How should I approach the management of erectile dysfunction in a patient with diabetes?

Management of erectile dysfunction (ED) in patients with diabetes should begin with a comprehensive assessment including discussion during routine diabetes reviews to identify ED and contributory factors such as cardiovascular disease and neuropathy. Lifestyle and risk factor modification, including weight loss, smoking cessation, and optimization of glycaemic control, should be advised as these can improve erectile function and enhance treatment efficacy. Pharmacological treatment with phosphodiesterase-5 (PDE-5) inhibitors is recommended as first-line therapy unless contraindicated, with the choice of agent guided by cost, patient preference, and comorbidities. Patients should be counselled on correct use, including dose timing and the need for sexual stimulation, and advised to try each PDE-5 inhibitor at the maximum tolerated dose 4–8 times before switching to an alternative agent. If PDE-5 inhibitors are ineffective or contraindicated, referral to specialist services for further assessment and options such as vacuum erection devices, intracavernosal injections, or surgical interventions should be considered. Additionally, assessment for hypogonadism is important as low testosterone may reduce PDE-5 inhibitor efficacy. Recent evidence highlights that men with diabetes may have more complex pathophysiology contributing to ED, including endothelial dysfunction and neuropathy, which may necessitate multimodal approaches and specialist input. Emerging pharmacotherapeutic strategies and combination therapies are under investigation for PDE-5 inhibitor non-responders, but current UK guidelines emphasize individualized treatment and specialist referral when first-line treatments fail.

Summary of approach:

• Screen for ED routinely in men with diabetes during annual reviews.
• Address lifestyle factors and optimise diabetes and cardiovascular risk management.
• Offer PDE-5 inhibitors as first-line pharmacotherapy, ensuring correct use and adequate trial before switching.
• Assess testosterone levels if poor response to PDE-5 inhibitors.
• Refer to specialist services if PDE-5 inhibitors are ineffective or contraindicated.
• Consider emerging evidence on complex diabetic ED pathophysiology when planning management.

This integrated approach aligns with UK NICE guidelines for diabetes and erectile dysfunction management NICE CKS,NICE NG28,NICE NG17 and is supported by recent systematic reviews and clinical studies emphasizing the need for tailored, multimodal management in diabetic patients Cayetano-Alcaraz et al. 2023Corona et al. 2024Dilixiati et al. 2024.