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Behavioral therapy for diabetes mellitus

B. KULZER

Impotence is one of the most common complications of the disease in men with diabetes. The occurrence of potency problems is clearly related to the quality of metabolic control, the presence of other risk factors, the duration of diabetes and age. It is known from studies that around 30-50% of all diabetics must expect to be confronted with the problem of erectile dysfunction in the course of their disease [10, 16]. In Germany, it is estimated that around 750 000 – 1 250 000 men with diabetes are affected by this problem at some point. Compared to men without diabetes, diabetics thus have a comparatively significantly increased risk with regard to the occurrence of erectile dysfunction. Individuals with diabetes therefore represent one of the largest groups of men with potency problems in terms of numbers.

Compared to all other secondary complications of diabetes, however, it is apparently still very difficult for experts and patients alike to deal with this complication of diabetes – despite the removal of taboos in dealing with sexual issues in everyday life and the so-called “sexual liberation” of our time. Impotence is by far the least researched, diagnosed and treated secondary complication of diabetes [7]. There is no other explanation for the fact that very few male diabetics mention this problem in medical consultations, only a negligible percentage specifically seek further diagnostic clarification, and even fewer accept therapeutic help options [2,6].

Overall—at least at the present time—the proportion of men with diabetes and potency problems who have never sought professional help, have not undergone any further diagnostics and have not made use of any therapeutic assistance such as medication, aids or therapeutic discussions predominates (see Fig. 6.22). On the other hand, however, the problem of erectile dysfunction is also ignored by the majority of physicians and members of the diabetes team, frequently presented as the unalterable fate of the course of diabetes, treated with unsuitable therapy recommendations (e.g., prescribing pseudo-circulatory drugs), and diagnosed and treated professionally far too rarely.

If one wants to take the main goal of diabetes therapy seriously—the preservation of a satisfactory quality of life despite and with diabetes—then a well-founded diagnosis regarding sexual dysfunction and treatment offers for erectile dysfunction therapy should be a self-evident, integral part of every diabetes therapy: After all, almost every second to third male diabetic is affected by this problem situation!

In practice, this can only succeed if:

  • in the context of diabetes treatment, the problem of impotence is not suppressed or delegated;
  • in diabetes training, the topic of impotence is not only mentioned as a possible secondary disease, but also talked about;
  • every man with diabetes is asked about possible sexual dysfunction as part of his medical history;
  • if necessary, a further—ideally very low-threshold—counseling, diagnostic and/or therapy service is provided that is tailored to the different needs of men with erection problems, which can range from the desire for pure information to time- and cost-intensive therapeutic interventions;
  • an interdisciplinary counseling and treatment program is available at the treating institution.

At least every diabetological focus facility, whether inpatient (e.g., diabetes specialist clinic) or outpatient (diabetological focus practice), should maintain mandatory close cooperation with a urologist or urological department and a psychotherapist or psychotherapeutic facility so that the various diagnostic and therapeutic steps can be coordinated.

Erectile dysfunction in diabetes mellitus as a behavioral health problem.

Whereas erectile dysfunction, even in diabetics, used to be understood primarily as a psychogenic problem, intensive research and improved diagnostic capabilities over the past 10 years have led to a much more in-depth understanding of the regulatory mechanisms of male erection and possible pathological processes [8]. It has become increasingly clear that the genesis of erectile dysfunction is often a multi-causal process and that organic causes play a far more important role in its causation than previously assumed.

This is especially true for men with diabetes, in whom organic factors predominate over psychological causes in the genesis of erectile dysfunction. This is due to the fact that many diabetics have a number of risk factors other than diabetes (e.g., hypertension, dyslipoproteinemia). In rare cases—in type II diabetes—erectile dysfunction may also precede the manifestation of diabetes or be the first sign of this disease, since the onset of diabetes is only one component of the more complex “metabolic syndrome”, which can have a vasodamaging effect over a long period of time even before diabetes.

With longer duration of diabetes and chronic hyperglycemic metabolic control, the risk of developing secondary complications of diabetes increases, which can severely disturb or even completely block the interplay of cavernous-venous, arterial and nervous components necessary for an erection. Vascular damage (due to micro- and/or macroangiopathies) as well as neurogenic lesions (polyneuropathies) are mainly responsible for this. In addition, there is the possibility of a temporary, passive disturbance of potency as a result of momentarily highly elevated blood glucose levels. In addition, diabetics also frequently take medications that have an erection-inhibiting effect (e.g., antihypertensive medication, lipid-lowering drugs).

