Clinical Context
Erectile dysfunction (ED) affects 35-75% of men with diabetes mellitus, with prevalence increasing with diabetes duration, poor glycemic control, and presence of microvascular complications. Diabetes-induced erectile dysfunction (DMED) is particularly challenging because multiple pathophysiological mechanisms contribute simultaneously: endothelial dysfunction impairs nitric oxide-mediated vasodilation, autonomic neuropathy disrupts nerve-mediated erection, and microvascular disease limits penile blood flow.
Phosphodiesterase-5 (PDE5) inhibitors like tadalafil remain first-line treatment, but response rates in diabetic men (approximately 50-60%) are lower than in non-diabetic ED (70-80%). The requirement for higher doses increases side effects, while some patients remain refractory despite maximum doses. These limitations have driven interest in combination approaches that might enhance PDE5 inhibitor efficacy or address pathways not targeted by these medications.
Moxibustion—a traditional Chinese medicine technique involving burning of dried mugwort (Artemisia vulgaris) near acupuncture points to generate therapeutic heat—has been used for centuries for various conditions including sexual dysfunction. Traditional theory holds that moxibustion strengthens kidney yang, promotes blood circulation, and warms the meridians—concepts that map roughly to improving vascular and neural function. This three-arm randomized trial compared combination therapy to each intervention alone.
PICO Summary
Population: Men with diabetes mellitus-induced erectile dysfunction (DMED), confirmed by International Index of Erectile Function (IIEF) scores and penile Doppler ultrasound.
Intervention: Moxibustion therapy at specific acupuncture points combined with low-dose tadalafil (typically 5-10 mg) over 8-12 weeks.
Comparison: Three-arm design: (1) low-dose tadalafil alone, (2) moxibustion alone, and (3) combination therapy, allowing assessment of additive or synergistic effects.
Outcome: Combined moxibustion plus low-dose tadalafil produced significantly greater improvement in erectile function (IIEF-5 scores) compared to either treatment alone. Penile blood flow parameters on Doppler ultrasound (peak systolic velocity) improved most in the combination group. Both treatments were well-tolerated with minimal side effects. The combination allowed lower tadalafil doses while achieving comparable or superior efficacy to higher-dose monotherapy.
Clinical Pearls
1. Combination Outperformed Monotherapy: The three-arm design clearly demonstrated that combination therapy was superior to either intervention alone. This suggests additive or potentially synergistic effects from addressing multiple pathways—pharmaceutical enhancement of nitric oxide signaling plus traditional therapy potentially affecting blood flow, nerve function, or other mechanisms.
2. Lower Doses May Suffice with Combination: Achieving effective results with low-dose tadalafil (rather than maximum doses) could reduce side effects (headache, flushing, dyspepsia, back pain) that limit patient adherence and satisfaction. This dose-sparing effect may be particularly valuable in patients who tolerate PDE5 inhibitors poorly.
3. Objective Doppler Improvement: Beyond subjective questionnaire improvement, penile Doppler showed increased blood flow. This objective measurement supports a genuine vascular effect rather than placebo response alone—though placebo effects in ED studies are substantial and the comparison was to other treatments, not placebo.
4. Safety Profile Favorable: Neither moxibustion nor low-dose tadalafil produced significant adverse effects. This safety profile supports consideration of combination therapy in appropriate patients, particularly those seeking alternatives to high-dose pharmaceutical monotherapy.
Practical Application
For diabetic men with erectile dysfunction who have partial response to PDE5 inhibitors or who experience dose-limiting side effects, combination with traditional Chinese therapies like moxibustion may be worth considering. This approach requires access to qualified traditional Chinese medicine practitioners who can perform moxibustion safely and effectively.
Patient selection should consider openness to traditional medicine approaches, access to practitioners, and willingness to commit to a treatment course (typically 8-12 weeks of regular moxibustion sessions). The time and cost investment is greater than pharmaceutical monotherapy but may be acceptable to patients seeking to minimize medication use or maximize treatment effect.
Continue addressing underlying diabetes management: glycemic control, cardiovascular risk reduction, and lifestyle modification all influence ED outcomes. Moxibustion and tadalafil address symptoms but don’t treat the underlying metabolic and vascular dysfunction driving DMED.
Broader Evidence Context
Traditional Chinese medicine for erectile dysfunction has been studied in numerous trials, predominantly from China, with generally positive results but variable methodological quality. Acupuncture, moxibustion, and herbal preparations have all been evaluated. Mechanisms proposed include improved blood flow, nerve function modulation, and antioxidant effects, though definitive mechanistic data are lacking.
Conventional ED treatment guidelines don’t currently include traditional Chinese medicine due to insufficient high-quality evidence by Western standards. However, for patients interested in integrative approaches, the evidence supports considering these therapies as adjuncts to, rather than replacements for, established treatments.
Study Limitations
Single-center Chinese study limits generalizability. Blinding was not possible for moxibustion, introducing potential bias. The comparison to active treatments (rather than sham moxibustion) doesn’t fully exclude placebo effects. Long-term durability of effects after treatment cessation wasn’t assessed. Cultural factors influencing acceptance and response to traditional medicine may not translate to other settings.
Bottom Line
Moxibustion combined with low-dose tadalafil improved erectile function and penile blood flow more than either treatment alone in men with diabetic erectile dysfunction. This combination approach may be valuable for patients with partial response to PDE5 inhibitors or those seeking to minimize medication doses. Access to qualified traditional medicine practitioners is required for implementation.
Source: Liu T, et al. “Moxibustion Combined with Low-Dose Tadalafil for Diabetes Mellitus-Induced Erectile Dysfunction: A Prospective, Single-Center, Three-Arm Randomized Controlled Trial.” Read article
