Erectile dysfunction (ED) is a very common complication in men with diabetes mellitus (DM). Diabetes causes changes to the endothelium and penile vascular system.
What is less often acknowledged is that men with type 2 diabetes also have higher prevalence of testosterone deficiency. In fact, testosterone deficiency in men precedes the development of insulin resistance and diabetes. Low levels of testosterone in men can lead to lower libido and poor erectile function.
A six-year study conducted in the UK on 518 men demonstrated a bidirectional relationship between obesity, metabolic syndrome, diabetes, insulin resistance, and testosterone deficiency. The study also found that testosterone replacement therapy could delay or prevent many of these conditions.
There is other data supporting a direct role of testosterone in insulin sensitivity. In one study, men who had lower than average testosterone levels were taken off testosterone replacement therapy. After two weeks, these men showed an increase in insulin sensitivity without apparent changes in body composition. This suggests that sex steroids have a direct effect in modulating insulin sensitivity, which also affects erectile function. Other studies have demonstrated the interplay between insulin sensitivity, triglycerides, and sex steroids. The effects of testosterone is immediate and not due to weight gain or increased obesity.
If you have type 2 diabetes, the next time you see your physician ask about your testosterone levels to find out if testosterone replacement therapy is right for you.
Good News About Treating Erectile Dysfunction
The good news about treating erectile dysfunction that is connected with type 2 diabetes is that studies show that it responds to treatment with SONICWAVE.
A 2022 study published in the journal of the American Society of Andrology and European Academy of Andrology concluded that “results of the clinical studies suggest that Li-ESWT is a safe and effective treatment in men with well-controlled DM and moderate or better ED.” See details here.
Men should talk to their doctors about their sexual health.
It’s easy enough to say, but following this advice is often a challenge. Both men and their doctors can take steps to make it easier to connect on issues of sexual health. For patients, this involves seeing a family doctor for regular checkups and being honest about personal issues. Meanwhile, your doctor should ask specific questions related to sexual health when conducting checkups. They should also be prepared to offer resources beyond just a prescription for PDE5 inhibitors like Viagra.
We know this is a challenge, but the stakes are high. By having the right conversations early on, men can often resolve issues like erectile dysfunction. They can also identify other health problems like diabetes and heart disease. In this article, I’m breaking down why people don’t talk to doctors about sexual health – and why that needs to change.
Why men don’t go to the doctor – and why they should start.
Going to the doctor is something we know we should do, but we often don’t get around to it. Like going to the gym. Or eating walnuts and avocados. Or going for that walk after dinner.
Men avoiding the doctor’s office is not just a stereotype. A recent Cleveland Clinic survey showed that only three in five men get a yearly physical. Meanwhile, 40 percent of men still don’t get a health issue checked out until it becomes unbearable. On top of that, the majority won’t talk about their health with others.
Look, we’re not saying that men should share personal health issues with everyone. Erectile dysfunction doesn’t make for good water cooler conversation. But your doctor does need to be in the loop about any body part that isn’t working properly. For many men, regular check-ups are a great opportunity to raise these concerns.
What sexual health issues should I discuss with my doctor?
Men are often unsure of what sexual health issues would be relevant in a check-up.
Is doing it a bit less than normal a health issue? Possibly not. Is a significant dip in sexual activity worth noting? Probably. Is being physically unable to have sex worth discussing? Absolutely!
Here are some of the common sexual health issues men should raise with a medical professional
Inability to get or maintain an erection
Extreme change in libido or stamina
Decrease in amount of sex or interest in sex
Unusual discharge from the penis
Pain, lumps, or other unusual growths on the testicles or penis
Need for STI protection and testing
While talking about these things with a family doctor can be worthwhile, note that you do not need a doctor’s referral to get support from a specialty clinic dealing with sexual health. For example, a local STI testing center may be worth consulting for infection concerns and an ED-focused clinic like FullMast is the best resource for sexual performance. If you live in the Greater Toronto Area, you can reference our Directory of Toronto Sexual Health Resources to find the best options near you.
