Sexual dysfunction in diabetes

doi:10.1016/B978-0-444-53480-4.00017-5

Handbook of Clinical Neurology

Volume 126, 2014, Pages 223-232

https://doi.org/10.1016/B978-0-444-53480-4.00017-5 Get rights and content

Abstract

We aimed to summarize the etiology, clinical characteristics, diagnosis, and possible treatment options of sexual dysfunction in diabetic patients of both sexes. Details of dysfunction in diabetic women are less conclusive than in men due to the lack of standardized evaluation of sexual function in women. Male sexual dysfunction is a common complication of diabetes, including abnormalities of orgasmic/ejaculatory function and desire/libido in addition to penile erection. The prevalence of erectile dysfunction (ED) among diabetic men varies from 35% to 75%. Diabetes-induced ED has a multifactorial etiology including metabolic, neurologic, vascular, hormonal, and psychological components. ED should be regarded as the first sign of cardiovascular disease because it can be present before development of symptomatic coronary artery disease, as larger coronary vessels better tolerate the same amount of plaque compared to smaller penile arteries. The diagnosis of ED is based on validated questionnaires and determination of functional and organic abnormalities. First-, second- and third-line therapy may be applied. Phosphodiesterase-5 (PDE-5) inhibitor treatment from the first-line options leads to smooth muscle relaxation in the corpus cavernosum and enhancement in blood flow, resulting in erection during sexual stimulus. The use of PDE-5 inhibitors in the presence of oral nitrates is strictly contraindicated in diabetic men, as in nondiabetic subjects. All PDE-5 inhibitors have been evaluated for ED in diabetic patients with convincing efficacy data. Second-line therapy includes intracavernosal, trans- or intraurethral administration of vasoactive drugs or application of a vacuum device. Third-line therapies are the implantation of penile prosthesis and penile revascularization.

Introduction

Impaired sexual function is a frequent complication in diabetes in both women and men. Studies in diabetes focus primarily on erectile dysfunction (ED) in men but there are also detrimental manifestations of sexual dysfunction in women and both have a relationship with depression and impaired quality of life. Moreover mostly in men, sexual dysfunction is associated with an increased cardiovascular risk and a poor life expectancy (Banks et al., 2013). This warrants a detailed analysis of sexual dysfunction in both sexes.

Section snippets

Sexual dysfunction in diabetic women

Studies in diabetic women are less conclusive than in men owing to several factors, including the lack of standardized definitions of sexual function in women, the low number of well-validated research methods, and social taboos regarding female sexuality (Althof et al., 2005). A loss of libido, problems with orgasm, lubrication and arousal, dyspareunia, and lower overall sexual satisfaction have all been reported with a significantly higher frequency in both type 1 and type 2 diabetic women (

Sexual dysfunction in diabetic men

Male sexual dysfunction is a common complication of diabetes. Studies on sexual function in diabetic and nondiabetic patients tend to focus primarily on ED. Besides the highly prevalent ED, the full spectrum of male sexual dysfunction consists of a multidimensional construct comprising abnormalities of orgasmic/ejaculatory function and desire/libido in addition to penile erection (Penson et al., 2009). In the UroEDIC study 55% of type 1 diabetic men had decreased libido, 34% suffered from ED

Definition

ED is defined as the persistant inability to achieve or maintain an erection sufficient to permit satisfactory sexual intercourse. Normal penile erection is a hemodynamic process that is dependent upon corporal smooth muscle relaxation mediated by parasympathetic neurotransmission, nitric oxide, electrophysiologic events and possibly other regulatory factors (Andersson, 2011).

Prevalence of erectile dysfunction in diabetes

The prevalence of ED among diabetic men varies from 35% to 75% in different publications. These differences can be

Treatment of erectile dysfunction in diabetic patients

Considering that diabetes is associated with several organic disturbances which can lead to ED, diabetic individuals are more likely to seek treatment for ED for nonpsychogenic causes and at presentation may have a greater severity of disease than nondiabetic subjects (Corona et al., 2004).

As ED is strongly associated with cardiovascular risk factors in diabetic men, the patients must be categorized by their cardiovascular status before planning their treatment. Two international consensus

