SexualDysfunctionin the DiabeticPatient
with Hypertension
PAULA ZEMEL, PhD
The prevalence of diabetes mellitus and hyperten-
skn In the United States is increasing partly be-
cause of the lnckence of these diseases in the
growing gerfatrk populatkn. Diabetes and hyperten-
don have bean assoctated with sexual dysfunctkn
in both men and women. Neuropathy, vascular in-
suffkiency and psychokgkal problems have been
implicated in impotence, impaired ejaculation and
decreased libtdo in men and in decreased vaginal
lubrkatkn, orgasmic dysfunctkn and decreased li-
bkk in women. Several investigations of women
with diabetes suggest fewer reports of sexual dys-
function than have been reported by diabetic men.
T he prevalence of diabetes mellitus in the United
States is increasing partly because of the high inci-
dence of this disease in the geriatric population. Twen-
ty-four million Americans or 11% of the United States
population are at least age 65; this segment is growing
2% each year. l The estimated annual incidence of
diabetes per 100,000noninstitutionalized civilians old-
er than age 65 in the United States is 907. The preva-
lence of diabetes for this age group is 8,017/100,000 or
8% (6,918 for men and 8,886 for women]. Prevalence
in the black population older than age 65 is substan-
tially higher: 13,427 or 13.4% (11,781 for men and
14,546 for women). Thus, the increase in the elderly
population projected in the next 20 years indicates a
corresponding increase in the number of persons, es-
pecially blacks, with diabetes.2 Both aging and diabe-
tes are known to predispose persons to hypertension
[Table Q3
Aging and diabetes are also associated with report-
ed changes in sexual functioning.4s5 Decreased sexual
activity has been attributed to the aging process and
From the Division of Endocrinology and Hypertension, Wayne
State University, Detroit, Michigan.
Address for reprints: Paula Zemel, PhD, Division of Endocri-
nology and Hypertension, 4H-University Health Center, 4201
St. Antoine, Detroit, Michigan 48201.
27H
However, there have been few evaluations of sexu-
al dysfunction in women and no standard methods
for assessment. Antlhypertensive agents, especially
diuretks, sympathetk inhtbttors and &blocking
agents have been associated with sexual dysfunc-
tion due to autonomk and hormonal effects. An es-
timated 40 to 80% of diabetk hypertenstves have
reported sexual dysfunction in several hwestfgatkns.
Clearly, the diabetic hypertenstve patient shoukl be
evaluated for sexual dysfunction, and appropriate
therapy, including changes in medication or referral
for sex counseling, should become routine in clinical
care. (Am J Cardkl 1988;81:27H-33H)
accompanying social and physical changes, including
the development of diseases such as diabetes and hy-
pertension. Thus, the purpose of this review is to de-
scribe approaches to evaluating sexual dysfunction,
summarize information regarding sexual dysfunction
in diabetic men and women [especially the diabetic
patient with hypertension], and describe implications
for clinical care.
EvaluatingSexualActivity and Dysfunction
Studies by Kinsey and co-workers7J were among
the earliest investigations to examine the relation be-
tween age and sexuality. This is particularly relevant
because the incidences of both diabetes and hyperten-
sion increase with aging. 3.gThese studies indicated
that there was a general decline in sexual activity dur-
ing adulthood, with women reporting lower levels of
activity than men. Finkle et allo reported that 65% of
men 170 years indicated that they had engaged in
sexual activity in a l-year period. Freeman reported
that 55% of men (average age 71 years] were sexually
active.*l These studies all suggest that there is a gradu-
al decline in sexual activity over the course of adult-
hood, although some level persists in late adulthood.
These age-related losses, however, do not consider
the heterogeneity of the geriatric population. Rowe
and Kahn12 state that the effects of environment, dis-
ease and psychosocial factors may skew the associa-
28H A SYMPOSIUM: THE SALT-SENSITIVE HYPERTENSIVE PATIENT

TABLE I Percent of Diabetic and Nondiabetic Patients Reporting confound the interpretation of reported levels of sexu-
a Medical History of High Blood Pressure, Unlted States, 1976 al activity. The 60-year-old subject may have reported
to 1980 different information than the 30-year-old if he or she
Age (years) had been interviewed 30 years earlier.
