To understand ED, it helps to know how erections work. When a man is sexually stimulated (usually with arousing thoughts or sexual touching) blood flow to the penis increases. Increased blood makes the penis firm. This is called an erection.

Most cases of ED can be described in one of two ways. Some men notice it is more difficult to get an erection when they want one. Others are able to get a firm erection but cannot maintain it as long as they want. In some men, the two problems are combined.

Diabetes is a known risk factor for ED. One study found that men with diabetes are three times more likely to experience ED. This may be because diabetes affects blood vessels or nerves responsible for erections.

Diabetes is not the only risk factor for ED. Cardiovascular (heart) disease, high blood pressure, high cholesterol, smoking, and certain medications can all affect erections. Certain surgeries, such as prostate cancer surgery, may also cause ED. Psychological stress due to relationship issues or work pressures can lead to problems. Any changes to erections can signal a health problem. Discussing it with your family doctor or your diabetes education team is important.

ED can be addressed in several ways. The first involves changing lifestyle to improve nerve signals and blood flow to the penis. Regular exercise, eating well, and taking steps to control blood glucose, blood pressure and cholesterol levels can all help.

The second approach focuses on both emotional and physical intimacy. Many couples say that talking about ED allows them to pay attention to their sexual intimacy, and explore different ways to experience pleasure. It may be something they have never done before. (See sidebar for more information.)

Finally, treatments for ED are available and can be very helpful. Possibilities include oral medications, self-injection, intraurethral therapy, vacuum devices, and surgical options.

Oral medications

Oral medications now available by prescription in Canada are sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra® and Staxyn™). They all work in a similar way, boosting a man’s natural ability to have an erection by improving blood flow to the penis, and allowing it to stay erect longer.

One advantage of oral medications is they only work when the man is sexually stimulated. Both mental and physical sexual stimulation are needed. In other words, if a man takes the medication and decides not to have sex, he will not get an erection.

Some key differences among the three medications exist (see table). The costs are very similar, although they are not typically covered by drug benefit plans.

Any man taking nitrate medications such as nitroglycerin tablets or patches, even only occasionally, should not use these medications. The combination may cause a serious drop in blood pressure. Other medications can affect how well these oral therapies are absorbed by the body. Be sure to discuss your current medications with your doctor or pharmacist.

In general, oral therapies work better if you can get some erection on your own. They will not work for all men. Try other ED therapies if these medications are not effective for you.

Oral Medications
	Viagra® (sildenafil)* Available in 25, 50 and 100 mg tablets for as-needed use	Cialis® (tadalafil)* Available as 5 mg tablet for daily use, or 10 and 20 mg tablets for as-needed use		Levitra® (vardenafil)* Available in 5, 10 and  20 mg tablets for  as-needed use	Staxyn™  (vardenafil)* Available in 10 mg orally dissolving tablets for  as-needed use
When do I  take it?	As needed: 30 to 60 minutes before sexual activity	Once a day: One low dose tablet about the same time each day (whether or not you plan to be sexual)	As needed: At least 30 minutes before sexual activity	As needed: 25 to 60 minutes before sexual activity	As needed: 45 to 90 minutes before sexual activity
When will  it work?**	30 minutes to four hours	Any time, (may not work until four to five days from starting the medication)	30 minutes up to  36 hours	15 minutes up to  eight to 10 hours	45 minutes up to eight hours
What are the  most common side effects?	Headache, indigestion, flushing, stuffy nose, dizziness	Headache, indigestion, back pain, muscle aches, stuffy nose, facial flushing		Headache, indigestion, flushing, stuffy nose	Headache, indigestion, back pain, muscle aches, stuffy nose, facial flushing
All of these oral therapies absolutely must NOT be taken with nitrate medications. *The time it takes for the medication to work does vary from person to person. It is suggested that you experiment to find the best timing for you. Table adapted from 40over40, a website devoted to education about ED.

Self-injection therapy

Self-injection therapy involves using a little needle to inject a small amount of medication into the side of the shaft of the penis. The same type of needle is used to inject insulin. Once the medication is injected, it directly increases blood flow in the penis. This usually starts to work within 10 to 20 minutes.

This treatment is usually effective regardless of the cause of ED. It may work when oral medications do not. There is a possibility of priapism (an erection lasting more than three hours). However, this risk is low, especially with careful dosing. The key to success with this method is to understand how and where to inject. It can be taught by urologists, some family doctors, and specially trained nurses. This therapy may be covered by your drug benefit plan.

Intraurethral therapy

Intraurethral therapy is similar to the self-injection method in that the medication works locally to increase blood flow in the penis. Rather than injecting medication, a special applicator is inserted into the urethra (the tube that drains urine from the bladder). It deposits a pellet of medication smaller than a grain of rice. Once absorbed into the penis, the medication increases blood flow. Some men have some burning sensation as the medication is absorbed. This therapy is not usually covered by drug benefit plans.

Vacuum device therapy

Vacuum device therapy is the one option for ED that does not involve medication. It involves placing the penis into a cylindrical tube attached to either a manual or battery-operated vacuum device. When activated, suction brings blood into the penis. Once the penis is erect, a constrictor band placed at the base of the penis maintains the erection for as long as the band is in place. It should not be left on for longer than 30 minutes at a time.

Men who are able to get a full erection but have difficulty keeping it may use the constrictor band on its own.

Ways to Promote Intimacy

Discuss how you are feeling with your partner. Explain the cause of the erectile dysfunction.
Include your partner in decisions about ED treatment.
Take the focus off intercourse or penetration. Try being sexual in other ways. For instance, try a sensual massage or bathing together.
Explore books and videos for ways to enhance sexual activity. A good book is The Complete Diabetes Guide for Type 2 Diabetes, by Karen Graham, RD, CDE, 2011.

Some good websites are:
Sexuality and Diabetes, About.com
Diabetes and Sex, Diabetes.co.uk

Try to increase your enjoyment by focusing the sexual experience on all of your senses (sight, touch, smell, taste and sound).
Consider meeting with a counsellor or sexual therapist to discuss ways to increase sexual pleasure.

Surgical options

Surgery can place an inflatable or bendable implant into the penis. Penile implants are usually only considered once all other therapies have been tried. An urologist can help you explore this option.

The available therapies have made ED very manageable. However, many couples find a sexual therapist or counsellor helpful. As well, some strategies can help promote sexual closeness (see sidebar). In counselling, suggestions can be offered about how to incorporate the treatments, along with ideas and activities to promote intimacy. Including your partner when considering options can help reduce stress and allow closer involvement. Since some partners blame themselves, it is important that both of you understand the cause of the ED.

Choosing a therapy for ED is a very personal decision, and should be discussed with your health care provider. The type of ED, personal preference, and financial considerations will influence your decision.