Sexual dysfunction is any problem that regularly interferes with a person’s sexual performance. Men and women with diabetes are more likely than nondiabetics to experience sexual dysfunction.
Sexual problems that may affect diabetic men include erectile dysfunction (impotence), ejaculation problems and low levels of testosterone. Diabetic women frequently experience vaginal dryness, pain during intercourse, decreased vaginal sensitivity, difficulty climaxing and decreased sexual desire or response.
Sexual dysfunction in people with diabetes often involves damage to blood vessels (diabetic angiopathy) or nerves (diabetic neuropathy). This damage usually results from poorly controlled glucose (blood sugar). Other common factors that contribute to sexual dysfunction include obesity, fatigue, depression, medications, urinary tract infections, yeast infections and overactive bladder.
Signs and symptoms vary according to the type of dysfunction the patient is experiencing. Diagnosis begins with a medical history and physical examination. The physician may order blood tests, urine tests, nerve tests or other tests depending on the patient’s gender and type of dysfunction involved.
Treating sexual dysfunction in people with diabetes includes controlling glucose. Additional treatment options depend on the individual case and may include medications, therapy or surgery.
About sexual dysfunction and diabetes
Sexual dysfunction is any problem that regularly interferes with an individual’s ability to perform sexual intercourse. Changes in sexual functioning are common as people age. Having diabetes, however, can result in earlier onset and increased severity of sexual problems.
Diabetic men and women are more likely than nondiabetics to experience sexual dysfunction. Depending on the cause of sexual dysfunction, its onset may be sudden and (usually) temporary, or gradual and permanent. Many diabetic patients experience a slow and steady decline in sexual functioning.
Sexual dysfunction in individuals with diabetes typically results from damage to the blood vessels (diabetic angiopathy) or nerves (diabetic neuropathy), and poor control of glucose (blood sugar). Many people with diabetes also suffer from high blood pressure, obesity, unhealthy cholesterol levels, fatigue, infections, hormonal conditions, bladder problems or depression, all of which can also contribute to sexual problems.
Because of differences in anatomy, men and women experience different types of sexual dysfunction. Patients experiencing sexual difficulties are encouraged to discuss issues openly with their partner and seek appropriate treatment.
Types and differences of sexual dysfunction
People with diabetes have an increased risk of sexual dysfunction. Sexual problems that commonly affect diabetic men include:
- Erectile dysfunction. This is an inability to consistently achieve or sustain an erection firm enough for intercourse. Men with this condition, which is commonly called impotence, may occasionally be able to have or sustain an erection.
Men with diabetes are three times more likely to experience erectile dysfunction than those without diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). In addition, men with diabetes and erectile dysfunction may experience the problem 10 to 15 years earlier in life than nondiabetics. It is not uncommon for a man seeking treatment for erectile dysfunction to learn that he has diabetes and that it may be the cause of his sexual difficulties.
- Male hypogonadism (low level of the hormone testosterone). Beginning in middle age, this condition is common in men. Researchers have found that obesity, diabetes, elevated blood pressure or unhealthy amounts of blood fats (cholesterol and triglycerides) are associated with hypogonadism. Insufficient production of testosterone has been linked to fatigue, diminished sexual desire, depression and the bone-thinning disease osteoporosis. Recent research suggests that hypogonadism may also be associated with insulin resistance, the progression of type 2 diabetes and possibly heart disease.
- Retrograde ejaculation. This condition occurs when part or all of the semen travels into the bladder rather than out of the penis during ejaculation. Retrograde ejaculation is typically caused by irregular functioning of internal muscles called sphincters. Men experiencing this problem may notice that a small amount of semen is discharged during ejaculation. They may also experience fertility problems.
- Premature ejaculation. Factors that may contribute to this common condition include diabetes, cardiovascular disease, nerve damage or urethritis.
- Delayed (retarded) ejaculation. This is a difficulty in ejaculating even when there is an erection and sexual desire. Risk factors for delayed ejaculation include diabetes, high blood pressure, nerve disease and prostate problems.
Women with diabetes are prone to sexual dysfunction as well. They commonly experience:
- Vaginal dryness. Decreased lubrication of the vagina, caused in part by nerve damage to cells that line the vagina, may lead to pain or discomfort during intercourse (dyspareunia). Another common sexual problem that affects women with diabetes is decreased vaginal sensitivity, which often makes orgasm difficult to achieve.
