Repercussions of DM in sexual life

Erectile dysfunction is defined as the inability of a man to achieve and/or maintain sufficient erection for sexual activity.

This complication (less often called 'impotence' these days) often occurs in middle-aged men. In a large study performed in Massachusetts, 52 percent of healthy middle-aged men manifested some degree of erectile dysfunction. The same study showed that the frequency increases with age, while it is three times more frequent in diabetics compared to non-diabetics of a similar age.

Table 19.1. Erectile dysfunction evaluation scale (International scale of erectile function, IIEF)

During the last 4 weeks:

1. How often did you have an erection during any sexual activity? 0-5

2. During sexual activity, how often did you have an erection that allowed penetration? 0-5

3. Out of all the times you sought sexual contact, how many times did you succeed? 0-5

4. How often did you maintain the erection after penetration? 0-5

5. How difficult was it for you to maintain the erection up to the completion of the contact? 0-5

6. How do you grade the confidence in yourself with regard to your ability to succeed and maintain a satisfactory erection? 0-5 Total score: 25-30: normal, 17-25: mild dysfunction, 11-16: moderate dysfunction, < 10: severe dysfunction.

In various studies, diabetic individuals manifest disturbances of erectile function at a rate from 33 to 75 percent.

The problem of erectile dysfunction considerably influences the patient's quality of life because it decreases self-esteem while at the same time creates problems in their personal life. Often the patient does not report his problem, but is willing to discuss it when asked by his treating physician. It is consequently essential, because of its frequency, that this sensitive problem is discussed discreetly, with the initiative of healthcare professionals in the diabetic clinics. Erectile dysfunction is basically diagnosed with a detailed medical history (Table 19.1) and is much less dependent on physical examination and special tests. Recently specific questionnaires with detailed questions concerning sexual activity have been developed, and if answered sincerely, they usually reveal the problem.

In order to exclude psychological causes, the confirmation or absence of automatic morning erections is (details of the first morning hours are reported at history taking and are recorded with a special instrument).

Erectile dysfunction is associated, in most cases, with diseases that affect the blood vessels, causing atherosclerosis. Thus, hypertension, hypercholesterolaemia, DM and smoking increase the risk of the problem. At the same time, it can be also due to psychological or emotional factors. Finally, the use of medicines (diuretics, beta-blockers) but also psychotropic substances (alcohol, marijuana, cocaine, etc.) can cause erectile dysfunction.

Erection involves the blood vessels and the nervous system of the body. The penis consists of two parallel structures, the corpus caverno-sum and the corpus spongiosum penis, which originate from inside the pelvis and end up at the tip of the penis. These structures consist of spongy tissue that contains many blood vessels. Usually the walls of the vessels are constricted and impede any additional blood to flow into the penis. Thus, the penis is relaxed most of the time. When a man is sexually aroused these blood vessels begin to dilate and blood flow is increased. Simultaneously, the veins that remove the blood from the penis constrict and prevent the fast and quantitative removal of blood. The combination of a big surge of blood with its decreased removal leads to the inflation and hardening of the penis and causes erection.

It should be noted that DM can cause hardening and stenosis of the arteries that impede the smooth and sufficient flow of blood into the penis. At the same time, DM can cause damage in the nerves that connect the nervous system with the penis, thus leading, through this additional mechanism, to erectile dysfunction. The presence of other factors, from those already mentioned, can also aggrevate the problem (mainly smoking, hypertension, alcoholic abuse and certain categories of medicines). In rare cases the existence of hypogonadism is also a contributory factor. Overweight or obese diabetic individuals very frequently suffer from this metabolic syndrome and are characterized, among other things, by low levels of sex hormone binding globulin (SHBG). This globulin is connected in plasma with the sex hormones. Decreased levels, although affecting the total levels of testosterone, do not influence the levels of free testosterone, which are the active levels. Thus, the determination only of levels of total testosterone in these individuals can create a false picture of hypogonadism.

In the context of investigating erectile dysfunction, apart from the classical routine tests, serum testosterone is often also ordered. If total testosterone is < 300 ng/dl, a second sample should be drawn between 7 and 10 a.m. in order to determine total testosterone, LH (luteinizing hormone) and prolactin levels. Measurement of free testosterone is performed when the levels of total testosterone are marginal and when there is indication for decreased levels of SHBG. If LH levels are low or normal with levels of testosterone < 200 ng/dl, or if hyperprolactinaemia or abnormal thyroid function are present, the patient should be referred to a specialist.

Erectile dysfunction in DM can be transient and reversible when diabetes is not controlled well. Good DM control is essential, although there are no large studies showing that the improvement of glycaemic control ameliorates erectile dysfunction. In certain cases, however, especially when a man has had DM for a long time, the disturbance may not be completely reversible.

The problem can occur in both types of DM. Men with Type 1 DM suffer from the illness for a long time and usually from a young age. They consequently stand a higher chance of manifesting erectile problems at a younger age. Patients with Type 2 DM are adults, frequently smoke and consume alcohol, and also have hypertension. Thus, they too frequently manifest erectile problems.

The problem of erectile dysfunction should be discussed with the doctor, becames nowadays pharmacological management of the problem may be possible.

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