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Diabetic erectile dysfunction (DED) hugely affected the patients' sexual life quality. However, there are no satisfactory therapeutic methods and intervention targets for this subtype of erectile dysfunction (ED). Inspired by the clinical practice of traditional Chinese medicine (TCM), we found that hirudin, the main active ingredient in the leech, could ameliorate the ED symptoms of the DED mouse model. To further reveal the underlying mechanism of hirudin, we designed a novel strategy to discover potential targets based on the diagnostic system of TCM, and found that myeloperoxidase (MPO) was a promising target of hirudin. Hirudin directly interacts with MPO and inhibits its activity, thus further decreases the content of oxidized low-density lipoprotein (ox-LDL) in serum. Our results demonstrated that the hirudin could ameliorate the symptoms of DED, and revealed the underlying mechanism of hirudin in regulating the activity of MPO.
Autonomic neuropathy and urologic complications in diabetes
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Diabetic autonomic neuropathy affects the entire autonomic nervous system and can lead to dysfunction of the cardiovascular, gastrointestinal, and genitourinary organ systems. Genitourinary dysfunction associated with diabetic autonomic neuropathy includes diabetic bladder dysfunction, sexual dysfunction, and recurrent urinary tract infections. Urological complications in diabetes mellitus are very common; in fact, genitourinary complications are more common than diabetic neuropathy or nephropathy. While several studies have reported on genitourinary dysfunction in individuals with diabetes, UroEDIC, an ancillary study to the Diabetes Control and Complications Trial (DCCT) and its observational follow up, the Epidemiology of Diabetes Interventions and Complications study (EDIC), comprehensively characterized the association between urologic complications and cardiovascular autonomic neuropathy. UroEDIC demonstrated significant associations between autonomic neuropathy and urologic complications in type 1 diabetes, specifically erectile dysfunction, female sexual dysfunction, and lower urinary tract symptoms. In this narrative review, we review the current literature on urological complications in diabetes.
A Small Group Randomized Double-Blind Placebo-Controlled Study to Evaluate the Efficacy of Daily Pentoxifylline in the Management of Patients With Erectile Dysfunction with Suboptimal Treatment Response to Sildenafil
2020, Sexual Medicine
Citation Excerpt :
The randomization list was computer generated, with equal allocation to the 2 treatment arms. ED in patients with diabetes mellitus can be contributed by the neurogenic component, which may result in poor response to PDE-5 inhibitor,15 as such, stratified randomization according to the presence of diabetes mellitus was fully implemented. The intervention group (S+P) were given pentoxifylline (400 mg) thrice daily orally for 8 weeks and the control group (S only) were given placebo capsules thrice times daily orally for 8 weeks.
Several studies have reaffirmed the use of regular pentoxifylline therapy in increasing the penile brachial pressure index in men affected by erectile dysfunction when compared to placebo.
The aim of this study was to evaluate the efficacy of pentoxifylline as an adjunctive treatment for patients with erectile dysfunction.
This study was a single center, prospective, randomized, double-blind, placebo-controlled trial. Subjects were recruited between April 2014 and November 2016 from the National University Hospital, Singapore. The combination therapy group was given pentoxifylline 400 mg thrice daily orally and the monotherapy group was given placebo capsules thrice daily orally. Both groups continued their on-demand 100 mg sildenafil. The treatment duration was 8 weeks. Efficacy was measured via the International Index of Erectile Function (IIEF-5) questionnaire at the eighth week. Differences in mean IIEF-5 score and the domains of the IIEF at 8 weeks between the 2 treatment groups were compared using independent sample t-test.
Baseline IIEF-5 and the IIEF-15 score vs post-therapy IIEF-5 and the IIEF-15 score.
50 patients were randomized into 2 groups. Patients in the 2 groups were comparable in terms of the demographic and clinical characteristics, comorbidities, and baseline IIEF-5 scores. The mean IIEF-5 score post-therapy of the combination therapy group vs the monotherapy group was 14.11 and 14.87, respectively. There was no significant difference between the outcomes of these 2 groups (unadjusted mean difference -0.76; 95% CI -4.01 to 2.49; P = .641) and the outcomes are the same even after adjusting for baseline IIEF-5 scores. There was a significant improvement in the “overall satisfaction” portion of the IIEF score for the combination therapy group as compared to the monotherapy group (unadjusted mean difference 0.12; 95% CI -1.49 to 1.25) and even after adjustment for baseline scores (adjusted mean difference 1.11; 95% CI 0.10 to 2.12; P = .032) the improvement is significant.
Our trial suggests that the use of combination therapy does not improve the management of patients compared to monotherapy.
Law YXT, Tai BC, Tan YQ et al. A Small Group Randomized Double-Blind Placebo-Controlled Study to Evaluate the Efficacy of Daily Pentoxifylline in the Management of Patients With Erectile Dysfunction with Suboptimal Treatment Response to Sildenafil. Sex Med 2019;8:14–20.
Does Chronic Hyperglycemia Affect Female Rat Sexual Behavior? Differences in Paced and Non-Paced Mating
2019, Journal of Sexual Medicine
Citation Excerpt :
DM2 has been associated with different disorders, such as cardiovascular dysfunction, neuropathy, nephropathy,7 and, importantly, sexual dysfunction in men8–12 and women.13–15 The effect of DM on human female sexuality varies, may affect all aspects of sexual function, and is mostly reported in patients with diabetes mellitus type 1 (DM1).12,16–18 In women with DM2, the results are controversial; the main problems described are a decrease in vaginal lubrication19–23 and orgasmic dysfunction.24–28
Diabetes mellitus has been associated with sexual dysfunction; however, in women this relationship is controversial. A study using a model of type 2 diabetes mellitus (DM2) failed to find a reduced receptivity in the non-paced mating (NPM), but the appetitive aspects of female sexual behavior have not been evaluated, for example, in the paced mating (PM) paradigm.
To evaluate all components of female sexual behavior (in NPM and PM) in a model of DM2 using ovariectomized (OVX) (treated with steroids) or intact female rats (non-OVX) in natural proestrus.
Neonatal females (3–4 days) were administered streptozotocin (STZ, 70 mg/kg, intraperitoneally) or citrate buffer. At week 8, a glucose tolerance test was performed. At week 10, half of the females were OVX, and in the other half (non-OVX) the estrous cycle was monitored. At the twelfth week, the sexual behavior tests were conducted; OVX females were treated with estradiol benzoate (10 μg, −24 hours) and progesterone (3 mg, −4 hours), whereas the non-OVX were evaluated on vaginal proestrus.
We registered in NPM and PM receptivity (lordosis quotient and intensity), as well as the number of proceptive and aggressive behaviors. Additionally, in PM we calculated the percentage of exits and the return latencies after receiving stimulation and the time the female remained in the male's compartment.
The STZ-treated females presented glucose intolerance and were hyperglycemic. Neonatal STZ treatment provoked changes in the females' sexual behavior depending on the paradigm and the hormonal condition. In the NPM, STZ-OVX females had decreased lordosis quotient and intensity and increased aggression, whereas, in the STZ-non-OVX females, there was a decrease in proceptivity; such changes were not observed in PM. Regardless of whether the STZ-treated females were OVX, they failed to perform the pacing behavior.
These data support the idea that chronic mild hyperglycemia, like that observed in DM2 (which represents 90% of the clinical cases), provokes marginal changes in most aspects of female sexual behavior.
The main strength of this work is the evaluation of consummatory and motivational aspects of female sexual behavior in a model of DM2. The main limitation is the duration of the experimental design that does not resemble the course of the disease in humans. No histologic or biochemical analyses were performed.
These results suggest that chronic hyperglycemia produces decreases in sexual behavior.
Hernández-Munive AK, Rebolledo-Solleiro D, Fernández-Guasti A. Does Chronic Hyperglycemia Affect Female Rat Sexual Behavior? Differences in Paced and Non-Paced Mating. J Sex Med 2019;16:1130–1142.
Sexuality Perceptions and Sexual Care Needs of Patients with Type 1 Diabetes Mellitus: A Mixed Methods Study
2023, Sexuality and Disability
Detecting and treating the protean manifestations of diabetic autonomic neuropathy
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View all citing articles on Scopus

