Epidemiological studies consistently show that prevalence of erectile dysfunction (ED) increases with ageing. Nonetheless, complaints of ED even in younger men are becoming more and more frequent. Healthcare professionals working in Sexual Medicine but even those operating in different clinical contexts might be adequately prepared to answer this increasing requirement. ED in younger men is likely to be overlooked and dismissed without performing any medical assessment, even the most basic ones, such as collection of medical history and physical exam. This is due to the widespread assumption that ED in younger individuals is a self-limiting condition, which does not deserve any clinical evaluation or therapy and can be managed only with patient reassurance. However, evidence shows that, in younger subjects, organic, psychological and relational conditions can contribute to the pathogenesis of ED and all these conditions might be evaluated and treated, whenever necessary. Among the organic conditions contributing to the onset of ED, metabolic and cardiovascular (CV) risk factors are surprisingly of particular relevance in this age group. In fact, in younger men with ED, even more than in older ones, recognizing CV risk factors or conditions suggestive of cardio-metabolic derangements can help identifying men who, although at low absolute risk due to young age, carry a high relative risk for development of CV events. In this view, the assessment of a possible organic component of ED even in younger individuals acquires a pivotal importance, because it offers the unique opportunity to unearth the presence of CV risk factors, thus allowing effective and high quality preventive interventions.
Since 1998, when sildenafil (brand name Viagra) first came on the market, oral therapy has been successfully used to treat erectile dysfunction in many men with diabetes. (Sildenafil was followed in 2003 by the drugs tadalafil [Cialis], vardenafil [Levitra] and avanafil [Stendra], which work in much the same way.) Some 50% of men with Type 1 diabetes who try the drugs report improved erections, and some 60% men with Type 2 diabetes do, too. However, that leaves a large percentage of men with diabetes and erectile dysfunction who do not respond to therapy with one of these pills. This article takes a look at what can be done to treat those men who do not respond to oral therapy.
If on one hand, depression and anxiety can lead to ED, drugs commonly used for their treatment can cause ED, as well. Sexual dysfunctions are common side effects of several psychotropic drugs that can disrupt sexual health by several different mechanisms (83). In particular, ED has been reported in subjects using serotonin selective re-uptake inhibitors (SSRI), lithium and benzodiazepines (83). SSRI are associated with a broad spectrum of sexual dysfunctions, but the most commonly reported complaints are delayed ejaculation or anorgasmia and reduced sexual desire (84). Several mechanisms could be advocated including the agonist effect on serotonin receptors type 2 and the increase in PRL levels. ED is a frequent complaint as well (84,85). The relationship between the use of SSRI and ED can be secondary to loss of sexual desire but SSRI, in particular paroxetine, are also able to inhibit cholinergic receptors and nitric oxide synthase (86). In addition, it has been observed that SSRIs might down-regulate hypothalamic-pituitary-testis axis in depressed men (87).
Alcohol abuse is the leading cause of impotence and other disturbances in sexual dysfunction.[3] Episodic erectile failure in alcoholic men is fairly routine, found to be significantly higher in men consuming more than three standard units of alcohol (12 g ethanol) daily and in subjects smoking more than 10 cigarettes/day.[4] Van Thiel and Lester[5] reported that 61% of patients dependent on alcohol reported sexual dysfunction, the most common being erectile dysfunction followed by reduced sexual desire. Erectile dysfunction and reduced sexual desire were frequently seen to be coexisting.[6–9] Vijayasenan,[10] found that of 97 male inpatients admitted for the treatment of alcoholism, 71% suffered from sexual dysfunction for a period of more than 12 months prior to admission to a hospital. The disturbances noted were diminished sexual desire (58%), ejaculatory incompetence (22%), erectile impotence (16%) and premature ejaculation (4%). Virtually all aspects of the human sexual response are affected by alcohol especially sexual desire and erection.[11]
Tobacco use though, was not found to be a significant determinant of sexual dysfunction. This is contrary to all reported evidence.[19] This finding is most likely to be due to our treatment of tobacco use as a categorical (present / absent) variable in a situation where almost 90% of the sample was using tobacco. Future studies need to use indices of severity to avoid this error.

Since the decrease in T levels is often a consequence of obesity or weight gain (51), the milestone of treating testosterone deficiency in obese men is encouraging substantial lifestyle changes, including physical activity and weight loss. In fact, it is universally recognized that a low calorie diet or bariatric surgery can induce a significant increase in T plasma levels, reaching 10 nmol/L with the most invasive surgical procedures (62). Weight loss-induced T rise is more evident in young individuals (62), and, therefore, it must be strongly recommended in this age band.
Sexual dysfunction and ED become more common as men age. The percentage of complete ED increases from 5% to 15% as age increases from 40 to 70 years. But this does not mean growing older is the end of your sex life. ED can be treated at any age. Also, ED may be more common in Hispanic men and in those with a history of diabetes, obesity, smoking, and hypertension. Research shows that African-American men sought medical care for ED twice the rate of other racial groups.
Researchers have found that one particular simple sugar, present in increased levels in diabetics, interferes with the chain of events needed to achieve and maintain erection and can lead to permanent penile impairment over time.  The results, which have implications for new types of erectile dysfunction treatments targeting this mechanism of erection, are described in the August 16 issue of the Proceedings of the National Academy of Sciences.
Carrying extra pounds can impact your sexual performance, and not just by lowering your self-esteem. Obese men have lower levels of the male hormone testosterone, which is important for sexual desire and producing an erection. Being overweight is also linked to high blood pressure and hardening of the arteries, which can reduce blood flow to the penis.
In some cases, however, these drugs may be unsuitable for patients with heart disease. If you are considering one of these drugs and you have heart disease, as many diabetics do, be sure to tell your doctor. In rare cases, the pills may create “priapism,” a prolonged and painful erection lasting six hours or more (although reversible with prompt medical attention).
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