Why your doctor should ask about sexual function
The question your doctor should ask is a simple one: Are you having sex on a regular basis in an intimate relationship? There are three reasons to ask this question:
Sex has many health benefits. Studies show that an active sex life lowers blood pressure, strengthens the immune system, and reduces the risk of heart disease and prostate cancer. While no one should feel forced to have sex by a doctor’s orders, having a bit more could help alleviate some of the psychological and physiological challenges that come with age.
Erectile dysfunction can signify other health challenges. Erectile dysfunction is often a blood flow issue. Since blood pumps from the heart, this is no small matter. Many people have discovered serious underlying conditions when undergoing testing for ED. In general, if a body part isn’t working like it used to, your doctor should know.
Intimacy can affect treatment and recovery from illnesses. Studies have shown that people with a healthy sex life with an intimate partner mange and recover from serious illnesses at higher rates. An Italian study, for example, found that men with type 2 diabetes who had a healthy sex life were significantly less likely to suffer from illness-related distress. According to renowned doctor and professor of Sexology Christian Graudaard, “a fulfilling sexual life might reduce morbidity and perhaps even mortality of patients. Sadly, nearly two-thirds of the aforementioned diabetes patients reported that sexuality had not been addressed by any doctor within the past year.”
It’s undeniable: sex makes a big difference in a man’s overall health. That’s why a doctor should ask specific questions on this subject when performing a check-up on an adult man.
Can sexual health issues be resolved by my family doctor?
If talking to a doctor about erectile dysfunction or other sexual health issues makes you nervous, it’s important to remember that it is worth the conversation. The earlier you begin treating something like erectile dysfunction, the more likely you are to completely resolve the issue.
Recent research has made multiple exciting erectile dysfunction treatments available to men. Some of these, such as SONICWAVE, allow for permanent ED treatment without drugs or surgery. There’s just one catch – it works best with early diagnosis. The health issues that often come with ED, like high blood pressure and diabetes, also benefit from early intervention.
Regular sex and healthy relationships are critical to the health of most men, but we rarely speak about this sensitive subject with our family doctor. A conversation about sexual health may not be one we’re comfortable initiating or participating in, but an honest dialogue with a qualified health professional can improve our relationships and sexual wellbeing. A doctor should ask about sexual health not only because it is relevant, but because they can truly improve patients’ lives by understanding how things are going in the bedroom.
“How often are you having sex?” might be the question that leads to big improvements in one’s health.
If you have questions, please call to set up an appointment at FullMast Men’s Health Clinics.
1-Hello, Dr. Mayer. Thank you for sitting down with me today. Would you mind discussing the main issues that come up most often in your clinic?
Well, primarily, men come into the FullMast clinic for erectile issues and questions about testosterone therapy. When a man comes into our office, and he’s around 45 years old and he presents with erectile issues, the first thing I have to think about is cardiovascular illness. Men who present with early-onset erectile dysfunction will most often have cardiovascular issues such as hypertension and high cholesterol.
2. As FullMast’s Chief Medical Officer, what are some concerns you’ve noticed when patients come into your office? How have you been able to address these?
I’ve noticed that some patients are reticent to come into a clinic where there are other men who are sitting around in the waiting room. They’re not necessarily ashamed, but there is still stigma around sexual health and erectile issues. In order to combat this, we manage our consultations according to a specific protocol. The consultations are an hour long. When a patient comes in for his consultation, the previous patient has already left. We have one treatment room. Our main concern is the comfort of the patient. We want to ensure privacy and confidentiality as much as possible.
3. What are some questions men should ask their doctors during their annual physical?
Annual physicals are not recommended for men until they’re 50 years old. Before 50 years of age it should be once every two years. During these annual checkups, they should ask for a colonoscopy, a rectal (prostate) exam, which involves the detection of PSA, the prostate-specific antigen. Certainly as a man gets older, he should ask about exercise and weight loss, especially if he is overweight or obese. Most physicians don’t talk to men about those issues. Even a slightly overweight man who doesn’t get that much exercise will present with signs of erectile dysfunction. The most common manifestations of ED are cardiovascular issues, hypertension, high cholesterol, and high blood sugar.
