All men experience changes as they grow older. Some changes are emotional and others physical. But perhaps the most troubling changes for many men are those that affect sexual function. Most men experience some degree of sexual dysfunction at one time or another. But if you have diabetes, the problems can be more difficult to handle. This is due to a combination of both biological and psychological factors.
A sexual encounter involves four important events: desire, arousal, orgasm and satisfaction. Both emotional and physical factors affect each of these stages. For men with diabetes, the emotional and physical burdens of the disease can take their greatest toll on desire and arousal. Diabetes can be both physically and emotionally overwhelming. There are so many things to worry about, so much to do to manage the disease, that you may feel too emotionally drained to even want to think about having sex.
Often, complications of diabetes can interfere with the physical aspects of sexual performance. For example, men with diabetes often have problems with circulation and neuropathy. This can directly interfere with the mechanics of achieving an erection. As a man with diabetes, you are also more likely to be on medications that can trigger penile failure.
But there is good news. Doctors and scientist are beginning to get a better understanding of the biology of sexual function and have developed breakthroughs in using drugs to treat erectile dysfunction. They are also beginning to understand more about how changing male hormone levels affect not only your libido, but also your insulin sensitivity and blood glucose levels. As a result, you may be better able to take steps to keep your blood glucose levels under control and enjoy a healthy sex life.
PROBLEMS WITH DESIRE
Desire can be defined as the wish or the motivation to have a sexual encounter. Society tends to stereotype all men as being ready for sex at the drop of a hat. But that is not an accurate description of any man, whether has diabetes or not. However, as a man with diabetes, you are more likely to have more health problems in general. This can leave you feeling unmotivated for sex in the first place. Or you could find that you can’t even think about sex because you are overwhelmed with the emotional burden of dealing with diabetes. You may find that this happens occasionally, frequently, or all the time. As if that is not bad enough, diabetes can reduce the amount of testosterone your body produces. This can make you feel less energetic and less interested in sex.
Testosterone may also affect the way insulin does its job. As testosterone levels decline, you may experience more insulin resistance and have a harder time keeping your blood glucose levels under control. This, in turn, can make you feel worse physically and further decrease your sexual desire.
If you are feeling low sexual desire, you may experience it in different ways. You may feel no motivation for sex with anyone at any time. This might indicate you have a medical problem, such as low testosterone, or it could be a reflection of your general state of health. Maybe you are taking medication that interferes with your libido.
If, however, you feel desire for someone other than your partner, or feel the urge to masturbate, there could be a problem with your current relationship. Maybe your partner no longer excites you. Maybe your arguments leave you too drained for sex.
Your low libido could also reflect feelings you have about yourself. Maybe you are feeling depressed or anxious about something. Maybe you are feeling stressed out by work. Maybe the emotional toll of dealing with diabetes leaves you zapped of all energy for sex.
What You Should Do
Fist, ask yourself if your low libido is really a problem. If your partner doesn’t want sex, then maybe you can coexist peacefully without it and find joy in some of life’s other pleasures.
If however, you desire sex with someone other than your partner, you may need to address problems with your relationship. Perhaps psychological or marital counseling would help the problem. If you are suffering from depression or anxiety, psychological counseling may also help.
If you do not want to give up sex, and the relationship is not the problem, then talk to your doctor. He will need to conduct a thorough examination to determine whether other medical problems might be contributing. Your doctor will also want to review all the medications you may be taking to see if any might be inhibiting your desire.
Your doctor will also determine whether or not your body has adequate amounts of testosterone. If your body doesn’t make enough testosterone, you could be a candidate for hormone therapy.
Before considering any sort of hormone therapy, your doctor may first try to eliminate any medications that may be inhibiting your sexual desire. Do not discontinue any medication on your own without first consulting your doctor. This could threaten your life. Your doctor will probably try switching you to another medication that does not have the same side effects.