Longitudinal studies are difficult to conduct and
Glucose Tolerance Status 20-74 20-44 45-54 55-64 65-74 are very costly, although they do allow the evaluation
Diagnosed diabetes 56.2 40.0 54.7 62.9
of the same cohort over time. George and Weiler13
62.9
Undiagnosed diabetes 50.0 31.2 51.4 50.2 58.9 measured sexual activity in a longitudinal study of 502
Impaired glucose tolerance 42.4 16.6 36.7 56.7 56.6 men and women aged 46 to 71. Levels of sexual inter-
Normal glucose tolerance 21.4 14.1 27.0 31.7 40.4 course were fairly stable within a given age group over
Ratio of diabetic patients 2.6 2.6 2.0 2.0 1.6 a 6-year period. Differences were found between age
to normal subjects
groups, with older participants reporting lower levels
* National Diabetes Data Group criteria applied to the results of a P-hour, of sexual activity over the entire period. Although 6
75-g oral glucose tolerance test. years is a relatively short time compared with the span
Reprinted with permission from Am J fvkt3 of sexual activity during ones life, the investigators
suggest that differences may be due to cohort differ-
ences. Thus, as younger adults age they may continue
to have higher levels of sexual activity than their el-
2.5
r ders of an earlier generation. Continued observation
I Moat Active
\\
91%
of these subjects, however, may show declines identi-
fied in other studies.
\
\ Intraindividual variation in sexual activity is im-
Moderately Active \ portant, as was emphasized in a study by Martin.14 A
\
\ \ total of 188 60- to %year-old men who had been mar-
\\,\ \
Least Active \ ried during the previous year participated in inter-
I 77% \
\ \ ,61%
views concerning their present and past levels of sexu-
\ 68% \\ - al activity. The frequency of activity declined when
,\ compared with recollections of past levels of sexual
\\ activity (Fig. 1). However, the decline was consistent
= I \\
with the level of activity before middle age. Masters
.\ and Johnson6 also reported that the best predictor of
\\
, ,29% the level of sexual activity in old age is the level of
\- activity in earlier years. Thus, levels of sexual activity,
\
\6% even though different measures of sexual activity may
I I H be used, seem to decline somewhat with aging. The
Ages 20-39 Ages 40-59 Last
degree to which the increased incidence of physiologic
variables associated with sexual function, such as dia-
FIGURE 1. The mean frequencies of sexual actlvlty recalled for
betes and hypertension, confound these age-related
ages 20 to 39 and 40 to 59 by respondents classlfled Into 3 levels of
changes is probably significant due to their prevalence
current sexual functlonlng. Percentages lndlcte how each mean
with aging; these variables are frequently not mea-
frequency compares to the mean rate of actlvlty malntalned over
sured in large studies on prevalence of sexual dys-
the previous 20-year period. (Reprinted with permlsslon from Arch
function.
Sex Behav.14)
Behavioral research in sexual activity usually con-
trols for relevant socioeconomic and psychological
variables, including age, marital status, economic sta-
tion of aging with disease and suggest that persons with tus, educational level and appropriate psychological
diseases be excluded to evaluate normal aging. measures. Other physiologic variables that can affect
Much research on sexual activity has used designs sexual activity, such as disease and use of various med-
and sampling procedures that make the generalization ications associated with sexual dysfunction, are fre-
of results difficult. Investigations frequently study quently not measured. However, medical research on
members of voluntary organizations or clients referred sexual activity usually includes measures of physiolog-
by other providers and do not use representative cross ic variables without statistically controlling for rele-
sections of defined populations.13 In addition, many vant socioeconomic and physiologic variables. Be-
studies are cross-sectional rather than longitudinal. cause most cases of sexual dysfunction are not solely
Cross-sectional studies can lead to confounding of age psychogenic or organic in nature, it is important for
and group membership variables. This is important in both aspects to be included when designing and con-
the evaluation of sexual functioning because each age ducting research in this area.