- Decreased arousal. Up to 35 percent of women with diabetes may exhibit a decreased or absent sexual desire or response, according to the NIDDK. A major reason for this is that chronic hyperglycemia can damage blood vessels and restrict blood flow to the vagina and clitoris. In addition, many women, including those without diabetes, experience a decreased desire to engage in sexual activity before, during and immediately after menopause.
- Polycystic ovarian syndrome (PCOS). PCOS, a risk factor for diabetes, is a hormonal disorder that can cause menstrual problems and pelvic pain
Many people with diabetes also are overweight or obese, suffer from fatigue, are prone to yeast or urinary tract infections, experience bladder problems such as overactive bladder, or have depression or anxiety, any of which can contribute to sexual difficulties. And like nondiabetics, people with diabetes may also experience sexual dysfunction caused by other factors, such as physical or psychological trauma or prostate disorders.
Risk factors and causes of diabetic sexual dysfunction
Sexual dysfunction in patients with diabetes often involves a type of nerve disease (diabetic neuropathy) called autonomic neuropathy. Uncontrolled glucose (blood sugar) is believed to be the leading cause of this nerve damage.
Autonomic neuropathy affects the autonomic nervous system (ANS), which is responsible for regulating the involuntary or subconscious systems of the body, such as digestion, blood flow and bladder control. The ANS also controls the body’s response to sexual stimuli. When an individual becomes sexually aroused, the autonomic nerves signal the body to increase blood flow to the genitals, which, in turn, promotes relaxation of the smooth muscle tissue. Damage to the autonomic nerves by neuropathy can impede normal sexual function, preventing the penis from becoming firm and preventing the vagina from becoming properly lubricated before and during intercourse.
Diabetic sexual dysfunction can also stem from vascular (blood vessel) disease, which typically also involves poor control of glucose. This diabetic angiopathy is characterized by the steady accumulation of fatty deposits (plaque) on the inner arterial walls (atherosclerosis). These fatty deposits can decrease the flow of blood to the penis and make achieving or maintaining an erection difficult or impossible. Sexual dysfunction in men may be a harbinger of the developement of coronary artery disease. In women, vascular damage can impair arousal by restricting blood flow to the genitals.
Other conditions related to diabetes that may contribute to autonomic neuropathy and vascular disease (and result in sexual dysfunction) include:
- High blood pressure (hypertension)
- Unhealthy levels of cholesterol
- Obesity or overweight
- Kidney disease (diabetic nephropathy)
Additional issues that may affect sexual functioning of people with diabetes include:
- Urologic (relating to the urinary tract) conditions. Individuals with poorly controlled diabetes are prone to certain urologic conditions, which can cause discomfort and impact sexual intercourse. These conditions may include:
- Overactive bladder
- Neurogenic bladder (loss of normal bladder function due to nerve damage)
- Urinary tract infection (UTI)
- Yeast infection (common among women)
Individuals with diabetes and a UTI or yeast infection should refrain from sexual activity during treatment of these conditions.
- Hormone disorders. A low level of testosterone (male hypogonadism), which reduces the sex drive, is common in diabetic men. Women can experience low levels of female sex hormones caused by disorders of the pituitary gland or ovaries. In addition, polycystic ovarian syndrome, in which the ovaries release high levels of male-type hormones, involves insulin resistance and increases the risk of type 2 diabetes in women.
- Sexually transmitted diseases (STDs). Individuals with diabetes are prone to certain types of skin conditions, such as dry, cracked skin, which may increase the risk of STDs. Thus, it is particularly important for people with diabetes to practice safe sex.
- Hyperglycemia. In addition to contributing to autonomic neuropathy and vascular disease, excess glucose levels in the blood can reduce testosterone and may contribute to diminished sexual interest.
- Cancer. Diabetes increases the risk of several types of cancer, including some that can affect sexual functioning. These include colorectal cancer, endometrial cancer, cervical cancer and possibly prostate cancer. Treatments for these tumors can also affect sexual function and in some cases could impede diabetic control (e.g., hormone therapy for prostate cancer may increase insulin resistance).
