Diabetes and erection problems in Valencia: getting the right ED treatment

If you have moved to Valencia with type 2 diabetes, you have probably already handed your diabetes care over to a Spanish health centre. Erection problems can be the one thing people don't bring up there, partly out of embarrassment and partly because it is hard enough to explain in a second language.

It is worth raising. The US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says more than half of men with diabetes will develop erectile dysfunction, that they are over three times as likely to get it as other men, and that it can start 10 to 15 years earlier. The standard ED tablets do work in diabetic men, just a little less reliably, and there are specific things your doctor will want to check. This page explains them using the Spanish product information, the ficha técnica, and shows how to get from your health centre to a specialist in Valencia.

Why diabetes affects erections

An erection needs working nerves to carry the signal and healthy blood vessels to let blood in. Years of raised blood sugar damage both. The NIDDK lists the things that make it worse: poorly controlled glucose, untreated high blood pressure or cholesterol, being overweight, inactivity, smoking and heavy drinking. Most of those are already on your diabetes checklist, which is good news: getting them on target helps your erections as well as your eyes, kidneys and heart.

The flip side is that damaged blood vessels in the penis can mean damaged vessels elsewhere. Spanish product information asks doctors to consider a patient's heart health before prescribing any of these medicines, because sex is physical exertion.

Four questions your GP will ask

1. Do you use nitrates or have angina? If so, no ED tablet is allowed: together they can cause a dangerous fall in blood pressure. Not having chest pain doesn't prove your heart is fine, which is why your doctor will check.
2. What do you take for blood pressure or your prostate? Alpha-blockers such as doxazosin and tamsulosin can add to the drop in blood pressure. The tadalafil ficha advises against pairing it with doxazosin; the vardenafil one says to start on 5 mg.
3. Are you on insulin or a sulfonylurea such as gliclazide? Sex counts as exercise. Ask your doctor or nurse how to avoid a hypo.
4. Have you already tried a tablet? A first failure is common with diabetes. These pills need sexual arousal, sildenafil is slower after a heavy meal, and the dose can be adjusted up to the authorised maximum. Doubling up or mixing two different ED drugs is not the answer.

Your route through the system in Valencia

Residents in the public system are registered at a centro de salud run by the regional health department (Conselleria de Sanitat) and carry the Valencian health card, known as the SIP card. If you are a UK or EU pensioner, that usually means your S1 has been registered with the Spanish Social Security institute, INSS. Your family doctor (médico de familia) can write the prescription and refer you on to Urología.

With private insurance, any prescription written by a doctor registered in Spain can be filled at a Spanish pharmacy; whether the visit is covered depends on your policy.

Short stays: the European card (EHIC, or TSE in Spanish) and the UK's GHIC are for treatment you need unexpectedly while here, which a routine ED prescription usually is not.

Either way you pay the full price for the tablets, because Spain's public system does not fund ED medicines, though your diabetes treatment is funded. Public hospitals in the city with urology departments include the Hospital Clínico Universitario, whose andrology unit treats erectile dysfunction, the Consorcio Hospital General Universitario and La Fe (pages in Spanish).

For a pharmacy open late or on a holiday (farmacia de guardia), the Valencia pharmacists' college, MICOF, has a search for open and emergency pharmacies on its home page, plus a free number for Valencia city, 900 500 952. Rotas change, so check before you set off.

The evidence in men with diabetes

Sildenafil (Viagra). Diabetic men made up 20.3% of the more than 8,000 patients in its clinical trials. Across those trials, 59% of the men with diabetes reported better erections, compared with 68% of men whose ED had a physical cause of any kind. The diabetes drug tolbutamide did not change how the body handled sildenafil.

Tadalafil (Cialis). The ficha says no dose adjustment is needed for diabetic men. It also lists diabetes among the factors present in some reports of sudden hearing loss after tadalafil, so stop taking it and get help at once if your hearing suddenly drops.

Vardenafil (Levitra and generics). In the trials of the melt-in-the-mouth tablets, 29% of patients had a history of diabetes. Metformin, sulfonylureas and glibenclamide did not alter vardenafil levels.

So none of these drugs is ruled out by diabetes itself, and none is known to interfere with metformin. The interactions that matter are with heart and blood pressure medicines, which many diabetic men also take.

What diabetic expats ask

Products that fit, and how they reach you

• Cialis Generic: tadalafil 5, 10 and 20 mg; 5 mg is the daily dose. A 40 mg strength is also listed, which is double the authorised maximum; we advise against it.
• Viagra Generic: sildenafil 25, 50 and 100 mg; its product information is the one that gives response rates in diabetic men.
• Levitra Generic: vardenafil 10 and 20 mg. With an alpha-blocker the product information says start at 5 mg, which we don't offer.
• Cialis Original: branded tadalafil, 20 mg only.

On ordering: we have no shop or pharmacy in Valencia and don't sell from a counter. Parcels are sent by post or courier, as explained on our delivery conditions page. Nobody here will review your diabetes or your other medicines, and customs can hold a parcel.

Other cities: ED after 60 in Alicante, nitrates and heart disease in Las Palmas de Gran Canaria, BPH and tadalafil 5 mg in Valladolid.

Sources: the AEMPS product information for Viagra, Cialis and Levitra (CIMA database); NIDDK, “Diabetes, Sexual, and Bladder Problems”; the Health Ministry's BIFIMED funding database; urology pages of the Hospital Clínico, Consorcio Hospital General and La Fe (Conselleria de Sanitat); MICOF. Nothing here replaces a conversation with your own doctor. In Spain, prescription-only medicines may not be sold online, and customs can hold a parcel that contains them. We do not check prescriptions: talk to your doctor before you order.