Erectile dysfunction in diabetes patients
What signs might help distinguish a psychogenic impotence from the organic? What widely used medical products cause impotence? How it is possible to help today to one suffering from impotence?
Half of all diabetes-sick suffer from an impotence but, for the clear reasons, patients often evade from discussion of sexual problems; besides, because of not skilled doctors in this point in question round this problem there was an atmosphere of diagnostic and therapeutic nihilism.
However today knowledge of man’s sexual functions and their infringements quickly extend and there are new methods of treatment of impotence. The attention to this problem can be reflected in quality of a life positively.
Periodically each man faces sexual difficulties; concept “impotence” applies when more than 75% of attempts to receive erection at the sexual intercourses terminate in failure.
Pathophysiology
At the arisen sexual desire blood from coming arteries directs in cavernal bodies, pressure of a sexual member and hardness, sufficient for penetration into a vagina is reached, then through an urethra sperm, a secret prostate and a seed liquid is thrown out and a feeling of pleasure (orgasm) is had. The folklore allocates yohimbine with mystical exciting properties.
For normal sexual function interaction vascular, nervous, endocrine systems and a certain condition of mentality is required. Problems with erection, or impotence, are a consequence of their mismatch.
The first that is required for man’s sexual activity, achievement and maintenance erection, is the vascular phenomenon started by nervous impulses and possible only in the certain hormonal environment and at corresponding mood.
As complication of diabetes impotence develops as a result of an inconsistency of vascular system and infringement of nervous regulation. Unlike many other complications of diabetes the impotence does not depend on duration of disease; is more often it is found out in patients with peripheral neuropathy. (The Impotence also is connected with alcoholism, psychological problems, syphilis, and a multiple sclerosis.)
Symptoms and diagnostics
The organic impotence begins gradually. First signs — decrease of hardness and frequencies of erections, occurrence of incomplete erections, and then and full loss of erectile functions. Usually libido is kept, therefore disease essentially influences quality of a life, a self-estimation and self-esteem, causes pressure and difficulties in dialogue.
The fear appears insolvent can in itself to cause impotence. It is necessary to exclude possibility of a psychogenic impotence (tab. 1), at its presence of the patient direct to the sexopathologist.
Table 1. Impotence. Organic and psychogenic.
Psychogenic Organic
The sudden beginning has begun gradual, creeping imperceptibly Periodic Progressing Situational Constant In the anamnesis it is possible to find out psychological stress it is connected with any disease or a drug intake Night/morning erection it is kept/Night/morning erection is absent During sexual intercourse pressure of a sexual member remains/during sexual intercourse pressure can disappear. The neurologic component of impotence consists in an insufficient relaxation of smooth muscles of a sexual member because of dysfunction of independent nervous system. The impotence also is necessary for excluding, as the aetiology defines a therapy choice. Diseases micro- and the macrovessels, leading impotences, can consist in stenosis arteries and an inconsistency of veins. Stenosis internal anal arteries — the most frequent reason. Doplerovsky ultrasonic research allows estimating degree of infringement of blood supply authentically. The pressure relation in a humeral artery and in an artery of a sexual member is an exponent of vascular disease: the index less than 0.7 specifies in the reduced blood supply. Even at a normal blood pressure in a sexual member its falling more low 0.15 at rest can be observed at pressure (that it to define, the patient ask within three minutes or before exhaustion occurrence to bend and unbend anklebones).
This phenomenon has received the name of the pelvic steal. Clinically such patients cannot support erection during sexual intercourse. To some patients help deesigner rings (them make Owen Mumford, Brook Hill, Woodstock, Oxford OX201TU).
The factors strengthening an organic impotence should be revealed and corrected. Hormonal infringements concern them (it is necessary to measure serum level of testosterone, prolactin, gonadotropin, thyroid gland hormones), insufficient degree of correction of a diabetes, anomaly of a sexual member and venereal diseases.
