Until 1998, effective pharmacotherapy of erectile dysfunction was limited to intracavernous self-injection therapy and transurethral therapy with alprostadil (MUSE™), the latter with clearly less efficacy. The approval of sildenafil marked a breakthrough in the conservative treatment of erectile dysfunction and revolutionized completely the management of this disease. With the availability of effective oral therapy, the management of erectile dysfunction became more and more an issue for the general or family practitioner, and meanwhile more than 70% of all Viagra™ prescriptions aremprovided by non-urologists. 

One major negative consequence of this development is that many physicians have given up any diagnostic screening in these patients, and are limiting their activities more or less to pure prescription of the medication. The urologist, who was for a long time the first referral for erectile dysfunction patients, should continue to underline his expertise in this field by providing a thorough diagnostic workup of patients comprising medical and sexual history, somatic examination, laboratory tests, including testosterone, prolactin and serum glucose, and intracavernosal pharmacotesting with 10–20 μg alprostadil combined with Doppler/ duplex sonography of the cavernous arteries.

In this connection, systolic peak flow velocities <25 cm/s are indicative of an arteriogenic etiology, and should prompt the urologist to refer the patient for a further cardiovascular screening, as a considerable subset of these patients are suffering from generalized atherosclerosis and therefore are at risk of coronary or cerebral artery disease.

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TERMINATION OF PREGNANCY

I have become pregnant and really don’t want a baby at the moment. Is diabetes grounds for termination of pregnancy?

No, not unless your doctor considers that the pregnancy would be detrimental to your health, which may sometimes be the case if you have complications of diabetes. If you do not have any complications the reasons for termination of pregnancy apply equally to women with and without diabetes.

I am going into hospital for an abortion. I am worried that the doctors might not do it as I have diabetes. Should I have told someone?

There is no added hazard for women with diabetes who undergo termination of pregnancy, and care of the diabetes during this operation does not raise any special difficulties. It is still important to tell your gynaecologist that you have diabetes so that good control can be maintained during this time.

FERTILITY

I have recently got married and my wife and I are keen to start a family. Are people with diabetes more likely to be infertile?

There is nothing to suggest that men with diabetes are any less fertile than men who do not have diabetes and in general this is also true for women. However, women with consistently high blood glucose readings may find it more difficult to conceive. This may be a good thing as there is sound evidence to show that the outcome of pregnancy is much worse in women who conceive when their control is poor.

I have been trying for a baby for years and we have now decided to go for fertility counselling and possible treatment. Can people with diabetes expect the same treatment for infertility as people without?

Yes. As mentioned in the previous question, diabetes is rarely the cause of infertility. If control is anything other than excellent, improving control, aiming for an HbA1c of less than 7.5% should be the first goal. Referral to an infertility expert is the next step but good control would be necessary before treatment could be started.

I have told that I have PCOS and my doctor says this might make it difficult for me to conceive and also puts me at risk of developing diabetes. Could you explain this.

Polycystic ovary syndrome (PCOS) is a condition in which the ovaries have multiple small cysts that interfere with function and may upset the normal hormone balance, causing irregular periods. This can lead to reduced fertility. PCOS is often associated with being overweight and can lead to an increase in body hair. It is also linked with insulin resistance and an increased risk of developing type 2 diabetes. There are a number of possible treatments but in the past few years, metformin has been identified as an effective treatment which may increase fertility and reduce body hair.