This change in the way erectile dysfunction is viewed has led various authors to conclude very hastily that erectile dysfunction—and especially in the group of diabetics with frequently additional, disease-related somatic risk factors—is a purely organically determined problem that should be considered and treated relatively independently of psychological factors [41. While the tendency to conceive of sexual dysfunction in somatic terms makes perfect sense and leads to greater clarity in diagnosis and treatment recommendations, this view runs the risk of reducing erectile dysfunction to a disorder of an organ function. However, this in no way does justice to the significance and complexity of human sexuality.

In the erectile dysfunction of diabetes, organic and psychological factors are so closely interwoven at a wide variety of levels that it is difficult and often even impossible to separate organic and psychogenic factors. This applies, for example, to the genesis of impotence, which can rarely be explained by a single cause, since it is often multifactorial and organogenesis and psychogenesis intertwine in a bundle of causes. For example, if erectile dysfunction in a diabetic is associated with elevated blood glucose levels, secondary diseases of diabetes, a lipid metabolism disorder, high blood pressure, additional medication, alcohol consumption, nicotine abuse, psychological stress associated with the disease and chronic partnership problems, it is almost completely futile to try to determine the actual cause of erectile dysfunction.

Since the various factors influencing erectile dysfunction at the somatic, psychological and behavioral levels are interrelated in a kind of bundle of causes, a distinction between “organic” and “psychogenic” erectile dysfunction can thus only be of heuristic value, since these are usually only very fuzzy mixed categories. For this reason, various authors [1,9,12] rightly propose to abandon the traditional distinction of an “organogenesis” and “psychogenesis” of erectile dysfunction in favor of a biopsychosocial perspective, as this also corresponds to behavioral or psychosomatic thinking.

Psychological aspects

Psychological factors are largely responsible for whether a diabetic experiences impotence as a problem, how he or she reacts to the diagnosis and deals with it, whether and to what extent he or she decides to undergo further diagnostics and therapy and actually implements the proposed therapeutic measures. The effects of erectile dysfunction on self-esteem, partnership and experienced quality of life also often depend much less on the severity of the dysfunction than on individual psychological coping or the type of communication between partners.

The individual problem view of erectile dysfunction is decisively determined by psychological factors because by no means all men with erection problems also perceive them as a serious problem, while other diabetics suffer greatly from them. Men of advanced age in particular (this age group includes many type II diabetics, who constitute the majority of all diabetics) often no longer attach such great importance to sexuality in their lives or report a decline in their partner's sexual interest, so that they do not regard erectile dysfunction as a serious loss of their quality of life.

However, this circumstance in no way means that these men do not also have a need to talk about their diminished sexuality in the context of a training event, a one-on-one conversation or a group of peers. The question is often asked whether this behavior is “normal” and whether other men feel the same way. For other men, sexuality is not of great importance either for personal reasons or because of the partner situation, so that the loss of erectile function is not experienced as very problematic.

Of the men for whom erectile dysfunction is a problem (and this is by far the larger proportion of all those affected), however, only a certain percentage—mostly irrespective of the extent of erectile dysfunction—seek to elaborate on the sexual difficulties or specifically try to get help. Talking about erectile difficulties still seems very problematic for many men, so that these are usually not reported spontaneously in the context of the medical history, but only when asked in detail [5].

The impact of not communicating about potency difficulties is powerfully illustrated by a case report by O'Dell and Shipp [11], who describe how a man repeatedly injected insulin into his penis in the belief that this would restore his potency.

On the other hand, it is unfortunately still not a matter of course today that every man is asked about possible sexual function impairments as part of diabetes therapy and is offered counseling. As Smith [141 was able to show in a study of patients with erectile dysfunction between the ages of 20 and 54, almost none of the diabetics affected received professional counseling. The men therefore first turned to people outside the diabetes treatment team: 46.2% sought advice from a pharmacist, 15.3% from a priest, 11.5% talked to friends about the problem, 3.7% sought advice from a urologist on their initiative, and 3.8% from a psychologist.

We came to a similar conclusion when evaluating the patient questionnaires in the context of the “men's round” at our clinic, where the overwhelming majority of all men stated that they had not yet made any attempts at treatment. In this case, a diabetology center offers a suitable setting for addressing this problem, since the barrier to talking about sexual difficulties is experienced by those affected as significantly lower than with their local family doctor or urologist. In our experience, it is also much easier to talk about possible erection problems in connection with diabetes.

In view of the still widespread reluctance to discuss sexual matters, addressing possible sexual problems must therefore be a task of the physician or another member of the diabetes team as part of the medical history and cannot be regarded as the diabetic's “duty to bring up”.