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Chapter 16 - Sexual dysfunction in diabetes

Abstract

Introduction

Section snippets

Sexual dysfunction in diabetic women

Sexual dysfunction in diabetic men

Definition

Prevalence of erectile dysfunction in diabetes

Treatment of erectile dysfunction in diabetic patients

J Urol

J Urol

J Sex Med

Eur Urol

J Sex Med

J Urol

Eur Urol

Diabetes Res Clin Pract

J Sex Med

Am J Cardiol

J Sex Med

Am J Cardiol

J Sex Med

J Sex Med

J Urol

Urology

J Diabetes Complications

J Urol

J Diabetes Complications

J Sex Med

Outcome measurement in female sexual dysfunction clinical trials: review and recommendations

J Sex Marital Ther

Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction

Pharmacol Rev

Female sexual dysfunction

Int Urogynecol J

Erectile function in men with diabetes type 2: correlation with glycemic control

Int J Impot Res

Erectile dysfunction severity as a risk marker for cardiovascular disease hospitalisation and all-cause mortality: a prospective cohort study

PLoS Med

New treatment options for erectile dysfunction in patients with diabetes mellitus

Drugs

Humoral effects of metoclopramide and domperidone in normal subjects and in hypertensive patients

J Endocrinol Invest

The neuropathy of erectile dysfunction

Int J Impot Res

Sildenafil citrate for the treatment of erectile dysfunction in men with Type II diabetes mellitus

Diabetologia

Erectile dysfunction and diabetes mellitus: mechanistic considerations from studies in experimental models

Curr Diabetes Rev

Advanced glycation endproducts are responsible for the impairment of corpus cavernosal smooth muscle relaxation seen in diabetes

BJU Int

Following the common association between testosterone deficiency and diabetes mellitus, can testosterone be regarded as a new therapy for diabetes?

Int J Androl

The SUBITO-DE study: sexual dysfunction in newly diagnosed type 2 diabetes male patients

J Endocrinol Invest

Erectile and endothelial dysfunction in type II diabetes: a possible link

Diabetologia

Sexual dysfunction in women with type 1 diabetes: a controlled study

Diabetes Care

Sexual dysfunction in women with type 1 diabetes

Diabetes Care

Determinants of female sexual dysfunction in type 2 diabetes

Int J Impot Res

Evaluation of sexual function in women with type 2 diabetes mellitus

Diab Vasc Dis Res

Impact of diabetes mellitus on the severity of erectile dysfunction and response to treatment: analysis of data from tadalafil clinical trials

Diabetologia

Sexual dysfunction in women with diabetes mellitus

J Sex Res