Type 2 diabetes and erectile dysfunction: How one couple revived their intimacy
'Many men feel embarrassed when I meet them, the term 'erectile dysfunction' rarely leave their lips. Instead they come in saying things like, 'it's not like it used to be, doctor' or 'it's not working properly down there'. There's often a feeling that they've somehow let themselves or their partner down,' says Ralph.
'It's my job to explain that ED is extremely common – particularly with age and underlying health conditions like diabetes – and that it's a medical issue, not a personal failing.'
Why this occurs, says Ralph, is because prolonged high blood sugar can damage the small blood vessels and nerves which are essential for an erection. 'This reduces blood flow and sensation in the penis. Men with diabetes are also more likely to have low testosterone, which further lowers sexual desire,' he adds.
Ralph also points out that psychological factors such as anxiety or low mood can worsen the problem. While other diabetes-related health problems, such as heart or kidney disease, may also play a role in reducing sexual desire and contributing to erection problems.
A midlife diagnosis that changed the marriage
Sara and Arion first met in 2008, moved in together within two months and welcomed their first child a year later. But their whirlwind romance stood the test of time, as they married and went on to have five sons together, now aged 16, 14, 12, nine and three.
'After so many years together we both know sex isn't the be-all and end-all, but it's certainly the important glue, and I'd say we connected this way three to four times a week' says Sara, who helps run Arion's restaurant. 'Having friends who haven't had passion that actually lasts, we always felt very fortunate in that area.'
A routine check-up a few years ago showed Arion was pre-diabetic. 'Diabetes is more prevalent in the South East Asian community, and in my line of work I'm constantly surrounded by delicious chapatis, naan, and we cook with ghee – admittedly not ideal for insulin levels,' he says.
According to Ralph, pre-diabetes is a 'warning sign' and prompt action – modifying lifestyle factors such as weight loss – can minimise the risks by getting the sugars controlled.
Determined to reverse the condition naturally, Arion improved his diet, installed a treadmill in the front room, and played football with his sons. But despite these efforts, by 43, he'd tipped into full Type 2 diabetes. This too, alas, is common says professor Ralph. 'Many patients progress to full blown diabetes, and all of the cardiovascular complications including ED.'
That's when things started to change in the bedroom.
'For someone who is naturally full of beans, Arion became more lethargic,' describes Sara. 'His erections were weaker, and intercourse became a struggle.'
The psychological impact of ED on a relationship
Sara admits she worried Arion had stopped finding her attractive. 'After five babies my body had changed, however many kegel exercises I did. There were tense evenings, and the longer it carried on, the more Arion lost his confidence. His enthusiasm for sex waned, I'm sure he feared it would result in failure.' She knew they needed to talk about it – but not during sex.
'I didn't want to bring it up while in bed, with all that pressure. So instead, the two of us we went out for a walk and I said, 'I love you, come on, let's talk about this.' Arion seemed relieved I'd raised it. 'Of course I still fancy you,' he reassured me. And I cried, 'Of course I don't think you're letting me down.' That initial conversation was an important first step.
Together, they focused on non-penetrative ways to stay intimate. 'We tried massages, different positions, using sex toys, and yes – forgive me if this is frank – we practised more oral sex,' admits Sara says. 'It was worth us both improving our technique, and just lightening up a little if things didn't work out.'
What are the treatment options and technical advances for ED?
When Arion decided he wasn't ready to stop having sex in the way they were used to, he went to the GP, who suggested Viagra.
PDE5 inhibitor oral medications – like sildenafil (Viagra) or tadalafil (Cialis) – remain the first-line treatment according to Ralph. These work by temporarily improving blood flow.
'However, they don't address another key issue that many men with ED face – the problem of blood leaking back out too quickly, which can make it hard to maintain an erection. Studies indicate that around half of men stop taking them within a year. Patients often report side effects like headaches or flushing and do not like having to plan sex around a pill.'