Impotence — a by-effect of many widespread medical products, therefore whenever possible it is necessary to cancel them. The medical products more often causing infringements erection Antihypertensive examples
Preparations of the central action
Diuretics
Ganglioplegic
Blockers
False neurotransmitters
Clonidine, alkaloids of Rauwolfia
Chlorothiazide, spironolactone
Geksametonium, trimetaphan
Guanetidin, propranolol
Methyldopa
Psychotropic Ingibitors monoamine oxidase tricyclic Energizers
Fenotiazids
Benzodiazepines
The means suppressing the central nervous system
Sedative preparations
Drugs
Anxiolytics
Alcohol
Blockers of chlolinergic receptors (in high doses)
Estrogen
Cimetidine
Anticarcinogenic preparations
According to different messages, infringements erection can cause set of preparations, however because of shortage of proofs of their action they are not mentioned here.
Treatment
The general practitioner can reveal a problem (usually at annual interrogation) to carry out differential diagnostics of an organic and psychogenic impotence, and also to try a number of medical procedures, including vacuum pumps, designer rings and yohimbine (as it is described more low). In the absence of result of the patient direct to specialise clinic for the further inspection and treatment.
Replaceable therapy by androgens. Unlike thyroid or adrenal the insufficiency which is giving in to treatment with oral by replaceable means, introduction of testosterone is interfaced to certain complexities. The tablets which are available are inefficient in maintenance of the necessary levels of a hormone in blood and hepatotoxic.
Treatment by androgens. Androgens do not appoint for treatment of impotence and infringements spermatogenesis until the diagnosis of hypogonadism is established. Treatment is necessary for spending under supervision in endocrinology centre.
For effect achievement it is necessary or parenteral introduction of the prolonged aethers тестостерона, or application new impregnated testosterone the plasters pasted daily on a skin of scrotum (one slice) or on a skin of a trunk or finitenesses (two slices). Each preparation has the advantages and lacks. It is necessary clinically and biochemically to estimate function of the prostate (to define levels of a specific antigene prostate in blood prior to the beginning and upon termination of treatment).
Psychotherapy and psychotropic preparations.
Impotence — a common symptom of depression which disappears after psychotherapeutic or medicinal correction. However, many newest and most effective energizers from group selective serotonin inhibitors return capture among by-effects have influence on sexual sphere and suppress both the libido, and erection. Other energizers, for example trazodol, imipramine and dezimpramin, complicate ejaculation (this by-effect use for treatment of men with premature ejaculation).
Yohimbine. Blocking presynaptic an alpha-2-adrenergic receptors, yohimbine increases hollinergic and reduces andrenergic influences that theoretically should help at a psychogenic impotence. The national rumour attributes yohimbine mystical exciting properties, however its clinical efficiency is limited also application is not licensed. Results are reached only in the event that the problem is reduced to a psychogenic impotence.
Research by a double blind method with placebo usage covered 101 men with a psychogenic impotence. Erectile function and ability to make sexual intercourse were restored at 37 % of the men applying yohimbine (in a dose of 5.4 mg) during from three days about three weeks from the therapy beginning. Only at 15 % of the patients accepting placebo, the same effect has been gained. This means can be appointed to diabetics without a hypertensia, afraid both injections in cavernous bodies, and vacuum devices, in a dose of 10-20 mg 30 minutes prior to the sexual intercourse.
In Great Britain yohimbine it is not licensed, but it is accessible and can help to 40 % of patients, especially at a psychological origin of a problem. Martin Dale Pharmaceyticals (UK) lets out it in capsules on 5 and 10 mg. We recommend 10 or 20 mg for half an hour before sexual intercourse.
