Issues with sexual function are very common and can cause significant anxiety and tension within relationships. The most common problem with sexual function that men complain of is “erectile dysfunction”.  This is the medical term for when you can’t manage to gain or keep an erection long enough to have satisfactory sexual intercourse.  The other major issue is loss of sexual desire or “libido”.

Sexual function is a really complex process. In order to have normal sexual function you need:

  • good circulation
  • a normal level of the hormone testosterone
  • to “be in the right place” psychologically

Each of these 3 elements can be affected by lifestyle.


These means the “plumbing system”, in this particular case, the blood vessels that supply the penis. There’s nothing special about these blood vessels – they are affected by all the same issues that can cause damage to blood vessels throughout the body like smoking, high blood pressure, obesity, low levels of physical activity and high cholesterol. There is increasing evidence that men who have erectile dysfunction are at increased risk of heart and stroke disease as it can be an early sign of hardening of the arteries.


Testosterone is often described as the “male” hormone. Women have it too although it much smaller amounts. One of it’s jobs is to control your sex drive and help with sexual function. It has other jobs too – it keeps bones strong, maintains muscle mass, and helps with your overall feeling of “well-being”. Low testosterone levels in men are known as male hypogonadism.

Again there are many reasons that people can develop low testosterone levels. Levels tend to gradually reduce as you get older. Certain medical conditions like problems with the pituitary gland or haemochromatosis are sometimes to blame. It is very common in men with diabetes although men with any sort of chronic disease are at increased risk.

Obesity is associated with raised inflammation levels within the body which tend to reduce testosterone levels. Sleep apnoea – a sleep disorder associated with obesity also reduces testosterone production. Other lifestyle causes include drinking too much alcohol, cannabis and anabolic steroid use.

Psychological causes

Stress and depression are well known to cause erectile dysfunction and loss of sexual desire.

Side effects of Medication

There are a whole lot of commonly used medications that may interfere with sexual function.  In particular anti-depressant and some medicines used for blood pressure can be implicated.  As we’ve mentioned already recreational drugs including alcohol, cannabis, heroin, methadone and anabolic steroids can all potentially have a negative effect on sexual function.

Diabetes and sexual function

People with diabetes are particularly affected as there are several ways the consequences of diabetes can interfere with normal sexual functioning. Erectile dysfunction occurs 3 times more frequently in men with diabetes than in the general population.  It affects 60% of men with diabetes and increases with age.  Men with diabetes develop erectile dysfunction 10-15 years earlier than the rest of the population.  Many men may already have erectile dysfunction at the time of diagnosis of diabetes. Investigations for erectile dysfunction can sometimes be the reason type 2 diabetes is picked up in the first place.

In men with diabetes there may be diabetic neuropathy (nerve damage). There may damage to both the small and large blood vessels that supply the penis. Poorly controlled diabetes and the weight problems associated with type 2 diabetes may lead to issues with hypogonadism (low testosterone levels).  There may also be a psychological element and of course there may be side effects of both prescription drugs and non prescription drugs such as alcohol and cigarettes.

What can be done about it?

Quite a lot.  The first thing to do is to speak to your GP or another health care professional about it.  Try not to be embarrassed – they won’t be.  It’s something they deal with everyday.

Your doctor will ask you various questions about your general health and also about you sexual problems.  They will examine you, usually including an examination of your genitals and prostate.  They will also check your blood pressure.  Usually blood tests will be performed for your general health, cholesterol, and testosterone.  If you are not known to have diabetes they will also check for that.

They will assess you for other factors that increase your risk of erectile dysfunction and discuss management of those.  These should include your weight, your diabetes control if you have it, if you smoke or not, if you drink excessive alcohol or use recreational drugs, if you have high cholesterol or high blood pressure, if you do enough exercise, if you’ve had major surgery or cancer treatment to your pelvic organs in the past etc.

Increased exercise, weight loss, stopping smoking and cutting down alcohol will be advised if appropriate.  Optimising other conditions eg. control of diabetes is also vital and an action plan for this will be discussed.  Often over time lifestyle improvements may be enough to improve symptoms although clearly this can be hard work.