Treatments for ED have advanced considerably, says Professor Ralph, with far more available today than 10 years ago. Second-line options include NHS-provided mechanical vacuum devices, which help draw blood back into the penis. 'While these are effective and non-invasive, many men find them inconvenient or uncomfortable long-term,' admits Professor Ralph.
Penile injections are another alternative. 'Alprostadil injections (which relax the blood vessels in the penis) are used when oral treatments fail and are effective in the majority of cases, but drawbacks include pain, priapism risk (an unwanted erection lasting hours), and the need for self-injection,' says Professor Ralph.
Penile implants are available too, but this surgical option tends to be reserved for more complex or persistent cases. They're irreversible but associated with high satisfaction rates.
'More recently, there's been growing interest in treatments that aim to restore function more naturally – especially among men (such as Arion) who want longer-term solutions or don't like the idea of planning sex around a pill.'
One example is low-intensity shockwave therapy which is a private treatment that uses sound waves to stimulate blood flow and encourage new blood vessel growth.
'It can benefit some, particularly those with mild ED, but the clinical results are mixed, and it requires multiple clinic visits, and can cost up to £3000 ($6,800),' explains Professor Ralph.
'Another option is Vertica, a handheld, at-home device, using radiofrequency energy to improve blood flow and reduce venous leak, a common cause of ED,' he adds.
A peer-reviewed study in the International Journal of Impotence Research reported that 85% of users experienced improvement at four weeks, and 93% had erections sufficient for penetration by 12 weeks.
It's approved by the MHRA (Medicines and Healthcare products Regulatory Agency) though is not available on the NHS and costs approximately £1250-£1500 ($2,800 - $3,400) , depending on the model.
Interestingly, says Ralph, the device worked just as well in men with diabetes 'who are typically harder to treat'.
'Around 40% of men in the trial had Type 2 diabetes – given how often ED and diabetes go hand in hand that's encouraging.'
Finding a way forward their sex life – what finally worked
For Arion personally, 'who doesn't even like taking paracetamol' it was the drug-free solution, Vertica, that worked.
'After about a month of using the device three to four times a week consistently we noticed a difference,' says Arion. 'My morning erections returned, full sex was mostly possible, and crucially my confidence improved,' says Arion. 'It felt like turning back time in a way we didn't think possible.'
Today, the couple feel closer than ever. 'It's just like normal again, before his diabetes diagnosis,' Sara says. 'We laugh more, talk more, touch more. We came through this hurdle together, and who knows, we're not ruling out baby number six in the future...'
The diabetes red flags to watch out for
The symptoms for both Type 1 diabetes and Type 2 can be similar, but Type 1 diabetes usually develops more quickly and is more common in younger people. The most common symptoms of Type 2 diabetes are:
Feeling very tired
Peeing more than usual
Feeling thirsty all the time
Losing weight without trying to
Other symptoms can include:
Blurred vision
Cuts or wounds taking longer to heal
Itching around your penis or vagina, or you keep getting thrush
Erectile dysfunction
These symptoms are the same for both adults and children. If you get symptoms (not everyone gets them), they may develop gradually and if concerned speak to your GP.
How to recognise ED
Early signs include reduced firmness, especially during morning erections, and difficulty maintaining an erection during intercourse.
