Resolving Erectile Dysfunction
Dear David and Aisha, I am a 39-year-old married man who has had type 1 diabetes for 22 years. My A1C levels run around 7.5%. About six years ago, I started having trouble with erections. Now they are very rare, even with ED pills. I know you say that there is more to sex than intercourse, and my wife and I still enjoy ourselves however we can. But we both miss the erections.
I have heard lately that erectile dysfunction can sometimes be improved. How can that happen? I don't want any surgeries. What do you know about recovering erections?
Happily Married but Frustrated
Dear Happily Married,
You picked a good time to write. Recent research has pointed to at least three ways that erectile dysfunction (ED) can be not only treated, but often resolved. Normalizing blood sugars can help; so can losing weight. There are also programs of "penis rehabilitation" that will improve erections.
First, what causes erectile dysfunction in diabetes? There are many causes, but the main one is nerve and blood vessel damage caused by high blood sugar. Elevated sugar levels contribute to inflammation, which can damage or kill nerves and narrow or block blood vessels, causing them to leak. Either factor can block erections.
Fortunately, we now know that lowering blood sugar allows nerves, and sometimes blood vessels, to heal and regenerate. Just as neuropathic pain in the feet often resolves as blood sugars improve, nerve function to the genitals can too.
Studies in the US, Egypt, and Italy consistently show that A1C levels are the strongest predictor of erection problems. The higher a person's A1C, the more sexual problems he is likely to have. Your level of 7.5% is a bit high. If you could get closer to 6.5%, your sex life might improve significantly.
Talk with your doctor or educator about the best ways to do that. It will take time for the nerves to heal. Don't expect immediate results, but over a year or so, you and your wife might be pleasantly surprised. You'll also be protecting yourself against future complications.
You don't say how heavy you are, but in heavy men, weight loss has recently been shown to improve erectile function scores rather dramatically. According to an Australian study of men with type 2, published on August 5, 2011, in the Journal of Sexual Medicine, weight loss improved sexual function, sexual desire, urinary function, and inflammation levels. Sexual function continued to improve during a year of follow-up.
The subjects in this study ate a high-protein, low-grain, high fruit and vegetable diet. Low-grain diets are often recommended for people with diabetes anyway, so here is another reason to consider them. Exercise was not part of the weight loss program in this study, but the researchers think that exercise helps.
Hunter Wessells, chairman of urology at the University of Washington School of Medicine, says, "Exercise has a set of potential effects that are not strictly related to weight loss." A recent Italian study in the Journal of Sexual Medicine found that exercise plus a PDE-5 inhibitor drug like sildenafil (Viagra) worked much better than the drug alone. Another Italian report showed that exercise was a major contributor to sexual function and blood vessel condition.
Reducing inflammation may have been a big part of the weight loss program's success. Blood tests done throughout the year showed that the diet lowered the levels of inflammation in the men's bodies. University of Adelaide researcher Dr. Gary Wittert said that inflammation could be part of what causes urological problems in overweight men.
Consequently, taking other steps to reduce inflammation might also heal ED. Ask your doctor about going on a low-cost anti-inflammatory medicine like salsalate, which has been shown to help diabetes in some studies. Also, make sure your dental health is good. A large Chinese study found that gum disease was strongly correlated with ED in men with diabetes. That doesn't prove that gum disease causes ED, but it is a major cause of system-wide inflammation, which won't do your blood vessels any good.
In addition to lowering blood sugars, reducing weight, and controlling inflammation, a number of treatments classed as "penis rehabilitation" have been effective in men with ED. Penis rehab involves ways of restoring blood flow to the penis. Many of these treatments were developed for men recovering from prostate surgery. They have been used by soldiers returning with injuries and PTSD. They also seem to be effective in some men with diabetes.
One way to improve penis circulation is to take low doses of a PDE-5 inhibitor, like Cialis, Viagra, or Levitra, on a frequent or everyday basis. A number of studies show that regular PDE-5 inhibitor use seems to heal blood vessels and increase smooth muscle mass in the penis. The smooth muscle helps hold blood in the penis.
A Russian study of men with ED taking vardenafil (Levitra) every other day found that they had much better erections and their blood vessels expanded more than men who took the drug only when needed for sex. Cialis has now been approved for everyday use, so that is an option for you. You could ask for referral to a urologist specializing in sexual function to obtain these meds.
With the PDE-5 treatments, it also helps to masturbate or have some sexual interaction with your wife to get the blood flowing more. Intercourse and ejaculation are not necessary; the point is to practice having erections.
Urologists like New York's Dr. Michael Werner say that using injectable erection medicines every other day or twice a week helps restore erectile function. These medicines can be given through an injection device, so you don't have to stick a needle in yourself. Again, the idea is to have erections to open the blood vessels.
These drugs can be expensive, but are sometimes covered by insurance. The three most common medications used for injections are papaverine, phentolamine, and prostaglandin E1. According to Dr. Werner, "Two-thirds of men who used the injections on average twice a week recovered erectile function to the point where they could have intercourse without any outside help."
Non-drug approaches to rehab include using a vacuum constriction device. This is a plastic cone that you place over the penis, then pump out the air inside to create a vacuum. The vacuum draws blood into the penis. For intercourse, an elastic band is slid over the penis to keep the blood in. But for rehab, you don't use the band; the idea is just to keep the erection for 10 to 15 minutes, or as long as possible. According to San Diego Sexual Medicine, doing this three times a week can help restore normal sexual function. This can be combined with a PDE-5 inhibitor.
Dr. Werner says, "A recent study of men (after prostate surgery) who committed to a program of penile rehabilitation showed that 52 percent of them recovered unassisted functional erections, compared to a recovery of 19 percent in the group who did not participate in rehabilitation." In this same study, 64 percent of men who went through penis rehab recovered adequate erections with Viagra, compared to 24 percent of other men.
It's a lot of work, but it's probably worth it. Your partner can help. According to Dr. Werner, "Studies have shown conclusively that the involvement of your partner (if you have one) is beneficial in making this process as smooth and successful as possible. Partner's motivation and interest are often driving factors in the rehabilitation."
A couple of final tips: First, don't forget to check your testosterone level. Testosterone is frequently low in men with diabetes and can cause loss of sexual interest and function. Don't stop doing the non-intercourse sex practices you and your wife have discovered. Finally, if erections are important to you, we encourage you not to wait. The longer the blood vessels stay blocked or leaking, the longer it will take to recover function.
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