Sexual Dysfunction Practice Exam: Diabetes Chapter 33

Erectile dysfunction (ED) is a common and often overlooked complication that affects 35% to 90% of men with diabetes. Beyond quality of life, the 2018 Clinical Practice Guidelines identify ED as a critical marker for vascular health, potentially preceding coronary artery disease by several years.

This practice exam tests your ability to screen effectively, interpret diagnostic criteria for hypogonadism, and select safe pharmacological interventions based on cardiovascular comorbidities.

Key Concepts Covered in This Exam:

Vascular Warning Signs: Understanding that ED may be an early marker of underlying atherosclerosis and coronary artery disease, necessitating cardiovascular risk assessment.
Screening Recommendations: Identifying the requirement to screen all men with diabetes for ED using sexual function history or tools like the IIEF-5 questionnaire.
First-Line Therapy: Recognizing phosphodiesterase type 5 (PDE5) inhibitors as the first-line treatment for ED and understanding the absolute contraindication for their use in patients taking nitrates.
Hypogonadism Diagnosis: Mastering the diagnostic criteria for biochemical hypogonadism, which requires morning total testosterone measurement.
Testosterone Replacement: Knowing when testosterone replacement therapy is indicated—specifically for men with clinically significant symptoms and confirmed biochemical hypogonadism—and its potential benefits on insulin sensitivity.

1. Case: A 45-year-old obese man with type 2 diabetes has symptoms of hypogonadism. Which of the following is a potentially reversible cause that should be addressed first?

Genetic factors
Age-related decline
Chronic inflammation
Obstructive sleep apnea and obesity

2. Case: A 48-year-old man with diabetes and ED is prescribed sildenafil. He is also taking medications for hypertension. Which medication is an absolute contraindication?

Nitroglycerin
Amlodipine
Hydrochlorothiazide
Metoprolol

3. Case: A 50-year-old man with diabetes asks whether there is a specific testosterone preparation that is superior for treating hypogonadism. Based on current evidence, what is the most accurate response?

There is no evidence that one preparation is superior
Intramuscular testosterone is always superior
Oral testosterone is the only effective option
Transdermal preparations are always superior

4. What percentage of men with diabetes at 6 years after diagnosis have been reported to have ED?

40%
50%
60%
30%

5. Men with diabetes appear to have what characteristic regarding side effects from PDE5 inhibitors compared to the general population?

Unpredictable side effects
Same rates of side effects
Lower rates of side effects
Higher rates of side effects

6. What is the mechanism by which ED develops in men with diabetes related to the cGMP/NO pathway?

Impaired vascular relaxation related to endothelial dysfunction
Enhanced vascular relaxation
Excessive cGMP accumulation
Increased NO production

7. Case: A 60-year-old man with diabetes is considering testosterone therapy for hypogonadism. What monitoring is recommended prior to and during therapy?

Blood pressure only
Liver function tests only
No monitoring is needed
Evaluation for prostate cancer and ongoing monitoring

8.

According to the guidelines, what is true regarding PDE5 inhibitor effectiveness in men with diabetes versus the general population?

PDE5 inhibitors are less effective in men with diabetes
PDE5 inhibitors have similar effectiveness but may be less effective in those with hypogonadism
PDE5 inhibitors are contraindicated in diabetes
PDE5 inhibitors are more effective in men with diabetes

9. Case: A man with diabetes presents with ED. He has no cardiovascular symptoms but is concerned about CV risk. How is ED related to cardiovascular disease?

ED only occurs after cardiovascular events
ED may be an early clinical indication of cardiovascular disease
ED has no relationship to cardiovascular disease
ED prevents cardiovascular disease

10. What is the current mainstay of first-line therapy for erectile dysfunction in men with diabetes?

Penile prosthesis
Vacuum constriction devices
Phosphodiesterase type 5 (PDE5) inhibitors
Intracorporal injection therapy

11. What is the rationale for the guideline recommendation that screening for symptomatic hypogonadism in men with type 2 diabetes is recommended rather than universal biochemical testing?

Testosterone testing is unreliable
Many men with type 2 diabetes and hypogonadism are asymptomatic, and treatment should be reserved for those who are symptomatic
Biochemical testing is too expensive
Symptoms are always present with low testosterone

12. Case: A 44-year-old man with diabetes and ED asks about vacuum erection devices. In what clinical context have these been shown to be effective?

Never effective in diabetes
As salvage therapy in combination with PDE5 inhibitors
Only as first-line therapy
Only effective after penile prosthesis

13.

What is the most significant predictor of hypogonadism in men with type 2 diabetes?

Glycemic control
Duration of diabetes
Age
Degree of central/visceral obesity

14. Case: A 47-year-old man with type 2 diabetes reports fatigue, muscle weakness, and low libido. His morning testosterone is low. What other condition should be considered given his diabetes?

Celiac disease
Hyperthyroidism
Obstructive sleep apnea
Vitamin B12 deficiency only

15.

What percentage of men with diabetes report complete ED if they are greater than 60 years of age?

30%
50%
40%
20%

16. What is the approximate prevalence of erectile dysfunction (ED) in adult men with diabetes?

10-15%
20-30%
60-75%
34-45%

17. Case: A 52-year-old man with diabetes and ED does not respond to PDE5 inhibitors. What is the most appropriate next step according to guidelines?

Order imaging of pelvic vasculature
Investigate for hypogonadism with morning testosterone level
Increase the PDE5 inhibitor to maximum dose more frequently
Discontinue all ED treatment

18. Why might measurement of bioavailable testosterone be helpful in some men with diabetes who have symptoms of hypogonadism but total testosterone in the lower normal range?