4. Do issues of mental health ever arise during these consultations?
Yes, these issues come up quite often. Men who are low on testosterone often come in slightly blue and with less energy. Sometimes, we have a conversation about the use of antidepressants. As part of the assessment, we also evaluate psychogenic causes of erectile dysfunction especially if the man is in his early thirties. Often times the causes are not organic but psychogenic. But keep in mind, psychogenic causes may also occur in men in their fifties as well.
5. Does fitness or nutrition ever come up during a consultation?
One of the first things we talk about is exercise. I usually ask them, ‘Do you walk?’ Walking is a good way to start becoming active. I recommend they measure the steps they take every day. There are many phone apps out there to help them keep track of the number of steps they take. I would recommend 1,000 steps per day, or 100 steps per minute to get their heart rate up.
Vitamin D is also important especially in the wintertime: 5,000 units per day along with magnesium. A trick I tell them is when to start and when to stop: if they go outside at noontime, and their shadow is longer than their height, take the vitamin D, but if at noontime, their shadow is shorter than height, don’t take it that day. I would also recommend lots of unsaturated fats, which can be found in olive oil, avocado, and walnuts (which contain arginine, a precursor for nitric oxide, which assists in producing a fully erect penis).
6. Do most men who come into your office have some type of support network?
They do, but it’s mostly support from their partner, especially because their partner is equally affected by these erectile challenges. They often come into the clinic with their partners. Men usually don’t like to talk about these issues with other people like friends or family members. Hopefully over time people will see sexual health as being another facet of overall health, but today, many men are still worried about how people perceive their masculinity. They don’t want to be questioned by their buddies or their friends. I’ve noticed men don’t joke about these issues until they’re in their seventies. In the1990s when Viagra come out, men became more open to discussing sexual health. It opened up the lines of communication; the commercials were humorous, and men felt more comfortable talking about it.
7. What age group do you see most often at the clinic?
The range is anywhere between 20-80 years old. Usually, younger patients have erectile issues that stem from psychogenic issues rather than men in their fifties and beyond. Younger men also have concerns with premature ejaculation.
8. Dr. Mayer, thank you for your time today. Before we say goodbye, is there anything else you would like to add?
Oh, that’s not a problem at all. Thank you. Yes, so I have noticed that many therapies nowadays focus on medications such as Viagra and Cialis, but there are many non-medicinal therapies and procedures out there. In fact, medications tend to wear off over time. FullMast has pioneered the first new and Health Canada approved treatment for erectile dysfunction called SONICWAVE, which is a non-surgical, non-medicinal therapy that uses high-frequency vibrations to stimulate nerve function, cell regeneration, and increase blood flow to the penis.
If a man has diabetes or has had prostate surgery or who presents with neurogenic issues, we’re going to recommend both SONICWAVE and Viberect. Viberect is another vibration technology that helps the secretion of nitric oxide. We believe in multimodal therapies so we also recommend pelvic floor exercises to strengthen the muscles that are responsible for maintaining blood flow and rigidity in the penis.
Overall, we’re here to help men handle the sensitive issue of erectile challenges by providing the best care possible at our clinic. We also want to open up the conversation about men’s sexual health and about maintaining sexual activity as men age. Myself and sexologist Dr. Stephen de Wit will be presenting at an upcoming talk on August 2nd to discuss these key topics in men’s sexual health.
What does it take for a man to have a good erection? This is a question that plagues many men who are trying to overcome sexual challenges. When I say a “good” erection, I mean an erection that is satisfying for both yourself and your partner. For many of our patients in Toronto, Vancouver, and other parts of Canada, achieving a “good” erection is a daily challenge
When seeking to resolve this issue, it is a good idea for men to understand the main cause of erectile dysfunction as well as being aware of risk factors and other contributing causes. A thorough diagnosis that recognizes the underlying reason for sexual difficulties will help you find the best treatments for your erectile issues.
What is the most common cause of erectile dysfunction?
The best way to understand erectile dysfunction is to take a look at what’s happening inside your body, especially where blood flow is concerned. This is because an erection involves blood flowing to the penis. This process allows the penis to become hard. For this reason, the main cause of erectile dysfunction is something called endothelial dysfunction.
