Mozambique, África (special for SIIC)

Diabetes is increasing worldwide with high health, social and economic impact.

Too often, the lack of prevention and a wrong lifestyle (i.e., unhealthy diet, lack of physical exercise), lead to a late diagnosis of diabetes and, many times, starting from complications they get to make a diagnosis of diabetes.

Increasing attention is focusing on erectile dysfunction in men with diabetes due to its multifactorial pathophysiology and the concurrence of the same components as vasculopathy, neuropathy, and depression. Erectile dysfunction is defined as the inability to achieve and/or maintain an erection sufficient to permit satisfactory sexual intercourse. Although erectile dysfunction is considered an age-related disease, affecting 20% of men aged > 40 years, it can be present across all the life-span from adolescence, especially when risk factors such as diabetes, metabolic syndrome or cardiovascular diseases coexist.

Erectile dysfunction, due to its evident presentation, can play a crucial role on “early” DM diagnosis and, thus, acts as an alarm bell for other silent complications.

Our hypothesis was that erectile dysfunction was associated with diabetes but we were surprised that the risk of erectile dysfunction in men with diabetes was more than three times higher compared to controls.

It is well known that many factors contribute to the complex pathogenesis of diabetes-related erectile dysfunction including diabetic neuropathy, micro- and macrovascular arterial disease (oxidative stress, endothelial dysfunction, dyslipidaemia, arterial hypertension, etc.), hypogonadism, psychogenic components, and drug side effects. However, further studies are necessary to better understand the exact pathophysiologic mechanism leading to dysfunction.

We showed an overall prevalence of erectile dysfunction of 59.1% in men with diabetes (52.5% if adjusted for publication bias). This condition was significantly higher in those with Type 2 diabetes compared with Type 1 diabetes and in older participants. Men with diabetes tend to develop erectile dysfunction 10-15 years earlier than those without diabetes. In fact, erectile dysfunction is the third most frequent complication of diabetes that affects the quality of life and it is often indicative of underlying vasculopathy representing a predictor of more serious cardiovascular disorders. Because the prevalence of diabetes is rising in high, middle, and low-income countries, our work aimed to give an overall estimate of erectile dysfunction in diabetes across several continents.

First of all erectile dysfunction should be considered a marker symptom for diabetes and men with erectile dysfunction should be screened for diabetes (and vice-versa). In addition, advancing age, duration of diabetes, poor glycaemic control, hypertension, hyperlipidaemia, sedentary lifestyle, smoking and the presence of other diabetic complications are associated with diabetes-related erectile dysfunction and, thus, have to be particularly considered in patients with erectile dysfunction. Finally, considering the association between depressive symptoms and erectile dysfunction, especially in diabetic patients, it is mandatory that the management should involve a multidisciplinary approach in which psychosexual counselling and specialist andrologist/urologist advice are required in addition to the skills and expertise of the specialist in metabolic diseases and to the traditional pharmacological therapy. In our meta-analysis, we did not consider prevention both for diabetes and erectile dysfunction. However, to make young males aware of health, in particular, sexual and reproductive health, will have to be the real challenge to fight metabolic and sexual disorders. Although our data offer novel insight into the extent of erectile dysfunction among men with diabetes, some limitations need to be considered. First, is the difficulty in providing erectile dysfunction prevalence by categories because of incomplete data available in published studies? Second, most information refers to the total population with diabetes and few studies have presented data separately for those with Type 1 and Type 2 diabetes. Third, the analysis of the others risk factors contributing to the diabetes-related erectile dysfunction was limited because of the small number of primary studies that provide complete clinical and biological features of the participants. For example, the use of antidepressant medication, an important contributor to erectile dysfunction in men with diabetes, was not analysable as a potential moderator of our findings. In conclusion, our study provides worldwide data on the prevalence of and risks factors for erectile dysfunction in diabetes. The relationship of erectile dysfunction with certain risk factors, such as age or cardiovascular risk factors (arterial hypertension), are well known and our study corroborates these associations. Future prospective and longitudinal studies in both but separately population with Type 1 and Type 2 diabetes, are needed to characterize others risk factors such as duration of disease or smoking which are involving in the development of erectile dysfunction. Furthermore, men with erectile dysfunction are at an increased risk for cardiovascular morbidity and/or mortality as well as for all-cause death. Thus, clinicians should have in mind that screening of erectile dysfunction in men with diabetes is a part of the assessment of their cardiovascular risk.