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Physicians know that diabetes can have profound effects on the health of their patients. But sometimes focusing on the most serious consequences of this debilitating disease can block their view of how it adversely affects a patient’s quality of life in other ways.

As the number of patients diagnosed with diabetes continues to grow in epidemic proportions, especially in the U.S., so does the need for primary care physicians, urologists and endocrinologists to ascertain and treat the less-acute, but nonetheless life-altering effects.

Changes in bladder and sexual functions are but two problems awaiting an aging population. But for diabetics, those complications often are amplified because of the nerve damage they can cause to the genitourinary system.

“This area is not talked about a lot, but it is extremely important,’’ said Dr. Samuel Crockett, medical director of the Florida Hospital Diabetes Institute in Orlando. Crockett, 67, is a board-certified endocrinologist who recently was listed by his peers as one of the “Best Doctors in America’’ for 2007. He has overseen the Diabetes Institute since 1993.

“Early education and early intervention will hopefully prevent or delay these disorders,’’ Crockett said, noting that nearly one-third of all diabetics have some degree of sexual dysfunction. But as those patients age into their late 40s and 50s, he said, that incidence increases to about 52 percent.

Diabetes is only one cause of sexual dysfunction, Crockett said. There are numerous “other contributors that are not neurological,’’ he said, including depression, stress, anxiety, or medications that have been prescribed for co-morbidities, such as hypertension, obesity and cardiovascular disease.

“High blood pressure, high lipids, being overweight, cardiovascular issues and aging, are the best predictors’’ of those who might develop sexual dysfunction, Crockett said. “But diabetes heads the list.’’

“One school of thought is that because the disorders of diabetes and erectile dysfunction both affect the lining of blood vessels, or endothelial dysfunction, they tie together,’’ Crockett said.

The urological effects of diabetes are most readily recognized in men, Crockett said, but that is partly because they are growing older and because their testosterone levels are decreasing.

“To have appropriate erectile function, you really need to have normal testosterone,’’ Crockett said. “As high as one-third of (male diabetics) have problems in that area.’’

But that is only one explanation endocrinologists consider, Crockett said.
“Not only do we look at the nervous system in erectile dysfunction, we also look at other factors,’’ he said. Another possibility is thyroid dysfunction, or hyper-secretion from the pituitary gland. “That may present as a nervous system disorder, but (sometimes) it is not. It is from overproduction of the hormone prolactin,’’ Crockett said.

Diagnosing these types of effects from diabetes is not always easy, Crockett said. It requires collaboration with other specialists.

“Primary care physicians and urologists are indispensable to (endocrinologists) in caring for people with diabetes.’’ That is because “95 percent of the care of a person with diabetes is in the hands of a doctor who does general practice,’’ he said.

It also is why it is so important that primary care doctors who are treating diabetic or pre-diabetic patients “get the glucose under control and try to emphasize good health habits’’ in their patients, Crockett said.

“Erectile dysfunction is not uncommon in people with diabetes,’’ Crockett said. Primary care doctors need to ask their patients about it, he said.

“Sometimes there is a reticence for exchange, and that depends on the doctor-patient relationship. … But it is important (for primary care physicians) to ask their patients’’ about sexual dysfunction, Crockett said, “and to follow up.’’

Toward that end, Crockett said there are a number of assessment tools and questionnaires that are used for screening abnormalities. Most of those include questioning patients about their lifestyles and habits.

“If it is not a neurological problem, per se, and it has no reversibility,’’ Crockett recommends “not smoking, being obese or sedentary.’’

“There is a lower risk of erectile dysfunction to those who exercise, and there is a lower prevalence of ED in men who do not have chronic medical problems and who have a healthy lifestyle,’’ he said.

But diabetes does not affect just men’s genitourinary functions. In a woman, diabetes can decrease vaginal lubrication and significantly hamper her ability to achieve an orgasm.

“It is very hard to measure and very hard to determine, particularly in ladies who have diabetes’’ Crockett said. “There is not a wealth of literature in that area, but it is extremely important’’ for doctors to address the problem when presented with the symptoms, he said.

Still, there are complications that are not defined by gender. One is neurogenic bladder, which occurs in those who have sustained acute nerve damage in the genitourinary system.

“Neurogenic bladder is something we never want to find,’’ said Crockett.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, damage to the nerves that go to the bladder can cause it to release urine when one does not intend to urinate, resulting in leakage. Or, damage to nerves may prevent the bladder from releasing urine properly, forcing it back into the kidneys and causing infections in the urinary tract or kidneys.

Urologists use urodynamics, which is a combination of using imaging equipment and pressure monitors, to determine if a patient has neurogenic bladder. If that is the diagnosis, treatment could involve medication to promote better emptying of the bladder, or it might require periodic insertion of a catheter to drain the urine, according to the NIDDK.

“The (conditions) that parallel sexual dysfunction (and other genitourinary system disorders), also parallel diabetes – obesity, hypertension and smoking,’’ Crockett said.

The best advice doctors can give patients is that by keeping their diabetes under control, they can lower their risk of sexual and urologic problems.



November 2007

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