Men and women with diabetes can have a normal sex life. Unfortunately, however it is known that in some cases, this condition can interfere with a range of sexual functions. Sri Lanka too is seeing an increase in the cases of diabetes, with more young persons being affected.

This article focuses on male sexual issues related to diabetes. Among them erectile dysfunction is by far the most common and most worrying sexual problem.

Erectile dysfunction (ED- also known as impotence), is the consistent inability to achieve or maintain an erection firm enough for satisfactory sexual intercourse.

More than half of men with diabetes have erectile dysfunction. ED due to diabetes occurs a decade or so earlier when compared to men without diabetes.

Other sexual problems that could occur

Men with diabetes, particularly in the early stages of erectile difficulties can experience early ejaculation. This condition, which may be distressing to either one or both partners, is known as premature ejaculation.

On the other hand problems of ejaculation may also involve a persistent delay in, or absence of orgasm and ejaculation, following normal sexual excitement. The volume of semen that a man releases may also be reduced.

Low libido or loss of sex drive is also a common sexual health issue for people with diabetes.

An individual's overall sexual drive varies between individuals. However, a man with low/absent sexual desire typically does not initiate sexual activity and may only engage in it reluctantly when it is initiated by his partner. This problem is often associated with erectile difficulties, and could either be its cause or its result.

Some painful conditions of the penis are known to be more common among men with diabetes:

The foreskin and the head of the penis can become red and painful. This problem could recur, and is often due to a fungal infection. It is called balanitis.

The penis can sometimes lose flexibility. It may then be forced to bend or arc during an erection, while causing pain. This is a condition of uncertain cause, referred to as Peyronie's disease.

The foreskin becomes very tight sometimes, making it difficult to pull it back over the head of the penis (glans). This causes pain, and is called Phimosis.

What are the reasons for sexual problems in a man with diabetes?

Diabetes is a complex disease process, with profound effects on all systems of the human body. The manner in which it leads to sexual problems too, is a culmination of several different factors rather than one single direct process. The following explains some of these factors.

a) Damage to blood vessels and nerves

The process of diabetes related vessel damage begins even before a person develops full blown diabetes. Fat deposits and blood clots frequently block the large pelvic blood vessels of diabetic men, thereby reducing the blood supply to the penis. Additionally, small vessels within the penis are diseased and further limit flow of blood into the erectile tissue. These factors make it difficult for a man to achieve an erection.

Diabetes also attacks the nerves of the body. Pleasurable sensations that usually occur in response to stimulation of the penis are impaired. Nerve damage also interferes with transmission of signals from the brain to the penis, which leads to a weakened erection.

b) Other conditions related to diabetes which contribute to erectile dysfunction

High blood pressure (hypertension), unhealthy cholesterol levels and excess body weight (overweight/ obese) are conditions which are closely linked to diabetes. These conditions contribute to disease of blood vessels throughout the body and act as risk factors for erectile dysfunction, similar to the way in which they act as risk factors for heart attacks and strokes.

Some medication used to treat high blood pressure is also linked to erectile dysfunction. This may also be true of some cholesterol lowering drugs.

c) Low testosterone levels

Studies have shown that a substantial portion of men with diabetes who suffer from erectile dysfunction have testosterone levels below the normal range. Although the reasons for this are not fully understood, low testosterone associated with diabetes may contribute adversely towards a man's sexual desire (libido) and the quality of his erection.

d) Psychological and relationship issues

Diabetes and its complications are associated with depression, which may predispose diabetic people to erectile dysfunction. Erectile dysfunction may then worsen existing depressive symptoms, thereby leading to a vicious cycle.

Furthermore, the reduction in erectile function that a man experiences can generate anxiety and make the situation worse.

Other general factors such as stress, misinformation, unrealistic expectations and poor communication with one's partner can also contribute towards many forms of sexual dysfunction.

e) Other non related medical disorders and drugs/ substance abuse

There are numerous other conditions and drugs/substances that may potentially lead to erectile dysfunction. Although not specific to diabetes, some of these maybe applicable to you:

• Smoking, excessive alcohol intake and illicit drug use
• Certain medications such as anti depressants, anti psychotics, some stomach ulcer medication, hormones and hormone modifying agents
• Neurological conditions such as spinal cord injury and multiple sclerosis
• Pelvic trauma, tumours or surgery (e.g. prostate surgery)

How can these problems be sorted out?

a) What can I do to help myself?

i) Modify your lifestyle

Regular exercise, balanced diet, smoking cessation and avoiding excessive alcohol use are important. Evidence shows that men who are able to make these changes could significantly retard the progression of their problems. Some men may even see an improvement. It is worthwhile noting that many of the specific treatments available for diabetes related sexual problems have the potential to fail, if not accompanied by suitable lifestyle changes.

ii) Crush the stigma; communicate effectively with your partner

Many men find it extremely difficult to work up the confidence to talk to their partner about sexual difficulties. In my experience this is specially so in a Sri Lankan setting. You probably feel embarrassed, frustrated, nervous and depressed. Your partner too, despite wanting to talk about it may not do so because she worries about hurting your feelings. She may also believe that she is to blame for the situation, and feel that you no longer find her attractive. This lack of communication can make your relationship worse.

A man is most likely to find his partner understanding and supportive when confided in. An open conversation can motivate you both to explore options to improve the situation together. It will leave both of you feeling hopeful and relieved.

It is also important for your partner to appreciate that older men and diabetic men require more physical stimulation to achieve an erection.

iii) Don't suffer in silence; seek doctors help

Many men who experience problematic erections suffer in silence because they are reluctant to consult a doctor. Although discussing your sex life may seem awkward to begin with, it is important to recognise that many doctors are familiar with issues regarding this topic, and there are doctors specially trained in managing sexual problems.

There are many forms of treatment available for erectile dysfunction, which include different kinds of oral medication, injections and vacuum devices. Self medication can be harmful as some treatment may be unsuitable for you. Therefore, a detailed discussion with your doctor is required before you embark on treatment. Ultimately, the goal of therapy is not just a rigid erection but a satisfactory sexual relationship and good health.