Prevalence and Risk Factors of Erectile Dysfunction in Patients with Type 2 Diabetes Mellitus in Erbil-Iraq

Abstract

Background and Objectives: Erectile dysfunction is a highly prevalent disease. It affects multiple aspects of health and can have a serious adverse effect on both the patients and their partners. Diabetes mellitus is a metabolic disorder associated with many chronic complications including erectile dysfunction. The aim of this study was to find out the prevalence and risk factors of erectile dysfunction in patients with type 2 diabetes mellitus. Patients and Methods: A cross-sectional study had been done on 100 adult male patients with type 2 diabetes mellitus, attending endocrinology outpatient at Erbil Teaching Hospital between June and December 2021, and another 50 age-matched non-diabetic controls. Each one of them underwent detailed history taking, clinical examination, and relevant biochemical study. Results: Sixty-three diabetic patients (63%) had erectile dysfunction compared to 6 nondiabetic subjects (12%). Mild, mild-to-moderate, moderate, and severe erectile dysfunction among these patients were 17 (27%), 21 (33.3%), 16 (25.4%), and 9 (14.3%), respectively. Among diabetics, erectile dysfunction was significantly associated with age, obesity, glycated hemoglobin level, duration of diabetes, presence of hypertension, dyslipidemia, and neuropathy (p= 0.001, 0.005, <0.001, 0.038, 0.02, 0.017 and 0.025 respectively) Conclusion: Erectile dysfunction was significantly more prevalent in patients with type 2 diabetes than in non-diabetic patients. Being older than 50 years old, obesity, glycated hemoglobin level higher than 9, diabetes more than 10 years duration, presence of hypertension, dyslipidemia, and neuropathy were significantly in favor of a higher prevalence of erectile dysfunction in this group.

Full text

* F.K.B.M.S (Int. Med), M.B.Ch.B. Lecturer, Department of Internal medicine,
College of Medicine, Hawler Medical University. Email: yahya.kamal@hmu.edu.krd
**M.B.Ch.B, MSc., Ph.D. Ass. Prof, Department of Internal medicine, College of Medicine,
Hawler Medical University Email: you_xati@yahoo.com
Corresponding Author: Yahya Kamal MohammedAli. Email: yahya.kamal@hmu.edu.krd
https://amj.khcms.edu.krd/
125
https://doi.org/10.56056/amj.2023.226
Advanced Medical Journal, Vol.8, No.2, P.125-135, 2023
Prevalence and Risk Factors of Erectile Dysfunction in Patients
with Type 2 Diabetes Mellitus in Erbil-Iraq
Yahya Kamal MohammedAli*
Yousif Baha'addin Ahmed**
Abstract
Background and Objectives: Erectile dysfunction is a highly prevalent disease. It affects
multiple aspects of health and can have a serious adverse effect on both the patients and their
partners. Diabetes mellitus is a metabolic disorder associated with many chronic
complications including erectile dysfunction. The aim of this study was to find out the
prevalence and risk factors of erectile dysfunction in patients with type 2 diabetes mellitus.
Patients and Methods: A cross-sectional study had been done on 100 adult male patients
with type 2 diabetes mellitus, attending endocrinology outpatient at Erbil teaching hospital
between June and December 2021, and another 50 age-matched non-diabetic controls. Each
one of them underwent detailed history taking, clinical examination, and relevant
biochemical study.
Results: Sixty-three diabetic patients (63%) had erectile dysfunction compared to 6
nondiabetic subjects (12%). Mild, mild-to-moderate, moderate, and severe erectile
dysfunction among these patients were 17 (27%), 21 (33.3%), 16 (25.4%), and 9 (14.3%),
respectively. Among diabetics, erectile dysfunction was significantly associated with age,
obesity, glycated hemoglobin level, duration of diabetes, presence of hypertension,
dyslipidemia, and neuropathy (p= 0.001, 0.005, <0.001, 0.038, 0.02, 0.017 and 0.025
respectively)
Conclusion: Erectile dysfunction was significantly more prevalent in patients with type 2
diabetes than in non-diabetic patients. Being older than 50 years old, obesity, glycated
hemoglobin level higher than 9, diabetes more than 10 years duration, presence of
hypertension, dyslipidemia, and neuropathy were significantly in favor of a higher prevalence
of erectile dysfunction in this group.
