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Sexual Dysfunction in Diabetes

Page history last edited by willbrant@gmail.com 13 years, 3 months ago


The Web diabetesmanager



Sexual Dysfunction in Diabetes


Tom F Lue, M.D.

William Brant, MD

Alan Shindel, MD

Anthony J. Bella, M.D.


Last Author Revision:  2009








Diabetes mellitus (DM) may lead to disruption of normal sexual function in both men and women via diabetic induced damage to the nerves and blood vessels essential for normal function of the genital organs.  Additionally, the presence of poorly controlled diabetes may increase the morbidity associated with the treatment of erectile dysfunction (ED) in men. In the Endotext chapter “Medical and Surgical Therapy of Erectile Dysfunction”, Bochinski, et al review the pathophysiology, work-up, and treatments for erectile dysfunction of any cause. In this chapter, we will focus specifically on sexual dysfunction in diabetics, with particular emphasis on practical information for practicing clinicians.




Erectile dysfunction is a common clinical problem and a serious detriment to quality of life for men and their partners. While the incidence of ED increases with age this is driven not so much by age in and of itself but by comorbid conditions associated with aging.  Examples include smoking, heart disease, high blood pressure, high cholesterol, and diabetes.[1] The incidence of ED in men with diabetes is approximately three-fold higher than in the general population.[2][3][4] ED may also be the presenting symptom for DM and may predict later neurologic sequelae.[5]




The pathophysiology of ED in DM is multifactorial, consisting of vascular and neurologic insults. There is impaired relaxation of the corpus cavernosal smooth muscle in diabetics in response to neuronal- and endothelial-derived nitric oxide, which may be due to the accumulation of glycosylation products .[6][7][8][9]  New evidence has suggested that in addition to problems with the arteries and nerves supplying the penis, men with diabetes may be at increased risk of low testosterone levels (aka hypogonadism).[10] [11] While the precices mechanism of this effect has not been entirely elucidated it may be secondary in some cases to a decline in the levels of pituitary hormones responsible for stimulating testicular production of testosterone.[12]  Low levels of testosterone may lead to a decline in sexual desire and, directly or indirectly, erectile dysfunction.[13]



Treatment of ED with phosphodiesterase type 5 inhibitors (PDE5i)


The treatment of ED in general was revolutionized by the availability of sildenafil (Viagra), followed by tadalafil (Cialis) and vardenafil (Levitra). The three medications work by a similar pathway. Sexual stimulation provokes the release of nitric oxide (NO), leading to increased cellular concentrations of cyclic guanosine monophosphate (cGMP) and subsequent penile smooth muscle relaxation. This process is reversed by the conversion of cGMP to guanosine monophosphate, which is mediated by phosphodiesterase type 5 (PDE5)- the predominant functional PDE type found in the penis. PDE5i act at this step to maintain elevated levels of cGMP and continued smooth muscle relaxation. Since the release of NO is a neurologically-mediated event, neuropathy (as may occur with diabetes) may blunt the efficacy of PDE5i. This is indeed borne out clinically, as diabetics have a poorer response overall to PDE5i than men with ED of other causes.


A prospective, multi-center, randomized, double-blinded (RCDB) trial of vardenafil in diabetics was carried out by Goldstein, et al [14]. The study consisted of 430 men with chronic ED, a hemoglobin A1c (HbA1c) of <12%, and no other serious confounding causes of ED (e.g. radical pelvic surgery, spinal cord injury, etc). Additionally, patients were excluded if they had unstable coronary disease or other contraindications to PDE5i use. The patients were evaluated using the erectile function (EF) domain of the 15 item International Index of Erectile Function (IIEF), 2 diary questions regarding the patient’s ability to penetrate (SEP2) and have successful intercourse (SEP3), and a global assessment question (GAQ) about whether or not the treatment had improved their erections. There were statistically and clinically significant improvements in all of the evaluated endpoints, with most of the improvements demonstrating a dose-relation. With 20 mg of vardenafil, the EF score was 19 (out of a total possible of 25) and 54% of men were able to complete intercourse, with an overall responder rate (as measured by the GAQ) of 72%. The effect was attenuated in patients with severe underlying ED but improvement remained significant. There was no correlation noted between different strata of HgA1c levels. The drug was well-tolerated with few patients discontinuing the study due to adverse side-effects.