If you have a reduction in the amount of testosterone your body produces, your doctor may suggest hormone therapy. Testosterone can affect libido and lack of it may contribute, at least in part, to any sexual difficulties you might be having. Your doctor can measure your testosterone levels and determine whether you would benefit from replacement therapy. Testosterone can be given by injection or through a transdermal patch. Testosterone injections are less desirable because they produce high levels at injection and then drop to very low levels before the next injection. Patches are applied over muscles, such as those on the arm or shoulder, or on the scrotum, although more success is reported with the muscles patches. The patch seems to produce testosterone levels that most closely approximate those found in the body.
Patients taking testosterone supplements report having more energy, a better mood and increased strength, libido and sexual function. Disadvantages are skin irritation and itching, but these usually go away. If you do take supplemental testosterone, make sure to monitor your blood glucose levels frequently and ask your doctor whether any adjustments in your insulin doses or oral medications are necessary. Low testosterone is associated with insulin resistance. Therefore, as you increase your testosterone levels, you may find an improvement in your insulin sensitivity and may find that you need less insulin. Check with your doctor before making any changes, however, and don’t change any doses without first checking your blood glucose levels.
Erectile dysfunction or the fear of erectile dysfunction can be a major problem for most men. You have erectile dysfunction, or impotence, if you cannot consistently maintain an erection long enough to have sexual intercourse. All men are bound to have problems maintaining a hard penis from time to time. And as you age, the problem may occur more frequently. But if you have diabetes, you may be especially concerned over the problem of erectile dysfunction, and with good reason.
The tough facts are that the incidence of erectile dysfunction increases as you age. The older you are, the more likely you are to experience occasional or complete penile failure. And if you have diabetes, you are likely to develop erectile dysfunction 10 to 15 years earlier than men without diabetes. A full 50% to 60% of all men with diabetes over the age of 50 have some sort of problems with erectile dysfunction.
It is not easy to figure out what causes erectile dysfunction. Certainly several biological components have to be functioning properly. A host of factors, including external stimuli, emotions, hormones, circulation and nerves, all play a role in achieving and maintaining a penile erection. A normal erection occurs when the brain receives a signal that makes you become sexually aroused. This could be provoked by the sight of an attractive woman, catching a glimpse of your spouse in the shower, having your penis stroked or even something you are thinking about. In the normal flaccid state, the muscles of the penis are contracted, allowing only a small amount of blood to enter the penis. When you are aroused, the nerves of your autonomic nervous system release chemicals known as neurotransmitters. These chemicals cause the penis muscles to relax, which allows blood to flow in and makes the penis hard.
If you have poor circulation, blood flow to the penis can be impaired and that can prevent an erection. Or if your nerves are damaged, they may not be able to deliver the signal to your penis that you are feeling aroused, and you may fail to get hard. And certain medications can impair your ability to have an erection. Psychological factors also play an important role. If you have had a failure because of physical reasons, you may become anxious and that could make it more difficult to become erect. The stress of managing your diabetes could be overwhelming and that can also affect your ability to feel aroused. It is often difficult to tell which of these is the greater problem.
Fortunately, there are now a wide variety of medications available that can help you achieve sexual satisfaction. In addition, there are several steps you can take to reduce the likelihood that you will experience sexual problems.
If you have problems achieving and sustaining a penile erection long enough to allow you to have intercourse, you may have some degree of erectile dysfunction. If you are able to have erections most of the time that allow you to have sexual intercourse, you probably don’t have erectile dysfunction. There are a variety of factors that can get in the way of an erection on occasion. But if penile failure consistently keeps you from enjoying sexual relations, then you have erectile dysfunction. The bottom line is that if you perceive it to be a problem, then it is a problem and it needs to be addressed.
Erectile dysfunction may have nothing to do with feelings of desire. Your general state of health, mental outlook, level of hormones such as testosterone, and blood glucose levels can all affect how you feel and whether or not you feel sexual desire. If you are unable to feel sexual desire, you don’t necessarily have erectile dysfunction. Usually, men with erectile dysfunction have a healthy libido.
Many factors can put you at risk for erectile dysfunction. It could be due to purely physical or medical factors such as heart disease, circulatory problems, high blood pressure, high cholesterol or neuropathy. If you have suffered any injury to the penis or genital region, this could also interfere with erection. Having poor blood glucose control over time can also increase your risk of erectile dysfunction.