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Ralph also points out that psychological factors such as anxiety or low mood can worsen the problem. While other diabetes-related health problems, such as heart or kidney disease, may also play a role in reducing sexual desire and contributing to erection problems. A midlife diagnosis that changed the marriage Sara and Arion first met in 2008, moved in together within two months and welcomed their first child a year later. But their whirlwind romance stood the test of time, as they married and went on to have five sons together, now aged 16, 14, 12, nine and three. 'After so many years together we both know sex isn't the be-all and end-all, but it's certainly the important glue, and I'd say we connected this way three to four times a week' says Sara, who helps run Arion's restaurant. 'Having friends who haven't had passion that actually lasts, we always felt very fortunate in that area.' A routine check-up a few years ago showed Arion was pre-diabetic. 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Treatments for ED have advanced considerably, says Professor Ralph, with far more available today than 10 years ago. Second-line options include NHS-provided mechanical vacuum devices, which help draw blood back into the penis. 'While these are effective and non-invasive, many men find them inconvenient or uncomfortable long-term,' admits Professor Ralph. Penile injections are another alternative. 'Alprostadil injections (which relax the blood vessels in the penis) are used when oral treatments fail and are effective in the majority of cases, but drawbacks include pain, priapism risk (an unwanted erection lasting hours), and the need for self-injection,' says Professor Ralph. Penile implants are available too, but this surgical option tends to be reserved for more complex or persistent cases. They're irreversible but associated with high satisfaction rates. 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How to recognise ED Early signs include reduced firmness, especially during morning erections, and difficulty maintaining an erection during intercourse.
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'Though unfortunately people are not entirely out of the woods at that point because they are still at risk of being triggered if they are stressed, in a situation that they'd previously associated with nicotine use, or if they see other people using nicotine.' Because of this, Levy recommends meeting with a behavioural therapist to help identify triggers which you can recognise and avoid, as well as working on healthy stress management techniques. 'When someone becomes addicted to a substance, it's as if their brain mistakes the substance use as a behaviour that's critical for survival,' she says. 'So it takes a lot of money and energy for them to prevent themselves from defaulting to using it. Behavioural health counsellors can help people to unlearn this automatic defaulting.' Some vapes contain more nicotine than traditional cigarettes. Photo / 123RF 3. Set boundaries A key component of behavioural management is not only identifying your triggers but setting boundaries. 'They're very similar tactics you would use for stopping smoking that you can apply to vaping as well,' says Salim-Sartoni. 'You can set rules for where you do and do not vape, so basically saying I'm only using my vape when I'm outside, but the home and car, I do not vape. Lower the nicotine, extend the time between vaping and set rules for where you do and don't vape.' Because this isn't always easy, Salim-Sartoni says that finding 'a buddy' who is also attempting to quit vaping can provide a vital support network which can make the whole process of setting boundaries much easier. 4. Distraction Finding a way to distract the brain is a key aspect of breaking any substance addiction. Salim-Sartoni says that there are all kinds of methods you can use to disengage your brain from the nicotine cravings, such as going to drink water, going to the toilet, playing a game on your phone or going for a walk. One surprisingly effective means of distraction is having a boiled sweet. 'The glucose receptor is very close to the nicotine receptor,' says Salim-Sartoni. 'And so the nicotine receptor feels that it's had something. The science steadily emerged to show this, but in our stop smoking clinics, we realised early on that people were eating a lot of sweet stuff when they were trying to quit, and this is why.' 5. Try apps or text message interventions According to the recent Cochrane review, some trials have found that text message-based interventions, which provide regular support and advice on quitting vaping can be effective. One study which examined a text message-based quit-vaping programme showed that users who used the programme were 35% more likely to quit vaping nicotine within seven months. As well as text message services, Levy says that there are a number of freely available apps and chatbots such as This is Quitting, which provide regular tips and encouragement, which have been shown to be effective in increasing quit rates. 6. Drug therapies For more powerful nicotine addictions, there are also pharmacological therapies such as the prescription drugs varenicline and cytisine. Varenicline binds to the nicotine receptors in the brain and blocks them, preventing the nicotine in vapes from binding to them, and so reducing withdrawal symptoms and cravings. Cytisine mimics the effects of nicotine and so tricks the brain into thinking it has ingested nicotine, which also reduces cravings. Finally, Salim-Sartoni emphasises that the most important thing of all for people looking to quit vaping, particularly ex-smokers, is that they don't return to smoking cigarettes again. 'Smoking is uniquely deadly, and some people can't stop nicotine or don't want to,' she says. 'If that's the case, then it is much better that they switch to e-cigarettes, particularly with the Government's ambition to reduce smoking rates in the UK to 5% or less by 2030.'