A similar RCDB trial of tadalafil in diabetics was performed by Saenz de Tejada, et al .[15] A total of 191 patients completed this study; evaluated parameters were very similar to the vardenafil study above. Exclusion criteria were also similar to the vardenafil study, except that patients with hypertension and hypercholesterolemia were also excluded in the tadalafil study. As in the vardenafil study, statistically and clinically significant improvements were noted in all of the evaluated parameters for men using tadalafil, regardless of severity of underlying DM or level of HgA1c, with an overall responder rate (as assessed by GAQ) of 64% by those using 20 mg. The drug was also well-tolerated with few discontinuations.


A unique study from Denmark attempted to assess the “real-life” use of sildenafil in diabetics in terms of how many patients wanted to try an agent, how many were eligible to do so, and how efficacious the medicine was . [16]Examining a diabetes outpatient clinic population of 326 men, 192 (59%) self-reported ED and 187 of these were over 40 years old. Of these 187 patients, 79 (42%) were excluded because of medical or pharmacologic contraindications to sildenafil use. A further 63 patients either declined to participate in the study or did not respond. This left 45 patients for the study (23% of those patients with self-reported ED). Of these, 10 dropped out due to lack of sexual partner and 2 others without recorded reason. Sixty-one percent of the remaining patients self-titrated to a maximum dose of 100 mg. Of the 33 patients remaining, 36% noted consistent improvement, 27% noted variable improvement, and 36% felt they had no improvement; overall, 54% felt that the medicine had met their expectations. If we consider that 18 patients total felt that the medicine met their expectations and that the starting pool was 187 patients with self-reported ED, this leaves less than 10% of patients with a satisfactory outcome, thus pointing out that PDE5i, while efficacious under normal study conditions, do not represent a panacea.


In 2008 the US Food and Drug Administration (FDA) approved low-dose (2.5-5 mg) tadalafil as a daily treatment for ED.  Hatzichristou et al. enrolled 298 men with diabetes (89% type 2) and ED in a RCDB lasting 12 weeks and assessed clinical response using the sexual encounter profile questions 2 and 3.  At baseline 38%, 42%, and 32% of men reported the ability to attain an erection sufficient for vaginal penetration (SEP2) in the placebo, 2.5 mg, and 5 mg groups, respectively. The percentages of men in the same groups able to maintain erection until the completion of satisfactory intercourse (SEP3) were 20%, 20% and 16%, respectively.  At the completion of the study, men treated with either the 2.5 mg or 5 mg dose of tadalafil manifested greater improvements in SEP 2 (increase from baseline of 5%, 20%, and 29%) and SEP3 (28%, 46%, 41%).  The lower success rate in the 5 mg group was likely accounted for by relatively worse diabetic disease at baseline in that group.  Patients treated with tadalafil reported improvements in erection (based on IIEF scores) irrespective of baseline IIEF scores.  Patients were significantly more likely to prefer tadalafil treatment compared to placebo.[17]


In addition to daily dosing as an alternative to on-demand dosing for PDE5i, there has been great interest in recent years in the use of PDE5i not just as a therapy to produce erections but as a means to halt or even reverse the penile tissue damage that leads to ED.  Studies in animals with a form of experimentally induced diabetes most similar to Diabetes mellitus type 1 have demonstrated enhancement of erectile function and preservation of penile tissue health when treated with either vardenafil or SK-3530 (a novel PDE5i that has not yet been approved for routine in humans).[18],[19]  A preliminary study of routine dose sildenafil vs. placebo for 4 weeks in 292 men with type 2 diabetes and ED revealed some improvements in blood tests used to measure oxidative stress in men treated with sildenafil.  Unfortunately, there were some differences between the placebo and sildenafil group at baseline and there were no significant erectile function differences after the 4 week course of daily treatment was completed.[20] Another study in 20 men with type 2 diabetes but no ED indicated that treatment with sildenafil 25 mg three times a day led to improved vascular function and a decline in blood markers for various types of inflammation and oxidative stress; the ultimate clinical relevance of these findings is however unclear.[21] These encouraging preliminary results will require further assessment before the routine use of PDE5i for reversal of tissue damage can be recommended routinely.  A degree of caution is required since, despite a series of encouraging pre-clinical animals studies, routine dose PDE5i for the management of ED related to pelvic surgery has not at this time been proven to be of benefit.[22]