Total testosterone is never useful
Low SHBG levels may affect total testosterone measurement
Bioavailable testosterone is easier to measure
Bioavailable testosterone is always more accurate

19. A patient with diabetes and hypogonadism asks about the conflicting evidence regarding testosterone therapy and cardiovascular outcomes. What is the most accurate statement based on current evidence?

Testosterone definitely decreases CV risk
Observational studies show mixed results
Testosterone definitely increases CV risk
All studies show testosterone has no effect on CV outcomes

20. Case: A 53-year-old man with ejaculatory dysfunction related to diabetes is interested in fertility. What is the most appropriate action?

Prescribe PDE5 inhibitors
Advise that nothing can be done
Refer to a health-care professional experienced in treatment of ejaculatory dysfunction
Recommend adoption only

21. Case: A man with diabetes and diabetic retinopathy presents with ED. Based on the evidence linking diabetic complications and ED, what is the clinical significance of this association?

Retinopathy has no correlation with ED
ED prevents retinopathy
Diabetic retinopathy has been shown to correlate with the presence of ED
Only neuropathy correlates with ED

22. Case: A 50-year-old man with diabetes and ED who does not respond to PDE5 inhibitors is found to have hypogonadism. What is the expected success rate when adding testosterone replacement?

25%
10%
50%
90%

23.

The prevalence of hypogonadism in men with type 1 diabetes is:

Higher than in men with type 2 diabetes
Lower than the general population
Similar to the general male population
Not well studied

24. When should morning testosterone levels be drawn for biochemical testing of hypogonadism?

After 11 am
Before 11 am or within 3 hours of awakening
In the evening
Any time of day

25.

Case: A 55-year-old man with type 2 diabetes reports difficulty achieving erections. What is the most appropriate first step in evaluation?

Prescribe a PDE5 inhibitor immediately
Check testosterone levels
Refer to urology
Obtain a sexual function history using a validated questionnaire

26. What percentage of newly diagnosed men with diabetes have been reported to have ED at presentation?

22%
48%
33%
10%

27. What is the prevalence range of ejaculatory disorders in men with diabetes?

10-25%
70-85%
15-30%
32-67%

28. According to Diabetes Canada guidelines, when should screening for ED begin in men with type 2 diabetes?

Only when symptoms are reported
At diagnosis of diabetes
After 5 years of diabetes
After 2 years of diabetes

29. A 58-year-old man with diabetes has been symptomatic for hypogonadism. His total testosterone is 7.8 nmol/L (low) on two separate morning tests. In the absence of symptoms, would treatment be recommended?

No, treatment should be reserved for those who are biochemically hypogonadal and symptomatic
Yes, but only if he has cardiovascular disease
Yes, all men with low testosterone require treatment
Treatment depends on A1C level only

30.

Case: A patient with ED asks about scheduled daily therapy with tadalafil versus on-demand dosing. What is an accurate statement about daily therapy?

Daily therapy has no benefit over on-demand dosing
Daily therapy only works in men without diabetes
Daily therapy is effective in diabetes and may improve efficacy
Daily therapy is contraindicated in diabetes

31. When counselling a patient about the potential effects of testosterone therapy on glycemic control in type 2 diabetes, what should be explained based on current evidence?

Testosterone has no effect on glucose metabolism
Testosterone always worsens glycemic control
Testosterone consistently improves A1C in all studies
Evidence is conflicting

32. What effect does significant weight reduction have on testosterone levels in hypogonadal men with diabetes?

No effect on testosterone
Decreases testosterone further
Generally associated with an increase in testosterone
Only affects estrogen levels

33. Which validated questionnaire can be used for assessing erectile function and measuring response to therapy?

Beck Depression Inventory
Mini-Mental State Examination
International Index of Erectile Function (IIEF)
Quality of Life Scale

34. Which type of ejaculatory disorder is most commonly associated with autonomic neuropathy in diabetes?

Delayed ejaculation
Retrograde ejaculation
Premature ejaculation
Painful ejaculation

35.

Case: A 42-year-old obese man with type 2 diabetes (BMI 38 kg/m²) has hypogonadism and ED. He asks whether weight loss might help both conditions. Based on evidence, what is the most appropriate counselling?

Testosterone therapy should be started first without lifestyle changes
Weight loss only affects glucose control
Weight loss has no effect on testosterone or ED
Weight loss can increase testosterone and may restore eugonadal state

36. Considering the evidence linking hypogonadism and cardiovascular mortality in men with diabetes, what is the most clinically relevant statement?

Hypogonadism has no relationship to CV mortality
Hypogonadal men with diabetes have lower CV mortality than eugonadal men
Only age affects CV mortality in this population
Hypogonadal men with diabetes have a higher risk for cardiovascular mortality

37. What is the reported prevalence of hypogonadotropic hypogonadism in men with type 2 diabetes?

30-40%
10-15%
50-60%
20-25%

38.

Case: A healthcare team is developing a protocol for screening men with diabetes for sexual dysfunction. Based on guideline recommendations, which approach is most appropriate?

Only screen men who specifically complain of ED
Screen all adult men with diabetes regularly for ED
Only screen men over age 60
Screening is not necessary as ED is not clinically significant

39. Case: A patient with diabetes asks about the impact of intensive glycemic control on ED. Based on DCCT and UKPDS data, intensive glycemic control was effective for:

Primary prevention and secondary intervention for neuropathy, which can impair erectile function
Immediate reversal of ED
Directly treating ED
Preventing all forms of sexual dysfunction

40.

Case: A 56-year-old man with type 2 diabetes, hypertension, and dyslipidemia presents with ED. When considering the relationship between ED and cardiovascular risk, what is the most appropriate clinical approach?

Focus only on treating the ED
Recommend against all ED treatment due to CV risk
Delay ED treatment until CV disease is ruled out completely
Ensure comprehensive CV risk assessment and management

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