The natural history of impotence in diabetic men

Diabetologia, Jun 1984

Summary The natural history of erectile impotence in diabetic men has been defined in a 5-year prospective study of 466 patients initially aged 20–59 years. Of the 275 who were originally potent, 78 (28%) have become impotent. Five features present at first interview were found to be independently predictive of the subsequent development of impotence; age (p< 0.0001), alcohol intake (p< 0.0001), initial glycaemic control (p= 0.03), intermittent claudication (p= 0.04) and retinopathy (p= 0.05). The development of impotence was also significantly associated with the appearance of neuropathic symptoms (p= 0.003) and poor glycaemic control in the intervening 5 years (p= 0.01). Only 11 out of 128 (9%) of those originally impotent regained potency; they were young, had short duration of diabetes, and often features of psychogenic impotence. Those with impotence originally but no clinically apparent micro/macrovascular or neuropathic diabetic complications developed retinopathy (p= 0.001) and neuropathy (p= 0.01) more frequently than their comparable potent counterparts. It is concluded that diabetic impotence rarely reverses, that it is strongly associated with neuropathic and vascular complications of diabetes, and that moderation of alcohol consumption and improvement of glycaemic control are possible preventative factors.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://link.springer.com/content/pdf/10.1007%2FBF00262216.pdf

