Could diabetes lower sperm count and lead to impotence? Here’s how to manage it

Why men with diabetes have trouble with erectile dysfunction?

That’s because this requires an interaction of three systems — the blood vessels, nerves and the male hormone, testosterone. Uncontrolled blood sugar can affect all three. Damage to the arteries by diabetes, high blood pressure and cholesterol, along with increasing age and smoking, can impede blood flow to the penis. Damage to the nerves (diabetic neuropathy) may impair autonomic and somatic nerve responses that are essential for erections.

Besides, diabetes is also associated with impaired relaxation of penile smooth muscle, a process that is important for achieving and sustaining erection that leads to a condition called erectile dysfunction (ED). At times, drugs used to treat high blood pressure (like beta blockers) can also contribute to ED. It is now understood that men with diabetes may also be at increased risk of low blood levels of the male hormone, testosterone.

Testosterone is the principal male hormone in our body and is secreted by the testes. It is responsible for a man’s libido. Deficiency of testosterone leads to reduced sexual desire and sperm formation but that’s not the only role it plays. A low level of testosterone can result in reduced bone mass (osteoporosis), muscle mass and strength. Besides, it has an impact on mood and behaviour too. Low testosterone can result in depression and lethargy.

How to measure the impact of diabetes on testosterone

The diagnosis of testosterone deficiency is made by checking the blood level of the hormone (total testosterone) along with some other tests. Blood sample for the test should be drawn around 8 am as the level declines during the day. The test should be performed by an accurate method like LCMS/MS (liquid chromatography and tandem mass spectrometry). The exact cut-off level to define a low level remains controversial. Levels below 250 ng/dl are clearly deficient and those above 300 ng/dl (or 320 ng/dl) are considered normal. There is a grey zone in between where treatment depends on presence of symptoms.

Testosterone can be administered as an injection or a daily gel applied on the skin and requires monitoring under medical supervision. However, even in those who are clearly deficient, testosterone may not always result in improvement in ED, thereby, highlighting the multiple factors at play for ED in diabetes.

What is the way forward for those who do not have testosterone deficiency but have ED?

The most popular and successful treatment for ED is the use of a class of drugs called phosphodiesterase inhibitors (PDE5I). Sildenafil (Viagra) was the first one to be marketed and it revolutionised the treatment of ED. Taldafil is longer acting and the most popular one at present. Through the nitric oxide / cGMP pathway, these drugs produce continued penile muscle relaxation and allow erections to be maintained for longer periods. Low dose Taldafil (2.5 to 5 mg) can be used on an intermittent or daily basis.

There can be significant drug interactions and those with heart disease need to be cautious. Never take these medicines without checking with your doctor. A more invasive approach to managing ED includes direct injection of blood vessel dilating drugs into the penis. Prostglandin E-1 is approved for this purpose. A rare side effect is priapism, sustained painful erection without sexual stimulus. Prostaglandin may also be administered via an intraurethral route.

If these local injections don’t work, vacuum erection devices (VED) may be useful. Penile prostheses are an effective option for diabetic men with ED if all else fails. It is prudent to ensure good control of diabetes before undergoing the procedure for best results. An emerging therapy for ED is low-intensity shock wave therapy (LiESWT), but more long term studies are needed.

Retrograde ejaculation, where the ejaculate goes back into the urinary bladder rather than being expelled through the urethra, is another abnormality that is sometimes seen in diabetes.

Regardless of the mode of treatment, psychological counselling remains an integral part of management. In addition, the fundamentals of diabetes management are important. Regular exercise, a healthy diet rich in fresh vegetables and weight management are the key. Weight loss can result in markedly improved sexual function. People with well controlled diabetes, blood pressure and cholesterol are much less likely to suffer from sexual issues. Don’t lose sight of the basics of diabetes management, ever.