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.

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.

If your patient develops end-stage renal disease, she may require hemodialysis or peritoneal dialysis to prolong her life. The physician probably won’t recommend dialysis until your patient’s serum creatinine level is about 6 mg/dl.

Hemodialysis

For hemodialysis, the surgeon creates an arteriovenous (AV) access site, usually in the patient’s arm, as shown. With each hemodialysis treatment, a needle is inserted into this AV access site. Blood is withdrawn through the arterial line and pumped through a semipermeable membrane in the hemodialysis machine. As the blood is pumped, dialysate moves through the membrane in the opposite direction, allowing body wastes to move by diffusion from an area of high concentration to an area of low concentration.

The pores in the membrane allow electrolytes, blood urea nitrogen, and creatinine to be filtered out, but they prevent larger particles such as blood cells and protein from passing through. The filtered blood is then returned to the patient through the venous line.

Hemodialysis can be performed in your patient’s home or in a medical facility. Treatments average 3 to 4 hours, three times each week.

Peritoneal Dialysis

In this closed-drainage procedure, a catheter is placed through an opening in the abdominal wall. At regular intervals, dialysate is instilled into the peritoneal cavity. Through osmosis and diffusion, fluid, electrolytes, and waste products are drawn from the blood, across the peritoneum, and into the dialysate. The peritoneum, which lines the peritoneal cavity, acts as a semipermeable membrane. The dialysate is drained regularly and replaced.

Most patients tolerate peritoneal dialysis better than hemodialysis. The patient’s blood pressure usually remains stable, and she experiences less cardiovascular stress and better control of her blood glucose levels. She’ll also have a decreased risk of retinal hemorrhage because she won’t need the higher doses of heparin that are used with hemodialysis. However, peritoneal dialysis places the patient at higher risk for developing an infection, such as peritonitis.

The most common cause of death in patients with Type 2 diabetes, CAD also develops in many patients with Type 1 diabetes. Patients who have had diabetes for 20 years or longer, are over age 40, or have many cardiovascular risk factors, such as hypertension, obesity, or lipid abnormalities, have a high risk of developing CAD. Men and women with diabetes develop CAD at about the same age.The development of atherosclerotic changes in the coronary arteries is closely related to the duration and severity of diabetes. The prolonged high levels of blood glucose, free fatty acids, and cholesterol damage the endothelial layer of the arteries. Monocytes adhere to the damaged arteries, and macrophages migrate to these areas. If your patient also has hypertension, the high pressure of blood flowing through the vessels increases the endothelial damage.

This all contributes to lipid accumulation and the development of atherosclerotic plaque. The macro phages release growth factor, which stimulates smooth-muscle cells to enlarge, multiply, and migrate through the layers of the arteries. This further narrows the lumen of the arteries. At the same time, increased numbers of platelets adhere to the damaged endothelium, which causes thrombus formation. If your patient has hyperglycemia, platelets are more likely to adhere to the artery wall. The combination of endothelial damage and increased platelet aggregation leads to accelerated thickening of the lumen, which results in vasoconstriction.

If your patient has insulin resistance, her triglyceride and lipoprotein levels will be elevated, which can damage the endothelial lining even further. Her pancreas produces excessive amounts of substandard insulin to overcome the body’s resistance to insulin. So, her body does not have sufficient, effective insulin, which is required to produce lipoprotein lipase, the enzyme that regulates cholesterol.

Progressive atherosclerosis, of course, reduces coronary artery blood flow, which increases the risk of developing myocardial ischemia and infarction.

If your patient has a myocardial infarction (MI), she’s at risk for developing diabetic ketoacidosis (DKA). The stress of an Ml causes the release of adrenal corticosteroids and catecholamines, which inhibit insulin action and stimulate glucose production. As the glucose level rises, the heart and other vital organs are deprived of their main energy source. As a protective mechanism, the body begins to break down fat to use as a substitute energy source. Fat breakdown is incomplete, causing excessive amounts of ketones to be released into the bloodstream. Because the kidneys can’t adequately excrete the ketones, DKA develops. This condition results in electrolyte disturbances, which can lead to life-threatening cardiac arrhythmias.

The treatment of diabetic retinopathy depends on the extent of retinal damage and may include laser photocoagulation or vitrectomy. With laser photocoagulation, the ophthalmologist uses laser beams to seal microaneurysms stream. The vascular lens refracts and focuses images onto the retina.