The endothelium is the lining on the inside of your blood vessels. They are important in regulating four things:
Vascular tone: the extent to which your blood vessels constrict or dilate
Cellular adhesion: the process whereby cells interact and attach to a surface
Thromboresistance: the resistance of a blood vessel to thrombus formation, a thrombus being a stationary blood clot along the wall of a blood vessel
Vessel wall inflammation: blood vessels become swollen in response to injury, infection, or illness
The endothelium is what causes vasodilation of the vessels in the penis, resulting in a full erection. So, in essence, the main cause for erectile dysfunction from a biological perspective is damage to the endothelium. Any form of chronic inflammation caused by hypertension, diabetes, high cholesterol, obesity, gout, and other inflammatory conditions can harm this function.
Here’s how it works: When we get excited, either through touch or visual stimulation, messages are sent to the endothelium of the penis to release a substance known as nitric oxide (NO). This chemical is responsible for vasodilation by accumulating something called cGMP. This nucleotide relaxes the blood vessels and allows blood to flow into the penis. When there is damage to the endothelium, there is less nitric oxide, which results in a non-fully erect penis. This is how drugs like Cialis or Viagra work. They prevent the breakdown of cGMP, which allows nitric oxide to be continually be released over a longer duration of time.
How can I prevent erectile dysfunction?
Now that we’ve identified the main cause of erectile dysfunction, it’s time to work backwards to determine a resolution.
To prevent or minimize erectile dysfunction, you must first start caring for your cardiovascular health. Believe it or not, common advice for reducing the risk of heart attacks and strokes is the very same guidance that can help you prevent ED. This is because same conditions that cause heart disease can cause erectile dysfunction. Consistent exercise, managing your weight by watching what you eat, and keeping your blood pressure in check are all important parts of many successful erectile dysfunction treatment plans. These simple changes may go a long way in helping you combat and overcome erectile dysfunction.
Identifying your personal risk factors for erectile dysfunction
Whether you have just started experiencing erectile dysfunction or have been working to manage it for a long time, chances are endothelial dysfunction is at the root of the issue. But what is causing it and how can you resolve it? This main cause of erectile dysfunction shows many warning signs and has many associated risk factors. Take a look at the list below to see how many apply to you.
Behaviours and Conditions that Put Men at a Higher Risk for Erectile Dysfunction Include:
A family or personal history of heart disease
Type two diabetes and prediabetes (read more about this risk factor )
Inflammatory conditions
Obesity
High blood pressure
High cholesterol
An inactive lifestyle (for example, working a desk job and not regularly getting exercise)
An unhealthy diet
Smoking
Taking medications related to blood flow (these may be required for your health, but considering current prescriptions is a good idea when trying to understand the causes of your ED)
There are many benefits to addressing these issues. Along with helping treat ED, these lifestyle changes can prevent a man’s likelihood of developing heart disease. Since heart disease is one of the leading causes of death in Canadian men, this is good news. I often include lifestyle change recommendations into the erectile dysfunction treatment plans I develop for patients in Toronto and Vancouver.
Is my cardiovascular health the only thing that can cause ED?
Blood flow and heart health are the main cause of erectile dysfunction, but there are other causes of erectile dysfunction which may be at play in a man’s individual situation. While these factors may restrict blood flow, they do not necessarily relate back to a person’s heart health or lifestyle. These can include:
A history of prostate issues, particularly if a man has undergone a prostatectomy
Penile injuries and damage to the tissue within the penis (this can be sustained through sexual injury, car accidents, and more)
Numbness or a lack of sensation in the penis (research shows that excessive bike riding can have this result for some men over time)
Neurological issues that affect the brain’s ability to communicate with the reproductive system. This can include Alzheimer’s disease, Parkinson’s disease, tumours, epilepsy, and multiple sclerosis.
Use of drugs that affect the central nervous system, including depressants (Xanax, Valium, alcohol etc), or stimulants (cocaine, amphetamines)
Use of various other drugs that may influence reproductive processes, such as cancer chemotherapy medications or synthetic hormones
Psychological, emotional or relationship issues
At Men’s Health Clinics like FullMast, a doctor will ask questions about all these risk factors in order to determine the causes of your individual ED issues. While the main cause of erectile dysfunction is always considered, these factors may also play a role.
Why does erectile dysfunction become more common as we age?
