Why it hits harder
Most causes of ED interfere with one step. Diabetes interferes with two.
Persistently high blood glucose damages the endothelium — the lining that produces the nitric oxide telling arteries to relax. At the same time, it damages the small nerves, the same process behind numbness in the feet. So the signal arrives weakly, and the vessels that receive it respond poorly.
That combination explains both the earlier onset and the reduced response to pills, which work by amplifying a nitric oxide signal that has to exist in the first place.
What still works
Pills are still worth trying properly. Response rates are lower than in men without diabetes but far from zero, and men with diabetes usually need the higher end of the dose range. This is a group where giving a full eight-attempt trial at maximum tolerated dose genuinely changes the outcome. What a fair trial looks like, and what comes after it.
Injections have a notably high success rate here, because they open the arteries directly rather than relying on a nerve signal getting through. Men with diabetes who fail pills often do very well on injections, and this step gets skipped more often than it should. How injections work.
Vacuum devices work by mechanics alone, so nerve and vessel damage barely affects them. A reasonable option, particularly alongside a pill.
Implants are a well-established endpoint for men with long-standing diabetes and severe damage. The one caveat is important: infection risk is meaningfully higher when blood sugar is poorly controlled, so surgeons usually want HbA1c brought down before operating.
Get testosterone checked
Low testosterone is considerably more common in men with type 2 diabetes than in the general population — a substantial share have measurably low levels. It is under-tested in this group.
It is worth two morning blood tests, because correcting a genuine deficiency improves libido and can improve how well pills work. What testosterone therapy does and does not fix.
Does better control reverse it?
Honestly: usually not, once damage is established. Nerve and vessel damage from years of high glucose does not readily undo itself.
What tight control does is slow or halt further progression — which matters a great deal, because the alternative is continued decline. Combined with weight loss, exercise and blood pressure control, it protects what function remains and improves the odds that treatment works.