Key words: Diabetes; Erbil-Iraq; Erectile dysfunction; Prevalence; Risk factors.
Introduction
Erectile dysfunction (ED) is a sustained
inability to have and keep an erection
enough to allow the sexual activity to be
satisfactory.1, 2 Available studies reveal
that ED is highly prevalent worldwide; it
affects multiple aspects of wellbeing and
can have a serious adverse effect on both
the patients and their partners.3-5 Based on
the variation in the study methods, cultural
differences, and the description of ED,
large variations in the prevalence of ED
are being identified.6 The prevalence of
ED is anywhere from 35% to 75% in
several cross-sectional publications.7-8
Notable findings have been published in
two landmark articles, the Massachusetts
Male Ageing Study (MMAS) from the
United States (USA) and the European
Male Ageing Study (EMAS) from
Europe.3, 9 About 52% had an occurrence
of mild to moderate ED in males aged 40-
70 years, and this was significantly

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associated with age, health, and emotional
condition, as stated by the MMAS.10-11
Whereas, based on different age
subgroups, the EMAS multicenter
population-based research for male
patients 40-79 years of age recorded an
incidence of 6-64 percent and an overall
prevalence of 30 percent.9, 11 Diabetes
mellitus (DM), on the other hand, is a
metabolic disorder associated with many
chronic complications including sexual
disorders.12 Current data shows that DM
seems to reach a pandemic level globally.
As of 2019, nearly 463 million adults (20-
79 years) were having diabetes; by 2045
this will go up to 700 million.13
Furthermore, the main burden and the
largest increase seems to be in the
developing countries. About 80% of
diabetic patients were discovered to be the
residents of low- and middle-income
countries.13 Diabetes typically causes
multiple variants of sexual dysfunction,
mainly ED, premature ejaculation and
diminished libido, occasionally
delayed/prolonged ejaculation.14-15 The
most common sexual disorder associated
with DM is erectile dysfunction.12, 16-17
The aim of this study is to find out the
prevalence of ED in patients with type 2
DM and its relation to several contributing
factors. More attention will be given to
certain risk factors to assess their
significance in developing ED.
Patients and Methods
This observational cross-sectional study
had been done at the endocrinology
outpatient at Erbil teaching hospital which
is located in the Kurdistan Region at the
north of Iraq. Recruitment was for six
months between June and December 2021.
We employed a convenience sampling
method. Men attending the endocrinology
outpatient at Erbil teaching hospital during
the study period were recruited if met the
inclusion criteria. The patients included in
this study must meet the following
inclusion criteria: (1) male patients; (2)
diagnosed with type 2 DM (as per the
American Diabetes Association
definitions); 18 (3) aged 20 years and more;
and (4) being married. The exclusion
criteria were: (1) pathological anomalies of
the genitals that might affect erection (e.g.,
Peyronie disease); (2) type 1 diabetes; (3)
a history of pelvic or gonadectomy
operation; (4) organ transplantation
history; (5) known or suspected chronic
disabling disease such as chronic renal
failure, chronic hepatic failure, chronic
heart failure and chronic obstructive
pulmonary disease; (6) a primary diagnosis
(e.g., hyposexuality) of concomitant sexual
dysfunction (such is primary
hypogonadism); and (7) Drug abuse
history over the past 12 months. In total,
180 male participants had been invited to
this study; however 150 participants were
included in this study. Of them, 100 were
suffering from Diabetes and considered as
patients group and 50 age-matched
disease-free participants who were named
control group (non-diabetic). Diabetes
period in this study is determined by the
date of onset of the disease. The BMI was
classified into: Normal=18-24.9 kg/m2,
Overweight >25-29.5 kg/m2 and Obese >
30 kg/m2.18 Smoking was classified into
either never-smoker (including ex-
smoker), or current smoker. We recorded
glycosylated hemoglobin A1c (HbA1c)
levels assessed in the last 3 months. DM
therapies were listed as oral anti-diabetic
drug (OAD) or insulin (alone or in
combination with OAD). The presence of
hypertension was assessed by history and
hypertension treatment was classified into
1/ Beta Blocker. 2/Angiotensin converting
enzyme inhibitor (ACEi) or angiotensin
receptor blocker (ARB). 3/Others. Ankle
systolic blood pressure (BP) was measured
and its ratio to the systolic BP of the arm
was calculated according to a standardized
method to find the ankle brachial pressure
index (ABI) and was used to evaluate the
presence of peripheral arterial disease
(PAD). A value of 0.9 or less in either legs

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is a agreed to be diagnostic for PAD.