The natural history of impotence in diabetic men

Diabetologia T h e natural history o f impotence in diabetic men D. K. M c C u l l o c h 0 R . J . Y o u n g 0 R . J . P r e s c o t t 0 I. W. C a m p b e l l a n d B. F. C l a r k e 0 0 Diabetic and Dietetic Department, Royal Infirmary, and Medical Computing and Statistics Unit, Edinburgh University , Edinburgh, Scotland , UK Summary.The natural history o f erectile impotence in diabetic duration o f diabetes, and often features o f psychogenic impomen has been defined in a 5-year prospective study o f 466 pattence. Those with impotence originally but no clinically apients initially aged 20-59 years. Of the 275 who were origiparent micro/macrovascular or neuropathic diabetic complinally potent, 78 (28%) have become impotent. Five features cations developed retinopathy (p=0.001) and neuropathy present at first interview were found to be independently (p = 0.01) more frequently than their comparable potent counpredictive o f the subsequent development o f impotence; age (p < 0.0001), alcohol intake (p < 0.0001), initial glycaemic conterparts. It is concluded that diabetic impotence rarely reverses, that it is strongly associated with neuropathic and vastrol ( p = 0.03), intermittent claudication ( p = 0.04) and retinocular complications o f diabetes, and that moderation o f pathy (p = 0.05). The development o f impotence was also sigalcohol consumption and improvement of glycaemic control nificantly associated with the appearance of neuropathic are possible preventative factors. Diabetes; impotence; alcohol; glycaemic control - 9 Springer-Verlag 1984 f r e q u e n t l y b e e n d e s c r i b e d [ 1-7 ], t h e f a c t o r s l e a d i n g t o its d e v e l o p m e n t a n d t h e p r o g n o s i s o f t h e e s t a b l i s h e d c o n d i t i o n r e m a i n u n c e r t a i n . W e r e p o r t a 5 - y e a r r e v i e w o f a c o h o r t o f d i a b e t i c m e n a g e d 2 0 - 5 9 y e a r s w h o s e sexu a l p o t e n c y at t h e o u t s e t h a s b e e n p u b l i s h e d p r e v i o u s l y [ 7 ]. T h e o b j e c t i v e s w e r e t o i d e n t i f y clinical f e a t u r e s assoc i a t e d w i t h t h e d e v e l o p m e n t o f i m p o t e n c e in t h o s e origi n a l l y p o t e n t a n d to r e c o r d t h e n a t u r a l h i s t o r y o f c o n t i n u i n g s e x u a l d y s f u n c t i o n a n d t h e d e v e l o p m e n t o f o t h e r d i a b e t i c c o m p l i c a t i o n s in t h o s e o r i g i n a l l y i m p o t e n t . Subjects and methods Of the original 541 men interviewed [ 7 ], 63 had died, 36 had moved from the Edinburgh area and 22 were untraceable. Six patients refused to be re-interviewed and a further 11 were considered unsuitable (five for psychiatric reasons, three had ~rebrovascular disease, one had sustained traumatic brain damage and two were no longer considered to have diabetes). Therefore 403 men were re-interviewed. The mean time interval between first and second interviews was 4 years 8 months (range 3 years 8 months to 6 years 2 months). The questionnaire and methodology used were as described previously [ 7 ].Thus in addition to assessing sexual function, direct enquiry was made as to drug therapy and macrovascular (ischaemic heart disease and peripheral vascular disease) or neurological disorders which might predispose to organic impotence. Impotence was defined as the absence of subjectively observed penile erections during the previous 6 months. Symptoms of peripheral and autonomic diabetic neuropathy were also sought but no objective tests of nerve function were performed. Retinopathy (direct fundoscopy through dilated pupils in darkened room) and proteinuria (Albustix) were documented. The average weekly alcohol intake of each was also estimated. For the purpose of analysis two groups were defined; those claiming to consume nil or less than 20 units of alcohol (one unit = 285 ml beer or alcoholic equivalent in spirit/sherry/vermouth) per week were classified as 'moderate' drinkers and those consuming more than 20 units of alcohol per week 'heavy' drinkers. The number of cigarettes smoked daily was recorded. Glycaemic control at the outset was assessed by taking the average of the six preceding clinic blood glucose values. Control was classified as 'good' if the mean blood glucose was < 9 mmol/1, 'fair' if 9.1-13.9mmol/1 and 'bad' if >14mmol/l. Diabetic control in the 5-year follow-up period was assessed as the mean of all the intervening clinic blood glucose results. Statistical analysis Statistical analysis was principally by the application of linear logistic models [ 8 ] which parallel the use of multiple regression for binomial response variables (e. g. potent/impotent). This allows simultaneous assessment of the influence of a number of variables on the occurrence of impotence while taking account of associations between the variables. Two tailed likelihood ration tests were employed to determine the significance of individual terms. Clinical feature Factors associated with the development of impotence Two hundred and seventy-five men potent at the original interview were re-interviewed and 78 (28%) had developed impotence, which in no case could be ascribed to recognised clinical factors, such as medication or obvious psychological cause. Those features present at the time of the original interview which correlated significantly with the subsequent development of impotence were age (p < 0.0001), alcohol intake (p<0.0001), glycaemic control (p=0.03), intermittent claudication (p = 0.04) and retinopathy (p = 0.05; Table 1). The fitted linear logistic model is: probability of impotence = EX/ (a-E ~) where x = - 4 . 2 6 4 + 0 . 