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This article explores the sexual complications of diabetes mellitus in both men and women, focusing on the barriers to diagnosis and management in India. It highlights the high prevalence of erectile dysfunction in diabetic men and the social and psychological factors contributing to female sexual dysfunction. The article also discusses the physician and patient-related barriers to addressing sexual problems in the Indian healthcare system.
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Introduction • Diabetes mellitus (OM) is a global epidemic causing a number of complications, one of them being sexual dysfunction in males and females • A threefold increased risk of erectile dysfunction (ED) has been documented in diabetic men, compared to non-diabetic men • Female sexual dysfunction appears to be more related to social and psychological components than that of the physiological consequence of diabetes • Conception and pregnancy is not easy for diabetic women • Sexual dysfunction due to diabetes often receives less attention than it deserves • Sex is generally considered as a taboo subject and is perceived as a sin
EPIDEMIOLOGY • It has been observed that approximately 35-75% of Indian diabetic men suffer from ED as compared to 26% of the general population • In addition, diabetic men sufferfrom ED 10-1 5 years early in their Iif~ compared to their normal counterparts • Premature ejaculation (PE) was likely to be associated with longer (> 10 years) duration of diabetes, poor metabolic control and concomitant cardiovascular disease (CVD) • It is seen that approximately 70% of diabetic women have certain degree of sexual dysfunction. Sexual dysfunction is associated with higher age, clinical depression and one or more diabetes-related complications
BARRIERS TO THE DIAGNOSIS OF SEXUAL PROBLEMS IN INDIA • PHYSICIAN RELATED BARRIERS • The main difference between eliciting ordinary medical history and sexual history is that the doctor is embarrassed and uncomfortable asking questions to the patient about their sexual life • In India, doctors may find it difficult to discuss the sexual process, any related misconceptions expectations and correct unrealistic • Physicians may lack the expertise to handle sexual problems
BARRIERS TO THE DIAGNOSIS OF SEXUAL PROBLEMS IN INDIA • PHYSICIAN RELATED BARRIERS • Considering the Indian diversity, doctors do not use regional terms/language for easy understanding of the patient e.g., local terminologies for sexual organs, activities, etc. • Doctors may not know what questions to ask or how to ask them, they may feel uncomfortable with the topic, awkward using sexual terms and fear of insulting the patient • Some physicians may believe that sexual history is not relevant to the chief complaint of the patient • Some physicians may remark that they do not have the time to address these concerns
BARRIERS TO THE DIAGNOSIS OF SEXUAL PROBLEMS IN INDIA • PATIENT-RELATED BARRIERS • Indian patients are often shy, feel uncomfortable discussing sexual complaints and may overcome the feeling of guilt and shame. Often, there is a stigma attached to seeking sexual consultation • Indian patients are reluctant to discuss sexual problems with their doctors and for those who are willing, they may not be sure whom to approach • There are a number of myths and superstitions around sexual problems
BARRIERS TO THE DIAGNOSIS OF SEXUAL PROBLEMS IN INDIA • PATIENT-RELATED BARRIERS • Due to the stigma attached, patients try to often hide their problems and find ways to cope with them • Sexual problems in men have an underlining chauvinistic attitude and feel that it is an assault to their masculinity • Patients are unaware of the effects of drugs and are often scared to take them • In India, sex education is a neglected entity and many do not feel the need to educate their children regarding it
DIAGNOSIS History taking • Comprehensive history taking is essential for the diagnosis of ED. It is important to elicit the following information regarding ED Onset and progression of ED • ED with a sudden onset, intermittent course, or short-duration may be due to psychogenic factors. The presence of rigid morning or night erections, or rigid erections at any sexual thought mainly suggests a psychogenic cause • Conversely, ED with a gradual onset, progressive course, or long duration suggests a predominantly organic cause such as diabetes, alcohol or tobacco consumption
DIAGNOSIS Predisposing factors and medications • DM • Peyronie'sdisease • Alcohol • Tobacco Relationship issues and any psychological problems • A detailed psychosocial history of the patient, including patient's assessment of his own sexual performance, patient's general attitude, and knowledge about sex may help rule out complex psychological problems • Illicit drug abuse • Past penile or prostate surgery • Antidepressants, Antihypertensives (hydrochlorothiazide), Antihistamines and Tranquilizer