group at a specific point in time has had unique experi- The prevalence of sexual dysfunction varies with
ences that make interpretation of results more prob- research design, population surveyed and criteria for
lematic. For example, 30- and 60-year-old persons sexual dysfunction. Reports of sexual dysfunction
have matured with different sets of social mores range from 1.7 to 34% when various groups are evalu-
toward sex that may affect their behaviors and may ated for incidence of sexual dysfunction.15-17 This
 June 15. 1988 THE AMERICAN JOURNAL OF CARDIDLOGY Volume 61 2SH

range may be due to criteria for defining sexual dys- TABLE II Prevalence of Sexual Dystunctlon In Dlabetlc Men
function, cultural factors or other unmeasured physio- Prevalence
logic, socioeconomic or psychological factors associ- Author Year No. of Diabetics (%)
ated with sexual activity.
Rundles*s 1945 89 with neuropathy 28
Diabetesand SexualDysfunctionin Men Martin2B
Rubin*
1953
1958
70 with neuropathy
198
54
55
Although initially described in 1798,18little system- Monteneroz8 1962 436 36
atic study of erectile dysfunction in diabetic men was Schofflingz9 1963 314 53
performed before the 1950s.1gIn recent years, ad- PrikhozhamsO 1967 350 75
vances in the abilities to measure and treat impotence Ellenberg3 1971 200 59
Faerman32 1972 299 40
has led to evaluations of its prevalence and proposed Kolodny33 1974 175 49
etiologies in the diabetic population as well as height- Newbauers 1977 148 43
ened awareness by the medical community.20-24 McCulloch35 1980 541 35
Reports of the frequency of sexual dysfunction in Jense@ 1981 80 44
Lipson3 1984 260 53
diabetic men ranges from 27.5 to 75% in various stud- McCulloch3s 1984 466 28
ies (Table II).25-37The same problems exist when eval-
uating research on the prevalence of sexual dysfunc- Adapted with permission from Mt Sinai J Med.
tion and sexual activity in nondiabetic patients, since
few case-controlled or longitudinal studies have been
performed.
The normal healthy erectile process is dependent
on many factors, including: (1) normal functioning of cation and impotence. 19Abnormal penile blood pres-
the hypothalamous-pituitary-gonadal axis, (2) intact sure and blood flow have been demonstrated,3gr40
penile blood flow, and (3) appropriate neurologic although no differences were shown between diabet-
function. Stimuli originating or perceived by the cere- ics with and without impotence.41
bral cortex are transmitted to the limbic system and Endocrine evaluations have not produced consis-
then to the thoracolumbar (T12 to L2) sympathetic tent abnormalities among diabetic patients with sexual
tract. The sympathetic nerves then seem to facilitate dysfunction and have demonstrated normal levels of
erection through involvement in muscle contractions serum testosterone, testosterone-estradiol-binding
during emission and ejaculation. Tactile genital stimu- globulin, free testosterone, luteinizing hormone, folli-
li initiate a spinal reflex arch with the afferent limb cle-stimulating hormone and prolactin.lg
located within the pudendal nerves, which stimulates Psychological evaluations have yielded conflicting
the sacral parasympathetic nerves (S2 to 54) resulting results as to the psychogenic factor in diabetic sexual
in dilatation of the arteriolar vessels that supply the dysfunction. Differing methods make comparisons
corpora cavernosa and spongiosum. Contraction of the among studies difficult. Approximately 9% of 497 men
ischiocavernosa muscle leads to compression of the with erectile dysfunction were identified as having a
veins draining the corpora cavernosa and spongiosum, psychogenic pattern of impotence, based on psychiat-
and with the increased blood supply, results in disten- ric evaluation and studies of nocturnal penile tumes-
