Sexual dysfunction commonly develops in people who have diabetic autonomic neuropathy. That’s because diabetic neuropathy affects the para­sympathetic fibers that regulate erections in men and vaginal lubrication in women. It also affects the sympathetic nervous system, which mediates orgasm and ejaculation.

Sexual Dysfunction In Men

Men with autonomic neuropathy may experience retrograde ejaculation (semen ejaculation into the urinary bladder) or impotence. Retrograde ejaculation results from damage to the efferent sympathetic nerves. These nerves normally coordinate the simultaneous closure of the internal vesicle sphincter and relaxation of the external vesicle sphincter during ejaculation. Signs and symptoms of retrograde ejaculation include cloudy urine after intercourse, infertility, and a decreased volume of ejaculate.

If your patient has incomplete retrograde ejaculation or the problem has recently been diagnosed, the physician may advise him to have intercourse when his bladder is distended. Other therapeutic options include taking an antihistamine or desipramine to restore ejaculation.

A patient who’s impotent can’t attain or maintain an erection despite having a normal sex drive. When evaluating whether impotence results from autonomic neuropathy, the physician will consider other possible causes, such as drugs, alcohol use, hormonal deficiencies, and psychological problems. The physician may evaluate the patient’s serum hormone levels and penile blood flow and pressure measurements to help make the diagnosis, or the physician may refer the patient to a urologist for further evaluation.

Because a patient with impotence may be hesitant to discuss his sexual concerns, you may have to bring up the subject yourself. For instance, you can say, “Many of my patients who have diabetes complain of impotence. Has this been a problem for you?” If he acknowledges the problem, explore it with him. Ask if anything seems to make the problem better. If he’s uncomfortable talking with you, give him an educational pamphlet or suggest that he discuss it with the physician.

Explain to your patient that effective and acceptable treatments are available. For example, vacuum devices can be used to draw blood into the penis to produce an erection. Or a rigid or semirigid penile prosthesis can be surgically implanted. The physician may also prescribe alprostadil, which the patient administers intracavernously shortly before sexual intercourse, or silenafil, which he takes orally 112 to 4 hours before sexual intercourse.

Sexual Dysfunction In Women

Women with diabetic autonomic neuropathy may experience difficulties with arousal, diminished vaginal lubrication, and anorgasmy despite a normal sex drive. Symptoms include dyspareunia (painful intercourse) and a delayed orgasm or none at all. If your patient is experiencing these symptoms, advise her to use a vaginal lubricant and to ask the physician for a referral to a gynecologist for further evaluation. Her gynecologist may prescribe an estrogen cream.

Water-insoluble fiber (which includes wheat, bran, and whole grain products) affects mainly the lower gastrointestinal (GI) tract, where it increases fecal bulk, helps to prevent constipation, and may reduce the risk of colon cancer. Water­soluble fiber (which includes guar and pectin) affects the upper GI tract by delaying gastric emptying and increasing the intestinal transport time. It may also lower levels of total cholesterol and LDL cholesterol.Although fiber’s beneficial effect on glucose level control remains unproved, eating 20 to 35 grams of water-insoluble or water-soluble fiber a day does promote evacuation and lower lipid levels. Instruct your patients who are increasing their fiber intake to do so gradually and to drink at least 8 cups of fluid a day to minimize GI discomfort.

To diagnose diabetic retinopathy, an ophthalmologist uses an ophthalmoscopic examination or fluorescein angiography. During an ophthalmoscopic examination, the ophthalmologist dilates the patient’s eyes with a mydriatic drug, such as atropine. This dilation permits viewing of the retina, retinal blood vessels, optic disc, macula, and other structures.The ophthalmologist uses fluorescein angiography to evaluate leaking or occluded retinal vessels. In this outpatient procedure, fluorescein dye is injected into an arm vein. Then the dye travels through the blood to different parts of the body, including the retinal capillaries. By using fluorescein dye and a fundus camera with filters, the ophthalmologist can better see the retinal blood vessels and determine if the patient has retinopathy and, if so, to what extent.

The physician usually diagnoses peripheral neuropathy by excluding other causes of your patient’s signs and symptoms. Typically, the physician will assess her neurologic function, evaluating her deep tendon reflexes and muscle strength and testing how well she senses temperature, light touch, sharp and dull sensations, vibration in her feet, and changes in the position of her toes.Temperature sensation in the feet and legs can be assessed by touching a cool metal object, such as a tuning fork, to the skin and asking your patient to describe the temperature. Light touch can be assessed by touching the skin with a wisp of cotton or a monofilament device and asking her to describe the location of the sensation. Sharp and dull sensation can be assessed by asking your patient to close her eyes and then alternately touching her feet with the dull and sharp ends of an object, such as a paper clip, and asking her to describe the sensation. Vibration sensation is assessed by placing a vibrating tuning fork on the distal first metatarsal head or the malleolus of your patient’s ankles and asking her to tell you when the vibration stops. To assess your patient’s position sense, ask her to close her eyes; then flex and extend her great toe and have her describe its position.