Erectile Dysfunction as an Early Marker of Microangiopathic Complications in Type 2 Diabetes Mellitus

Research Article

Austin Andrology.2017; 2(1): 1012.

Erectile Dysfunction as an Early Marker of Microangiopathic Complications in Type 2 Diabetes Mellitus

Caretta N¹*, de Rocco Ponce M¹, de Kreutzenberg SV², Guarneri G², Garolla A¹, Avogaro A² and Foresta C¹

¹Department of Medicine, Section of Endocrinology and Centre for Human Reproduction Pathology, University of Padova, Italy

²Section of Diabetes and Metabolic Diseases, Department of Medicine, University of Padova, Padua, Italy

*Corresponding author: Caretta N, Department of Medicine, Section of Endocrinology and Centre for Human Reproduction Pathology, University of Padova, Via Giustiniani, Padua, Italy

Received: January 27, 2017; Accepted: February 20, 2017; Published: February 22, 2017


Erectile dysfunction (ED), a very frequent finding among type 2 diabetes patients (T2DM), is associated with cardiovascular disease. To investigate the prevalence of ED among our T2DM population and its association with microangiopathic complications (diabetic retinopathy (DR) and microalbuminuria [mAlb]), we performed a retrospective cross-sectional study involving 121 patients attending the Diabetology Unit of Padua Hospital. All subjects were studied with accurate anamnesis, IIEF-5 questionnaire, microalbuminuria determined in spot urine sample, fundus examination and carotid artery echo-color-doppler. ED prevalence was 64.8% while DR and mAlb prevalence was 25.6% and 23.1% respectively. In ED group vs. non-ED, DR prevalence was 32.9% vs. 11.9% (p=0.012) and mAlb prevalence was 26.6% vs. 16.7% (p=0.218). ED group had a worse glycemic control (HbA1c 7.6 ± 1.6 vs. 7.0 ± 1.0 %, p=0.010) and a longer T2DM duration (10.3 ± 9.2 vs. 6.0 ± 5.7 years, p=0.002). Furthermore, ED was associated with a higher carotid intima-media thickness (IMT 0.9 ± 0.2 vs. 0.8 ± 0.2 mm, p=0.049). ED was the first vascular complication in 57% of patients, occurring some years before DR and mAlb. Association with DR and mAlb is independent of common cardiovascular risk factors. In conclusion, ED onset in diabetic subjects is a very important finding that can be considered an early microangiopathic marker in T2DM subjects, suggesting the evaluation for the presence of other microangiopathic complications and a more intense control of cardiovascular risk factors.

Keywords: Erectile Dysfunction; Diabetes; Diabetic Retinopathy; Microalbuminuria; Cardiovascular Disease; Nitric Oxide


ED: Erectile Dysfunction; T2DM: Type 2 Diabetes Mellitus; DR: Diabetic Retinopathy; Malb: Microalbuminuria; DN: Diabetic Neuropathy; IIEF-5: International Index Of Erectile Function – 5; MI: Myocardial Infarction; CVD: Cardiovascular Disease; CHD: Coronary Heart Disease; Hba1c: Glycated Hemoglobin; LH: Luteinizing Hormone; FSH: Follicle-Stimulating Hormone; E2: Estradiol; PSA: Prostatic-Specific Antigen; Egfr: Estimated Glomerular Filtration Rate; LDL: Low-Density Lipoprotein; HDL: High-Density Lipoprotein; IMT: Intima-Media Thickness; BMI: Body Mass Index; NO: Nitric Oxide


Type 2 diabetes mellitus (T2DM) is not merely a disorder of carbohydrate metabolism, but a cause of vascular diseases affecting nearly all arterial vessels which are classically divided in microangiopathic and microangiopathic. The link between diabetes and macroangiopathic disease was suggested many years ago, observing a higher risk of myocardial infarction (MI) and cardiovascular death in several diabetic populations. In Italy, diabetic patients have a cardiovascular mortality excess of about 30-40% vs. non diabetic individuals [1-3]. Microangiopathic disease is characterized by three major manifestations: diabetic retinopathy (DR), diabetic neuropathy (DN) and diabetic nephropathy. Around 30% of diabetic patients suffer from DR, ranging from mild to severe. Male sex, higher glycated haemoglobin levels, longer duration of diabetes mellitus, higher blood pressure values and use of insulin are all associated with the development of retinopathy [4,5]. Diabetic nephropathy in T2DM occurs in 20-40% of patients and microalbuminuria (mAlb) is a marker of early nephropathy [6,7]. DR and mAlb are both associated with an increased incidence of cardiovascular disease (CVD) and mortality [4,7]. Erectile dysfunction (ED), defined as the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance [8], may be the first sign of CVD. Montorsi et al. have shown that ED can precede coronary and peripheral artery disease of some years [9] and a relationship between ED and silent myocardial ischemia has been demonstrated in apparently uncomplicated T2DM patients [10]. ED has a much higher prevalence among diabetic vs. non-diabetic subjects [11]. A large Italian case study observed a prevalence of 35.8% [12], while others between 35 and 90% [13]. The ADVANCE study (Action in diabetes and Vascular Disease: Preterax and Diamicron Modified- Release Controlled Evaluation) showed that in diabetic patients the presence of ED at the enrolment was associated with a high risk for all cardiovascular events, coronary heart disease (CHD) and cerebralvascular disease [14]. To our knowledge, no data is still available about onset precocity of ED among microangiopathic complications, therefore we investigated the prevalence of ED among our T2DM population, its association with micro-vascular complications (DR and mAlb) and their occurrence timing.

Materials and Methods

This is a retrospective cross-sectional study, involving 121 patients attended at the Diabetology Unit of Padua Hospital, who followed a normal screening schedule for the complications of T2DM. All patients were T2DM patients and had an age between 40 and 78 years with a mean age of 58.2 ± 8.5 years, mean T2DM duration of 8.8 years, BMI 29.0 ± 4.7 Kg/m2 and glycated haemoglobin (HbA1c) 7.5 ± 1.4% (Table 1). All the subjects underwent an accurate medical history collection including ongoing therapy, International Index of Erectile Function (IIEF-5) questionnaire, physical examination (weight, height, BMI, waist circumference and blood pressure), biochemical blood tests (fasting plasma glucose, glycated haemoglobin, total cholesterol, high-density lipoprotein cholesterol, triglycerides, and creatininemia), hormone levels (LH, total testosterone, estradiol (E2) and PSA). Blood collection and pressure measurements were performed in fasting condition, between 08.00 and 10.00 a.m., avoiding cigarette smoking for a minimum of 12h. Blood samples were collected in SST II, LHPST II, and EDTA tubes and analysed concurrent to blood draw. We excluded patients with post-surgical ED, neoplastic patients, with end-stage renal or liver insufficiency and transplanted patients.