Elsevier

Medicine

Volume 47, Issue 2, February 2019, Pages 106-109
Medicine

Complications of diabetes
Sexual problems in diabetes

https://doi.org/10.1016/j.mpmed.2018.11.004Get rights and content

Abstract

Diabetes mellitus causes sexual dysfunctions via autonomic neuropathy and endothelial dysfunction in the genitals, and via its effects as a chronic disease on the individual's global health and well-being. The most commonly complained of sexual dysfunction associated with diabetes is erectile dysfunction (ED), experienced by 35–90% of men with diabetes. It is increasingly recognized that the multiple factors causing ED in men also affect sexual function in women. In a recent study, 44% of women with type 1 diabetes and 25% with type 2 diabetes had a sexual dysfunction, but diabetic women complain of problems with sex much less often than diabetic men. The success of Viagra brought ED into the social and medical limelight; loss of arousal and therefore desire in women is a more multifactorial, and less visible, problem.

Introduction

Sexual dysfunction affects both men and women with diabetes. Around 35–90% of men with diabetes experience erectile dysfunction (ED).1 In a recent study, 44% of women with type 1 and 25% with type 2 diabetes mellitus had a sexual dysfunction (see Ahmed et al., Further reading). People with type 1 diabetes with a sexual dysfunction have been found to have a lower quality of life and greater psychological distress.

The pathophysiology of sexual dysfunction in diabetes is multifactorial.2 Diabetes causes autonomic neuropathy affecting the nerve supply to the genitals that controls arousal. It also causes vascular disease, disrupting the blood flow to the genitals in arousal: nitric oxide produced by the vascular endothelium mediates the smooth muscle relaxation that allows increased blood flow into the genitals during arousal. Low testosterone levels are more common in men with diabetes – these can cause reduced libido and ED, as well as low mood.

Diabetes is a chronic disease, and the associated stress of long-term symptoms, medical appointments, investigations and daily treatments can affect sexual function via the person's mood, anxiety levels, fatigue and general well-being. People with diabetes can have co-morbidities of hypertension, hyperlipidaemia, cardiovascular disease or other endocrine dysfunction, and these, and their associated treatments, can affect sexual function. And of course people with diabetes, like the general population, have sexual dysfunctions that may not be uncovered until a change of health status brings the problem to light – the sexual dysfunction may pre-date the diabetes. The longer the duration of diabetes and the older the patient, the more likely they are to have a sexual dysfunction (see Bak, Further reading).

Section snippets

Taking a sexual history

Sexual dysfunction is best raised directly and considered holistically. Enquiry about sexual dysfunction should be a routine part of longterm diabetic care, as enquiry about mood is (see Phillips, Further reading). Patients are more likely to raise the subject if given explicit permission to do so – ‘Many people with diabetes find it affects their sex life. Is this something that has bothered you?’ They may not immediately discuss the topic, but they have discovered that you can hear about

Examination

Men should have a genital examination to check for penile abnormality, normal genital skin, testicular presence and volume.

Women complaining of painful sex should have a pelvic examination to exclude genital dermatology, including postmenopausal atrophy, and rule out gynaecological causes of dyspareunia.

ED is an independent risk factor for cardiovascular disease, so confirm the patient has had recent checks of blood pressure, weight, smoking status, lipids and glycaemic control, as well as an

Investigation

For men, a 9 am testosterone concentration should be measured on two occasions at least a week apart. If testosterone is low then check gonadotrophins, to characterize the hypogonadism, and sex hormone-binding globulin (SHBG). Prolactin and thyroid-simulating hormone (TSH) should be checked as hyperprolactinaemia and throid imbalance can cause sexual dysfunction. Lipids and glycated haemoglobin (HbA1c) should also be measured for cardiovascular risk assessment.3 In women two

Treatment

Phosphodiesterase type 5 inhibitors (PDE5Is) are the first-line treatment for ED in all men as long as there are no contraindications (Table 1). All PDE5Is rely on adequate sexual stimulation to work as, by inhibiting the breakdown of cyclic guanosine monophosphate (cGMP), they potentiate the nitric oxide-mediated smooth muscle relaxation that allows blood flow into the erectile tissue (Figure 1).

Men with diabetes often report that PDE5Is helped their ED at first and then became ineffective.

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