0 5 5 age +1.504 alcohol +0.446 control +1.656 intermittent claudication + 0.468 retinopathy (alcohol intake, glycaemic control, intermittent claudication and retinopathy take values 0, 1 or 2, if appropriate, according to the category of the patient). Other clinical features originally ascertained which failed to show an association with the subsequent development of impotence, were duration of diabetes (even when insulin-treated patients were considered alone), type of treatment, proteinuria, and symptoms of peripheral and autonomic neuropathy. When all the predictive factors were retained in the analysis and additional associations were sought among the variables recorded at review, only the development of symptomatic peripheral neuropathy (p = 0.03) and poor glycaemic control in the intervening 5 years (p = 0.01) reached conventional levels of significance (though development o f intermittent claudication was close, p--- 0.07). The progress in sexual function of all the men re-interviewed with respect to the relevant factors other than age and glycaemic control (alcohol consumption, symptoms of peripheral/autonomic neuropathy and microor macrovascular complications) is shown in detail in Among the 63 patients who died during the follow-up period, the mean age at death was 52.3 __.9 years and the mean duration o f diabetes was 16.7+9.6 years. The causes of death were ascertained in all 63 cases. These were myocardial infarction (24), sudden unexplained deaths (8), chronic renal failure (6), cardiac failure (6), cerebrovascular accident (5), pneumonia (3), pulmonary embolism (2), and one case each of carcinoma of stomach, carcinoma of bronchus, hepatoma, cerebral tumour, carcinomatosis from an unidentified primary tumour, septicaemia following amputation for gangrene, cirrhosis of liver, ketoacidosis and hypoglycaemic coma. Although 41 (65%) of the deaths were in men who had been impotent at original interview, impotence per se was not significantly associated with mortality when tested with linear logistic models. Instead the features present at the outset, which were significantly predictive of death during the follow-up period, were age (p< 0.0001), nephropathy (p< 0.0001), previous myocardial infarction (p= 0.0001), symptomatic autonomic neuropathy (p=0.01) and retinopathy (p=0.05). Thus, only six of the impotent men who died had isolated impotence. Of the remaining 35, each had at least one major complication of diabetes when originally interviewed. This study has defined, for the first time, the natural history of impotence in diabetic men. Our original crosssectional study of impotence in 541 randomly selected diabetic men [ 7 ] identified a prevalence of 35%. Of the 190 originally impotent patients, 41 had died during the 5 years, 21 were unavailable or unsuitable and 128 were re-interviewed. Only 11 (9%) of those originally impotent had regained potency. Even among the 45 men with isolated impotence at the outset (i. e. no micro/macrovascular disease or symptomatic neuropathy) only seven (16%) regained potency. Those recovering erectile function were significantly younger, had shorter duration of diabetes and often some psychological or organic factor had been present at initial interview which in retrospect was quite sufficient to account for temporary impotence. In the vast majority of cases, therefore, impotence developing in diabetic men is persistent. Impotence per se was also found to be significantly associated with the subsequent development of retinopathy and symptomatic peripheral and autonomic neuropathy but it did not confer an increased risk of mortality. The original cross-sectional study demonstrated that established impotence was significantly related to age, retinopathy and symptomatic peripheral and autonomic neuropathy. The present follow-up study has identified some features which are predictive of the subsequent development of impotence. Age, alcohol intake, glycaemic control, peripheral vascular disease and retinopathy at the first interview were all associated with the development of impotence within 5 years. Age is, of course, a well-recognised associated feature of impotence, both in diabetes [ 1-7 ] and normal men [ 9 ]. However, it has not been demonstrated previously that high alcohol consumption and poor glycaemic control may dition and other diabetic complications, if not already present, will often become manifest shortly after. 1. Rubin A , Babbott D ( 1958 ) Impotence and diabetes mellitus . JAMA 168 : 198 - 500 2. Sch6ffling K ( 1960 ) St6rungen der Kleindriisenfunktion bei m~innlichenZuckerkranken . Beitr Sexualforsch 19 : 1 - 83 3. Montenero P , Donatone E ( 1962 ) Diab6te et activit6 sexuelle chez l'homme . Diabete Metab 10 : 327 - 335 4. Ellenberg M ( 1971 ) Impotence in diabetes: the neurologic factor . Ann Intern Med 75 : 213 - 219 5. Faerman I , Vilar O , Rivarola M , Rosner JM , Jadzinsky MN , Fox D , Perez Loret A , Bernstein-Hahn L , Saraceni D ( 1972 ) Impotence and diabetes. Studies of androgenic function in diabetic impotent males . Diabetes 21 : 23 - 30 6. Kolodny RC , Kahn CB , Goldstein HH , Barnett DM ( 1974 ) Sexual dysfunctionin diabetic men . Diabetes 23 : 306 - 309 7. McCulloch Dig , Campbell IW , Wu FC , Prescott RJ , Clarke BF ( 1980 ) The prevalence of diabetic impotence . Diabetologia 18 : 279 - 283 8. Cox DR ( 1970 ) The linear logistic model . In: Analysis of binary data. Methuen , London, pp 14 - 29 9. Kinsey AC , Pomeroy WB , Martin CE ( 1948 ) Age and sexual outlet . In: Sexual behaviour in the human male . Saunders , Philadelphia, pp 218 - 262 10. Gaskell P ( 1971 ) The importance of penile blood pressure in cases of impotence . Can Med Assoc J 105 : 1047 - 1051 11. Abelson D ( 1975 ) Diagnostic value of the penile pulse and blood pressure. A Doppler study of impotence in diabetics . J Urol 113 : 636 - 639 12. Ruzbarsky V , Michal V ( 1977 ) Morphological changes in the arterial bed of the penis with ageing. Relationship to the pathogenesis of impotence . Invest Urol 15 : 194 - 199 13. Michal V ( 1982 ) Arterial disease as a cause of impotence . Clin Endocrinol Metab 11 : 725 - 748 14. Rundles RW ( 1945 ) Diabetic neuropathy; general review with report of 125 cases . Medicine (Baltimore) 24 : 111 - 160 15. Martin MM ( 1953 ) Involvementof autonomic nerve fibres in diabetic neuropathy . Lancet 1 : 560 - 565 Received: 15 August 1983 and in revised form: 28 March 1984


This is a preview of a remote PDF: https://link.springer.com/content/pdf/10.1007%2FBF00262216.pdf

D. K. McCulloch, R. J. Young, R. J. Prescott, I. W. Campbell, B. F. Clarke. The natural history of impotence in diabetic men, Diabetologia, 1984, 437-440, DOI: 10.1007/BF00262216