Dr. Hunter Wessells talks with Diabetes in Control Publisher Steve Freed during the ADA meeting in San Diego, California, about some important points in his ADA presentation, Urologic Complications and Sexual Dysfunction for Men and Women.
This interview has been edited for clarity and length. The full video interview is available here.
What is a urological problem seen in men and women with diabetes? We know sexual dysfunction but what are the other things?
Some of them are conditions that are also seen with aging but some of them are more specific to diabetic men and women. Sexual dysfunction includes erectile dysfunction in men, lack of sexual desire in women which could be related to hormonal or central nervous system issues which is currently underexplored and need more research. The classic sexual dysfunction in men and women entails an arousal disorder and lack of lubrication, lack of the normal virginal responses to arousal which include orgasm and ejaculation. Lack of ejaculation in men interfere with fertility and may be related to nerve damage and also there can be pain conditions as well. So, sexual dysfunction is a general term that includes subsets.
Diabetes is defined as an A1c of 6.5% or 7%. At what point do you see most sexual dysfunction; does it start at prediabetes or do you have to wait till 8 or 9%?
You can get it across the whole range and there is an interaction between age or the amount of time and the diabetes. The longer you have had the diabetes the more likely you are likely to get these complications. You can have a man with an A1c of 11% and no urological complications at all, then you can have another with 6.5% who gets it. So, there are other factors in play. Other urological complications include bladder problems, incontinence in women or involuntary urine leakage, lower urinary symptoms like having to go to the bathroom frequently, getting up at night and these can be bothersome as well. None of these issues are like blindness or amputation but now men and women with diabetes are living longer and have these other complications under control, these urologic issues are going to have a greater impact on the quality of life and the day to day activities.
When a person’s blood sugars are elevated, the more susceptible they are for diseases and they usually have more urological related infections. What are your thoughts about controlling and preventing yeast and bladder infections by reducing blood sugars?
There is always been this idea that tighter glycemic control will reduce the risk of UTI. We see in our cohorts we have been studying with long standing diabetes that at the highest levels of A1c, there is a risk of UTI but getting from a A1c of 7% or a 6% is not going to change your risk of UTI and its going to be pretty low. As you start getting high up in the range you start seeing those problems.
As urologists do you see more prostate cancer from patients with diabetes than those without diabetes?
No, we don’t really but it may change the way the blood test PSA performs; that may be influenced by your blood glucose. It could affect screening or other testing that is done to achieve early detection.
Why should diabetes care providers take the time to ask their patients about urological symptoms?
It’s an opportunity to create dialogue with the patient about their blood glucose control and also an opportunity to improve their quality of life because many of these conditions are treatable with either lifestyle modifications, medications or interventions to reduce blood glucose.
How can these types of symptoms be elucidated in the cause of a busy clinic meeting?
You can use questionnaires to get some of the basic information and there are good questionnaires for male or female sexual dysfunction. You don’t want to make decisions simply based on a questionnaire. If it’s not bothering the patient then you may not do anything about it.
Once patients experience urological symptoms do they progress inevitably to irreversible problems?
New data shows that there is a subset of patients who are moving in and out of a state of urological problems like incontinence or sexual dysfunction. Those patients may be the ones in particular that an intervention might be very timely.
What can patients and providers do to mitigate the onset and progression of sexual and urinary dysfunction?
Gaining control of the diabetes which includes exercise, avoiding smoking, maintaining good blood pressure control and many more.
A good presenter gives information that the audience takes home and practices what they have been taught. If there were just a couple things that you wanted the family practitioner, the physician or PCP to walk away with from your presentation, what would that be?
That this is important to the patient and it affects their quality of life. It has a bigger impact on the quality of life than other things that we think of like kidney damage in the intermediate phases. Controlling an incontinence issue may be more impactful to a patient. The other takeaway is 50% of men are going to have sexual dysfunction by the time they are 50 years old if they have diabetes which is much high than the rest of the population and we need to be thinking 10 or 20 years ahead of that and using that in educating patients. The last thing is that there are some effective treatments for some of these conditions and if the PCP or providers can’t manage that themselves they should get help because we can improve a lot of these symptoms.
When it comes to sexual dysfunction for men there are a lot of things out there (pumps, injections, etc.). Is there anything that really stands out besides Viagra?
Viagra, Cialis, and Levitra are our first line therapies and they are all very effective. The other things are helpful but many patients are not really interested trying them. We desperately need new strategies but there is not a whole lot in the pipeline right now.
When it comes to sexual dysfunction, how important is controlling your blood sugar? A person who has sexual dysfunction can’t get an erection and they are trying to control their blood sugars. Do you see that coming back if they get their blood sugars to the normal range?
Those studies have not been done in the way you described. If we had a man in their 40s with their A1c about a point above the goal, what should we do? We should drive down that A1c, we should have them address weight issues, smoking, exercise, and we need to design a study in order to address that question which is very important.
Have you been successful in that respect with any of your patients in having them coming back from their sexual dysfunction?
Yes, anecdotally, but we cannot base guidelines or a message to an entire scientific community based on that level of evidence.