tion, engorgement and rigidity of the penis.19 cence.42 Thirty-two percent of the total group had
Sexual dysfunction in the diabetic patient may re- abnormal glucose tolerance. In a study of diabetic cou-
sult from neurologic dysfunction of the pelvic auto- ples, the diabetic partner more frequently portrayed
nomic nervous system, vascular insufficiency, psycho- increased fear, anxiety, tiredness, and problems with
logical problems, medications used to treat hyperten- daily life than the nondiabetic spouse in response to a
sion (prevalent among diabetics), or a combination of questionnaire.43 No relation between impotent and
these causes. nonimpotent diabetic men was identified by psychiat-
Diabetic neuropathy may be implicated in the ric assessment.44Buvat,41on the other hand, compared
pathophysiology of sexual dysfunction due to the fact impotent and nonimpotent diabetic responses to Min-
that potency depends on the integrity of the autonomic nesota Multiphasic Personality Inventory evaluations
nervous system and that an association has been found and responses to interviews; 60% of the impotent dia-
between impotence and the incipient, asymptomatic betics had abnormal scores. Scores were normal in all
neurogenic bladder. 31,3gA survey of 200 diabetic men nonimpotent diabetics. The most frequent disturbed
showed 59% to be impotent: of these, 82% had neurop- scores were depression and psychasthenia. Interviews
athy. Neuropathic symptoms were also shown to be also indicated that psychogenically impotent men had
correlated with reported sexual dysfunction in a group more performance anxiety and self-depreciation than
of Type I diabetics but not their age-matched con- other subjects. Clearly, more systematic evaluation of
trols35 as well as in a prospective study of 466 diabet- the role of psychogenic factors in the etiology of sexual
ics.38Histologic abnormalities of autonomic nerve fi- dysfunction is needed.
bers have also been demonstrated in the corpora The diabetic who is also hypertensive has an even
cavernosa of diabetics.32 greater likelihood of sexual dysfunction than the dia-
Vascular insufficiency may cause sexual dysfunc- betic without hypertension.36 This is particularly true
tion in diabetics because macrovascular disease in- for the hypertensive diabetic patient taking antihyper-
volving the bifurcation of the aorta may lead to claudi- tensive medications.
30H A SYMPOSIUM: THE SALT-SENSITIVE HYPERTENSIVE PATIENT
TABLE Ill Sexual Dysfunctton In Diabetic Women
Sexual Dysfunction
Diabetics
Author Year Study Characteristics
Kolodny5 1971 125 diabetics (L
100 nondiabetic controls
Ellenberga 1977 54 diabetics with neuropathy,
46 without neuropathy
Jensen36 1981 80 diabetics 8 40 controls,
25 diabetics with neuropathy
& 55 wlthout neuropathy
Tyrer@ 1983 82 type 1 diabetics 8
47 controls,
intercourse less than l/month
anorgasmic,
14 diabetics with neuropathy
8 50 without neuropathy
Johnsonso 1984 57 black & Mexican-American
diabetics
Screiner- 1987 55 diabetics & 65 controls
Type l-anorgasmlc.
Engels
-insufficient lubrication:
Type P-anorgasmic
-insufficient lubrication
Controls = diabetics without neuropathy.
l
1 I I I
5 10 15
Duration of Diabetes (Years)
FIGURE 2. Relation of duration of diabetes mellltus to lncldence of
sexual dysfunction In 125 female dlabetlcs between the ages of 18
and 42. (Reprlnted with permlsslon from Dlabetes.6)
SexualDysfunctionin DiabeticWomen
Although sexual dysfunction among diabetic men
has been evaluated, little work has been done on sexu-
al dysfunction in diabetic women. This may be part of
a more general tendency to ignore the sexual implica-
tions of physical illness in women.45 Evaluations of
sexual dysfunction in diabetic women have focused
primarily on organic causes, although several studies
evaluate psychogenic causes.
