Dealing With the Fallout of Diabetes' Effects on Men's Sexual Health
Black, Hispanic and Native American people have a higher rate of developing diabetes during their lifetimes than white people.
There are two primary types of diabetes: type 1 and type 2. Both types cause an inability to properly metabolize, or break down, sugars. Type 1 is caused by insulin deficiency, whereas type 2 is caused by insulin resistance. People with type 1 diabetes don't produce enough insulin in their pancreas. The pancreas of people with type 2 diabetes makes enough insulin but the cells of the body are resistant to its action, so insulin resistance develops.
If diabetes goes undiagnosed or is not properly controlled, it can lead to serious health complications, such as heart disease, stroke, blindness, kidney disease and nerve complications. Uncontrolled diabetes also increases the likelihood of sexual health problems in men, including erectile dysfunction (ED)—the consistent inability to achieve and keep an erection firm enough for sexual intercourse—low testosterone (low-T), low libido, retrograde ejaculation and balanitis, an inflammation of the penis head.
Women with diabetes may experience diminished sexual arousal and desire and inadequate vaginal lubrication. The lack of lubrication can lead to pain during intercourse.
Erectile dysfunction due to diabetes
Diabetes is an insidious disease for men and can have wide-ranging effects. Fundamentally, the problems that men develop related to diabetes occur because of the impact the disease has on the nerves and blood vessels.
From an erectile standpoint, diabetes hits two main mechanisms by which men get an erection.
"When we have too much sugar floating around in the bloodstream, that sugar is deposited in the walls of our blood vessels and in the walls of our nerves," said Frederick Taylor, M.D., a urologist at Central Ohio Urology Group, with multiple locations in Ohio. "And when that sugar builds up in the blood vessels, it makes the blood vessels dilate less well, or essentially increases the likelihood of atherosclerosis, or hardening of the arteries."
When the sugar builds up in the walls of the nerves, nerve signaling is not as efficient as it should be, Taylor said.
To have an erection, nerves need to carry a signal from the brain down the spinal cord. Those nerves release nitric oxide, which tells the blood vessels to dilate. It's the dilation of the blood vessels in the genital area that increases the blood flow into the erectile bodies and causes an erection to occur.
"If we have sugar building up in the nerves, we're not going to get the signaling from the brain down the spinal cord as strongly as we normally would," Taylor explained. "And even if that signal does make its way to the arteries, they're not able to dilate as efficiently as they used to because of that sugar building up in the arteries."
This is why men with diabetes are more likely to develop ED. In addition to ED, nerve damage from diabetes can cause other problems for men, including overactive bladder, incontinence and urinary tract infections (UTIs).
Treatment for type 1 diabetes involves taking insulin. Men typically have to take insulin therapy for the rest of their lives.
Insulin comes in various types, including short-acting insulin, rapid-acting insulin, intermediate-acting insulin and long-acting insulin. It can be administered with an injection or an insulin pump, a small device worn outside the body that's programmed to deliver specific amounts of insulin throughout the day.
Men with type 2 diabetes usually need treatment with oral medications for several or even many years but may eventually need insulin to maintain glucose control. There are many types of prescription medications for diabetes.
Metformin, a medication in the biguanides class, is commonly the first drug prescribed for people with type 2 diabetes. An oral medication that comes in regular and slow-release forms, metformin works by inducing the liver to stop converting protein or fat into sugar. While this action does not lead to an increase in the release of insulin, it can make the body more sensitive to its effects.
There are different classes of drugs that work in different ways to lower blood glucose levels, including but not limited to the following:
- Alpha-glucosidase inhibitors
- Bile acid sequestrants
- Dopamine-2 agonists
- Dipeptidyl peptidase 4 (DPP-4) inhibitors
Side effects and costs
Insulin may cause side effects, such as:
- Redness, swelling and itching at the spot of injection
- Changes in the feel of the skin, skin thickening or a slight depression in the skin
- Weight gain
Possible side effects of diabetes medications, such as metformin, include nausea, bloating, diarrhea, vitamin B12 deficiency and stomach ache. These problems typically go away in a few weeks as your body adjusts to the medication.
People with diabetes have average medical expenditures of $16,752 annually, of which $9,601 is attributed to diabetes, according to the American Diabetes Association (ADA). This is more than twice the medical expenditure of people without diabetes.
Diabetes and sexual health
Uncontrolled blood sugar in men can cause problems that affect their sex life. Diabetes is one of the primary causes of ED: More than half of men with diabetes develop ED.
Treatments for men with diabetes and ED include a group of oral medications known as phosphodiesterase type 5 (PDE5)inhibitors. These include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra), among others.
Other treatment options include intracavernosal injections, wearable devices and, as a last resort, penile implants.
"We know that men with diabetes do statistically respond less well to PDE5 inhibitors," Taylor said. "I think it's very much worth a try because if they're effective, certainly they can be a safe and effective long-term treatment option for guys."
The best way to avoid developing ED is to prevent nerve and blood vessel damage caused by diabetes. This can be done by keeping blood sugars under control and avoiding smoking and drinking alcohol to excess. Maintaining blood pressure and cholesterol at normal levels also helps.
