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Erectile dysfunction in diabetes mellitus as a behavioral health problem

Whereas erectile dysfunction, even in diabetics, used to be understood primarily as a psychogenic issue, 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 particularly true for men with diabetes, in whom organic factors predominate over psychological causes regarding the genesis of erectile dysfunction. This is because many diabetics have several risk factors besides 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 conceptualize sexual dysfunction somatically makes 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 frequently 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.

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