Layout of Presentation

Modus Operendi
Introduction

Sexual dysfunction is a common

complication of diabetes mellitus
Introduction

One of the most neglected complication of

diabetes (price, 1993).
Introduction

It Causes a great amount of unhappiness, distress and

disappointment, both to the patient and his partner
Introduction
Surprisingly it is still not being taken seriously by the physicians.

Physicians still consider talking or discussing about sexual problems

a taboo, that it is purely in sexologists or psychiatrists domain, that

enquiring about sex life impinges on the patient’s privacy, that they

being ‘busy’ since managing sexual problems are cumbersome, and

that they are not trained at all to deal with these types of problems
SEXUAL
DYSFUNCTION IN
MALE DIABETICS
 
For our understanding, they would be classified under 3 headings

02

Erectile Ejaculatory Desire

disorders disorders disorders

01 03
I. ERECTILE DISORDERS
Insufficiency of the penile erection, so called The number of patients who admit
‘DIABETIC IMPOTENCE’ is the first and erectile dysfunction increases with age.
the most frequent sexual problem among the Over the age of 60 years, more than 70%
diabetic men of diabetics suffer from sexual
dysfunction.

The current consensus is that

Erectile dysfunction refers to the
approximately one out of every two
consistent inability to attain or maintain
men with clinically apparent
an erection of sufficient rigidity to permit diabetes are sexually
satisfactory sexual intercourse with or dysfunctional. (Ertekin, 1988).
without the loss of Libido.

The relationship between sexual

Prevalence of sexual dysfunction in impotence and diabetes was
diabetes varies from 23 – 59% universally accepted and
attributed to diabetic autonomic
neuropathy, following review by
rundles in 1945.
II. EJACULATORY DISORDERS
Some patients may complain of reduced or absent
ejaculation. No spermatozoa can be found in post –
orgasmic specimens unlike in retrograde ejaculation. They
may have genuine decline in semen production or
alternately, interference with passage into the urethra..
• Some may have delayed ejaculation secondary to decreased
sexual erectile arousal secondary to sub clinical reduction of
afferent sensation due to penile neuropathy, (sensory deficit
impotence)..

Finish

• Experience loss of the ‘pumping sensation’

associated with ejaculation.

• Some patients may have premature ejaculation..

Start

• In a small number of diabetic males • Retrograde ejaculation – This is the commonest and
ejaculatory disturbance develop before well recognized ejaculatory disturbance in diabetics.
the erectile problem.
Reported incidence varies from 1 – 20%, commonly
• During the course of the disease, 14%.
abnormities of ejaculation are present in • This may be one of the causes for infertility in
nearly half of the ED patients.. diabetics
III. DESIRE DISORDERS
 
DESIRE DISORDERS
Some studies have reported that a quarter
of the patients may develop desire
problems.

01

02
The desire component of sexual response
cycle remains intact in many diabetics.

In some, desire problems may be

secondary to psychogenic or
other associated disorders
PATHOGENESIS OF DIABETIC
IMPOTENCE
Pathogenesis of Diabetic Impotence

• Marginal role in the Diabetic impotence- ANS Old concept:

pathogenesis diabetic damage. The features Diabetes causes both large
and small vessel disease.
Psychological factors
sexual dysfunctions. suggestive of neurogenic
impotence include: Atherosclerosis appears account for up to 90%
• Many diabetic males more frequently and at an of all cases
have a degree •Persistence of libido – earlier age. Small vessel
hypogonadotrophic hallmark feature angiopathy is characterized New concept:
hypogonadism. by thickening of basement •Sexual knowledge,
•No erection at any time membrane.
•Retinopathy is one of the
•cultural and social
• Some males may have •Diminished testicular
high levels of function predictive factors of background of the
testosterone-binding consequent development of patient,
globulins. •Absent anal and bulbo – erectile dysfunction. •personality,
cavernosal reflexes •previous sexual
• Some may have •Increased incidence of
experiences, partner’s
hyperprolactinaemia due •Interruption of urination internal pudendal artery
sclerosis is known in
reaction etc.
to inhibition of LH.
Secretion. diabetes with ED.

Endocrine Vascular
Neuropathic Psychological
factor factors
factor factors
CLINICAL APPROACH & DIAGNOSTIC EVALUATION OF ED
Tests:
• Nocturnal Tumescence
Detailed clinical history and (NPT) using stamp test or
examination Regiscan
. •Visual (erotic) stimulation
test
•Tests for peripheral
neuropathy
•Hormonal assays
 

Vascular assessment – arteriography;

- Intracavernosal injection of vasoactive
drug (ICIVAD)
TREATMENT
Correct reversible factors:

a. Control diabetes and attain glycemic control

Psychosexual therapy:
b.Diet and drugs for primary and associated
a.Couple to be treated together
conditions
b.Sex education
a.Correct malnutrition
c.Improve relationship and communication
b.Avoid smoking and alcohol
d.Graded tasks including sensate focus
c.Least offensive antihypertensive etc.
and then non – coital and coital sexual
drugs to be used.
exercises.
e. Reassurance, reduction of performance
anxiety, redefining success, CBT
f. Emphasis on participative
g. sex rather than penetrative sex.
Drugs
I. ORAL AND TOPICAL PHARMACOTHERAPY
 