Dyslipidemia was defined by the presence
of any of the following: total cholesterol
>4.5 mmol/L, low density lipoprotein >2.6
mmol/L, triglycerides >1.7 mmol/L, high
density lipoprotein <1.1 mmol/L, or non-
high-density lipoprotein >3.4 mmol/L.
Total serum testosterone levels were
considered to be normal (>10 nmol/L) or
low (<10 nmol/L), depending on the
agreed reference ranges.19 Thyroid
Stimulating Hormone TSH: was classified
into Normal (0.4-4 IU/ml) or High (>4
IU/ml). Prolactin Hormone also was
classified into either Normal (< 20 mcg/L)
or High (> 20 mcg/L). Neuropathy (by
neurological examination) and
nephropathy (by testing for
microalbuminuria or elevated levels for
creatinine) were investigated by history,
examination, and laboratory testing.
Educational level of the participants was
classified into Primary (elementary),
Secondary (Intermediate and Preparatory)
or other (higher education, post-
graduation). Alcohol drinking was
classified into either yes (regardless of
amount, frequency, or type) or No. Due to
participants’ very low responsiveness
screening for depression was omitted from
the study. ED was evaluated using a face-
to-face interview approach implementing
the five questions of the International
Index of Erectile Function Questionnaire
(IIEFQ).20 IIEFQ-5 is scored on a Likert
scale (0-5), in which a higher score
suggests better sexual function. Sexual
dysfunction severity was divided into five
classes according to the total score (i.e.,
severe 5-7, moderate 8-11, mild to
moderate 12-16, mild 17-21 and no
erectile dysfunction 21-25). Data was
analyzed using SPSS (Statistical Package
for Social Scientists) version 25.0 for
Windows (Chicago, Illinois, USA).
Descriptive statistics in terms of mean and
standard deviation (SD) was computed for
the continuous variables. While descriptive
statistics consisting of frequencies and
percentages (%) was computed and level
of significance was investigated using the
Pearson Chi-square test to analyze the
association between categorical data. A p-
value ≤ 0.05 was regarded as significant.
All patients involved in our study were
invited to join voluntarily. We obtained
informed consent from our subjects based
on a thorough clarification of the study's
goals and procedures. This study was
carried out in agreement with the ethical
standards set out at the Helsinki
Declaration and was accepted by Hawler
Medical University’s ethics committee.
Respondents were further assured of
confidentiality and anonymity. All
participants were informed that they can
refuse to participate and / or withdraw
from this research.
Results
We recruited 100 participants with type 2
diabetes Miletus ,with mean age of
51.6±11.4 years old, 54% were above 50
years, 32% were obese, more than 40%
were with HbA1c above 9, more than 50%
were with DM Duration above 10 years,
86% were receiving oral hypoglycemic
agents, 53% with hypertension 19%
receiving Beta Blocker medications,43%
were currently smokers,48% had
dyslipidemia ,74% were of secondary
education, 28% with peripheral arterial
disease , 47% suffering from neuropathy,
39% from Nephropathy,6% were alcohol
users, 9% with high prolactin level, 16%
with low testosterone levels and 15% were
with high TSH levels Table (1).

