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Secrets of Individualization: Unspoken
issues in Diabetes
Introduction
• Diabetes has been described as the ‘most complex and demanding’
of any common chronic disease to manage
• There are many unspoken issues experienced by the diabetic
patients which needs due consideration as they usually go unnoticed
in the routine clinical practice
• Of these sexual manifestations in particular is missed out as patients
are bit hesitant to discuss with the physician especially in India
Introduction
• Sexual dysfunction is a common, underreported and largely
underappreciated complication of diabetes
• A large number of cases go unrecognised owing naturally to the
traditional reluctance both on the part of the patient as well as the
physician in discussing such issues which are considered too
personal to be discussed outside the bedroom
• Just as a good blood sugar control is necessary to lead a healthy
life free from the well known complications of diabetes on kidney,
eye, nerve, foot and heart, it is also very important for leading a
normal sexual life
Sexual Dysfunction in diabetes
• Men: Diabetes is an established risk factor for sexual dysfunction in
men; a threefold increased risk of erectile dysfunction (ED) was
documented in diabetic compared with nondiabetic men
• Women: The evidence regarding the association between diabetes
and sexual dysfunction is less conclusive, although most studies
have reported a higher prevalence of female sexual dysfunction
(FSD) in diabetic women as compared with nondiabetic women
It is now well known that diabetes has a major impact on both male
as well as female sexual functioning
Erectile dysfunction (ED)
In males, the common
problem is that of erectile
dysfunction (ED) which is
the inability to initiate or
maintain an erection
Erectile dysfunction (ED)
• Epidemiological studies suggest that both type 1 and type 2
diabetes are associated with an increased risk of ED worldwide
• Few other studies show that approximately 35 -75 % of men
with diabetes face this issue as compared to 26 % of the
general population
• Also, diabetic men suffer from this problem 10-15 years early in
their life as compared to their normal counterparts
ED and diabetes: risk factors and association
• Advanced age and longer duration of diabetes
• In diabetes, it involves both vascular as well as neural mechanisms
with atherosclerosis in the penile and pudendal arteries which are
the major causes of erectile dysfunction
• Microvascular & macrovacular diabetic complications -especially
autonomic neuropathy arising due to chronic uncontrolled diabetes
• The proposed mechanisms of ED in diabetic patients are
represented by vasculopathy, neuropathy, visceral adiposity, insulin
resistance, and hypogonadism
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
Int J Impot Res. 2013;25(1):1-6
ED and diabetes: risk factors and association
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
Int J Impot Res. 2013;25(1):1-6
ED and diabetes: risk factors and association
• Hypoxia secondary to diabetes-induced dysfunction of vasa
nervorum supplying the nerve trunks and ganglia alters neuronal
electrophysiology and axonal transport
• Moreover, diabetes is commonly associated with hypertension,
hyperlipidemia overweight and obesity, metabolic syndrome,
smoking, sedentary lifestyles
• Use of antihypertensive drugs (β-blockers, thiazide diuretics, and
spironolactone), psychotropic drugs (antidepressants), & certain
fibrates
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
Int J Impot Res. 2013;25(1):1-6
Female sexual dysfunction (FSD): Risk factors
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
Pathophysiology of FSD in diabetes
• The pathogenic factors of sexual dysfunction among diabetic women
include hyperglycaemia, infections, as well as vascular, neural,
neurovascular and psychosocial derangements
• Hyperglycaemia reduces hydration of vaginal mucosa and results in
poor vaginal lubrication and dyspareunia
• Also, associated genitourinary infections can cause dyspareunia
• The normal female sexual response requires an intact sensory and
autonomic nervous system to ensure proper interpretation of and
response to erotic stimuli
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
Pathophysiology of FSD in diabetes
• Diabetes causes vascular and nerve dysfunction which can lead