A. Central agents
i. Adrenergic receptor antagonists
Phentoamine
Yohimbine
 
ii. Dopamine receptor agonists
N 02
Apomorphine P TIO
O
Bromocriptine II INTRACAVERNIOSAL THERAPY

   
1
I ON0 Papaverine
iii. Serotonergic receptor agonis T
OP
Trazodone Papaverine – phentolamine mix

  Prostaglandin E 1
Trimix (papaverine phentolamine –

B. Peripherally acting agents prostaglandin E 1)

Sildenafil, Tadalafil (Papaverine/phentolamine–

L – arginine prostaglandinEI– Chlorpromazine)

 

 
 
 
Other treatment Options

PENILE PROSTHESIS

PENILE VASCULAR
SURGERY
PENILE VACUUM DEVICES
(Manual or automatic – produce
erection by vacuum and
placement of rings).
SEXUAL DYSFUNCTION
IN DIABETIC WOMEN
Less attention has been paid to diabetic women concerning their sexual problems. It
is probably related to:

Sexuality of
women is less
1 Passive participation
affected by in sex may often be
diabetes enough in sex.

3
2
They are less likely to reveal their problems
Orgasmic dysfunction

•Usually gradual and progressive

Other Dysfunctions
•Reduced vaginal
•Time of onset 4-8 years after
lubrication and dyspareunia
diagnosis
are related to concomitants
6 1
of diabetes mellitus.
•Women experience gradual
decrease of frequency of orgasm or
• Infections, particularly
lessening of intensity
vaginal, cause tissue 5 2
tenderness, pruitis,
•Though sexual interest is not
malodorous discharge and
diminished, they need extended
decreased vaginal
4 3 direct sexual stimulation
lubrication etc, leading to
dyspareunia.
•Underlying mechanism is still
 
uncertain. However, neuropathic,
vascular and psychogenic factors
have been implicated.
Take Home message
STEP B
A simple, straight forward, professional attitude and enquiry, provided confidentiality and privacy are assured,
would encourage the patients to discuss their concerns or problems concerning their sexuality.

STEP D

01 03
A holistic, comprehensive
START

management of diabetics
entails that the physician
Avoid Myths Sensuality attends to the sexual problems
routinely in all his clients.

STEP A

02 STEP C
04

STOP
Sex is basic need of life
Sensuality is more
Sexual dysfunctions Qyacks
important than
Sexuality
REFERNCES:
1.Bancroft .J – (1989) Human sexuality and its problems. Churchill Livingstone, New York.
2.Byer C.O & Shainberg L.W. (1994), Dimension of Human Sexuality, 4 th Edition, Brown & Benchmark
publishers U.S.A..
3.Dr. Raj Bramhabhatt FPAI, Mumbai, (1998) Therapy of Common Sexual progress a hard book.
4.Ertekin C. – (1988) Diabetes mellitus and sexual dysfunction – a review. Scandinavian Journal of Sexology,
Vol 1. no. 13 – 21.
5.Fairburn C.G. et al (1982) – The effects of diabetes on male sexual function. Clin Endocrinol Metab. 11:
749 – 767.
6.Kaiser F.E, Korenman SG, (1988) impotence in diabetic men. Am J Medicine, 85: suppl 5A: 147 – 152.
7.Kar.N & Kar G.C (2005) Jaypee brother medical publishers (p) Ltd., New Delhi –. Comprehensive text
book of Sexual medicine.
8.Kolodny R.C, Kahn, CB, Goldstien HH (1974) Sexual dysfunction in diabetic men. Diabetes. 23: 306 – 309
9.Lehman T.P., Jacobs, JA (1983) Etiology of diabetic impotence. J. Uroi. 129: 229 – 294.
10.Mc Culloch D.K, Campbell IW. Wu FC, Prescott RJ. Clarke BF (1980 The prevalence of diabetic
impotence. Diabetologia. 18: 279 -283.
11.Mc Culloch D.K, Young RJ, Campbell IW, Prescott RJ. & Clarke BF (1984) the natural history of
impotence in diabetic men. Diabetologia. 26: 437 - 445.
12.Price DE (1983) Managing impotence in diabetes. D.M.J. Indian ed, 9:9. 803 – 804.
13.Priyam N, Lamba P.S. (2002), Impotence, Diabetes today, Vol 12. No. 1.
14.Rundles RW. (1945) Diabetic neuropathic. Medicine; 24: 111 – 160.
15.Sundaram A, et al (1997) Sexual dysfunction in men with Diabetics mellitus. Proceedings NNDU (Nova
Nordisk) Diabetes update 103 – 109.