In female sexual response, vasodilatory changes in-
clude myotonia, skin flush, increased blood pressure
and vasodilation of the vagina, labia minora and clito-
ris. Lubrication occurs with secretions from Bartholins
and Skenes glands. During orgasm, contractions of the
pelvic and perineal muscles occur, followed by rever-
sal of vasocongestion, myotonia, skin flush and elevat-
ed blood pressure. 46Extrapolations from data on stud-
Controls ies in men suggest that the lubrication and vasodilation
W) (%) phases are analogous to male erection.
35 6
Early research hypothesized that diabetic women
had increased incidence of sexual dysfunction due to a
13 12' host of factors, including neuropathy, susceptibility to
infection, microvascular changes and the chronic@ of
28 25 and attendant psychosocial adaptation to diabetes5
44 20'
The prevalence of sexual dysfunction in diabetic
5 4 women is summarized in Table III. These studies used
different populations and control groups and focused
17 12 on various hypotheses. Different measures of sexual
21 12'
dysfunction also make comparisons between studies
difficult. Because little research has been conducted in
53 ... this area, currently published studies will be briefly
reviewed.
15 2
In the 197Os,2 preliminary studies were published
10 5 which explored sexual dysfunction in diabetic wom-
32 4 en. Kolodny5 interviewed 125 diabetic and 100 non-
29 9 diabetic sexually active women about their sexual ac-
tivities. The groups were similar with respect to socio-
economic and demographic variables and there were
no differences in age at menarche, incidence of dys-
menorrhea, parity, frequency of coital activity, sexual
interest by self-estimation and history of psychiatric
care. There was a significant difference in the inci-
dence of sexual dysfunction between the 2 groups.
Thirty-five percent of the diabetic women reported
complete absence of orgasmic response during the
year preceding inquiry compared with 6% of nondia-
betic women. In addition, 91% of the nonorgasmic
diabetic women had been orgasmic in the past; orgas-
mic difficulties developed gradually over a 6.month to
l-year period, and in all cases followed the onset of
diabetes. Figure 2 shows the relation between the du-
ration of diabetes and the percentage of patients with
orgasmic dysfunction, although no correlation coeffi-
cient was given for this curve.
I
20 In contrast, Ellenberg conducted an evaluation of
sexual dysfunction in 54 women with diabetes who
had clinically demonstrable neuropathy as demon-
strated by absent deep tendon reflexes and sensory
impairment involving the feet and toes. Forty-six dia-
betic women without neuropathy served as controls
and were matched for age and duration of diabetes.
There was no significant difference between these
groups. Decreased libido or orgasm, or both, were re-
ported by 13% of those with neuropathy and 12% of
those without neuropathy.
The differences between these 2 reports may be, in
part, due to differing methods for eliciting responses
regarding sexual activity. Ellenberg reported that sub-
jects were questioned as to their interest in sex and
presence or absence of orgasmic reaction. Kolodnys
study used a history format based on a method de-
scribed by Masters and Johnson.6 The Kolodny study
also described the experimental and control groups on
a wide range of variables, whereas Ellenberg only
classified his groups by age, duration of diabetes and
presence or absence of neuropathy; he did not include
a nondiabetic control group.

TABLE IV Sexual Dyetunctlon Due to Antihypertensive
Decreased
Impotence Libido
Thiazide + +
diuretics
lndapamide + +
Furosemide,
ethacrynic
acid
Spironolactone
p blockers
Methyldopa
Clonidine
Guanabenz
Reserpine
Prazosin
Hydralazine
Guanethidine
Guanadrel
Minoxidil
Captopril
t = yes; - = no.
Reprinted with permission from Drug Intel1 Clin Pharm 1984;18:113-121.