to structural and functional changes in female genitalia and may
impair sexual response
• Diabetic vasculopathy may lead to impaired local blood flow and
inhibition of the engorgement of the clitoris and lubrication of the
vagina during arousal, resulting in dyspareunia or decreased
arousal
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
Consequences of sexual dysfunction
Sexual dysfunction is thus related to
•Marital dissatisfaction
•Depression
•Poor emotional acceptance of diabetes and sexuality
•A reduced acceptance of the problem and its treatment
Consequences of sexual dysfunction
Sudden onset of the problem could most likely have an emotional
or psychological effect such as
•Stress
•Depression
•Disaffection
•Performance anxiety
Challenges in management
• Many clinicians find asking about sex embarrassing & feel
inadequately trained in this area Sexual Dysfunction is a difficult
subject to approach
• Embarrassment is a barrier for both individual & clinician
• A number of barriers that stop healthcare professionals raising
the subject of sex have been identified
: Diabetes & Primary Care Vol 15 No 6 2013
Challenges in management
• Lack of relevant training
• Embarrassment
• Time constraints
• Conservative sexual beliefs
• Insufficient knowledge on sexual health
• Insufficient acceptance of the individual’s special sexual profile
: Diabetes & Primary Care Vol 15 No 6 2013
Challenges in management
• Respecting confidentiality at all times can be especially important in
this area
• Furthermore, cultural and religious attitudes need to be considered
• It is also important to enquire about the partner’s sexual and
general health
• It is always helpful to encourage the partner to attend or offer for
him or her to come to the follow-up appointment to obtain this
person’s perspective
: Diabetes & Primary Care Vol 15 No 6 2013
A comprehensive medical examination
A complete examination of medical history focusing on high risk factors
such as the following should be done
A large number of medicines as well as emotional issues need to be ruled
out. It is important to note that sexual desire is not lost with ED-only the
ability to act on those emotions
Individualization in Clinical Evaluation and
Management of sexual dysfunction
Three essential concepts underlie the management of sexual
problems generally in men and women:
•Adoption of a patient-centered framework for evaluation and
treatment
•Application of the principles of evidence-based medicine in
diagnostic and treatment planning
•Adoption of a common management approach for sexual
dysfunction in both men and women
Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004
Diabetes & Primary Care Vol 15 No 6 2013
Diagnostic and management algorithm for sexual
dysfunction (SD) in men and women
Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004
Diabetes & Primary Care Vol 15 No 6 2013
Basic principles for sexual history-taking
• Allow the patient to feel in control
• Provide explanations for answers
• Help the patient feel less abnormal (destigmatize)
• Provide encouragement and positive support
• Initiate the discussion of sensitive topics
• Defer sensitive questions
• Be aware of patient’s cultural background
• Ensure confidentiality
• Avoid judgmentally
Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004
Diabetes & Primary Care Vol 15 No 6 2013
Physical Examination
• The physical examination is an essential component of sexual dysfunction
evaluation in every case
• The physical examination should include a general screening for medical
risk factors or comorbidities that are associated with sexual dysfunction,
such as body habitus (secondary sexual characteristics), assessment of the
cardiovascular, neurological and genital system, with particular focus on the
genitalia & secondary sex characteristics
Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of
Sexual Medicine Vol. 1, No. 1, 2004
Diabetes & Primary Care Vol 15 No 6 2013
Physical Examination
• The physical examination is used to corroborate aspects of the
medical history and may sometimes reveal unsuspected physical
findings (e.g., decreased peripheral pulses, vaginal atrophy,
atrophic testes, penile plaque)
• Every effort should be made to ensure the patient’s privacy,
confidentiality and personal comfort while conducting the physical
examination
Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004
Diabetes & Primary Care Vol 15 No 6 2013
When to refer?
