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 Table of Contents    
ORIGINAL ARTICLE
Year : 2017  |  Volume : 39  |  Issue : 5  |  Page : 600-604  

Erectile dysfunction: An underestimated presentation in patients with diabetes mellitus


1 Department of Psychiatry, S. N. Medical College, Agra, Uttar Pradesh, India
2 Department of Medicine, S. N. Medical College, Agra, Uttar Pradesh, India

Date of Web Publication24-Oct-2017

Correspondence Address:
Zeeshan Anwar
Department of Psychiatry, S. N. Medical College, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7176.217015

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   Abstract 

Introduction: Erectile dysfunction (ED) is a common complication of diabetes mellitus. ED, like other sexual disorders, is often under-reported and under-diagnosed, as talking about sex is considered a taboo in our society. Methodology: All the male patients with diabetes mellitus (with or without active complaints of ED) attending Medicine or Psychiatry OPD of the institute during the study period were enrolled in the study. They were investigated for their body-mass index (BMI), blood sugar and lipid profile; and were assessed on HAM-D, General Health Questionnaire-30, IIEF, sex myth checklist and QOL Instrument for Indian Diabetes Patients (QOLID). Result and Discussion: In the present study, a total of 138 diabetic patients were assessed, and those with severe ED were found to have poor glycemic control, worse lipid profile, higher body mass index, later age of onset, and longer duration of untreated diabetes as compared to non-ED patients. ED patients also scored higher on depression rating scale, had poorer general health and quality of life (QOL). Early attention to ED in diabetic patients can improve general health and QOL of the sufferers. Conclusion: DM patients with poor glycemic control and advanced age have a higher propensity of developing severe ED, which further deteriorates the already compromised health & QOL.

Keywords: Diabetes mellitus, erectile dysfunction, male


How to cite this article:
Anwar Z, Sinha V, Mitra S, Mishra AK, Ansari MH, Bharti A, Kumar V, Nigam AK. Erectile dysfunction: An underestimated presentation in patients with diabetes mellitus. Indian J Psychol Med 2017;39:600-4

How to cite this URL:
Anwar Z, Sinha V, Mitra S, Mishra AK, Ansari MH, Bharti A, Kumar V, Nigam AK. Erectile dysfunction: An underestimated presentation in patients with diabetes mellitus. Indian J Psychol Med [serial online] 2017 [cited 2019 Apr 24];39:600-4. Available from: http://www.ijpm.info/text.asp?2017/39/5/600/217015


   Introduction Top


Erectile dysfunction (ED) is a common condition among diabetic men[1] and previous researches show a prevalence of 20%–85%; occurring with a greater frequency and at an earlier age compared to general population.[2],[3],[4] However, since many men are too embarrassed and reluctant to admit having ED or to talk to a doctor about the issue, precise estimates are difficult to have.

The origin of ED in diabetic men is multi-factorial, and its main underlying contributors may be grouped under neurological, vasogenic and psychogenic causes. Neuronal- and endothelial-derived nitric oxide is the principle mediator of corporal smooth muscle relaxation and consequent penile erection, whose impairment in diabetes mellitus (DM) might lead to ED.[5] Previous studies have shown conflicting results regarding the association of poor glycemic control with ED.[4],[6],[7] However, hypertension, obesity, metabolic syndrome, atherogenic dyslipidemia, autonomic neuropathy and drugs that are commonly given to diabetic patients (i.e., antihypertensive agents) have consistently shown a higher risk for ED[8] in diabetic men.