While ED can strike at any age, statistics demonstrate a considerable increase in erectile dysfunction (ED) with increasing age: up to 75% of men who are 75 years of age or older suffer from erectile dysfunction. So what happens to men as they age? Why does it become more difficult to have an erection and why are erections not as hard or long-lasting as they once were? Perhaps most importantly, can erectile dysfunction be prevented as we age and can the downward progression be altered? The answer to both these questions is a resounding “yes.”
Many people I meet in my Vancouver and Toronto erectile dysfunction clinics ask me about the relationship between age and ED, stating that it was “so much simpler” when they were young. The truth is that the process of getting an erection was never simple for your body, even if it once occurred without much visible effort. A complex chain of biological processes must occur to produce an erection. This includes psychogenic, neurogenic, vascular, hormonal, and muscular events. An interruption to these processes can get in the way of getting an erection. As we age, there is an increased likelihood of us experiencing health issues related to erectile dysfunction, particularly heart health which is the main cause of erectile dysfunction. By keeping an eye on a man’s overall health, we can often prevent, minimize, or treat his erectile issues.
Why does erectile dysfunction matter for Canadian men?
Sexual health can play into a person’s personal health, self-esteem, and well-being. It can also have an influence on the health of romantic relationships. Evidence shows that many couples prefer sexual intercourse where the male partner has a fully erect penis. Also, many couples report missing the feelings of excitement and pleasure that come from this particular form of intercourse. They also report a happier sense of “coupling” when sexual intercourse is enjoyable for both partners. A man with a non-erect penis may still have an orgasm and ejaculate during sexual intercourse, but for many men and for many couples, this may not be enough.
If you are a Canadian man seeking more information about the possible causes and treatments for your erectile dysfunction, contact us today for a free and fully confidential consultation.
Julia, a 57-year-old woman presented to my clinic because her husband John of 20 years had lost interest in having sex with her which resulted in them living in a sexless marriage for the previous two years. Julie was experiencing a roller coaster of emotions thinking she was no longer desirable or that he was having an affair.
She and her husband John never discussed the fact that their sex life had all but disappeared. She was very anxious and the situation was having a negative impact on their relationship and she worried about their future together. She loved him dearly and was still very much attracted to him.
For many years, they enjoyed a happy and healthy relationship and sex life. They had the building blocks of a very successful marriage; good jobs, a lovely home wonderful children and a great sex life. Sex had always been the grout of their relationship and without it, she felt they were crumbling.
Julia then recalled that toward the end of their sex life, John was having difficulty attaining an erection and began to lose his erection in the middle of their lovemaking. She remembers attributing this to her having gained a bit of weight during the menopausal time.
Given the fact that he was losing his erections and his age of 60 it was likely that he was suffering from Erectile Dysfunction (ED) defined by the DSM-V (the bible of sexual disorders) as the inability to attain and maintain an erection adequate for penetrative sex.
Erectile dysfunction is common and treatable
ED is very common and may affect men at any age although it is more common in the later years. It is not uncommon for men to be embarrassed and stressed by ED as this strikes directly at their manhood. It may affect a man’s sexual self-esteem and is a common contributor to relationship issues. For these reasons, it is often difficult for men to discuss ED with their partners and/or their doctors.
Good hard erections are about blood flow. Extra weight especially abdominal weight may increase the risk of ED as will alcohol and certain health conditions like diabetes and medications. It is vital that men speak to their doctors about ED as it may be a risk factor for heart disease and is called the “canary in the coal mine. “ I encouraged Julia to have a conversation with her husband about ED as a health condition.
It would be important for him to speak to his doctor about it because many times, treating an underlying condition may reverse erectile dysfunction and if that did not do the trick then medications such as PDE5 inhibitors (Viagra, Cialis, Levitra, Staxyn), vacuum pumps, injections, pellets and/or SONICWAVE™ an innovative new therapy might.
Julia felt equipped to have a dialogue with her husband and she realized this was important for them to address together. “Silent no more!” she proclaimed as she left my office armed with new health information.
Julia, a 57-year-old woman presented to my clinic because her husband John of 20 years had lost interest in having sex with her which resulted in them living in a sexless marriage for the previous two years. Julie was experiencing a roller coaster of emotions thinking she was no longer desirable or that he was having an affair.