The further step of undergoing detailed diagnostics is also influenced less by the clinical findings and more by the personal attitudes of those affected. In numerous instances, men with diabetes refrain from further diagnostic measures after being informed in detail about possible therapy recommendations that could result from the diagnostic process – e.g., erectile tissue auto-injection therapy (SKAT), vacuum pump, penile prosthesis, sexual counseling/therapy [21]. This may be due to feelings of shame or fears (e.g., fear of having a vasoactive substance injected into the base of the penis), moral or religious beliefs (e.g., the opinion that a possible pharmacological or technical aid to achieve an erection contradicts the actual natural course of an erection), or the lack of consent from the partner.

Detailed counseling, such as that which takes place in our clinic as part of the weekly “men's round” or can also take place in a one-on-one conversation, in which the possible therapeutic consequences are already made clear to the patient before a decision is made for possible diagnostic measures, can help to avoid superfluous diagnostics that may be burdensome for the patient and expensive for the payer. On the other hand, specifically addressing possible barriers to further diagnostics can help to reduce irrational fears and promote the ability of the patient and his or her partner to make decisions about targeted diagnostic measures.

Even after a detailed diagnosis, which results in an attempt to describe the cause of the problem as well as a therapy recommendation, only a relatively small percentage actually decides to implement a recommended therapy measure [3]. Here, too, factors such as the age of the patient, his partnership situation, the wishes of his partner, the importance of sexuality for his self-esteem and self-confidence, moral concepts or the presence of fears determines to a greater extent the decision of a diabetic for SKAT therapy, vacuum pump, penile prosthesis implantation or sex therapy than the result of the diagnostic process.

For example, the fear of prolonged erections or the feeling of shame before seeking emergency urological services in case of a possible priapism can be a very decisive barrier to the use of SKAT therapy. Vacuum pump therapy scares off many men when first demonstrated, as the non-discreet method of application requires confident use of this device. The implantation of a penile prosthesis is not a realistic alternative for many diabetics due to the high effort, the increased possible surgical risks or side effects for this group of patients, the finality of this step and an often non-existent acceptance of the partner.

The decision to seek psychotherapeutic support alone or with the partner also depends less on the diagnostic findings, but to a greater extent on the individual attitude to sexuality CZ. B. Willingness to talk about one's own intimacy), the personal assessment of the therapist CZ. B. trust in the therapist) or possible attributed contents of a therapy, e.g., practical exercises). Moreover, experience has shown that psychological support is usually only very hesitantly taken up if it involves a consultation service or an external counseling center [15].

Quite independently of the causative factors, erectile problems are usually also associated with massive self-doubt and male identity problems, since in our culture potency is regarded as an important feature of male identity, along with performance. These psychological effects of disturbed sexual behavior must be included in the diagnosis and therapy of erectile dysfunction. If a diabetic already has problems with his self-esteem due to his disease and if the two central “pillars of masculinity”—performance and potency—are then equally restricted as a result of the diabetes, men with diabetes often experience this as very stressful and as a significant loss of quality of life.

Due to an excessive mental preoccupation with one's own sexual behavior, due to the tendency to consciously control oneself during the sexual act or due to thoughts of possible consequences of a renewed failure situation, many men experience a significant loss of spontaneity and an increasing cognitive control of sexual behavior when erection problems first occur. Often in such a situation, men also become much more sensitive to actual or exaggeratedly perceived or anticipated negative reactions from their partner. This in turn increases the fear of failure and often leads to pronounced avoidance behavior, with the result that sexual contact tends to be avoided or communication with the partner about an experience of failure does not take place.

As with all fears, pronounced avoidance behavior and a strong cognitive preoccupation with possible negative consequences intensify the fear of another failure (“fear of fear”). This can lead to sexuality no longer being perceived as a spontaneous, pleasurable experience, but rather being experienced within a relationship as increasingly stressful and anxiety-ridden, with lasting effects on quality of life and the partner relationship. This “vicious circle,” consisting of experiences of frustration, self-doubt, fear of failure, increasing cognitive control and avoidance behavior, and increased sensitivity to actual or anticipated environmental reactions, occurs in almost all sexual dysfunctions, regardless of etiological genesis. However, in men with diabetes, due to metabolic derailments (temporary potency problems due to poor metabolic control), there is an increased likelihood that sexual fears of failure will occur at some point, setting in motion the “vicious circle” described above.

The knowledge of an increased risk of potency problems as a diabetic—which is addressed in diabetes training, for example—can also lead to a pronounced fear of expectations with a self-reinforcing character. The extent to which erectile dysfunction affects self-esteem and the partnership is often relatively independent of the severity of the dysfunction and depends more on the individual's ability to cope, communication between the partners and the use of competent support options.