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Table (1): Diabetic Participants' Distribution according to study Variables
Study Variable
Percentage
Age
>50 years
(54)54%
≤50 Years old
(46)46%
BMI
Normal
(33)33%
Overweight
(35)35%
Obese
(32)32%
HbA1C
<7
(39)39%
7-9
(20)20%
>9
(41)41%
DM Duration
>10 Years
(54)54%
≤10 Years
(46)46%
DM Treatment
Oral Agents
(86)86%
Insulin
(14)14%
Hypertension
Present
(53)53%
Absent
(47)47%
Hypertension Treatment
Beta Blocker
(19)19%
ACEi or ARB
(17)17%
Other
(17)17%
Currently Smoker
Smoker
(43)43%
Non
(57)57%
Dyslipidemia
Present
(48)48%
Absent
(52)52%
ABI
Present
(28)28%
Absent
(72)72%
Neuropathy
Present
(47)47%
Absent
(53)53%
Nephropathy
Present
(39)39%
Absent
(61)61%
Education
Primary
(17)17%
Secondary
(74)74%
Other*
(9)9%
Prolactin Hormone
High
(9)9%
Normal
(91)91%
Testosterone Hormone
Low
(16)16%
Normal
(84)84%
TSH
High
(15)15%
Normal
(85)85%
Alcohol drink
Drinker
(6)6%
Nondrinker
(94)94%
*: other: higher education including undergraduate and postgraduate
We further recruited 50 diabetic free
participants as control group. Their demographic features are shown in Table
(2).
Table (2): Control Participants' Distribution according to study Variables
Study Variable
Percentage
Age
>50 years
(22)44%
≤50 Years old
(28)56%
BMI
Normal
(27)54%
Overweight
(13)26%
Obese
(10)20%
Hypertension
Present
(18)36%
Absent
(32)64%
Hypertension Treatment
Beta Blocker
(4)8%
ACEi or ARB
(8)16%
Other
(6)12%
Currently Smoker
Smoker
(30)60%
Non
(20)40%
Dyslipidemia
Present
(12)24%
Absent
(38)76%
ABI
Present
(6)12%
Absent
(44)88%
Neuropathy
Present
(4)8%
Absent
(46)92%
Nephropathy
Present
(2)4%
Absent
(48)96%
Education
Primary
(15)30%
Secondary
(24)48%
Other
(11)22%
Prolactin Hormone
High
(2)4%
Normal
(48)96%
Testosterone Hormone
Low
(4)8%
Normal
(46)92%
TSH
High
(1)2%
Normal
(49)98%
Alcohol drink
Drinker
(3)6%
Nondrinker
(47)94%
The study showed that ED was
significantly higher (p =<0.001 using
Pearson Chi-square) among Diabetic
group 63% Vs 12% among control
(Nondiabetic) groups Table (3)

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Table (3): Erectile dysfunction distribution among study groups
Study Variable
ED
Not ED
P Value (Pearson Chi-square)
DM
(63) 63%
(37) 37%
<0.001
Not DM
(12) 12%
(88) 88%
In this study diabetic participant were
distributed according to ED severity into 23% mild, 60% moderate and 12% were
severe Table (4).
Table (4): Diabetic Participants' Distribution according to ED severity
Erectile Dysfunction Severity
No.
%
Mild
17
27.0
Mild to Moderate
21
33.3
Moderate
16
25.4
Sever
9
14.3
There was a statistically significant
association between increase in age and
ED presence (p=0.001), being older than
50 was associated with higher ED
prevalence. Also, a statistically significant
association was found between ED and
BMI classification, Obese participants
were with higher chance to develop ED
(p=0.005). No statistical difference was
found between ED presence and smoking,
educational levels, or Alcohol use (p=0.71,
0.23 and 0.64 respectively) Table (5).