Ten to thirty percent of ED cases may be purely psychogenic.[9] Depression is a common psychiatric condition seen in diabetics, and previous studies show that presence of one increases the risk of development of other,[10],[11],[12] with the likely bi-directional causal relationship.[13] While depression might be an important contributor to psychogenic ED in diabetic men; psychological factors may also aggravate ED by directly inhibiting spinal centers and causing excessive sympathetic outflow, or increasing peripheral catecholamine levels leading to decreased cavernous smooth muscle relaxation.[9]

ED in the presence of normal sexual desire leads to increase in mental stress, disordered interpersonal relationship, and interference with sexual life. Thus, ED may be a major determinant of quality of life (QOL) in DM. Previous studies have mainly focused on patient evaluation and partner satisfaction, and little attention has been given to QOL.[4] In an international study, it was seen that diabetic men with ED have more severe dysfunction and worse QOL than nondiabetic men with ED.[1] However, given the attitude of Indian society to sexuality; effect of ED on QOL in DM warrants attention. The primary aim of the study was to assess the prevalence of ED among diabetic men and to compare the DM patients with severe ED with those having a normal erection on various sociodemographic and clinical correlates.


   Materials and Methods Top


The study was conducted in male diabetic patients attending outpatient Departments of Medicine and Psychiatry of a Medical College in northern India from February 2015 to May 2015. It was a cross-sectional study and all the consecutive male patients fulfilling the inclusion criteria of duration of diabetes of at least 1 year were enrolled in the study after taking written informed consent. History of pelvic trauma, pelvic surgery (hernia, hydrocele etc.), psychiatric disorder (in acute phase or in treatment phase) and debilitating disease (tuberculosis, AIDS, etc.,) were our exclusion criteria. Those who had the unfavorable penile anatomy for a sexual act (such as hypospadias and peyronie plaques) and neurogenic disorders (spinal cord injury, multiple sclerosis, etc.,) were also excluded from the study.

Patients were assessed using predesigned semi-structured sociodemographic parameters. Participants with severe ED (those who scored 10 or less points in erectile function domain of International Index of Erectile Function [IIEF]) were considered as ED cases, those who scored more than 25 had no ED and were non-ED cases and participants with mild to moderate ED were excluded from the study to ensure that participants are better representative of their respective groups (as DM patients are more likely to have severe ED)[14] and comparison of various clinical correlates and parameters is better. Mild to moderate cases of ED can be due to various unidentified reasons including psychological and so they were excluded to be more precise in our selection of only those patients who have ED due to DM. A detailed history was taken regarding age, socioeconomic status, personal and family history of diabetes, any past psychiatric illness, hypertension, duration of diabetes and type of medication currently taking for diabetes. General physical, systemic and mental state examinations were done, and body mass index (BMI) was recorded. Patients were thoroughly investigated for blood sugar (fasting and postprandial), HbA1c, lipid profile (serum triglyceride [TG], low-density lipoprotein [LDL], very LDL [VLDL], high-density lipoprotein [HDL]), blood urea, serum creatinine, serum bilirubin, SGOT, and SGPT. Apart from this all the subjects were assessed using the following scales at the time of interview: Hamilton rating scale for depression (HAM-D),[15] General Health Questionnaire (GHQ)-30,[16] IIEF,[17] sex myth checklist (SMCL),[18] QOL Instrument for Indian Diabetes Patients (QOLID).[19]


   Results Top


We surveyed a total of 184 male diabetic patients who had presented to medicine or psychiatry OPD during the study. Those 46 participants who had scored 11–25 in IIEF scoring were excluded from the study and remaining 138 were subsequently evaluated. 56.5% (78/138) of them were suffering from severe ED. Maximum number of participants (54.3% [75/138]) falls in 40–59 years of age group, but most of the patients with severe ED are of 50–69 years of age, which account for 58.9% (46/78) of total patients with severe ED. 76.08% (105/138) of the participants were on oral hypoglycemic agents and remaining 23.9% (33/138) were on insulin therapy. Nearly 15.2% (21/138) of the patients have previously consulted a quack or faith healers.

