectile dysfunction in men with type 2 and type 1 diabetes is rather underestimated. In clinical practice, the subject of sexual performance can be perceived as too personal and sensitive. Therefore, many men (especially older men who are not very sexually active) do not go to the doctor and go undetected.

In epidemiological studies where erectile dysfunction is determined using a questionnaire, most men consider their sexual performance to be a very intimate subject and prefer not to answer certain questions. Therefore, the status of erectile dysfunction cannot be determined in subjects with incomplete information regarding their erectile function.

Medscape: The science is increasingly united around the fact that it’s not just type 1 and type 2 diabetes but rather the following five subtypes:

  • Severe autoimmune diabetes, corresponding to classic type 1 diabetes

  • Severe insulin-deficient diabetes (SIDD)

  • Severe insulin-resistant diabetes (SIRD)

  • Mild diabetes linked to obesity

  • Mild age-related diabetes

Do these five subtypes now play a role in medical practice?

Malmi: All five subtypes are relatively new (the first publication of them was in 2019) and have only been used for scientific purposes. To date, it is still too early to use diabetes subtypes in clinical practice.

One of the reasons is that the clustering algorithm is very sophisticated. Another reason is that the C-peptide (which is used to calculate HOMA2-B and HOMA2-IR, two variables needed for clustering) is not a routine measurement.

More importantly, we still do not have sufficient evidence to know whether therapy tailored to individual diabetes subgroups would actually be beneficial, relative to current guidelines. The subgroup-specific treatment approach should be investigated in randomized, controlled studies.

Medscape: One of the conclusions of the study is that patients with SIRD and SIDD should be investigated specifically for erectile dysfunction. In terms of clinical practice, does this mean that the doctor should ask diabetic patients targeted questions about erectile problems?

Malmi: Yes. Because although we are not yet able to use this new classification of diabetes in clinical practice, men with a form of diabetes characterized by obesity and insulin resistance and who have high levels of fasting insulin (similar to subjects in the SIRD subgroup) and diabetics with severe insulin deficiency (similar to subjects in the SIDD subgroup) should be asked explicitly about erectile function.

Medscape: Thank you very much for the discussion.

This article was translated from the German edition of Medscape.

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