Peyronie's disease due to diabetes
Many men with diabetes also suffer from Peyronie's disease, a condition marked by the buildup of scar tissue in the penis that leads to curved (and sometimes painful) erections. While we don't fully understand the correlation between diabetes and Peyronie's disease, we do know that men with diabetes are more likely to develop the condition, Taylor said.
"I have several men in my practice with type 1 diabetes who, unfortunately, developed Peyronie's disease in their early 30s, and likely those things are related," he said. "It probably does have to do with general wound-healing mechanisms. We know that that fundamentally is the cause of Peyronie's disease."
Peyronie's disease likely develops as a result of the microtraumas that men normally experience during sex, caused by excessive pressure to the erect penis during intercourse. This is further exacerbated by the decreased wound-healing ability of men with diabetes.
Bobby Najari, M.D., a urologist at NYU Langone Health in New York City, has also had young male patients present with Peyronie's disease. These patients often have type 1 diabetes and need an insulin pump to help control it.
"I definitely see an association between diabetes and Peyronie's disease," Najari said. "I think based on what we know about diabetes, particularly uncontrolled diabetes, it's intuitive because poor glucose control leads to impaired healing, and ultimately, Peyronie's disease is a disease of improper healing in the erectile tissue. It makes sense that the worse your diabetes, the more likely you are to have more significant curvature or more significant scar formation when you develop Peyronie's disease."
Complications and related conditions
Men with diabetes may also develop ejaculatory dysfunction.
"Normally at the time of orgasm, there are muscles that surround the prostate gland that spasm," Taylor said. "That spasming of the muscles is what induces the pleasurable sensation of orgasm, but those muscles also squeeze around the prostate gland to propel the ejaculatory fluid forward and out the end of the penis. Because of some nerve-signaling issues, guys with diabetes might not generate that same muscle contraction."
As a result, men with diabetes may develop retrograde ejaculation, which occurs when the seminal fluid goes backward into the bladder instead of forward out of the penis. This condition can become a fertility issue for some men, because if they're not able to propel the fluid forward, they won't be able to get the sperm where they need to go for fertilization.
In those cases, medications can help promote ejaculatory function. Alternatively, a urologist or fertility specialist can retrieve sperm, which can then be used for assisted fertility techniques.
The impact of diabetes on the nerves tends to be directly related to how far those nerves are from the spinal cord, Taylor said. Diabetic neuropathy, the nerve damage that occurs with diabetes, can cause burning and pain in the feet and lower legs.
"That happens just because of the physical distance that those nerves are from the spinal cord," Taylor said. "As the disease progresses, we can develop neuropathy in areas much closer to the spinal cord; things like our hands and then, of course, in the genital area."
Therefore, a decrease in penile sensitivity can be the result of diabetic neuropathy. This condition can also make it more difficult to achieve an erection and an orgasm.
"Orgasm and ejaculation are independent processes," Taylor explained. "We can have an orgasm without having an ejaculation, particularly if we have retrograde ejaculation. A lot of guys complain about the inability to achieve orgasm, and oftentimes, that happens because of this lack of sensitivity of the tissue."
Type 1 diabetes and low-T
The American Urological Association (AUA) guidelines consider low blood testosterone as anything less than 300 nanograms per deciliter (ng/dL). Low testosterone, also known as low-T, is common in men with diabetes, whether type 1 or type 2.
Low-T is also linked to metabolic syndrome—a group of risk factors such as hypertension and excess belly fat—which increases the risk for heart disease, diabetes and other health issues.
There is definitely a higher rate of low-T among men who have diabetes, according to Petar Bajic, M.D., a urologist at the Center for Men's Health in the Glickman Urological & Kidney Institute at Cleveland Clinic.
"The question of whether it's the diabetes that's causing it, that's not always easy to answer," Bajic said. "We know that testosterone levels decrease with age. We know that certain things that affect your overall health may be associated with lower testosterone."
Typically, when Bajic sees a man with diabetes for evaluation of low-T, it's because he's experiencing erectile dysfunction.
"And even if the testosterone is low, a lot of times we get it back up to normal and it doesn't necessarily restore that function because there is some damage that's been done there because of the diabetes," he said.
The research is currently inconclusive regarding whether all men with diabetes and low-T should be put on testosterone replacement therapy (TRT), according to Neel Parekh, M.D., a men's fertility and sexual health specialist with Cleveland Clinic. More randomized controlled trials are needed.
However, for patients who have low-T and diabetes and exhibit symptoms, Parekh offers TRT. Men with diabetes and low-T commonly experience an array of symptoms, including low libido, low energy, fatigue, difficulty sleeping and trouble maintaining weight loss.
"Studies have shown that starting testosterone therapy in these patients really helps them maintain stricter blood sugar control and are more likely to lose weight as well," he said. "A combination of those things makes it easier for them to get their diabetes under better control."
The first step for anyone who suspects they might be at risk for diabetes—or any condition, really—is to see your doctor. Don't have a doctor you see regularly? You should. Fortunately, telehealth makes it easy to connect with a doctor who can answer your questions and evaluate your situation. Many physicians offer video visits, which are a good way to see a doctor quickly since a lot of them have same-day appointments.
Giddy Telehealth is an easy-to-use online portal that provides access to hundreds of healthcare professionals whose expertise covers the full scope of medical care, including chronic conditions such as diabetes.