Table (5): Distribution according to Sociodemographic Variables among Diabetic Patients
Sociodemographic Variable
ED
No ED
P Value (Pearson Chi-
square)
Age
> 50 Years
(42) 77.80%
(12) 22.20%
0.001
≤ 50 Years
(21) 45.70%
(25) 54.30%
BMI
Obese
(26) 81.30%
(6) 18.80%
0.005
Overweight
(23) 65.70%
(12) 34.30%
Normal
(14) 42.40%
(19) 57.60%
Currently Smoker
Yes
(28) 65.10%
(15) 34.90%
0.703
No
(35) 61.40%
(22) 38.60%
Education
Primary
(13) 76.50%
(4) 23.50%
0.231
Secondary
(43) 58.10%
(31) 41.90%
Other
(7) 77.80%
(2) 22.20%
Alcohol user
Yes
(4) 66.7
(2) 33.3
0.847
No
(59) 62.8
(35) 37.2
There was a strong association between
ED and HbA1c levels, higher HbA1c (>9)
was in favor of higher ED presence
(p<0.001). Furthermore, the prevalence of
ED was significantly associated with a
longer duration of DM (p=0.038). Also,
ED prevalence was significantly higher in
diabetic patients with hypertension than in
non-hypertensive patients (p=0.02). Plus,
the presence of dyslipidemia in diabetic
patients was again significantly associated
with higher ED than those who did not
have dyslipidemia (p=0.017). ED
prevalence was significantly higher in
Diabetic patients with neuropathy than
those with no neuropathy (p=0.02). |on the
other hand, there was no significant
relationship between the prevalence of ED
and type of DM treatment, type of
antihypertensive medication, PAD, or
nephropathy among diabetic patients

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(P=0.63, 0.13, 0.276 and 0.06 respectively) Table (6).
Table (6): Distribution according to chronic illnesses and complication Among Diabetic
Patients
Study Variable
ED
No ED
P Value (Pearson Chi-
square)
HbA1C
>9
(35) 85.40%
(6) 14.60%
<0.001
7-9
(8) 40.00%
(12) 60.00%
<7
(20) 51.30%
(19) 48.70%
DM Duration
>10 Years
(39)72.20%
(15) 27.80%
0.038
≤ 10 Years
(24) 52.20%
(22) 47.80%
DM Treatment
Insulin
(8) 57.10%
(6) 42.90%
0.624
Oral Hypo.
(55) 64.00%
(31) 36.00%
Hypertension
Yes
(39) 73.60%
(14) 26.40%
0.019
No
(24) 51.10%
(23) 48.90%
Hypertension treatment
B Blocker
(14) 73.70%
(5) 26.30%
0.135
ACE or ARB
(12) 70.60%
(5) 29.40%
Other
(13) 76.50%
(4) 23.50%
Dyslipidemia
Yes
(36) 75.00%
(12) 25.00%
0.017
No
(27) 51.90%
(25) 48.10%
PAD
Yes
(20) 71.40%
(8) 28.60%
0.276
No
(43) 59.70%
(29) 40.30%
Neuropathy
Yes
(35) 74.50%
(12) 25.50%
0.025
No
(28) 52.80%
(25) 47.20%
Nephropathy
Yes
(29) 74.40%
(10) 25.60%
0.0599
No
(34) 55.70%
(27) 44.30%
No statistical difference was found in the
prevalence of ED among diabetic patients
and levels of prolactin, TSH or
Testosterone levels (p=0.44, 0.155 and
0.082 respectively) Table (7).
Table (7): Distribution according to hormones' level of Diabetic Patients
Hormone
ED
No ED
P Value (Pearson Chi-square)
Prolactin
High
(5) 55.60%
(4) 44.40%
0.44
Normal
(58) 63.70%
(33) 36.30%
TSH
High
(7) 46.70%
(8) 53.30%
0.155
Normal
(56) 65.90%
(29) 34.10%
Testosterone
Low
(7) 43.80%
(9) 56.30%
0.082
Normal
(56) 66.70%
(28) 33.30%
Discussion
In order to keep marital peace and
happiness, healthy sexual functioning is
necessary. Diabetes mellitus can cause
normal sexual function to be disrupted in
both men and women as a result of
diabetic-induced end organ damage and
psychological stress. This study showed
that the prevalence of ED was significantly
higher among diabetic group versus non-
diabetic group (63% VS 12 %) with p <0.