• Pronounced psychosexual therapy needs
• A desire to initiate therapies for ED such as intracavernosal
injections, intraurethral pellets and surgery options
• Non-response to PDE-5 inhibitors
• Consideration of testosterone replacement therapy
• A requirement for specialist investigations, such as exercise
tolerance testing
• Referrals for comorbidities found during assessment
• The sexual dysfunction being of a nature that is outside the
competence of the clinician
Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004
Diabetes & Primary Care Vol 15 No 6 2013
Individualization of goals
Once a diagnosis is made, preventive measures such as
•Improving glycaemic and blood pressure control
•Controlling cholesterol
•Participating in a consistent exercise program
•De-stressing
•Quitting smoking
•Reducing alcohol intake have shown to be beneficial in patients
with ED
Drugs for Erectile Dysfunction
PDE-5 inhibitors:
•The generic oral medications available to treat erectile dysfunction as
a first line options-Tadalafil, Vardenafil, Avanafil, and Sildenafil - have
been used successfully in people with diabetes
•In general, however, the success rate of these medications is less than
the reported success rates in people without diabetes
•These medications may help 50% to 60% of men with diabetes
Drugs for Erectile Dysfunction
Testosterone:
•Testosterone injections or patches should be tried in patients with
documented low testosterone levels
•For patients who cannot be given oral therapy, intracavernosal
injections of vasoactive drugs under the training of a trained urologist or
andrologist are an acceptable alternative
Drugs for Erectile Dysfunction
Mechanical therapy:
•Mechanical therapy involving vacuum-assisted erection devices as
well as penile prosthesis are also a viable option.
Psychotherapy:
•Psychotherapy should routinely be offered to all patients and their
partners
Conclusion
• Sexual dysfunction can be a huge psychological burden on patients
with diabetes and can have a negative impact on marital relations
that are already burdened by the existence of a chronic illness
• Thus, the recognition and identification of this problem and proper
treatment and counseling by the treating doctor go a long way in
restoring normalcy in the lives of many couples who quietly suffer
the agony of this disorder
• It is very important to recognise that sexual dysfunction is a
common complication of diabetes and it is alright to discuss it with
your doctor who can help you get over it

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Secrets of individualisation unspoken issues in diabetes

  • 1. Secrets of Individualization: Unspoken issues in Diabetes
  • 2. Introduction • Diabetes has been described as the ‘most complex and demanding’ of any common chronic disease to manage • There are many unspoken issues experienced by the diabetic patients which needs due consideration as they usually go unnoticed in the routine clinical practice • Of these sexual manifestations in particular is missed out as patients are bit hesitant to discuss with the physician especially in India
  • 3. Introduction • Sexual dysfunction is a common, underreported and largely underappreciated complication of diabetes • A large number of cases go unrecognised owing naturally to the traditional reluctance both on the part of the patient as well as the physician in discussing such issues which are considered too personal to be discussed outside the bedroom • Just as a good blood sugar control is necessary to lead a healthy life free from the well known complications of diabetes on kidney, eye, nerve, foot and heart, it is also very important for leading a normal sexual life
  • 4. Sexual Dysfunction in diabetes • Men: Diabetes is an established risk factor for sexual dysfunction in men; a threefold increased risk of erectile dysfunction (ED) was documented in diabetic compared with nondiabetic men • Women: The evidence regarding the association between diabetes and sexual dysfunction is less conclusive, although most studies have reported a higher prevalence of female sexual dysfunction (FSD) in diabetic women as compared with nondiabetic women It is now well known that diabetes has a major impact on both male as well as female sexual functioning
  • 5. Erectile dysfunction (ED) In males, the common problem is that of erectile dysfunction (ED) which is the inability to initiate or maintain an erection
  • 6. Erectile dysfunction (ED) • Epidemiological studies suggest that both type 1 and type 2 diabetes are associated with an increased risk of ED worldwide • Few other studies show that approximately 35 -75 % of men with diabetes face this issue as compared to 26 % of the general population • Also, diabetic men suffer from this problem 10-15 years early in their life as compared to their normal counterparts