Consequences for practice

Training

Since sexual problems can be a very common secondary complication of the underlying disease of diabetes, this aspect of the disease should definitely be addressed in diabetes training. On the one hand, this has preventive significance, since potency problems are by no means an inevitable consequence of diabetes and a diabetic is thus shown ways in which potency problems can be prevented. On the other hand, diabetics with existing potency problems can learn more about possible factors influencing and causing impotence and about further diagnostic and therapeutic options. The exchange with other people affected by the same condition, which can be found in almost every group due to the prevalence figures of impotence in diabetes, can also be a valuable help for the further handling of the problem.

Both the type of training (preferably not in lecture style, but in dialogue) and the setting (preferably not in a large group, group together with women) should be adapted to the treatment of this topic, which is difficult to address even for many therapists. Although we have had excellent experiences in our clinic with weekly group meetings of men affected in the same way, there should in any case be the possibility of being able to discuss this problem in a separate setting (individual conversation in a room that guarantees protection of the privacy of the individual).

Behavioral medicine diagnostics

The goal of all therapeutic efforts in erectile dysfunction associated with diabetes should be to offer the patient an opportunity to discuss his or her problem with a specialist who is as knowledgeable as possible in both diabetology and sexual medicine, to suggest further diagnostic clarification options, and, if necessary, to offer various treatment options.

In practice, however, somatic diagnostics often take precedence over a detailed anamnestic interview, with the argument that the findings must first be collected before a goal-oriented discussion can take place. However, thanks to a structured anamnesis, it is often possible to obtain sufficient information about the genesis and the further diagnostic procedure of erectile dysfunction [1,13]. The following factors can be considered as indications for a more organic or psychogenic cause of erectile dysfunction:

Primary (initial) ED: If erectile dysfunction occurs initially (primary ED) and organic causes can be ruled out as the causative factor, it is reasonable to suspect that a lack of sex education, educational factors or problems with gender identity could be responsible. This should be considered especially in juvenile type I diabetics who have grown up rather overprotected due to the disease and have a rather very cognitively controlled lifestyle due to the demands of diabetes therapy and therefore developed fears towards areas of life that are very emotionally centered.

Long-lasting, complete loss of libido: The occurrence of erectile dysfunction is usually independent of the need for sexuality (libido). If a patient reports a severe, prolonged loss of libido, the cause is often not organic factors or secondary damage due to diabetes. Instead, other—more psychological—factors need to be clarified in more detail. In this case, however, it is important to ask exactly about the temporal relationship between the occurrence of the appetence and sexual disorders in order to be able to distinguish a primary libido disorder (before the occurrence of the sexual disorder) from a secondary appetite deficiency (as a consequence of the sexual disorder). As an exception, however, hyperglycemic metabolic derailments should be noted, since with very high blood glucose levels, a general lack of interest and apathy can also very much limit the need for sexuality.

Protracted or acute onset of ED: Diabetics whose erectile problems are related to incipient or worsening sequelae typically describe that their potency problems appeared slowly, rather imperceptibly, and then worsened almost insidiously. Since erectile dysfunction is rarely the first complication of diabetes, the status of other secondary conditions should be carefully assessed in this finding. Typically, the probability of an organic cause increases to the extent that other nerves (e.g., in the legs) and vessels (e.g., in the eye, kidney) are already damaged by the diabetes. In contrast, a very rapid, acute occurrence of erection problems, possibly in connection with a clear life-historical context or stressful events, is more indicative of a possible psychogenic cause.

Onset of ED corresponds with poor metabolic control: If the onset of erection problems is accompanied by a marked deterioration in blood glucose levels, the suspicion of passive potency problems is obvious, especially if this condition turns out to be reversible with the achievement of normoglycemia. The value of the long-term glucose (HbAl, HbAlc, Glyco-Hb), which should be routinely collected in diabetic patients, can provide an initial orientation whether there might be an influence of the current or chronic blood glucose derangement on sexual functioning.

Occurrence of ED in a temporal relationship with the use of additional medication: If erectile dysfunction occurs in a temporal relationship with the use of additional medications, a possible drug influence regarding ED must also be clarified. It should be noted that many people with diabetes take a number of other medications (e.g., antihypertensives, lipid-lowering drugs, painkillers) in addition to their diabetes medication due to other risk factors associated with the metabolic syndrome or as a result of diabetes-related or diabetes-associated concomitant diseases.

Situation-, partner- or sexual practice-related occurrence of ED: If erectile dysfunction occurs only in certain situations, episodically, with a certain sexual partner or only in connection with certain sexual practices, this is an apparent indication of psychogenic causative factors. In contrast, a continuous course independent of these influencing factors is more indicative of an organic disorder.