001. This finding was in line with several
studies from USA and Egypt.21-23 This
study showed that being older in age was
significantly associated with ED (p

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=0.001). A cross-sectional survey of 400
Malaysian men confirmed this
conclusion.24 Due to alterations caused by
atherosclerosis and the resulting decreased
blood supply to the genitalia, aging posed
a substantial risk for developing ED.
Significantly higher prevalence of ED was
detected among obese group (p= 0.005),
which was consistent with Polish research
that revealed that a BMI of over 30 kg/m2
was associated with a threefold increased
probability of sexual dysfunction.25 For
obese patients, erectile dysfunction is
caused by a number of issues that are
common in people who have a lot of fat
tissue, such as cardiovascular disease,
diabetes, and dyslipidemia. This study
revealed no association between ED and
level of education (p=0.23) which was in
contrast to two studies from Malaysia
which showed men with secondary
education were more prone to develop ED
compared to those with tertiary
education.24, 26 The disparity in sample size
and sampling procedure might explain the
discrepancy, especially as most of the
persons sampled in our study were the
visitors to public hospitals and most were
from a lower socioeconomic and
educational level. This study yielded in no
significant difference between smoking
status and ED (p=0.71) however this
finding was contradicted by the
Massachusetts Male Aging Study, where
cigarette smokers were found to have a
1.97 times higher risk to develop ED.27 In
Finland, 1130 men between the ages of 50
and 70 were tracked for ten years in a
study comparable to the Massachusetts
Male Health Study, the odds-ratio in this
study was 1.4, however it did not meet
statistical significance according to the
author of the mentioned study.28 This
disparity might be explained by the varied
methodologies utilized in those studies, as
cross section studies in general may not be
able to detect causal and temporal links
between cause and effect. According to the
Boston Area Community Health Survey,
the risk of having ED became considerable
only after 20 pack-years. 29 This study
showed no statistical association between
ED and alcohol consumption (p=0.64),
while a Chinese meta-analysis cross-
sectional study indicated that small to
moderate alcohol intake (up to 21
drinks/week) was found to be associated
with lower probability of erectile
dysfunction (OR = 0.71, P = 0.000). A
non-linear association was discovered
between the risk of ED and alcohol intake,
in a dose-response meta-analysis.30
Possible explanation of this disagreement
is that being alcoholic is a social stigma
among Iraqi people and a lot of individuals
hide the fact of drinking alcohol. Binge
drinking has been shown to affect
microvascular and macrovascular function,
which might indicate early signs of
cardiovascular risk.31 Epidemiologic
research shows that consuming alcoholic
beverages at low levels (1–2 drinks per
day) on a regular basis may reduce the
incidence of unfavorable cardiovascular
events.32 This study found a clear positive
relationship between ED and both HbA1c
level, and DM duration (p=0.001,0.038,
respectively), which was supported by
studies from the United Kingdom (Five
cross-sectional studies including 3299
patients).33 Available data has revealed a
link between erectile dysfunction and
glycemic management, as well as the
duration of diabetes.33, 34 Diabetic males
have a nearly threefold increased risk of
developing ED when compared to non-
diabetics in similar studies and they are
also more likely to acquire ED 10 to 15
years before non-diabetics.3 This study
revealed a significant association between
hypertension and ED on one side and
dyslipidemia and ED on the other side
(p=0.02 and 0.017 respectively).
Comparable results were found within an
Italian study of 555 men 17. However,
studies from China and USA showed no
significant association between serum lipid
and the risk of ED, pointing to the
apparent conclusion that dyslipidemia does
not have a significant role in the

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probability of developing ED in
diabetics.34, 35 The current study's findings,
on the other hand, revealed no statistically
significant differences in ED across
various antihypertensive groups. This
might be due to the fact that many patients
were using more than one kind of
antihypertensive medication, which could
lead to confounding results if some
medicines have a neutral/positive effect on
the ED while others have unfavorable
effects. Some earlier antihypertensive
classes (beta blockers, diuretics) have a
history of causing erectile dysfunction,
whereas other medicines (ACEIs, calcium
channel blockers) appear to be neutral.