Psychological factors can also make erectile dysfunction more likely. These include depression, anxiety and low self-esteem. Emotional factors can also come into play. Perhaps you are having problems with your partner, are bored, or harbor some resentment or anger about issues outside of the bedroom. These problems can feed on each other and make the problem worse. Maybe one day you started out feeling overtired and stressed from work and were unable to perform. This can make you anxious and even increase your stress level, making it even more difficult the next time you attempt intercourse.
Medications you may be taking for other conditions can also interfere with your ability to have an erection. Common culprits are blood pressure medicines, such as beta-blockers and diuretics, some antidepressants, some antianxiety drugs, and some stomach ulcer medications. Even drugs such as alcohol or marijuana can interfere with erectile function. Cigarette smoking can also increase your risk of penile failure, because it contributes to poor circulation. The table below show some common medications that may be contributing to the problem
What You Should Do
If you are having problems maintaining erections, contact your health care provider. These issues can be difficult to discuss, but be aware you are not alone and should not feel embarrassed. This is a medical issue, and just as you would talk to your doctor about having difficulty breathing, you can talk to your doctor about the function of your penis.
Your doctor will want to first figure out whether your problem has a physical basis and will most likely conduct a thorough physical exam. Your doctor might want to know when your last successful erection occurred, how often you experience erectile failures, whether you are able to have an erection with masturbation, or whether you experience any nocturnal erections. If there are no physical barriers to erection, your penis will normally become hared several times during the night during REM or dream sleep. You can conduct a little self-test to see whether you experience these nocturnal erections.
Before you go to bed, you can wrap a strip of paper around your penis and secure it with a small piece of tape. Do not wrap a whole strip of tape around your penis, however. If you have nocturnal erection, then the piece of paper will be broken in the morning.
Your doctor will want to know whether you are taking any medications that could be contributing. Make sure to bring a complete list of all your medications, even over-the-counter drugs or herbal remedies, to your doctor’s appointment. Your doctor will also want to know about any emotional or psychological issues that could be bothering you. Are you having marital difficulties? Are you under an unusual amount of stress at work? Have you lost interest in your partner? If psychological factors are contributing, it is more likely that your difficulties came on suddenly. If there is a psychological cause, for example, you may be able to maintain an erection while masturbating or you may experience nocturnal erections, but you may be unable to sustain an erection when you are trying to make love to your wife. If impotence is due to physical factors, it is more likely that you have been experiencing a gradual decline in performance over the past several months or years. If your problem is purely physical, you may be unable to sustain an erection under any circumstances.
Before your doctor prescribes a treatment, he will want to determine what is causing a problem. It will be important to distinguish between a physical source or a psychological source of the penile failure. There are certain tests your doctor can conduct to get at the source of the problem. In addition to standard lab tests, including a urinalysis and blood glucose test, your doctor will also measure the level of hormones, including testosterone, in your blood.
Your doctor can also test your erectile response to the injection of a drug that will induce an erection if you have a normally functioning penis. If you are injected with one of these drugs, often a prostaglandin, and you fail to have an erection, your doctor can conclude that your erectile problem is due to poor circulation. If you have an erection, then your problem could be due to nerve damage or to psychological factors. If your problem is psychological or neurological, you may find relief in one of several oral or injected drugs now on the market that affect the signaling system in nerves that lead to erection. If your problem is due to poor circulation, these drugs will probably not be as effective.
Other treatment options included abstinence and surgery. If your problem is due to poor circulation, you and your doctor need to discuss whether your heart and circulation system are strong enough to withstand the levels of exertion and excitement that may be brought on by the prolonged sexual intercourse that may result from successful therapy.
Before reviewing the treatment options, your doctor will first try to eliminate any medications that may be causing your erectile dysfunction. You should not stop any suspect medication without your doctor’s supervision. Discontinuing a needed heart or high blood pressure medication without medical supervision could be life-threatening. Instead, your doctor may want to try switching you to another medication that will not cause erectile dysfunction. In fact, some medications for heart disease or high blood pressure may actually enhance erectile function.
If you have eliminated suspicious medications and your doctor believes that sexual activity will not harm your health, then there are several treatments you can consider: abstinence with or without psychological counseling, injectable or oral medications, mechanical devices or surgical implants.
