Multidisciplinary Chinese Expert Consensus On Diabetes Mellitus Combined With Male Sexual Dysfunction Ⅲ

(I) Epidemiological status of sexual dysfunction in male diabetic patients

With the development of Chinese society and the change of people's lifestyle, the incidence of diabetes is increasing and tends to be younger.

1. Sexual dysfunction is a common comorbidity in male diabetic patients, including low libido, erectile dysfunction, ejaculation dysfunction, and lack of orgasm.
2. The overall prevalence of ED in male diabetic patients is 52.5%, and it can be as high as 75% in patients with type 2 diabetes.
3. The prevalence of premature ejaculation in patients with type 2 diabetes is as high as 40.2%~78.9%.
4. The prevalence of retrograde ejaculation is 3~4 times that of the general population.
5. The rate of consultation for male sexual dysfunction with diabetes is low, and the actual prevalence may be higher.
6. The incidence of depression and anxiety in diabetic patients is 2~3 times that of the general population.
The number of men with diabetic sexual dysfunction is increasing rapidly, which not only seriously threatens the physical and mental health of patients, but also has adverse effects on the overall quality of life and family harmony of patients. Therefore, diabetes combined with male sexual dysfunction should attract the attention of both doctors and patients.

 

 

 

 

 

 

 

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(II) Diabetic patients are prone to sexual dysfunction

Diabetes can lead to pathological and physiological changes closely related to sexual function, which can easily lead to the occurrence of sexual dysfunction: (1) Reproductive endocrine: leading to a decrease in testosterone levels and a decrease in androgen receptor sensitivity; (2) Hemodynamics: increased blood viscosity, thickening of blood vessel walls, and reduced elasticity; (3) Degeneration of peripheral nerves, weakened sensation of sexual stimulation and signal transmission; (4) Lesions of the corpus cavernosum and tunica albuginea, directly leading to difficulty in penile erection, weak erection, and erectile pain; (5) Lesions of nerve and muscle tissue related to ejaculation lead to damage to the bulbospongiosus muscle, ischiocavernosus muscle, and pelvic floor muscles, affecting penile erection and ejaculation; (6) Diabetes often leads to emotional changes in patients, anxiety, and depression, which can easily lead to and aggravate various problems in sexual function.

(III) Main clinical manifestations of sexual dysfunction in diabetic patients

The occurrence of sexual dysfunction in diabetic patients is related to the condition, course and individual differences of diabetes.

1. Erectile dysfunction: manifested as decreased penile erection hardness, shortened erection duration, and even complete loss of erectile function.
2. Ejaculation dysfunction: (1) Premature ejaculation: The main manifestation is a shortened latent period of intravaginal ejaculation; (2) Retrograde ejaculation: During sexual intercourse, there is a feeling of ejaculation, but no semen is ejaculated. After ejaculation, sperm can often be found in urine centrifugation, or the urine fructose test is positive; (3) Weak ejaculation: Semen flows out of the urethra, not in a jet-like state, accompanied by a decrease in sexual pleasure; (4) No ejaculation: There is a more serious erectile dysfunction or nervous system disease, and even with sufficient penile stimulation, it is still impossible to reach ejaculation climax; (5) Dry ejaculation: There is an ejaculation action, but no semen enters the bladder or flows out of the urethra.

3. Lack of orgasm: mainly secondary to other types of sexual dysfunction, such as some diabetic patients with shortened intravaginal ejaculation latency (IELT) or lack of orgasm due to delayed ejaculation or weak ejaculation.
4. Low libido: affected by endocrine, psychological and other factors, sexual desire decreases, that is, under the influence of various sexual stimuli, the subjective psychological activities of initiating and maintaining sexual behavior are weakened, and the sexual fantasies and responses to potential sexual cues before the start of sexual behavior are weakened.
In addition, due to the negative personal impact of diabetes and the occurrence of sexual dysfunction on patients, such as worry, worry, confusion and/or avoidance of sexual intimacy, the mental and psychological burden is increased, affecting the relationship between husband and wife, and further aggravating sexual dysfunction.