Furthermore, data shows that angiotensin
receptor blockers may improve erectile
function.36 A significant increase in ED
was reported among diabetic individuals
with neuropathy (p=0.025), while no such
significant increase was detected among
diabetic participants with nephropathy
(p=0.06) in this research. Similar findings
were found in a Turkish,7 Japanese
multicenter cross-sectional study, 37
Romanian38 and Indian studies.39 This
research found no link between the
presence of peripheral artery disease and
ED (p=0.27), however a study from the
United States of 690 males found a
favorable link 40. This discrepancy might
be related to differences in research
duration and sample characteristics.
Several atherosclerotic risk factors can
lead to occlusive disorder in various
arteries, eventually leading to some degree
of vascular ED. Reduced neuronal or
endothelial NO, as well as prolonged
tissue ischemia; can result in decreased
cavernosal smooth muscle relaxation. DM
treatment showed no significant difference
for ED prevalence (p=0.63). Same results
were found with a Japanese 37 and a
Chinese study.1 The level of serum
prolactin had no effect on ED (p=0.44),
according to this study. In contrast to
research from China, which found a
deleterious impact on erectile function, 41
our study found no such effect. This
disparity might be explained by
differences in research duration and
sample size, especially as the current
investigation focused solely on diabetes
patients rather than the general population.
The frequency of hyperprolactinemia was
9% in the study group, with most of them
having just a mild (less than twice) rise in
serum prolactin. This study showed no
significant association between ED and
testosterone levels (p=0.082). This finding
contradicted other studies which showed
lower levels of serum testosterone were
associated significantly with higher
prevalence of ED in men with Type 2 DM.
A research done on 198 men with type
2diabetes had showed that the presence of
ED was significantly associated with both
low levels of serum testosterone.42
Different methodologies and inclusion
criteria might be the cause of the disparity,
as one of the exclusion criteria in our study
was a documented history of diagnosed
primary hypogonadism. Finally, there was
no association between TSH levels and ED
in this investigation (p=0.155), however
this contradicted an Italian multicenter
prospective analysis of 48 males at
endocrinology and andrology clinics in
university hospitals, which revealed
hypothyroidism nearly tripled the
occurrence of ED.43 In hypothyroid males,
Krassas et al. found a considerably higher
prevalence of ED than in controls (p
0.0001).44 This discrepancy could be
explained by the participants' different
characteristics, and by the fact that this
study investigated the presence of thyroid
disorders in diabetic patients with ED,
whereas most other studies looked into the
presence of sexual disorders in those with
thyroid dysfunction.
Study Limitation
We are aware of several limitations of our
study. First off, since this study is cross- sectional in nature, we cannot be certain
that ED and the study factors are related in

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a causal way. Furthermore, because the
sample was drawn from a single center, we
were unable to generalize this information
across the country. Finally, no information
was gathered about the individuals' social
situation or partner, two factors that could
theoretically influence the prevalence of
ED.
Conclusion and Recommendation
Erectile dysfunction was significantly
more prevalent in patients with type 2
diabetes than non-diabetic patients. Being
older than 50 years old, obesity, HBA1c
level higher than 9, DM more than 10
years duration, presence of hypertension,
dyslipidemia and neuropathy were
significantly in favor of higher prevalence
of ED in this group. Considering the
increased frequency of ED in type 2
diabetes patients, physicians should focus
on early detection and treatment of ED in
diabetic men. Furthermore, maintaining
effective glycemic management, avoiding
DM-related comorbidities, and managing
obesity, hypertension and dyslipidemia
may lower the chance of developing ED.
Conflicts of interest
The author reports no conflicts of interest.
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