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Vacuum devices have been in use since the 1970s. A translucent tube is placed over the penis and air pumped out to draw blood into the erectile tissue. A constriction band around the base of the penis then maintains the erection (Figure 22.7). This simple non-pharmacological approach is surprisingly effective and safe, once patients have become skilled in using the device. Response rates in men with diabetes are around 70%, and the device can work in those who failed to respond to PDE5 inhibitor treatment.
Female sexual dysfunction
Sexual dysfunction seems to be much less common in women with diabetes than in men, but there is an increased risk of vaginal dryness and impaired sexual arousal. Menstrual irregularities are also common in women with diabetes, particularly in those with obesity and poor glycaemic control. Insulin requirements alter around the time of menstruation in about 40% of women with diabetes; the majority need more insulin, but about 10% require less. Type 2 diabetes and impaired glucose tolerance (IGT) are common in women with the polycystic ovary syndrome (PCOS), features of which include oligomenorrhoea or amenorrhoea, polycystic ovaries on ultrasound examination, obesity, hirsutism and raised circulating androgen levels (Box 22.4). Both type 2 diabetes and PCOS share an association with insulin resistance. It is thought that hyperinsulinaemia stimulates androgen synthesis and thecal hypertrophy in the ovary.
Genitourinary infections are common in women with diabetes. Vaginal candidiasis is especially frequent in poorly controlled subjects; it can be irritating and painful and may interfere with sexual activity. Treatment involves improving control, and local or oral antifungal agents, including fluconazole. Other genital infections, such as genital herpes and pelvic inflammatory disease, occur in women with diabetes, but possibly no more frequently than in the general female population. However, urinary tract infections are frequent in patients with poorly controlled diabetes, and especially in those with autonomic neuropathy and bladder distension (Box 22.5). Vulvo-vaginal candidiasis is a recognised side effect of the new SGLT2 inhibitors for treating type 2 diabetes.
Contraceptive advice is essential in diabetes. On the available evidence, low-dose ( < 30 μg oestradiol) combined oral contraceptives can be used safely in type 1 and type 2 diabetes; all women who take the pill should have their blood pressure and serum lipids reviewed regularly. Progesterone-only pills are also suitable for use in diabetes, but they may cause menstrual irregularities. As these are not thought to be associated with vascular disease, they are often used more in older women or in those with diabetic complications or risk factors (Figure 22.8).
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Rudy Bilous MD, FRCP, Professor of Clinical Medicine, Newcastle University, Honorary Consultant Endocrinologist, South Tees Foundation Trust, Middlesbrough, UK Richard Donnelly MD, PHD, FRCP, FRACP, Head, School of Graduate Entry Medicine and Health, University of Nottingham, Honorary Consultant Physician, Derby Hospitals NHS Foundation Trust, Derby, UK
A John Wiley & Sons, Ltd., Publication This edition first published 2010, © 2010 by Rudy Bilous and Richard Donnelly. Previous editions: 1992, 1999, 2004
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