The vacuum adaptations causing erection. In some devices the vacuum for strengthening of arterial inflow and occlusive rings for prevention of venous outflow from cavernous bodies is used. Some share of technical skill is necessary for use of such devices, however, once having accustomed, the man can cause erection at any time, sufficient for penetration into a vagina. However it is thus impossible ejaculation as rings compress that part of an urethra which passes through a sexual member, so strongly that prevent a current of a seed liquid. To keep pressure of a sexual member help designer rings in addition to alprostadil to ointment Independent insidepenis injections. Alprostadil (prostaglandin Е1), papaverine, alprostadil in a combination with papaverin and fentolamin were applied by patients independently to calling erection. In a usual condition the sympathetic nervous system supports a penis in powerless or not-erected condition. The vazo-active means entered in cavernous of a body block or overcome sympathetic influence and stimulate a relaxation of trabeculae of smooth muscle in erectile bodies of a sexual member. The subsequent sharp inflow of blood in cavernousе bodies squeezes emissary veins usually providing its outflow from a penis. The combination of the strengthened arterial inflow and the blocked venous outflow from cavernous bodies cause erection.
The unique preparation resolved for introduction in cavernousе of a body, is alprostadil, but we in ours Online pharmacy without prescription more tend to prescribe viagra.
Technics of introduction of insulin. It is necessary for this way of treatment of patients to train. Under supervision of a diabetes specialist the patient masters technics of introduction of insulin a syringe with a needle № 26 in lateral part of a body of a sexual member, and also vazo-active preparation in one of cavernous bodies. Thanks to cross blood circulation the preparation entered into one of cavernous of bodies, gets on an opposite side; thus, full erection comes in some minutes after its introduction.
Speed of an exhaustion. Despite high efficiency of a method, at long independent application for many patients the exhaustion quickly develops. According to the data of one research, from 140 patients only 20 % had satisfaction at long treatment, and 112 (80 %) have stopped injections. Men with a psychogenic impotence had the highest indicators of satisfaction (42 %). At them as the main reason of cancellation interest loss served. At long treatment patients with dislipoproteinemia require the constant control.
By-effects inside-penis injections. The main by-effect — a pain in the sexual member, meeting in 50 % of cases. Those men who have independently stopped treatment is more often complain of a pain, however it is not the most unpleasant by-effect. Priapism, or long erection, 6 hours lasting more, — the urgent condition demanding the immediate urological help for evacuation of blood, accumulated in cavernous bodies. Treatment is preferable for spending within 24 hours. There is an accepted scheme of elimination of priapism, caused by alprostadil.
New approaches
New, noninvasive methods of treatment are worthy.
Alternative way of application alprostadil. Application of alprostadil in a kind intraurethral suppository with applicator was studied. Research was spent by a double blind method with the platsebo-control and covered 1511 men with various organic infringements erection; 996 (66 %) have answered on intraurethral entered alprostadil erection, sufficient for the sexual intercourse. Subsequently to them in the selective image gave alprostadil or placebo. The sexual intercourses were more successful at application alprostadil (65 % against 19 %). Under messages, 7 from 10 cases of application alprostadil come to an end with successful sexual intercourse. System effects are changeable, and such complications as priapism and fibrosis of a penis, meet less often, than at alprostadilов injections, but the irritation mucous vaginas is occasionally marked. The stored experience of such application alprostadil still is too small.
Local vasodilating means. Application of local vasodilating preparations is not innovative. In certain cases successfully apply glyceryl trinitrate. Successfully applied combination of three local vazodialators with various mechanisms of action (for example, 3 % aminophylline, 0.25 % dinitrate is new and 0,05 % codergocrine mezilate), ointment are put on a head and a body of a sexual member. The General practitioner can try to appoint alprostadilов ointment and yohimbine in the absence of a hypertension at the patient Loss of pressure of a sexual member at penetration into a vagina (a syndrome of pelvic steal and-or venous insufficiency) overcome with the help of designer rings in a combination with combined alprostadil ointment.
Oral means for treatment of infringements erection. Sildenafil.
Erection depends on relaxation smooth cages of cavernous bodies, caused by nitrogen oxide and its secondary intermediary — cyclic guanosine monophosphate (cGMP). Being today in a working out condition sildenafil — a preparation for the intake, possessing inhibitor action concerning enzyme phosphodiesterase, being the basic enzyme in cavernous bodies at the person. Relaxation strengthening of smooth cages cavernous bodies should be result of reception of this preparation. Preliminary researches testify to good shipping of a preparation and its efficiency at infringement erection.