BMI of ED cases was found to be higher than non-ED patients. Random blood sugar, fasting blood sugar (FBS) and postprandial blood sugar (PPBS) of severe ED patients were higher than patients without ED which is in accordance with the poorer HbA1c levels in ED patients. Lipid profiles of DM patients with and without ED were also significantly different, with higher values of serum TG, LDL, and VLDL in ED cases. Serum HDL levels in two groups showed no significant difference. A mean HAM-D score of ED cases was significantly more than non-ED cases. All the patients were also assessed by GHQ-30 and ED cases clearly had poorer general health than non-ED patients.


   Discussion Top


In the present study, we have recruited a total of 184 male DM patients, and 67.4% (124/184) of the participants were found to be suffering from ED and 42.4% from severe ED. This is in accordance with the previous research[2],[3] on diabetic patients. Garg et al.,[20] reported 78%, Sundaram et al.[21] 66%, Schiavi et al.[22] 77% and Kloner[23] 75% prevalence of ED in DM patients. In the present study, we found a significant association between the prevalence of severe ED and age of the participant. Prevalence increases from 10.3% in patients <40 years of age, 54.6% in 40–59 years age and 100% in patients of more than 60 years of age [Table 1]. In our participant's duration of untreated DM in severe ED patients was significantly more than non-ED patients [Table 2] as reported by several previous studies.[20],[24],[25] It is because as the age of the patient progresses and duration of DM increases various complications of DM and age related changes in body sets in.[20] In the present study, we have also seen that age at which diabetes was first diagnosed was significantly higher in ED cases than non-ED casets [Table 2]. It was probably because patients with ED have a general tendency to ignore their symptoms, and delay treatment seeking because of ignorance, embarrassment, and lack of information.[26]
Table 1: Sociodemographic profile

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Table 2: Comparison of the sociodemographic and clinical parameters among the erectile dysfunction and nonerectile dysfunction patients

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Our data show that poor glycemic control, as indicated by increased FBS, PPBS, and HbA1c, was more commonly seen in ED cases [Table 2]. In a study done by Weinberg et al.,[27] a poor glycemic control was associated with a heightened risk of ED and was considered an independent risk factor for ED by Awad et al.[28] However, many of the previous studies showed conflicting result in this regard.[6],[7] Advanced glycation end products (AGEs) have been implicated in the pathogenesis of DM, which are created through a nonenzymatic reaction between reducing sugars and free amino groups of proteins, lipids, or nucleic acids.[29] AGEs modifies the extracellular matrix and intercellular adhesion, which favors its deposition in penile connective tissue. AGEs form covalent bonds with collagen, which leads to vascular wall thickening and decreased elasticity that strongly contributes to dysfunction of cavernous tissue. This formation of AGEs in DM shows a positive correlation with advancing age and poor glycemic control.[30],[31] Studies have also shown that in DM patients, a blood sugar O-GlcNAc (associated with hyperglycemia) inhibits the enzyme that starts the chain of vascular events leading to an erection.[20]

We have also seen that among our participants, BMI of ED casets was significantly higher than non-ED cases [Table 2], as reported by Viswanathan et al.[32] and Al-Hunayan et al.[33] in their studies. Previous studies on diabetic patients had shown that lipid profile is more commonly deranged in DM patients with ED.[20] In our participants, lipid profile was within normal range in both the groups, but those with severe ED were on the higher side of the normal range, and difference in two groups was found to be statistically significant except for plasma HDL.

It has been well established that depression is more prevalent among the diabetic patients as compared to general population.[34],[35],[36],[37] In our study, the severity of HAM-D score of ED cases was found to be significantly more than non-ED cases [Table 3], which shows that ED is an independent risk factor for depression or could be the other way round. Depression is frequently associated with impairment in erectile function, diminished libido and sexual activity[38],[39] Thase et al. demonstrated that in depressed patients nocturnal penile tumescence (NPT) time and penile rigidity are significantly reduced than nondepressed controls and confirmed these findings in a repeat study with a new group of patients.[38],[39] Steiger et al. found that complete lack of NPT was reversed after antidepressant therapy in depressed patients.[40] These findings suggest that in some of the depressed patients there is a neurophysiologic link between ED and depression.
Table 3: Comparison of Hamilton Rating Scale for Depression, General Health Questionnaire-30, Quality of Life Instrument for Indian Diabetes patients, sex myth check list scores between erectile dysfunction and nonerectile dysfunction patients