In the 198Os, several studies contributed additional
data concerning sexual dysfunction among diabetic
women. Jensen35evaluated sexual dysfunction in 80
diabetic women receiving insulin and 40 age-matched
women without diabetes. A questionnaire and inter-
view found that 27.5% of diabetic women and 25% of
controls reported sexual dysfunctions. When diabetic
women were evaluated by presence or absence of pe-
ripheral neuropathy, 44% of women with neuropathy
experienced sexual dysfunction compared with 20%
without neuropathy.
Tyrer and co-workers48 compared sexual respon-
siveness in 82 Type 1 diabetic women with 47 controls.
There was no significant difference in the reported
incidence of infrequent intercourse (5% for diabetics
and 4% for controls). Diabetic women are also more
likely to report extremes in vaginal lubrication and
infrequent sexual interest than controls. Diabetics
with neuropathy reported less arousal during sexual
activity, although the difference was not significant.
Other reports of sexual dysfunction among women in-
clude reports of decreases in arousal, vaginal lubrica-
tion, vaginal and clitoral sensation and orgasm.49
The impact of diabetes type on sexuality in women
was evaluated by Schreiner-Engel et a1.50A significant
difference in lubrication and frequency of orgasm was
observed in Type 2 diabetics when compared with
controls, a difference not seen in Type 1 subjects. Psy-
chogenic factors were also measured and suggest that
diabetes type may be associated with sexual respon-
siveness and marital satisfaction, with lower levels of
these constructs associated with Type 2 diabetes.
There is a paucity of information regarding sexual
dysfunction in women with diabetes and hyperten-
sion.
The incidence of sexual dysfunction among dia-
betic men and women differs widely and has been
attributed to psychogenic factors that may affect fe-
male sexual responsiveness. Because the female dia-
June 15, 1988 THE AMERICAN JOURNAL OF CARDIOLOGY Volume 61 31H
Agents
impaired Decreased Vaginal
Ejaculations Gynecomastia Lubrication Priapism
t
-
-
+
t
- -
-
-
betic should be at equal risk for developing neuropa-
thy, it has been assumed that there is an equal effect of
diabetes on female sexual activityv4 Results of studies
conducted to date do not support this hypothesis. The
differences reported in these studies suggest an associ-
ation with sexual dysfunction, primarily reported as
decreased libido and problems with lubrication, dura-
tion of diabetes and with presence of neuropathy.
More research that uses well-planned designs, focuses
on multifactorial approaches, and develops and uses
measures of sexual dysfunction that can be compared
are needed to understand the organic and psychogenic
components of sexual dysfunction in diabetic women.
Hypertensionand SexualDysfunction
AmongDiabetics
Antihypertensive agents have been associated with
sexual dysfunction because of their effects on the auto-
nomic nervous and hormonal systems.51-53There is
some evidence that hypertension itself may also be
associated with sexual dysfunction. Bulpitt et aF4 eval-
uated control, treated and untreated hypertensive
men; 25, 17 and 7% of these subjects reported impo-
tence, respectively. Although the percentage of un-
treated hypertensives reporting impotence is not sig-
nificantly different from the control group, it does
suggest an independent contribution of hypertension
to sexual dysfunction.
Types of sexual dysfunction noted include de-
creased libido, decreased vaginal lubrication, delayed
orgasm or anaorgasmia, gynecomastia, impotence, pri-
apism, and retarded and retrograde ejaculation.55 The
associations between various antihypertensive agents
and sexual dysfunction are listed in Table IV. In gen-
eral, diuretics, sympathetic inhibitors and /3-adrener-
gic blocking agents have been associated with sexual
dysfunction, particularly impotence, decreased libido
and impaired ejaculation. Vasodilators, angiotensin-
converting enzyme inhibitors and calcium channel
32H A SYMPOSIUM: THE SALT-SENSITIVE HYPERTENSIVE PATIENT

TABLE V Other Drugs Reported to Cause Sexual Dysfunction

Drug Manifestation

/ \ \- Ath;ro&otic c \
Antidepressant agents Decreased libido,
(trlcyclics and MAO inhibitors) impotence,
impaired ejaculation,
delayed orgasm in females
Antipsychotics Decreased libido,
impotence,
impaired ejaculation,
decreased orgasm in females
Alcohol Decreased libido,
Impaired ejaculation,
decreased vaginal lubrication Sexual Dvsfunction
Antichollnergics Impotence
Antineoplastlcs Impotence
Benzodlazepines Decreased libido M&l m
Cimetidine Impotence, Ejaculatory Decreased Vaginal
Dysfunction Lubricabon
gynecomastla.