Other potential causes of sexual dysfunction not necessarily associated with diabetes include:
- Depression, stress, anxiety or other psychological factors
- Abuse of alcohol or drugs
- Side effects of antihypertensives, antidepressants or other medications
- Prostate disorders such as benign prostatic hyperplasia (BPH)
- Pelvic trauma
- Stress and other psychological factors
Signs and symptoms of sexual dysfunction
Signs and symptoms of sexual dysfunction depend on the type of problem an individual is experiencing. For instance, men with erectile dysfunction (the inability to achieve or maintain an erection) may not experience any additional symptoms, whereas men experiencing retrograde ejaculation (when semen backs up into the bladder) may exhibit:
- Minimal discharge of semen during ejaculation
- Cloudy urine
- Fertility problems
Women with diabetes who experience sexual dysfunction most often experience decreased vaginal lubrication during sexual activity. This can lead to pain or discomfort during sexual intercourse. Additional symptoms of sexual dysfunction experienced by women with diabetes may include:
- Loss of or reduced interest in sexual activity
- Absent or diminished sensation in the genital region
- Occasional or chronic inability to reach orgasm
- Frequent yeast infections
Diagnosis methods for sexual dysfunction
Individuals with diabetes who experience sexual dysfunction should immediately notify their physician. Some patients may feel uncomfortable discussing their sexual difficulties with their physician. However, patients should recognize that their physician views sexual dysfunction as a medical condition and has discussed sexual difficulties with countless other patients.
Diagnosing sexual dysfunction begins with a physical examination and a review of the patient’s medical history and often the psychiatric history. During these histories, the physician may ask questions about:
- The duration and frequency of the problem
- History of sexual activity
- Sexually transmitted diseases (STDs)
- Current and previous medications
- Smoking and use of alcohol
- Anxiety, stress or depression
- Hormonal conditions
- Pregnancies or prostate problems
A physician will typically check the glucose (blood sugar) of patients with diabetes. Certain laboratory tests may also be performed, depending on the patient’s gender and type of dysfunction. Male patients may also be referred to a urologist or andrologist (specialist in male reproductive health). Female patients may be referred to a gynecologist or urologist.
Tests that may be recommended for men experiencing sexual dysfunction include:
- Prostate exam (digital rectal exam, DRE) and testicular exam.
- Blood tests. These can reveal conditions such as low levels of testosterone (male hypogonadism) and high levels of a substance called prostate specific antigen (PSA), which may indicate prostate cancer or prostatitis (prostate inflammation caused by infection).
- Urine tests. These may reveal disorders such as STDs or other infections.
- Ultrasound. A painless imaging test that can evaluate matters such as the flow of blood to the penis, prostate enlargement or incomplete emptying of the bladder. This test may reveal prostate or bladder-emptying problems. It may also be used to check for signs of atherosclerosis.
- Culture of prostate discharge.
- Nerve (sensory) tests. Tests that measure the strength of nerve impulses in a specific region of the body. These tests, such as electromyography (EMG), are particularly useful in evaluating the effects of diabetic neuropathy.
- Nocturnal penile tumescence (NPT). Also called the stamp test or rigidity test, this test determines whether erections occur during sleep, a normal occurrence for most men. If so, the cause of erectile dysfunction is typically mental rather than physical.
Tests that may be recommended for women experiencing sexual dysfunction include:
- Pelvic examination.
- Urine tests. These may reveal disorders such as STDs or other infections.
- Blood tests to measure hormone levels.
- Cultures of vaginal discharge.
- Nerve tests.
- Laparoscopy. This minimally invasive surgical procedure, which can help identify the cause of pain during intercourse, allows the physician to view inside the abdomen and reproductive organs, and check for structural abnormalities.
Treatment of sexual dysfunction
Left untreated, sexual dysfunction can affect a person’s quality of life. It can increase stress, trigger feelings of depression and even interfere with management of glucose (blood sugar) in people with diabetes.
Treatment of sexual dysfunction is directly related to its cause. Sometimes the solution for sexual problems is clear. For instance, if sexual difficulties stem from factors such as smoking or abuse of alcohol, normal sexual functioning may resume after an individual makes the appropriate lifestyle modifications (e.g., restricting consumption of alcohol, quitting tobacco).
Sexual dysfunction associated with high blood pressure, a major diabetic risk factor, can often be reversed by reducing blood pressure through exercise, diet and, if necessary, medications. Individuals who experience sexual difficulties because of psychological factors may benefit from mental health counseling or sex therapy.
Sexual dysfunction caused by long-term nerve damage (autonomic neuropathy), on the other hand, cannot generally be reversed, although researchers are studying ways to repair nerve injury caused by diabetic neuropathy. However, patients can help prevent further damage from neuropathy – and vascular disease – by controlling glucose. This can be achieved with insulin therapy, exercise and diet in individuals with type 1 diabetes and exercise, diet and (if necessary) medications in those with type 2 diabetes or other forms of diabetes, as recommended by the individual’s physician.