If the cause is thought most likely to be purely psychological and stress or depression are implicated you may be referred for counselling or to a stress management course, or possibly started on drug treatment for depression.  Some people may also benefit from treatment with Viagra or other similar drugs for a short period of time until their symptoms improve.

PDE5I drugs (phosphodiesterase 5 inhibitors) – this is the group of drugs of which the most well known is Viagra (Sildenafil).  They have really revolutionised the treatment of erectile dysfunction for a lot of men in the last 20 years.  They work by relaxing the muscles in the blood vessels of the penis allowing increased blood flow.  They don’t actually cause an erection – sexual stimulation is still required.  They can be prescribed on the NHS for people with certain conditions like diabetes, but if you don’t fall into one of the categories you may have to pay for a private prescription.

This group of drugs can’t be used in people who have had a heart attack, stroke or a serious abnormality of their heart rhythm in the last 6 months.  They also can’t be used if people have frequent angina attacks, or bad heart failure or very low or very high blood pressure.  Common side effect include dizziness, flushing, back pain and nausea.

There are certain angina tablets (nitrates) that they can’t be taken with Viagra and other similar drugs, and if you take tablets for blood pressure the combination may cause your blood pressure to be lower than usual.  This doesn’t generally cause problems but dizziness is possible.

For people who don’t benefit from Viagra there are several alternatives.  Vacuum devices can be used to cause an erection with a ring placed on the base of the penis during intercourse to maintain it.  Injections into the penis via a special pen injection device before intercourse can also be very effective.  Other less frequently used treatments are MUSE which is a medicated pellet which is inserted into the penis.  Occasionally implants may be surgically inserted into the penis which can be inflated for intercourse.  This last group of treatments would all be through referral to a specialist erectile dysfunction service.

For people who have a low testosterone level there is the possibility of testosterone replacement.  The chance of it being successful depends on how low the level is.  People with a mildly reduced level who are overweight/don’t exercise or drink alcohol heavily may not get much benefit from it and may achieve much more benefit from losing weight and improving their lifestyle.  On the other hand people with very low levels are usually referred to an Endocrinologist for consideration of treatment.  The Endocrinologist will initially do some specialist blood tests to see if there are any specific hormone problems that need addressed.  If this is not the case, and it looks as if the low level is just due to diabetes they will discuss a trial of treatment with you.

Although testosterone treatment in itself is not thought to cause prostate cancer, if you have an undiagnosed prostate cancer already present it may make it worse, hence your prostate blood test (PSA) is checked prior to starting treatment.  Testosterone can occasionally increase elements of your blood count and blood fats.  It can also occasionally cause liver problems so it is important to check these tests too.  Your blood tests will be checked periodically whilst you remain on treatment.

Testosterone is not very effective in tablet form so treatment options are usually a gel (eg. TOSTRAN or TESTOGEL) that is applied daily or an injection (eg. NEBIDO) that is given after 6 weeks initially, then every 3 months.

Testosterone can’t be used in people with unstable heart disease.  Opinion is changing about the use of testosterone in people with prostate cancer but this is something that would be guided by a prostate specialist.

If you are on testosterone treatment your progress will usually be monitored by an Endocrinologist (hormone specialist).

If you have significant health problems eg. cardiac failure or a recent heart attack your doctor will need also need to assess if it would be safe for you to resume sexual activity.  Sexual activity is thought to be equivalent in terms of effort to walking up 2 flights of stairs in 10 seconds or walking a mile in 20 minutes.  If there is any doubt in this regard your doctor may send you for further assessment of your heart.

Often there are multiple complex components which lead to erectile dysfunction.  Some people will benefit from simple lifestyle measures whilst others will need a combination of lifestyle optimisation, tablets like Viagra and testosterone supplementation.  Failing that discussion with your GP about referral on to a specialist erectile dysfunction service may be appropriate.  Don’t be embarrassed to seek help if you are struggling with this issue.

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