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GHQ-30 scoring of the participants with ED was found to be significantly higher than those without any impairment in erection, showing that ED deteriorates the general health of diabetes patients [Table 3]. De Berardis et al. showed that ED in type 2 diabetes is related to health status perception.[4] QOL of all the participants was assessed using QOLID and in most domains, ED cases have poorer quality, except for “financial worries” and “symptoms bothersome” in which the two groups shows no significant difference. Various other workers have also reported that ED patients have reduced QOL, high level of depressive and anxiety symptoms which might be due to lowered self-esteem, the effect on marriage and relationship and other co-morbidities.[41],[42] There was no significant difference in the prevalence and pattern of sexual myths among the ED and non-ED cases.


   Conclusion Top


In the present study, we found that diabetic males with severe ED have a significantly higher age and poorer glycemic control. Age at which DM was first diagnosed and duration of untreated DM was significantly more in ED cases, due to their general tendency to ignore their symptoms and delay treatment seeking, and is a possible explanation of poorer glycemic control in ED cases. Depression in ED cases is more severe than non-ED cases. Development of ED in DM patients is primarily due to vascular and neurologic factors although psychological factors also play an appreciable role and should not be completely neglected. General health and QOL of DM patients is usually poor than general population which is further deteriorated by the presence of ED. As ED is quite commonly seen in diabetic patients, treating physician must keep an eye on patients at risk and educate them properly so that they can discuss the problem with their physicians and the progress of this serious disabling disorder, responsible for deteriorating the general health and QOL of diabetic patients, can be halted at early stages.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Penson DF, Latini DM, Lubeck DP, Wallace KL, Henning JM, Lue TF; Comprehensive Evaluation of Erectile Dysfunction (ExCEED) Database. Do impotent men with diabetes have more severe erectile dysfunction and worse quality of life than the general population of impotent patients? Results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction (ExCEED) Database. Diabetes Care 2003;26:1093-9.  Back to cited text no. 1
[PUBMED]    
2.
Romeo JH, Seftel AD, Madhun ZT, Aron DC. Sexual function in men with diabetes type 2: Association with glycemic control. J Urol 2000;163:788-91.  Back to cited text no. 2
[PUBMED]    
3.
Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61.  Back to cited text no. 3
[PUBMED]    
4.
De Berardis G, Franciosi M, Belfiglio M, Di Nardo B, Greenfield S, Kaplan SH, et al. Erectile dysfunction and quality of life in type 2 diabetic patients: A serious problem too often overlooked. Diabetes Care 2002;25:284-91.  Back to cited text no. 4
[PUBMED]    
5.
Hurt KJ, Musicki B, Palese MA, Crone JK, Becker RE. Akt-Dependent Phosphorylation of Endothelial Nitric-Oxide Synthase Mediates Penile Erection. Vol. 99. 2002 Proceeding of the National. Academy of Science, USA; 2002. p. 4061-6.  Back to cited text no. 5
    