Treatment of ED with other modalities


Intracavernosal alprostadil injection therapy in diabetics was evaluated in a large, multicenter trial by Heaton, et al[23] . Over 300 men entered the trial, 83% completing the titration period and proceeding to home use. Of those patients using the medication at home, 79% required 30 micrograms/dose or less, and 72% remained satisfied with the initial dose during the followup period (6 months). There were 2 instances of priapism (sustained erection of greater than 4 hours unaccompanied by sexual stimuli) neither of which required intervention, 1 patient developed a penile nodule, and 24% of patients reported penile pain with injection; the pain led to patient drop-out in 5% of the treatment group. A smaller, more recent study with longer followup (10 years) found that diabetic patients tended to shift towards decreased frequency of use but preferred stronger agents (mixtures of alprostadil with other vasodilators such as papavarine and phentolamine), with type 1 diabetics stabilizing their doses within 5 years and type 2 diabetics stabilizing within 9-10 years.[24]


In patients for whom injection therapy does not work vacuum erection devices (VED) may be useful. There is a paucity of data specifically evaluating the use of VED in diabetics but the drop-out rate for patients is generally quite high, even for patients who are able to achieve a rigid erection with the device. One subset analysis found that despite a good response (i.e. rigid erection) using VED, only 50% of those couples found the treatment to be satisfactory . This may be due to the “unnaturalness” of the devices, as well as the fact that they may have several local side effects, including petechiae (small red dots from broken capillaries), a feeling of having a cold penis, and abnormal sensation of ejacuation.



Penile Prosthetics


When there is lack of efficacy or dissatisfaction with other modalities, penile prostheses are often the best alternative for erectile dysfunction in diabetics. Unlike the other modalities, prosthesis surgery is irreversible in that the corporal tissue is permanently altered such that physiologic erections are no longer possible. If the prosthesis has to be removed, there will be complete ED. While a variety of exotic materials, flaps , and grafts have been used, most contemporary prostheses are hydraulic or semi-rigid.[26][27]Of all modalities for management of ED, prostheses have the highest satisfaction rates, with 2 large studies demonstrating greater than 95% satisfaction.[28][29] While this high rate of satisfaction is encouraing it must be understood that the population of men who are motivated enough to undergo surgery for erectile function may not be representative of the larger population of ED patients.


Although some studies suggest that elevated HbA1c levels may predict a higher rate of infections in diabetics having penile prosthesis surgery, more recent studies refute this.[30] A large study from Wilson, et al demonstrated that neither diabetic status nor preoperative HgA1c were risk factors for prosthesis infection. A more recent study also finds that elevated HbA1c is not a risk factor for infection but notes that short-term poor glucose control (as defined by morning fast glucose levels >200 ng/ml) is, although that data is hampered by very low numbers of patients within that set.[31][32]


Treatment of low testosterone levels


Although there is some controvery over what constitutes a true "low" testosterone level and the best way to measure it, well designed studies have indicated that men with low levels of testerone and symptoms of hypogonadism (such as decreased libido, decreased energy, depression, anxiety, fatigue, weight gain, etc) may benefit from testosterone replacement therapy.   To our knowledge there have not been specific studies of sexual function in hypogonadal, diabetic men treated with testosterone.  However, the general efficacy of testosterone in improving sexual function (particularly sexual desire and response to PDE5i in cases of initial failure to respond) in appropriately selected patients is well known.[33] In addition to improving sexual symptoms in these men, testosterone supplementation may have beneficial effects with respect to lean body mass and insulin sensitivity in diabetic men with hypogonadism.[34][35]


A number of different testosterone formulations are available.  Patients can discuss available options with their health care providers