The choroid, or middle coat, is made up of many arteries and veins. The retina, the innermost coat of the eyeball, is rich in neurons, including the rods and cones, which serve as visual receptors. The retina is connected to the optic nerve, which conducts visual information to the brain. The vitreous humor-a thick, gelatinous material-fills the space behind the lens. It maintains the shape of the eye­ball and placement of the retina. and thus reduce their risk of bleeding. Laser photocoagulation can also be used to control new blood vessel growth .

The ophthalmologist uses vitrectomy, a surgical procedure, to treat advanced complications of proliferative retinopathy, such as vitreous hemorrhage and tractional retinal detachment.

Vitrectomy requires the use of local or general anesthesia. To begin the procedure, the ophthalmologist makes a small incision behind the cornea. Then he removes blood and fibrous tissue from the vitreous humor and replaces them with another fluid, such as normal saline. A silicone oil or gas can be used to hold the retina in place.

Riskier than laser photocoagulation, vitrectomy can result in total vision loss. Because of this, vitrectomy is typically performed on patients with a high risk of complete vision loss - for example, those with bleeding into the vitreous humor and some vision loss that hasn’t resolved after 6 months.

If your patient maintains better blood glucose control, her pain and other symptoms may decrease. As nerve cells regenerate with improved blood glucose levels, your patient’s pain may worsen initially, but it will decrease over time.To prevent foot complications, your patient may need to use lamb’s wool padding to protect her feet from trauma. The physician may also refer her to a podiatrist, who will assess her feet regularly and gently file any callused areas, if necessary. Your patient may also need a referral to an orthotic or other foot care specialist to fit her for custommade shoes, molded insoles, or other orthotic devices to protect her feet. In some cases, your patient may require bed rest or crutches. Some patients with foot ulcers have casts applied so that they can walk while the ulcers heal. The cast redistributes foot pressure so that the ulcerated area bears much less weight than it would normally.

For pain associated with peripheral neuropathy, the physician may prescribe:

• a nonnarcotic analgesic, such as ibuprofen or sulindac
• tramadol hydrochloride
• phenytoin or carbamazepine
• a tricyclic antidepressant, such as amitriptyline, alone or with a phenothiazine derivative
• mexiletine
• topical capsaicin 0.075%.

Narcotic analgesics usually aren’t prescribed because peripheral neuropathy is a chronic condition, and the patient would risk developing an addiction. However, other therapeutic options may include transcutaneous electrical nerve stimulation therapy or referral to a pain control clinic.

Curing Steps for Patients

If your patient experiences painful paresthesia, especially at night, tell her to stretch gently or to get up and walk around. Also, teach her how to safely massage her feet and legs, and explain that this sometimes helps to block pain sensations. If appropriate, teach your patient how to safely use the TENS unit. Teach her about guided imagery, meditation, progressive relaxation techniques, exercise, and therapeutic massage.

Teach your patient the importance of foot care, and review safety measures she can take to prevent trauma. For instance, advise her to avoid prolonged standing and strenuous weight-bearing exercises. Tell her to wear well-cushioned, properly fitting shoes and to walk in well-lit areas where the ground is smooth.

If your patient has decreased temperature sensation, advise her to prevent severe burns by checking the water temperature with a part of her body that’s sensitive to temperature, such as forearm. If she experiences abnormal cold sensations, advise her to wear thin gloves in the spring or fall. When temperatures drop, she should wear heavier, insulated gloves. Tell her that mittens may be warmer than gloves. If cold feet are a problem, tell her to wear comfortable insulated socks with her shoes.

Review with your patient the name, dosage, action, and adverse effects of all her prescribed drugs. If she’s using topical capsaicin, tell her to wear gloves when she applies it, avoid contact with her eyes, and wash her hands immediately after application. Also, warn her that she may experience transient burning of the affected area after applying capsaicin.

Encourage your patient to avoid drinking alcohol. Explain that alcohol abuse may contribute to the progression of peripheral neuropathy. If appropriate, refer your patient to a counselor or to Alcoholics anonymous. If she smokes, encourage her to stop. Explain that cigarette smoking can worsen her condition and that stopping may slow its progress.

Explain that your patient should have her feet inspected at least four times a year and that a physician should perform a thorough physical examination and neurologic assessment at least once a year.