Managing impotence in diabetes.

Should be part ofa diabetes care service Erectile impotence affects over one third of diabetic men.' Effective treatments have been available for over a decade, yet it remains the most neglected complication of diabetes. It is not discussed in the British Diabetic Association's current guidelines for diabetes care2 or in its recent proposals for the audit of diabetes services.3 Most impotent men want help but are reluctant to discuss the problem.' Few people would dispute that impotence can cause great unhappiness-so why has the problem been neglected for so long? It is difficult to resist the conclusion that the explanation lies in the previous widespread reluctance to discuss sexual problems. With inhibitions about sexual matters gradually changing, should impotence now be regarded as another diabetic complication and be managed routinely as part of a diabetes care service? Erectile failure in diabetes is progressive and usually irreversible.4 Autonomic neuropathy is probably the most important aetiological factor, but arterial insufficiency may also contribute.5 Psychological problems are common in impotent men-indeed, impotence may cause psychological dysfunction. But there is no evidence that psychological problems are commonly tle main cause of impotence in diabetes. Psychosexual counselling alone rarely restores potency.6 Although impotence in diabetes cannot be cured, several effective treatments exist. Penile prostheses have been available for many years, and good results have been reported in selected patients.7 Provision of prostheses by the NHS, however, is unusual as they are expensive and require an operation under general anaesthesia. For most doctors treating impotence two methods of treatment are available: intracavemosal injection and vacuum tumescence. Intracavernosal injection of a vasoactive agent such as papaverine is widely used. The patient should be taught how to inject himself and should be given a test dose in hospital (usually 15 mg). The dose is incrementally increased until a satisfactory erection is achieved. This may require several hospital visits, but well motivated patients can experiment with increasing doses at home. Papaverine is not licensed for selfinjection, so informed consent should be obtained. Complications of self injection are uncommon. Infection and fibrosis have been reported.8 Patients should be told to seek medical advice iftheir erection lasts more than four hours as there is a risk of priapism. This can be treated by removing blood from the corpus cavemosum with a syringe and injecting an a adrenergic agent such as metaraminol or phenylephrine. Prostaglandin E1 is an alternative to papaverine and …