(IV) Screening and diagnosis of diabetes and male sexual dysfunction: points to note

Only by early screening and early diagnosis can the condition be assessed in time, blood sugar can be effectively controlled, and the occurrence and progression of diabetes and sexual dysfunction can be slowed down.
1. All adult male diabetic patients diagnosed should undergo sexual function assessment in a timely manner, such as IIEF, ASEX-male scale, or consultation with urologists;
2. Pay attention to blood sugar and urine sugar screening for male sexual dysfunction patients to exclude or confirm abnormal glucose metabolism.
3. For confirmed patients, timely etiology diagnosis is performed. Clinically, the diagnosis of diabetes combined with male sexual dysfunction is not difficult. Evaluation of the type and severity of sexual dysfunction and accurate etiology diagnosis are conducive to the formulation of scientific and reasonable treatment and rehabilitation plans.

(5) Precautions when using hypoglycemic drugs in patients with diabetes and male sexual dysfunction
For patients with male sexual dysfunction, drugs that have a protective effect on the reproductive system or have minimal side effects should be selected and used based on the metabolic characteristics and side effects of hypoglycemic drugs with different mechanisms on the premise of effectively controlling blood sugar.
1. Metformin: Suitable for patients with type 2 diabetes who are overweight and obese, and can be used in combination with other oral hypoglycemic drugs. Combined use with insulin can reduce insulin dosage, reduce the risk of hypoglycemia and prevent weight gain. Metformin has a neutral or possibly beneficial effect on sexual function in patients with diabetes.
2. Insulin: A few literature reports that intensive insulin treatment can significantly improve the IIEF-5 score of male erectile dysfunction patients with diabetes, but there are also reports that there is no significant improvement, so further observation is needed.
3. Sulfonylureas: Animal experiments have found that sulfonylurea hypoglycemic drugs can improve the sexual function of experimental rats, but there are few studies on the impact on human sexual function, and the conclusions are inconsistent, and further observation is needed.
4. Thiazolidinediones: They may have an inhibitory effect on testosterone synthesis, but most studies suggest that they have no adverse effects on male erectile function caused by diabetes.
5. DPP-4i: It has a neutral effect on body weight. A few animal experiments have shown that sitagliptin can protect testicular spermatogenesis through antioxidant, anti-inflammatory and anti-apoptotic mechanisms.
6. GLP-1RA: It can reduce body weight and improve insulin resistance. Animal experiments and clinical trials of several different types of GLP-1RA have shown that it can improve sexual function. However, more large-scale clinical trials with sexual function as clinical outcome are needed to confirm this.
7. SGLT-2i: This type of drug exerts a hypoglycemic effect by increasing urinary glucose excretion. Attention should be paid to its impact on the genitourinary tract (such as infection); animal experiments show that SGLT-2i can improve erectile dysfunction in diabetic rats, but at present There is a lack of research reports on the impact on sexual function in patients with diabetes.

(VI) Issues to note when using PDE5i

PDE5i is the first-line drug for treating ED caused by various reasons. 1. PDE5i is the first-line drug for erectile dysfunction in men with diabetes. 2. PDE5i can be used simultaneously with drugs that improve microcirculation, but be aware of adverse reactions. 3. PDE5i cannot be taken simultaneously with nitrate antihypertensive drugs to avoid synergistic antihypertensive effects. 4. PDE5i should be used with caution in combination with √ receptor blockers (adrenergic receptor antagonists used to improve urination symptoms). 5. PDE5i is not an "aphrodisiac" or "aphrodisiac" and will not increase the patient's sexual desire, but it will improve the patient's erectile function and help increase sexual desire. 6. PDE5i of different types, dosage forms, and doses can be selected under the guidance of a urologist and can be used alone or in combination. 7. PDE5i is safe and has no significant effect on fertility; 8. Long-term use is non-addictive. 9. A small number of patients experience side effects such as dizziness, facial flushing, green vision, myalgia, etc. after taking the drug.
(VII) Regarding blood sugar and glycosylated hemoglobin (HbA1c) control
1. Blood sugar control: (1) Blood sugar control is the key to preventing the occurrence and progression of diabetic sexual dysfunction. (2) There is a so-called "metabolic memory effect" in the pathological and physiological mechanism of diabetic complications. "Good metabolic memory effect" has positive significance in preventing and preventing the occurrence and development of sexual dysfunction in diabetic patients; on the contrary, if blood sugar cannot be effectively controlled in the early stage of onset, the "bad metabolic memory effect" formed in the early stage may have a negative impact on the rehabilitation and treatment of patients with diabetic sexual dysfunction. Therefore, patients should maintain a good lifestyle for a long time and use appropriate hypoglycemic drugs to maintain stable glucose metabolism in order to slow down nerve and vascular lesions and reduce the occurrence and progression of sexual dysfunction.