Unrestricted occurrence of spontaneous erections, nocturnal erections and ability to successfully masturbate: Organic disorders are characterized above all by the fact that erection problems occur consistently, irrespective of the situation, and the ability to spontaneously erect is also no longer present. If, on the other hand, erection is possible through masturbation and the ability to have spontaneous erections at night or in the morning is not impaired, then this speaks against an organic impairment of erectile function.

ED in connection with stressful life events or psychiatric diagnoses: Since erectile dysfunction occurs to a greater extent in connection with very stressful life events and is found more frequently in clinical pictures such as depression, anxiety or alcoholism, if these influencing factors are present, it should be examined whether there is a clear connection with the occurrence of the sexual disorder or whether the erectile dysfunction is confounded with this problem. It should be noted that psychological problems such as anxiety, depression, and compulsions occur more frequently in diabetics and that long-term alcohol abuse could also have led to pancreatitis with subsequent secondary diabetes.

In the next step of the interview, the information obtained from the medical history can be summarized in a “working hypothesis” or “tentative diagnosis” and, in a further step, the various diagnostic measures can be presented against the background of the therapeutic possibilities. In this context, the patient should also be questioned regarding his or her level of suffering, motivation for a possible solution to the problem, and desire for further therapeutic assistance. In addition, the importance of coordinating further diagnostic or therapeutic steps with the partner, if possible, should also be pointed out.

A summary of the advantages and disadvantages of the respective therapy strategies and a presentation—possibly also a trial (e.g., with the vacuum pump)—of the various aids should aim to increase the individual's ability to decide which form of diagnostics he is aiming for and which forms of therapy are suitable for him. For example, in older diabetics in whom vascular surgery or the implantation of a penile prosthesis are ruled out due to advanced arteriosclerotic changes, or in whom the injection of vasoactive substances is associated with too high risks due to acute cardiovascular problems, the question arises whether further diagnostics make sense at all, since the potential therapeutic measures have already been determined regardless of the outcome of the diagnostic process. This also applies to patients who reject technical aids to achieve an erection in advance or who do not want psychotherapeutic discussions.

Interdisciplinary therapy offers

For the planning of therapy offers, it is important to consider the different needs of patients, which can range from the desire for conclusive information about the genesis of erectile dysfunction and its treatment options to time- and cost-intensive diagnostic and therapeutic interventions. Considering the interconnectedness of psychological and somatic factors described above, both the diagnosis and the treatment of erectile dysfunction in men with diabetes should be based on a behavioral medical model of thinking and treatment and should generally be carried out in an interdisciplinary manner.

As practice shows, the success of therapy measures depends strongly on the extent to which the therapy offer is kept very low-threshold and an exchange between the various specialist disciplines takes place. Therefore, in view of the frequency of impotence problems in diabetics, a concept for systematic anamnesis, diagnostics, training, and therapy should exist in every outpatient and inpatient diabetology center and there should be close cooperation with a urologist or a urology department and psychotherapists or a psychotherapeutic facility.

In our clinic, a diabetes specialist clinic, we have had very good experience with a systematic questioning of the patients in the anamnesis, further diagnostics with the help of a questionnaire, a weekly “men's round” jointly led by a physician and psychologist for information, individual diagnostics and the possibility of exchange between equally affected persons as well as the offer of further diagnostic measures, further discussions and the initiation of therapy measures (more detailed description in [6]). It has proven advantageous that the treatment of impotence takes place in the context of diabetes therapy, that the treatment offer is transparent for the patient, and that the interdisciplinary offer of further diagnostics and therapy is frequently taken up, not least because of the personal contact with the therapists through the “men's round”.

If one takes the problem of erectile dysfunction in diabetes seriously, one should always be aware that therapeutic offers should not be limited to those men who address the problem of their accord, and also take into account the fact that the larger proportion of diabetics do not seek further therapeutic steps. However, even for these patients, the task is to come to terms with the fact of dwindling or absent potency, to talk about it with their partner—which many men find very difficult—and to try out new forms of sexuality.

Ultimately, therefore, the outcome of therapeutic efforts should be to help the patient (and his or her partner) arrive at a decision for the therapeutic intervention that best suits him or her (both). This therapeutic intervention should contribute to increased sexual satisfaction, reduction of fear of failure, and ultimately an improvement in quality of life. It remains important to note that the restoration of the man's erectile capacity can contribute decisively to this, but does not necessarily have to!

Literature

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Author: P. SCHMIDT und K.P. JÜNEMANN
Source: Erektile Dysfunktion Diagnostik und Therapie