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.