2. HbA1c control: Generally speaking, for most diabetic patients, the control target for HbA1c level should be less than 7%, but it is also necessary to determine individualized control targets in combination with the patient's age, course of disease, life expectancy, comorbidities and severity of complications.

(VIII) Lifestyle intervention for patients with diabetes and male sexual dysfunction
Lifestyle intervention for patients with diabetes and sexual dysfunction is very necessary, mainly including scientific diet, smoking cessation and alcohol restriction, regular exercise, weight control, psychological adjustment, etc.
1. Scientific diet: Emphasize a reasonable diet structure and eat low glycemic index (low GI) carbohydrates. It is recommended to eat olive oil, legumes, natural grains, fruits and vegetables, moderate fish, dairy products and red wine, and a small amount of meat products.
2. Reasonable exercise: Long-term regular physical exercise can slow down the occurrence and development of diabetes and diabetic sexual dysfunction. Such as swimming, pelvic floor exercises and squatting movements.
3. Control weight: Obesity is a systemic metabolic disorder and is associated with a variety of chronic diseases, including diabetes combined with sexual dysfunction.
4. Psychological adjustment: Patients with diabetes combined with sexual dysfunction are prone to psychological problems, such as anxiety and depression. Therefore, on the one hand, patients need to build confidence and maintain an optimistic and healthy mental state, and on the other hand, they can seek guidance from psychological experts.

(IX) What are the measures to prevent the occurrence and progression of sexual dysfunction in diabetic patients?

The prevention of sexual dysfunction in diabetic patients mainly includes:

 

1. Control blood sugar;

2. A good lifestyle;

3. For those with clear evidence of vascular and neuropathy, drugs such as improving microcirculation and antioxidants can be used to protect nerves and blood vessels to prevent or block the development of sexual dysfunction.

(X) TCM treatment of diabetic male sexual dysfunction and "tonifying the kidney and strengthening yang"

Traditional Chinese medicine is a feature of Chinese medicine, especially in the syndrome differentiation and treatment of men's diseases. Syndrome differentiation and treatment is the core of TCM treatment. Diabetes combined with sexual dysfunction includes the main TCM syndrome types such as kidney yang deficiency type, kidney yin deficiency type, qi stagnation and blood stasis type. Generally speaking, "tonifying the kidney and strengthening yang" is only a treatment method for "impotence" of kidney yang deficiency type, and is not suitable for the treatment of "impotence" of kidney yin deficiency type and qi stagnation and blood stasis type. Blindly "tonifying the kidney and strengthening yang" may lead to adverse consequences. Therefore, TCM treatment of diabetes combined with male sexual dysfunction does not necessarily require "tonifying the kidney and strengthening yang".
(XI) Objectively evaluate treatment expectations
The rehabilitation results of patients with diabetes combined with male sexual dysfunction are affected by many factors. Therefore, it is necessary to have reasonable expectations for the treatment of diabetes combined with sexual dysfunction.

 

1. The treatment effect of sexual dysfunction in diabetic patients is worse than that of the general population.
2. Correctly understand "treating symptoms" and "treating the root cause". Patients' misunderstanding of "treating symptoms" and "treating the root cause" will affect the implementation of the treatment plan.
3. The efficacy is affected by many factors. The patient's other underlying diseases, diabetes course, blood sugar control effectiveness and stability, sexual dysfunction treatment time and drug selection, patient age, compliance with treatment and individual differences will affect the treatment effect.
4. Emphasize the role of spouse in treatment.
5. Pay attention to the impact of mental and psychological factors on efficacy

(XII) Pay attention to other common concomitant diseases, improve chronic disease management awareness, and promote patient rehabilitation