  • 7. ED and diabetes: risk factors and association • Advanced age and longer duration of diabetes • In diabetes, it involves both vascular as well as neural mechanisms with atherosclerosis in the penile and pudendal arteries which are the major causes of erectile dysfunction • Microvascular & macrovacular diabetic complications -especially autonomic neuropathy arising due to chronic uncontrolled diabetes • The proposed mechanisms of ED in diabetic patients are represented by vasculopathy, neuropathy, visceral adiposity, insulin resistance, and hypogonadism Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105 Int J Impot Res. 2013;25(1):1-6
  • 8. ED and diabetes: risk factors and association Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105 Int J Impot Res. 2013;25(1):1-6
  • 9. ED and diabetes: risk factors and association • Hypoxia secondary to diabetes-induced dysfunction of vasa nervorum supplying the nerve trunks and ganglia alters neuronal electrophysiology and axonal transport • Moreover, diabetes is commonly associated with hypertension, hyperlipidemia overweight and obesity, metabolic syndrome, smoking, sedentary lifestyles • Use of antihypertensive drugs (β-blockers, thiazide diuretics, and spironolactone), psychotropic drugs (antidepressants), & certain fibrates Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105 Int J Impot Res. 2013;25(1):1-6
  • 10. Female sexual dysfunction (FSD): Risk factors Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
  • 11. Pathophysiology of FSD in diabetes • The pathogenic factors of sexual dysfunction among diabetic women include hyperglycaemia, infections, as well as vascular, neural, neurovascular and psychosocial derangements • Hyperglycaemia reduces hydration of vaginal mucosa and results in poor vaginal lubrication and dyspareunia • Also, associated genitourinary infections can cause dyspareunia • The normal female sexual response requires an intact sensory and autonomic nervous system to ensure proper interpretation of and response to erotic stimuli Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
  • 12. Pathophysiology of FSD in diabetes • Diabetes causes vascular and nerve dysfunction which can lead to structural and functional changes in female genitalia and may impair sexual response • Diabetic vasculopathy may lead to impaired local blood flow and inhibition of the engorgement of the clitoris and lubrication of the vagina during arousal, resulting in dyspareunia or decreased arousal Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2014:7 95–105
  • 13. Consequences of sexual dysfunction Sexual dysfunction is thus related to •Marital dissatisfaction •Depression •Poor emotional acceptance of diabetes and sexuality •A reduced acceptance of the problem and its treatment
  • 14. Consequences of sexual dysfunction Sudden onset of the problem could most likely have an emotional or psychological effect such as •Stress •Depression •Disaffection •Performance anxiety
  • 15. Challenges in management • Many clinicians find asking about sex embarrassing & feel inadequately trained in this area Sexual Dysfunction is a difficult subject to approach • Embarrassment is a barrier for both individual & clinician • A number of barriers that stop healthcare professionals raising the subject of sex have been identified : Diabetes & Primary Care Vol 15 No 6 2013
  • 16. Challenges in management • Lack of relevant training • Embarrassment • Time constraints • Conservative sexual beliefs • Insufficient knowledge on sexual health • Insufficient acceptance of the individual’s special sexual profile : Diabetes & Primary Care Vol 15 No 6 2013
  • 17. Challenges in management • Respecting confidentiality at all times can be especially important in this area • Furthermore, cultural and religious attitudes need to be considered • It is also important to enquire about the partner’s sexual and general health • It is always helpful to encourage the partner to attend or offer for him or her to come to the follow-up appointment to obtain this person’s perspective : Diabetes & Primary Care Vol 15 No 6 2013
  • 18. A comprehensive medical examination A complete examination of medical history focusing on high risk factors such as the following should be done A large number of medicines as well as emotional issues need to be ruled out. It is important to note that sexual desire is not lost with ED-only the ability to act on those emotions
  • 19. Individualization in Clinical Evaluation and Management of sexual dysfunction Three essential concepts underlie the management of sexual problems generally in men and women: •Adoption of a patient-centered framework for evaluation and treatment •Application of the principles of evidence-based medicine in diagnostic and treatment planning •Adoption of a common management approach for sexual dysfunction in both men and women Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004 Diabetes & Primary Care Vol 15 No 6 2013
