THE ETIOLOGY AND MANAGEMENT OF ERECTILE, EJACULATORY, AND FERTILITY PROBLEMS IN MEN WITH DIABETES-MELLITUS

Erectile impotence is more common in the diabetic than the general pop ulation, occurs at a younger age, and is often associated with ejacula tory problems. For these, and possibly for other more subtle reasons, fertility may be a problem for men with diabetes. The symptoms of erec tile and ejaculatory dysfunction are frequently not discussed between patient and doctor. Psychological factors are important but the vast m ajority of diabetic patients have an organic basis for their impotence . Both neurogenic and vascular factors are important in the pathogenes is of erectile failure. Autonomic neuropathy is almost certainly the c ause of the ejaculatory failure that may be present in up to 40% of me n with diabetes. The final biochemical mediator of erection within the penile erectile tissue is nitric oxide and a key enzyme in its degrad ation is phosphodiesterase (type V). Drugs that affect the metabolism of this enzyme are being developed to treat erectile failure. At prese nt, the self injection of intra-cavernosal erectogenic agents (such as prostaglandin E1) provide the main form of therapy for erectile failu re. Vacuum devices are a simple alternative and venous ligation surger y may be effective for a properly selected cohort of patients. Prosthe tic implants are a final option for patients in whom all else has fail ed. Fertility problems, particularly when associated with ejaculatory failure can be overcome with modern assisted reproductive techniques. Nowadays, these will frequently involve gamete micro-manipulation.