Decreased Libido Decreased Libido
decreased libido Impotence Orgasmic Dysfunction
Disopyramlde Decreased libido,
impotence FIGURE 3. Disruptive Influences In sexual dysfunction In dlabeilc
Disulflram Decreased libido,
and hypertensive patlents.
impotence
Lithium Impotence
Narcotic analgesics Decreased libido,
Impotence.
impaired ejaculation, Mexican-American, and white men and women in a
decreased vaginal lubrication
Decreased libido.
diabetic clinic population is shown in Table VI.
Steroids
impotence In an evaluation of male diabetics receiving meth-
yldopa or clonidine in addition to hydrochlorothiazide
Reprinted with permisslon from Drug Intel1 Clin Pharm.5g as second-step therapy for hypertension, 75% of male
patients taking methyldopa were found to have sexual
dysfunction, including 90% of the black male pa-
tients.j2 Sexual dysfunction averaged 40% among 77
TABLE VI Hypertension and Sexual Dysfuncllon In Dlabetlcs diabetic hypertensive men.63
Also, another evaluation of 57 diabetic minority
% with % with Sexual
Hypertension Dysfunction
women indicated that 73% of black and 80% of Mexi-
can-American women who had hypertension also had
(;roup Men Women Men Women sexual dysfunction .60Sexual dysfunction, then, is dis-
proportionate among hypertensive diabetics, especial-
Black 63 63 60 50
Mexican-American 34 15 45 55
ly blacks. There is a great need for research on the
White 36 ... 66 contributions of diabetes, hypertension and aging to
Total 47 35 53 53 changes in sexual activity.
Reprinted with permisslon from Arch Int Med.Br Implicationsfor ClinicalCare
There are a number of factors that can potentially
disrupt sexual activity in the diabetic with hyperten-
sion. These include medications, atherosclerotic dis-
blockers have been associated with few reports of sex- ease, autonomic neuropathy, psychologic factors and
ual dysfunction.56-5g aging (Fig. 3). Evaluation of these factors, possible en-
Although few of these agents are associated with docrine, urologic or neurologic disorders and alcohol
decreased vaginal lubrication, there is little research or other drug use during a review of systems can help
relating antihypertensive agents to sexual dysfunction identify other causes of sexual dysfunction.
in women. These studies focused primarily on men Furthermore, assessment of individual levels of
and frequently did not consider concomitant use of sexual activity can establish a baseline for evaluating
medications known to affect sexual dysfunction or the changes that may occur during the course of diabetes
presence of other diseases (Table V). or hypertension. If the inclusion of sexual topics is a
Because hypertension is 2 to 3 times more prevalent routine part of health care, a healthy attitude is com-
in diabetic than in nondiabetic persons, the sexual municated to the patient. A recent survey suggested
dysfunction attributed to diabetes may be compound- that male physicians generally attend more to the sex-
ed by hypertension and medications used for its treat- ual functioning of male diabetic patients than to that of
ment.60*61The increased prevalence of both diabetes female diabetic patients. 23Also, men were viewed as
and hypertension in black men and women also in- being more troubled than women by sexual dysfunc-
crease their likelihood of having sexual dysfunction. tion and were more likely to be referred for further
The prevalence of diabetes and hypertension in black, evaluation or treatment.
 June
If sexual dysfunction is not improved by changes in
treatment or further evaluation and underlying causes
appear to be psychogenic, counseling with a sex thera-
pist may be helpful.
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