Medical therapy • Oral PDE5-1 are used as the first-line treatment for ED • They inhibit PDE-5 enzyme that normally degrades cyclic guanosine monophosphate (cGMP) in the cavernous smooth muscles • This leads to prolonged activity of cGMP, which decreases the intracellular calcium concentrations, maintains smooth muscle relaxation and results in rigid penile erections
Other alternatives • Intracavernosal injection and transurethral therapy • Vacuum constrictive devices • Phyto-neutraceuticals combined with L- arginine and antioxidants • Stem-cell therapy • Gene therapy
PREVENTION AND DIABETES CONTROL • ED due to diabetes, especially T1 DM can be reversible provided hyperglycaemia is controlled through lifestyle modifications-exercise and diet, avoidance of smoking and appropriate use of oral hypoglycaemic agents and/or insulin • Kegel exercises also help to correct PE • Physical exercise and weight reduction can improve erectile function by decreasing endothelial dysfunction, insulin resistance and the low-grade inflammatory state already associated with diabetes and metabolic dysfunction • Additionally, in order to treat the patient's comorbidities, medications with the least adverse impact on erectile function should be sought e.g., antihypertensives and antidepressants
PREVENTION AND DIABETES CONTROL The medications that can cause ED are • Diuretics • Antihypertensives • Antihistamines • Antidepressants • Parkinson's disease drugs • Tranquilizers • Muscle relaxants • Nonsteroidal anti-inflammatory drugs • Histamine H2-receptor antagonists • Hormones • Chemotherapy medications • Prostate cancer drugs • Anti-seizure medications
COUNSELLING STRATEGIES- THE MAINSTAY OF MANAGEMENT • The counselling session should begin with an open-ended question e.g., what changes have you noticed? followed by a statement that It is common for men with diabetes to have sexual problems then further targeting patients age, medications, risk factors, lifestyle, etc. • Patients may have numerous doubts and queries related to the use of medication prescribed • These concerns need to be addressed at first • ED or sexual dysfunction of any form affects not only the patient, but also his partner. The partner may believe that ED indicates either a lack of affection or transfer of sexual relations elsewhere
COUNSELLING STRATEGIES- THE MAINSTAY OF MANAGEMENT • Where possible, couples should be welcomed to each consultation and should be offered psychosexual counselling along with any other intervention which is prescribed • It is important for the partner of an ED patient to talk to him about the problem. The care and concern of a partner is often the reason a man seeks medical advice and counselling • Partners can give valuable support throughout the treatment process. This can be useful in helping couples to re-establish a sexual relationship, even when there has been a lengthy period without sexual activity because of ED
COUNSELLING STRATEGIES- THE MAINSTAY OF MANAGEMENT • Understanding the causes and the way the treatment of ED works this can help partners cope with their personal problems which they may suffer as a result of the ED • Along with the treatment it is very helpful for a partner to understand that sexual stimulation is still needed for an erection to happen • Review of accomplishments should be done at every follow-up session
PATHOGENESIS OF SEXUAL COMPLICATIONS IN WOMEN WITH DM • To identify whether a diabetic woman has sexual dysfunction and to prescribe an appropriate treatment, the physician should identify the factors that contribute to sexual dysfunction • One must assess the woman's current interpersonal and psychosocial status, her sexual and medical history, comorbid illness as well as her medications
Medical history should be obtained especially pertaining to • Duration of diabetes • Glycaemic control • Presence or absence of chronic diabetes complications • Pharmacologic treatment of diabetes • Episodes of hypoglycaemia • Symptoms or signs of depression • Comorbid medical conditions • Surgical history • Medications other than antibiotics for diabetes • Menopausal status
Medical history should be obtained especially pertaining to • Personal habits such as smoking, alcohol intake, duration and type of exercise • Gynaecologic history and history of sexual function • Age of menarche • Regularity and duration of menstrual cycle • Menstrual flow • Fertility in terms of time required to achieve conception, miscarriages, and pregnancy outcomes