The Diabetes Control and Complications Trial (DCCT), the largest and most thorough diabetes study to date, concluded that maintaining near-normal glucose levels reduced diabetic patients’ risk of developing nerve damage by 60 percent.
Treatment options for men with diabetes who experience sexual dysfunction may include:
- Medications to treat erectile dysfunction (the inability to have or maintain an erection). These oral medications, one of the most commonly prescribed groups of drugs, are known as PDE-5 inhibitors. Researchers have studied use of these medications by diabetic men and found them to be generally safe and effective.
PDE-5 inhibitors are not used if a patient takes nitrates (type of heart medication) or cannot safely engage in intercourse because of certain cardiac or other conditions. Also, the U.S. Food and Drug Administration (FDA) has cautioned that a small number of men taking these drugs have suddenly lost vision or hearing.
In addition, certain medications may be directly injected into the penis or inserted into the urethra.
- Hormone therapy. A deficiency of testosterone (male hypogonadism) often contributes to sexual dysfunction in men with diabetes. Testosterone can be administered to patients via injection, topical gel or a patch. However, some research indicates that this treatment might increase the risk of prostate enlargement or cancer. Thus, patients undergoing hormone therapy are advised to have regular prostate examinations. Other possible risks of testosterone therapy may include sleep apnea, baldness, skin problems, breast enlargement and excessive production of red blood cells.
- Antibiotics for bacterial prostate or urinary tract infections.
- Kegel exercises to strengthen the muscles of the pelvic floor.
- Vacuum devices. The physician may recommend a vacuum tube and pump mechanism, which relies on pressure to deliver blood into the penis. The patient will place a band around the penis to sustain an erection after the vacuum tube is removed.
- Surgery. The patient may decide to improve functioning by having penile implant surgery, in which a prosthesis is inserted into the penis. Surgery may also be performed to unclog blood vessels and allow more blood to reach the penis.
Treatment options for women with sexual dysfunction may include:
- Over-the-counter or prescription vaginal lubricants.
- Kegel exercises.
- Hormones. Hormone replacement therapy (HRT) — estrogen or a combination of estrogen and progesterone — may improve vaginal lubrication and have some other benefits. Systemic (throughout the body) HRT, such as pills or injections, is no longer routinely prescribed to menopausal women because of possible risks including blood clots and breast cancer. A vaginal estrogen cream may be recommended. In some cases women may be prescribed testosterone.
- Use of a handheld vibrator on or around the clitoris to increase sexual pleasure and achieve orgasm more easily.
- Oral stimulation by a partner, which may induce orgasm.
- Use of a clitoral engorgement device. The FDA has approved a prescription device that stimulates blood flow to the genitals using a vacuum. This mechanism, which increases lubrication and the ability to reach orgasm, can be used before intercourse to achieve arousal or as a method of self-stimulation.
- Antifungal medications for yeast infections medications for yeast infections.
- Antibiotics for bacterial urinary tract infections.
In addition, women with poor bladder control (neurogenic bladder) should empty their bladder before and after sexual intercourse.
A physician may also prescribe treatments for conditions that contribute to sexual dysfunction — for example, exercise and diet for obesity, sleep therapy and relaxation training for fatigue, bladder training and anticholinergic drugs for overactive bladder, alpha blockers or 5-alpha reductase inhibitors for prostate enlargement, and antidepressants, therapy and exercise for depression.
Recent research suggests that medications that treat erectile dysfunction might also improve sexual satisfaction and relieve symptoms such as pain during intercourse in diabetic and nondiabetic women. However, further study is needed to establish this finding, and the FDA has not approved use of this medication by women.
Questions for your doctor on sexual dysfunction
Preparing questions in advance can help patients have more meaningful discussions with healthcare professionals regarding their conditions. Patients may wish to ask their doctor the following questions about sexual dysfunction and diabetes:
- How can diabetes affect my sex life?
- Because of my diabetes, do I have an increased risk of certain types of sexual problems?
- What types of sexual problems am I at greatest risk of developing?
- Will I need to be referred to a urologist or other specialist?
- What diagnostic tests will I need to have? What do they involve?
- Is nerve damage, blood vessel damage, cholesterol problems, high blood pressure or obesity contributing to my sexual difficulties?
- What are my treatment options? How do their risks and benefits compare?
- Will any of the medications or treatments for my sexual dysfunction affect my diabetes or diabetic treatments?
- Will controlling my diabetes improve my sex life?
- How can I prevent sexual dysfunction?