People with diabetes are at higher risk for bladder issues, sexual dysfunction, and other conditions related to the urinary tract and sexual organs. Hunter Wessells, MD, FACS, explains how health care professionals can treat these complications to improve quality of life for their patients.

Q: How can diabetes affect the urinary tract and sexual organs?

A: Diabetes can affect the urinary tract and sexual organs through nerves, blood vessels, and metabolic effects. The disease can make urinating more frequent and can cause incontinence. In rarer cases, it can deaden the nerves so the bladder doesn’t feel itself filling up, and the bladder can get overstretched and become nonfunctional.

Diabetes also affects the nerves that coordinate sexual responses in men and women and can lead to reduced arousal, which translates into reduced erectile function in men and problems with lubrication and arousal in women. There can also be loss of the sense of orgasm. Normal sexual function results from a complex series of events. When diabetes puts these events out of balance, it can cause dysfunction.

Q: What is the risk for urinary tract and sexual problems in people with diabetes?

A: The risk (PDF, 985 KB) accumulates over decades. In men with diabetes, many begin to develop erectile dysfunction (ED) in their fifties, and the percentage goes up with age. It’s higher than in the general population, where there’s already a lot of ED. In women, the prevalence of sexual dysfunction is probably a little lower, but it’s still in that 30–40% range.

With bladder problems, it’s a little harder to tell. We don’t have as much information on risk over the long term, and that’s a gap in knowledge that we’re trying to close.

People with type 2 diabetes may have a longer period of exposure to high blood glucose levels before diagnosis, so some of these metabolic, vascular, or nerve problems could happen silently, but they’re still prevalent. Some additional factors in type 2 diabetes related to the metabolic syndrome, such as blood pressure control and weight, may also affect and exacerbate some of these urologic problems.

Q: What symptoms related to the urinary tract might your patients with diabetes report?

A: In women, we see bladder overactivity—having to go more frequently—as well as the involuntary leakage of urine, or incontinence. Those are both more common in women with diabetes. The association between urinary tract infection (UTI) and diabetes is complex. Meeting blood glucose targets can lower the risk for UTIs.

In men, symptoms include a reduction in the stream or frequent urination. These symptoms also happen as men age, and they are not easy to disentangle from prostate symptoms. Benign prostatic hyperplasia (BPH) is a very common age-associated phenomenon in men that leads to many urinary problems.

Q: What symptoms related to sexual function do patients report?

A: In men, the most common sexual dysfunction is the inability to obtain and maintain an erection. They may also have a reduction in sexual desire, or libido. This is often mediated by hormones and is relatively common, but sometimes it’s an effect of the ED rather than a separate condition. And then a small percentage of men with diabetes will have ejaculatory dysfunction: either the complete inability to have an ejaculation or some change in ejaculation.

In women, sexual dysfunction has different components. Diabetes can have a multidimensional impact, including low desire, lack of lubrication, lack of arousal, and decreased orgasmic function.

Q: How can health care professionals diagnose urologic complications and sexual dysfunction?

A: Patient-reported symptoms are the gold standard for diagnosing ED in men, female sexual dysfunction, and urinary symptoms. It’s not like when you take a blood pressure measurement to diagnose hypertension. You must ask the patient about these conditions. It’s part of excellent diabetes care to assess all these domains and make sure that we’re addressing not only complications of diabetes but also quality of life.

For the diabetes specialist or educator working with the patient with diabetes, these symptoms should be managed in the context of other disease conditions. Not a lot of diagnostic tests are necessary. It’s really taking a good history and physical examination and making sure you understand the patient’s problems.

The diabetes health care professional can ask some very simple questions as part of a general visit, such as, “Are you having any difficulty with your sex life or are you having any urinary problems?” There also are validated objective questionnaires that can be used to assess for sexual dysfunction or urinary symptoms.

For some men, their first symptom of an underlying disease such as diabetes is ED. So, for the general practitioner, sexual dysfunction can be an important indicator.

Q: Do you have tips for how health care professionals can broach these sensitive topics?

A: The key is to make it normal to talk  about sexual and urinary problems, to remind patients that we talk about these things all the time. So, asking the question as part of the routine practice is, I think, the most important thing we can do. By asking, we signal to the patient, “This is important, and I’m interested in your problems.”

Q: How are symptoms treated?

A: We have behavioral treatments to retrain the bladder. We have medications for urinary problems, and then there are more advanced surgical treatments for severe cases.

For ED in men, there are well-established treatments approved by the U.S. Food and Drug Administration across the whole range of severity, from phosphodiesterase inhibitor medicines for milder cases, to injection therapies for more severe forms of ED, and penile implants for the most severe cases.

Some emerging therapies for ED include shockwave therapy and injections of platelet-rich plasma. However, these therapies are still not well standardized, the evidence is mixed, and they are costly and not covered by most insurance. The good news is that the National Institutes of Health is funding some rigorous studies of both of those treatments.

For women, not as many treatment options are available, but one medication is approved for the treatment of low desire. We’ve been researching the association between female sexual dysfunction and a couple other conditions that might be interacting with it. One is depression, and the other, interestingly, is urinary incontinence. Taking the whole context of the patient’s medical and social situation, and treating some of these other associated conditions, could help with the sexual dysfunction.

Evidence suggests that reducing weight by 5–10%, which has been shown to be achievable in other studies, can improve incontinence in women who have activity-related incontinence or overactivity of the bladder. We don’t yet know whether weight loss can improve sexual dysfunction in women, but that’s one of our hypotheses that we hope to investigate. For women who recently started to experience mild to moderate sexual dysfunction, could sexual dysfunction be reversed through an intensive approach that involves weight loss, exercise, diet, and maybe medications?

We don’t have significant data on whether weight loss can address urinary symptoms in men because it’s difficult to tease out the role of the prostate in male urinary symptoms. 

Q: Are patients with urinary or sexual dysfunction issues typically referred to a diabetes educator or urology specialist, or are these issues typically handled by the endocrinologist or primary care professional?

A: Fortunately, I think some of the sexual dysfunction problems in men are now being managed by primary care professionals and other medical specialists. Men and women with urinary symptoms will more often be referred to a urologist.

Q: What research is being conducted or is needed in this area?

A: Work that many people have done through the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has made us more aware of how many people have these types of problems, and we’re moving toward strategies to treat or even prevent them.

We know there are very clear associations between diabetes and low testosterone, particularly in men with type 2 diabetes. These associations often relate to the effects of excess weight on hormonal function. But we don’t understand as much about the hormonal functions that may affect bladder or sexual function in women. Those pathways are not as well established. Not much research funding has emphasized female sexual dysfunction, and it remains a gap.

Importantly, none of our treatments are really directed toward diabetes-associated complications. The mechanisms in diabetes may be different, and the medications needed may be different. We need to generate new knowledge about that, and advances in technology and analyses will help. For example, we’re going to be using advanced RNA sequencing to try to identify new mechanisms that cause diabetes-associated urinary symptoms. That could lead to potentially new therapies.

We’re really fortunate that NIDDK is devoted to understanding the causes and complications of diabetes so that we can try to advance the field slowly but surely, and it’s going to benefit patients and their families. Diabetes research is the most important work I do, because it has the potential to affect so many people.

What approach do you take in addressing urologic problems with your patients with diabetes? Tell us below in the comments.