ED has the same pathophysiological basis as many chronic diseases such as diabetes, hyperlipidemia, hypertension, arteriosclerosis, cerebrovascular disease, etc. These diseases often occur together. At the same time, there are commonalities or similarities in prevention, treatment and rehabilitation. Therefore, we should actively pay attention to and prevent various other concomitant diseases.
It is very important to establish chronic disease management awareness. (1) Doctors, patients, their family members or sexual partners need to cultivate enough patience and be mentally prepared for a "protracted war". (2) Doctors should improve patient compliance and adjust and improve the diagnosis and treatment plan in a targeted manner according to the changes in the condition and the patient's feedback, such as timely adjustment of drug types and dosages, dietary structure guidance, sexual life guidance, multidisciplinary consultation, etc., to more effectively promote patient recovery. (3) Patients should strengthen self-discipline and management and strictly implement the treatment plan formulated by the doctor. Conduct sexual function rehabilitation training according to the doctor's plan; at the same time, pay attention to lifestyle management, including dietary structure adjustment, quitting bad living habits, and choosing reasonable exercise methods.

 

(XIII) Multidisciplinary collaboration for diabetes combined with male sexual dysfunction

 

In the modern clinical medicine model, the specialization of each discipline tends to be stronger, and the integration and collaboration between different disciplines are very necessary. The pathological, physiological and psychological mechanisms of diabetes combined with male sexual dysfunction are complex, the clinical manifestations are diverse, the rehabilitation process is long, and it presents multi-system, multi-organ and multi-level individual characteristics. Therefore, the formulation, implementation, effect observation and evaluation of the diagnosis and treatment plan cannot be completed independently by doctors in a certain field or profession. Multiple related professional disciplines must participate in the joint evaluation of the patient to avoid the "fragmented" and "independent" diagnosis and treatment model. Mainly including endocrinology, urology, psychiatry and psychology, and traditional Chinese medicine.

1. Endocrinology: For male adult diabetic patients, ask and evaluate the sexual function status, judge the existence of sexual dysfunction and its relationship with diabetes. If sexual dysfunction is suspected, refer to the urology department for comprehensive evaluation and intervention; for patients without sexual dysfunction, health education should be carried out, and relevant evaluations should be carried out regularly; the endocrinology department is the main department for diagnosis and treatment of diabetic patients, the first line of defense for prevention and treatment, and patients have strong compliance. Therefore, endocrinologists should strengthen their awareness of prevention, screening, diagnosis and treatment of diabetes combined with sexual dysfunction, and refer suspected patients to the urology department for further evaluation.

2. Urology: Mainly responsible for the diagnosis and treatment of sexual dysfunction. For male patients with sexual dysfunction, detailed medical history, especially family history, and routine screening of blood sugar indicators are required. For patients with suspected or confirmed diabetes and poor blood sugar control, refer them to the endocrinology department for further diagnosis and treatment in a timely manner.
3. Department of Traditional Chinese Medicine: Traditional Chinese medicine has unique advantages in treating sexual dysfunction. Traditional Chinese medicine syndrome differentiation and treatment and acupuncture often have good effects on patients. Endocrinology and urology can recommend consultation with the Department of Traditional Chinese Medicine according to the patient's condition.

4. Department of Psychiatry and Psychology: The role of mental comfort and psychological counseling is easily overlooked. Patients with diabetes and sexual dysfunction often have mental and psychological problems that affect the treatment effect. Endocrinology and urology physicians can recommend patients suspected of having mental and psychological problems to the Department of Psychiatry and Psychology for consultation and necessary psychological assessment and intervention according to the patient's relevant conditions.

In addition, since diabetic patients often have multiple system diseases such as obesity, hypertension, hyperlipidemia, sleep apnea, reproductive endocrine disorders, etc., the evaluation and diagnosis and treatment of diabetes and sexual dysfunction also requires the participation of multiple disciplines including nutrition, respiratory, and cardiovascular departments.

Keywords: diabetes; male; sexual dysfunction; erectile dysfunction; ejaculation dysfunction; low libido; lack of orgasm; Western medicine; traditional Chinese medicine; prevention; diagnosis; treatment; guidelines