6.
De Angelis L, Marfella MA, Siniscalchi M, Marino L, Nappo F, Giugliano F, et al. Erectile and endothelial dysfunction in Type II diabetes: A possible link. Diabetologia 2001;44:1155-60.  Back to cited text no. 6
[PUBMED]    
7.
Shiri R, Ansari M, Falah Hassani K. Association between comorbidity and erectile dysfunction in patients with diabetes. Int J Impot Res 2006;18:348-53.  Back to cited text no. 7
[PUBMED]    
8.
Kalter-Leibovici O, Wainstein J, Ziv A, Harman-Bohem I, Murad H, Raz I; Israel Diabetes Research Group (IDRG) Investigators. Clinical, socioeconomic, and lifestyle parameters associated with erectile dysfunction among diabetic men. Diabetes Care 2005;28:1739-44.  Back to cited text no. 8
[PUBMED]    
9.
Dey J, Shepherd MD. Evaluation and treatment of erectile dysfunction in men with diabetes mellitus. Mayo Clin Proc 2002;77:276-82.  Back to cited text no. 9
[PUBMED]    
10.
Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care 2001;24:1069-78.  Back to cited text no. 10
[PUBMED]    
11.
Rubin RR, Ma Y, Marrero DG, Peyrot M, Barrett-Connor EL, Kahn SE, et al. Elevated depression symptoms, antidepressant medicine use, and risk of developing diabetes during the diabetes prevention program. Diabetes Care 2008;31:420-6.  Back to cited text no. 11
[PUBMED]    
12.
Katon W, Russo J, Lin EH, Heckbert SR, Karter AJ, Williams LH, et al. Diabetes and poor disease control: Is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosom Med 2009;71:965-72.  Back to cited text no. 12
[PUBMED]    
13.
Seidman SN, Roose SP. The relationship between depression and erectile dysfunction. Curr Psychiatry Rep 2000;2:201-5.  Back to cited text no. 13
[PUBMED]    
14.
Penson DF, Wessells H. Erectile dysfunction in diabetic patients. Diabetes Spectrum 2004;17:225-30.  Back to cited text no. 14
    
15.
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 15
[PUBMED]    
16.
Goldberg DP. Manual of the General Health Questionnaire. Windsor, England: NFER Publishing; 1978.  Back to cited text no. 16
    
17.
Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822-30.  Back to cited text no. 17
[PUBMED]    
18.
Kumar P. Manual for Sex Myth Checklist. Jaipur, India: Department of Psychology, Sardar Patel University; 1993.  Back to cited text no. 18
    
19.
Nagpal J, Kumar A, Kakar S, Bhartia A. The development of 'Quality of Life Instrument for Indian Diabetes patients (QOLID): A validation and reliability study in middle and higher income groups. J Assoc Physicians India 2010;58:295-304.  Back to cited text no. 19
[PUBMED]    
20.
Garg S, Rijhwani P, Gupta D, Khandelwal M, Kumar K, Gupta R. Study of erectile dysfunction in type-2 diabetic patients. Int J Healthc Biomed Res 2013;3:210-6.  Back to cited text no. 20
    
21.
Sundaram A, Mosesc RA, Ilango S, Dusaisamy S. Sexual dysfunction in men with diabetes mellitus. In: Nor Nordisk Diabetes Update. 1997. p. 93-102.  Back to cited text no. 21
    
22.
Schiavi RC, Stimmel BB, Mandeli J, Rayfield EJ. Diabetes mellitus and male sexual function: A controlled study. Diabetologia 1993;36:745-51.  Back to cited text no. 22
[PUBMED]    
23.
Kloner RA. Assessment of cardiovascular risk in patients with erectile dysfunction: Focus on the diabetic patient. Endocrine 2004;23:125-9.  Back to cited text no. 23
[PUBMED]    
24.
Cho NH, Ahn CW, Park JY, Ahn TY, Lee HW, Park TS, et al. Prevalence of erectile dysfunction in Korean men with Type 2 diabetes mellitus. Diabet Med 2006;23:198-203.  Back to cited text no. 24
[PUBMED]    
25.
Fedele D, Coscelli C, Santeusanio F, Bortolotti A, Chatenoud L, Colli E, et al. Erectile dysfunction in diabetic subjects in Italy. Gruppo Italiano Studio Deficit Erettile nei Diabetici. Diabetes Care 1998;21:1973-7.  Back to cited text no. 25
[PUBMED]    
26.
Ansong KS, Lewis C, Jenkins P, Bell J. Help-seeking decisions among men with impotence. Urology 1998;52:834-7.  Back to cited text no. 26
[PUBMED]    
27.
Weinberg AE, Eisenberg M, Patel CJ, Chertow GM, Leppert JT. Diabetes severity, metabolic syndrome, and the risk of erectile dysfunction. J Sex Med 2013;10:3102-9.  Back to cited text no. 27
[PUBMED]    
28.
Awad H, Salem A, Gadalla A, El Wafa NA, Mohamed OA. Erectile function in men with diabetes type 2: Correlation with glycemic control. Int J Impot Res 2010;22:36-9.  Back to cited text no. 28
[PUBMED]    
29.
Uribarri J, Woodruff S, Goodman S, Cai W, Chen X, Pyzik R, et al. Advanced glycation end products in foods and a practical guide to their reduction in the diet. J Am Diet Assoc 2010;110:911-6.e12.  Back to cited text no. 29
    