This may hardly seem like a treatment. But before resorting to medication or surgery, you may want to consider whether you can make adaptions in your life to get along with erections. This could mean finding new ways to experience sexual pleasure for you and your partner. You may also want to combine this with psychological counselling to explore whether there is nonphysical cause of your erectile dysfunction. You may also choose this course if you and your doctor decide that you may have other medical problems that would make sexual activity unwise
There are several drug therapies available that can induce a penile erection. Yohimbine is an old remedy, heralded for more than a century as an aphrodisiac. It comes from the bark of the yohimbe tree. This drug seems to be most successful in men who still have erections, but have problems with rigidity. It has not been extensively tested in men with diabetes, because they typically do not seek treatment until they have lost complete ability to sustain erections.
The drug sildenafil (Viagra) has created the greatest media interest. It was originally tested in volunteers as a blood pressure medication with lackluster results. Researchers were alerted to its erectile potential when the research volunteers refused to give up the drug. A little detective work revealed that it could induce erections.
Viagra can be taken in pill form and stimulates and maintains an erection 30 to 60 minutes after being swallowed. The erection persists for about an hour and appears to work in up to 80% of patients. Side effects include headache, diarrhea, flushing, low blood pressure and disturbed color vision.
Other drug therapies include apomorphine, which works on the centers in the brain that triggers erection. It seems to work in 70% of people with mild erection dysfunction. Phentolamine (Vasomax) is a drug that had been used in injectable form, but it is now in pill form. It can improve erections in 40% of mild cases.
Injectable forms of the erectile drug alprostadil are in popular use too. This drug can be injected 20 minutes before sex and lasts for more than an hour. The big drawback to this approach is the pain of having to stick a needle directly into your penis. One novel way around this is the suppository form of alporstadil known as Muse. This is inserted into the tip of the penis in the urethra 5 to 10 minutes before sex and provides an erection that lasts an hour. It can be used twice a day, but it is not safe if used with a pregnant partner. Drawbacks include pain reported by some patients and low blood pressure.
Another, perhaps less palatable, treatment for erectile dysfunction is a mechanical vacuum device. The device consists of a long, clear plastic tube, a vacuum pump, and a constriction band. The plastic tube is slipped over the penis and the vacuum pump is turned on. This pulls blood into the penis to achieve an erection. Once the erection is complete, a rubber band is placed at the base of the penis to maintain the erection. These devices are especially useful in patients with vascular disease. Side effects include a feeling of coldness or numbness during erection and difficulty ejaculating because of the ring.
Surgical implants have been in use for more than 30 years, but with the advent of newer drug therapies they seem to be on the decline. Many different implant models are available. They are usually inflatable or a semirigid rod. All can make the penis hard on demand, but they differ on how soft they allow the penis to become after intercourse. The drawback is that they have to surgically implanted and there is a risk of infection. Patients with diabetes are especially susceptible to infection. Also, the components of the devices can be broken or the fluid in the prosthesis can leak. Patients also report reduced sensation, reduced penile length and frequent pain
The best way to prevent erectile dysfunction is to take steps to prevent impairment of the circulatory system and damage to the nerves. This can be done by keeping your blood glucose levels as close to normal as possible over the long term. You can further preserve erectile function by keeping your blood pressure and cholesterol levels under control. If you smoke, stop smoking. Eat a healthy, balanced diet, try to reduce the stress in your life, and get plenty of exercise. If you do have to take medications for other conditions, ask your doctor whether they can affect erectile function.
Sources and References
The Diabetes Problem Solver—Quick Answers to Your Questions About Treatment and Self-Care by Nancy Touchette
Sexual Dysfunction in Diabetes by Várkonyi Tamás and Peter Kempler
Sexual Dysfunction and Diabetes by G Jackson
Diabetes, Sexual Dysfunction and Therapeutic Exercise: A 20-year Review by Ade Adeniyi, Jokotade Adeleye and Celia Adeniyi
Efficacy of Ellagic Acid and Sildenafil in Diabetes-Induced Sexual Dysfunction by S Goswami, R Razdan et al