Ejaculatory dysfunction


Men with diabetes may have sexual disorders other than erectile dysfunction. Examples include diminished sexual desire, lack of ejaculation with sexual climax (anejaculation or retrograde ejaculation), and premature ejaculation. Successful antegrade ejaculation depends on the coordination of three neurologic events: seminal emission, bladder neck closure, and contraction of the muscles of the pelvic floor (e.g. bulbocavernous, ischiocavernous, etc.). In diabetes, derangements of the nerves controlling closure of the connection between the bladder and urethra may disrupt normal ejaculation.  In this situation ejaculate is deposited in the innermost portion of the urethra but the connection between the bladder and urethra does not close.  Since the bladder neck is open, some or all of the ejaculate may leak backwards into the bladder during the muscle contractions that normally expel the semen from the penis.  In the most severe cases there may be total lack of seminal emission. Either of these conditions will impact fertility.  It may also be a source of psychological disturbance to the man; indeed, some men report that they are not able to fully enjoy orgasm in the absence of ejaculation. From a fertility standpoint, sperm may be retrieved from post-ejaculate urine and then used for artificial insemination. Alternative strategies to overcome retrograde ejaculation generally focus on attempts to help the bladder neck close.  A variety of pharmacologic agents have also been used, including anticholinergics, antihistamines, and alpha-adrenergics .[36][37] 


Female Sexual Dysfunction


Our understanding of the medical and physiological aspects of females sexual function is poor relative to our understanding of men's sexual physiology and function. It is recognized that diabetes can be detrimental to female sexuality in a multifactorial manner, including both psychologic and physiologic dimensions. [38][39]The best studied  class of female sexual dysfunctions (at least with respect to medicophysiological research) is arousal disorder; physiologically, this is accompanied by vasodilation and engorgement of the female external genitalia.[40] Given that the processes involved in female genital engorgement are governed by many of the same molecular processes that occur duing male genital engorgement, Caruso et al [41]undertook a RCDB trial of 100 mg sildenafil in type 1 diabetic women with sexual dysfunction. Of the 28 women who completed the trial, significant improvement was seen in both subjective and objective parameters. Subjectively, arousal, orgasm and dyspareunia were all improved in those taking sildenafil in comparison to baseline and those taking placebo. Color Doppler ultrasonography was performed on the clitoral arteries, revealing an increase in blood flow in these women. However, it should be noted that the use of ultrasonography in the evaluation of women with sexual dysfunction is not routine and these results should be interpreted with caution.


The importance of managing lifestyle factors in treating sexual problems in diabetes


As with most aspects of diabetes care, routine exercise, careful monitoring of glucose levels, and usage of appropriate therapies to prevent hyperglycemia are key to preventing progression of diabetes-induced sexual problems.  Weight management and dietary prudence are also critical in the management of diabetes.  There is evidence to suggest weight loss may reverse erectile dysfunction in some men.  In a study of 65 obese men with ED and the Metabolic Syndrome (MetS, obesity with at abnormalities of blood pressure, abnormal glucose level/diabetes, and abnormal cholesterol levels), eating a "Mediterranean diet" (emphasizing fresh fruit and vegetables) for two years led to normalization of erectile function (as determined by an International Index of Erectile function score greater than 22) in 13 of 35 men compared to 2 of 30 men in the group that did not have dietary manipulation.[42]  A similar study in women with sexual dysfunction and MetS showed a significant improvement in mean sexual function (mean increase on the Female Sexual Function Index from 19.7 to 26.1 in the treatment group vs. no change from baseline in the control group).  Also noted in both of these studies were improvements in serum insulin and glucose level in men and women who ate the Mediterranean diet.[43] 




Sexual dysfunctions are common in people with diabetes and may arise from a variety of vascular, neurologic, and hormonal derangements. While PDE5i do not work as well in diabetics as in other populations, they still represent a good first-line treatment. If their use is unsatisfactory, intracorporal injections and implantable prosthesis are excellent alternatives. Vacuum devices represent another viable alternative, although satisfaction is generally not as high. Beyond erectile difficulties, men may complain of ejaculatory symptoms which arise from neuropathy of sympathetic nerves. Female sexual dysfunctions may be underreported in diabetics but further clinical advances may lead to increased hope and more efficacious treatments for these disorders.




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