30.
Neves D. Advanced glycation end-products: A common pathway in diabetes and age-related erectile dysfunction. Free Radic Res 2013;47 Suppl 1:49-69.  Back to cited text no. 30
[PUBMED]    
31.
Peyroux J, Sternberg M. Advanced glycation endproducts (AGEs): Pharmacological inhibition in diabetes. Pathol Biol (Paris) 2006;54:405-19.  Back to cited text no. 31
[PUBMED]    
32.
Viswanathan V, Agarwal S, Kumpatla S. Severity of erectile dysfunction and prevalence of premature ejaculation among type 2 diabetic men referred to an ED clinic of a tertiary care centre. J Assoc Physicians India 2009;57:604.  Back to cited text no. 32
    
33.
Al-Hunayan A, Al-Mutar M, Kehinde EO, Thalib L, Al-Ghorory M. The prevalence and predictors of erectile dysfunction in men with newly diagnosed with type 2 diabetes mellitus. BJU Int 2007;99:130-4.  Back to cited text no. 33
[PUBMED]    
34.
Roy T, Lloyd CE. Epidemiology of depression and diabetes: A systematic review. J Affect Disord 2012;142Suppl:S8-21.  Back to cited text no. 34
    
35.
Li C, Ford ES, Strine TW, Mokdad AH. Prevalence of depression among U.S. adults with diabetes: Findings from the 2006 behavioral risk factor surveillance system. Diabetes Care 2008;31:105-7.  Back to cited text no. 35
    
36.
Kendrick T, Dowrick C, McBride A, Howe A, Clarke P, Maisey S, et al. Management of depression in UK general practice in relation to scores on depression severity questionnaires: Analysis of medical record data. BMJ 2009;338:b750.  Back to cited text no. 36
[PUBMED]    
37.
Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence & determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res 2010;132:195-200.  Back to cited text no. 37
[PUBMED]  [Full text]  
38.
Thase ME, Reynolds CF 3rd, Jennings JR, Frank E, Howell JR, Houck PR, et al. Nocturnal penile tumescence is diminished in depressed men. Biol Psychiatry 1988;24:33-46.  Back to cited text no. 38
    
39.
Reynolds CF 3rd, Frank E, Thase ME, Houck PR, Jennings JR, Howell JR, et al. Assessment of sexual function in depressed, impotent, and healthy men: Factor analysis of a Brief Sexual Function Questionnaire for men. Psychiatry Res 1988;24:231-50.  Back to cited text no. 39
    
40.
Steiger A, Holsboer F, Benkert O. Studies of nocturnal penile tumescence and sleep electroencephalogram in patients with major depression and in normal controls. Acta Psychiatr Scand 1993;87:358-63.  Back to cited text no. 40
    
41.
Fagan PJ, Schmidt CW Jr., Wise TN, Derogatis LR. Sexual dysfunction and dual psychiatric diagnoses. Compr Psychiatry 1988;29:278-84.  Back to cited text no. 41
    
42.
Jønler M, Moon T, Brannan W, Stone NN, Heisey D, Bruskewitz RC. The effect of age, ethnicity and geographical location on impotence and quality of life. Br J Urol 1995;75:651-5.  Back to cited text no. 42
    



 
 
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