Sex is not just a physical act: It results from a combination of physiologic, affective and cognitive factors. Because of the complexity of sexual functioningwith both organic and psychological factorsit tends to be poorly understood.
One of the more common complications of diabetes is sexual dysfunction, which affects approximately 1/3 of women and more than 1/2 of men with diabetes (1). The literature on prevalence is inconsistent, with estimates ranging from 11 to 80%; however, those of us in practice know that it is a common and sensitive indicator of poor glycemic control. Enzlin (1) showed that the prevalence of sexual dysfunction in a group of patients with type 1 diabetes was 27% for women and 22% for men. The Massachusetts Male Aging Study (3) showed the prevalence of erectile dysfunction to be 52%. While one can have sexual dysfunction without erectile dysfunction, it is unlikely that one would see erectile dysfunction without sexual dysfunction; once again the only consistency is inconsistency.
Women with diabetes and sexual dysfunction have different concerns and needs than men. In women with diabetes, sexual dysfunction is most closely related to psychosocial problems and depression (1). In the literature, there is little association between sexual dysfunction and glycemic control. Deterioration of glycemic control, however, is frequently associated with depression, which in turn is associated with sexual dysfunction. Therefore, in women, the predominance of psychosocial and depressive etiologies should not blind us to the possible role of blood glucose (BG) levels or the consequent vascular disease as the root cause or a contributory factor in sexual dysfunction.
Although commonly used synonymously, we should not confuse sexual dysfunction in men with erectile dysfunction, as they are 2 separate conditions. By concentrating on erectile function alone, we may do a disservice to the patient by failing to recognize other factors. There is a strong possibility that psychosocial and depressive factors affect men as much as they do women.
One common factor between men and women with diabetes is that sexual dysfunction is underdiagnosed and undertreated. We rarely diagnose sexual dysfunction unless we ask the right questions; thus, a complete sexual history must be part of our assessment of the patient with diabetes. Generally speaking, healthy or responsive sexual functioning involves the participation of a partner; therefore, diagnosis and treatment should involve both partners.
Patients are reluctant to discuss their sexual function, but once they do open up, they often describe a long and complex history that might have been dealt with years previously. The combined use of tools such as the Sexual Health Inventory for Men and the Hamilton Depression Scale will provide the clinician with objective information to assist diagnosis and treatment. The use of these tools is a good, non-judgemental trigger to elicit disclosure of extremely sensitive patient concerns.
Erectile dysfunction is primarily a vascular and neuropathic disease; as with other microvascular complications of diabetes, the best treatment is prevention. It should be noted that our diagnosis of diabetes is based on the threshold at which microvascular complications (particularly retinopathy) start, and that the incidence of those complications is directly related to BG levels. The best way to avoid or control microvascular complications is to treat according to the Canadian Diabetes Association’s Clinical Practice Guidelines (5). The vascular changes that lead to erectile dysfunction may be virtually eliminated by keeping preprandial BG below 7.0 mmol/L, blood pressure £130/80 mm Hg, LDL-C £2.5 mmol/L, and by appropriate use of ACE inhibitors and ASA. Erectile dysfunction in men is often the result of failure to adequately control glycemia and other comorbidities. Any symptoms of neuropathy, such as burning pain or dysthesia of the feet, decrease in fine touch, vibration or temperature sense should presume erectile dysfunction unless proven otherwise. Similarly, if vascular disease is present, we should always ask about adequacy of erections, taking into account iatrogenic impotence due to medications and/or male andropause. Fortunately, PDE5 inhibitors now offer a simple and frequently effective treatment for erectile dysfunction; but while we can offer relief of this symptom, we must be mindful that erectile difficulties are most commonly due to a failure to control the primary disease and this should be addressed in the treatment plan.
Sexual dysfunction is a common complication of diabetes, which is underdiagnosed and undertreated resulting in a significant burden of disease not only to persons with diabetes but also their partners and families. Prevention, recognition and treatment of sexual dysfunction need to be part of our treatment plan. We now have effective treatments for many people with erectile dysfunction but we need to remember that sexual function is multifactorial and, in order to give comprehensive care to the patient, we need to consider all possible factors.
Enzlin P, Mathieu C, Van Den BA, et al. Prevalence and predictors of sexual dysfunction in patients with type 1 diabetes. Diabetes Care. 2003;26:409-414.
Klein R, Klein BE, Lee KE, et al. Prevalence of self reported erectile dysfunction in people with long term IDDM. Diabetes Care. 1996;19:135-141.
Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts male aging study. J Urol. 1994;151:54-61.
Wang CJ, Shen SY, Wu CC, et al. Penile blood flow study in diabetic impotence. Urol Int. 1993;50:209-212.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2003;27(suppl 2):S1-S152.