  • 20. Diagnostic and management algorithm for sexual dysfunction (SD) in men and women Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004 Diabetes & Primary Care Vol 15 No 6 2013
  • 21. Basic principles for sexual history-taking • Allow the patient to feel in control • Provide explanations for answers • Help the patient feel less abnormal (destigmatize) • Provide encouragement and positive support • Initiate the discussion of sensitive topics • Defer sensitive questions • Be aware of patient’s cultural background • Ensure confidentiality • Avoid judgmentally Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004 Diabetes & Primary Care Vol 15 No 6 2013
  • 22. Physical Examination • The physical examination is an essential component of sexual dysfunction evaluation in every case • The physical examination should include a general screening for medical risk factors or comorbidities that are associated with sexual dysfunction, such as body habitus (secondary sexual characteristics), assessment of the cardiovascular, neurological and genital system, with particular focus on the genitalia & secondary sex characteristics Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004 Diabetes & Primary Care Vol 15 No 6 2013
  • 23. Physical Examination • The physical examination is used to corroborate aspects of the medical history and may sometimes reveal unsuspected physical findings (e.g., decreased peripheral pulses, vaginal atrophy, atrophic testes, penile plaque) • Every effort should be made to ensure the patient’s privacy, confidentiality and personal comfort while conducting the physical examination Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004 Diabetes & Primary Care Vol 15 No 6 2013
  • 24. When to refer? • Pronounced psychosexual therapy needs • A desire to initiate therapies for ED such as intracavernosal injections, intraurethral pellets and surgery options • Non-response to PDE-5 inhibitors • Consideration of testosterone replacement therapy • A requirement for specialist investigations, such as exercise tolerance testing • Referrals for comorbidities found during assessment • The sexual dysfunction being of a nature that is outside the competence of the clinician Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women. Journal of Sexual Medicine Vol. 1, No. 1, 2004 Diabetes & Primary Care Vol 15 No 6 2013
  • 25. Individualization of goals Once a diagnosis is made, preventive measures such as •Improving glycaemic and blood pressure control •Controlling cholesterol •Participating in a consistent exercise program •De-stressing •Quitting smoking •Reducing alcohol intake have shown to be beneficial in patients with ED
  • 26. Drugs for Erectile Dysfunction PDE-5 inhibitors: •The generic oral medications available to treat erectile dysfunction as a first line options-Tadalafil, Vardenafil, Avanafil, and Sildenafil - have been used successfully in people with diabetes •In general, however, the success rate of these medications is less than the reported success rates in people without diabetes •These medications may help 50% to 60% of men with diabetes
  • 27. Drugs for Erectile Dysfunction Testosterone: •Testosterone injections or patches should be tried in patients with documented low testosterone levels •For patients who cannot be given oral therapy, intracavernosal injections of vasoactive drugs under the training of a trained urologist or andrologist are an acceptable alternative
  • 28. Drugs for Erectile Dysfunction Mechanical therapy: •Mechanical therapy involving vacuum-assisted erection devices as well as penile prosthesis are also a viable option. Psychotherapy: •Psychotherapy should routinely be offered to all patients and their partners
  • 29. Conclusion • Sexual dysfunction can be a huge psychological burden on patients with diabetes and can have a negative impact on marital relations that are already burdened by the existence of a chronic illness • Thus, the recognition and identification of this problem and proper treatment and counseling by the treating doctor go a long way in restoring normalcy in the lives of many couples who quietly suffer the agony of this disorder • It is very important to recognise that sexual dysfunction is a common complication of diabetes and it is alright to discuss it with your doctor who can help you get over it

Editor's Notes

  1. The schematic representation of temporal effect of microvascular deficit and advanced glycation endproducts (AGEs) on erectile function with particular emphasis on nitrergic nerves