Patient T is large man, 44 years of age, who is admitted to the emergency department with complaints of nausea, vomiting, and excessive urination. He and his wife had been out riding their motorcycles over the past weekend and eating a high-fat diet, as they do most weekends. They decided to come to the emergency department suspecting food poisoning. He is a White male with seasonal allergies and hypertension, but no other significant medical history. His surgical history is positive for an appendectomy at 15 years of age without complications. His family history is positive for type 2 diabetes, coronary artery disease, cerebrovascular accident, hyperlipidemia, hypertension, and obesity. Upon physical assessment, Patient T is alert and oriented. His height is 5 feet 10 inches; weight 239 pounds without shoes; BMI 34.4 kg/m²; blood pressure 146/82 mm Hg on medications; pulse 83 beats per minute, regular rate and rhythm; and oral temperature 37 degrees Celsius. His lungs are clear to auscultation, and heart sounds are clear, without rubs or murmurs auscultated. The abdomen is soft and nontender in all quadrants. Peripheral pulses are present at +2 at all extremities. Patient T's feet are free from lesions, with a positive Babinski reflex, and all extremities are warm to touch and responsive to monofilament test. Laboratory results include:

The patient reports that the only medications he is currently taking are over-the-counter cetirizine (Zyrtec) and chlorthalidone 25 mg/day for hypertension.

The emergency physician diagnoses Patient T with new-onset type 2 diabetes and refers him to the inpatient diabetes educator for survival skills education. He is discharged on metformin 1000 mg twice daily and blood glucose monitoring twice a day for the next month. In addition, Patient T is instructed to follow-up with his primary care provider within the next 72 hours for further diabetes evaluation.

The certified diabetes educator meets with the patient and his wife to provide information on metformin, a biguanide. Education focuses on the drug's mechanism of action, lifestyle modification (especially diet), and recognition and treatment of hyperglycemia.

Patient T is provided with a blood glucose monitor and instructed on the frequency, use, and importance to the management of diabetes. He is informed of the discharge order to monitor his glucose levels twice daily. The diabetes educator encourages him to alternate the times of his monitoring to obtain the greatest amount of information to guide management decisions. Patient T and his wife ask many questions and are able to verbalize the instructions given.

At the conclusion of the visit, Patient T's wife timidly asks if there are any other things diabetes could affect. The educator begins to list the many possible chronic complications, but the wife stops her and states that the patient has recently had problems performing. Patient T, mortified, states he is fine, but his wife disagrees, stating she loves him and wants their physical relationship back. When asked how long the problem had been occurring, the patient states that the problems began in the last month. The educator provides information regarding the impact of stress, elevated glucose levels, diet, and obesity on erectile function.

As a first step, the educator encourages Patient T to obtain better glycemic control, improve his diet, and manage any stress he may be experiencing. Because these are all modifiable conditions, they should be addressed first and may resolve the sexual dysfunction. If the condition remains a persistent issue, the patient is instructed to discuss further options (e.g., medication) with his primary care provider. Patient T and his wife are agreeable to this plan and appear more comfortable and relaxed.

Patient K is an active White man, 75 years of age, presenting to his physician's office for his three-month diabetes evaluation. He has a positive history of diabetes for the past 20 years, and a 28-year history of hypertension and hypercholesterolemia. Past surgical history is positive for bilateral knee replacement 10 years ago, two angioplasties with stents within the past five years, and non-emergent coronary artery bypass surgery two years ago. He continues to smoke despite multiple attempts to stop and strong advisement by all providers involved in his care.

Currently, his blood pressure is 152/84 mm Hg, and his pulse is 78 beats per minute, regular rate and rhythm. He is 5 feet 10 inches tall and weighs 252 pounds. Laboratory analysis reveals the following results:

The patient's current medications include:

Patient K's wife of 46 years, Mrs. K, accompanies him to the visit. While reviewing the results of the patient's laboratory tests and blood glucose results, Dr. G detects tension between the patient and his wife. When his wife attempts to ask a question regarding Patient K's blood glucose levels, he snaps at her to leave him alone and stop nagging. Mrs. K leaves the office in tears. Patient K apologizes to Dr. G for the outburst and states that he has not been sleeping well. When asked how often this was happening, Patient K states only a few times a month.

Over the next 18 months, Patient K and his wife continue to attend his scheduled appoints without fail. The tension in the couple's relationship continues, but Dr. G feels that he should not pry. However, at the next visit Dr. G notes that Patient K is more withdrawn than usual and is avoiding all eye contact with Mrs. K as she sits on a stool in the corner of the room rather than in the seat next to the patient, as she usually does. Furthermore, Mrs. K is not engaging in any of the comforting gestures he has come to expect from her (e.g., rubbing Patient K's back and hand).

Dr. G reviews Patient K's medical record and notes a weight gain of 20 pounds and an increase in his HbA1c (from 8.0% to 9.2%). Even more tension and perceived friction is evident between the patient and his wife. When Dr. G asks about Patient K's activities, the only response is a shrug from the patient's shoulders and a roll of the eyes from Mrs. K. Dr. G can no longer ignore these behaviors. He has known the couple for more than 20 years and has noted a dramatic change just in the last two years. He closes Patient K's chart and tells the couple what he has been witnessing.

Both the patient and his wife begin to cry. Patient K states that it is a personal problem they are handling, and he is uncomfortable talking about it. Dr. G asks Mrs. K to have a seat in the waiting room. After the wife has left the room, Dr. G asks for details, reassuring Patient K that everything they discuss will be confidential and that he will not be judged. Eventually, Patient K confides that he has been a poor husband and does not know how to make his wife happy. Dr. G asks if either of them is seeing other people. Patient K responds that he is not, and while he does not think Mrs. K is, he would not blame her if she was. He also states that he is not "a real man." Dr. G presses the patient regarding what has made him feel this way. After several moments, Patient K admits that he has been unable to achieve an erection for the last 20 months, despite a previously healthy sex life and continuing to find his wife attractive.

Dr. G assures the patient that many men experience erectile dysfunction and that, with treatment, he should be able to experience a healthy sex life with his wife once again. Dr. G and Patient K discuss the many treatment options available, addressing benefits and potential drawbacks of each. In addition, Dr. G emphasizes the importance of lifestyle changes in improving sexual functioning, encouraging the patient once again to quit smoking and lose weight. These changes may also help control Patient K's HbA1c, which has been rising despite treatment. If his level remains high, insulin therapy may be considered. Due to Patient K's reluctance to add another medication to his regimen, he decides to try a vacuum pump device. The patient and his wife meet with an educator for information regarding safe application of the device and conditions requiring healthcare provider notification. Although the couple is initially timid and appears embarrassed, the educator puts them at ease and the education session progresses. Patient and Mrs. K are encouraged to go home and practice.

After six months, Patient K returns to Dr. G's office with his wife. Unfortunately, even with significant practice, the couple remains unable to achieve a fulfilling sex life. Dr. G assesses the patient's testosterone level to determine if this is a contributing factor. The result is 205 pg/mL (normal range: 44–244 pg/mL), effectively ruling out a hormonal etiology. Although the vacuum pump device allows for a functional sexual relationship, they miss the spontaneity they once enjoyed. As a result, Patient K expresses interest in investigating the available pharmacologic options.

Following an in-depth discussion of each agent, Patient K ultimately decides to utilize sildenafil. Dr. G provides the couple with education regarding the drug interactions and possible adverse effects, taking time to answer any questions and to emphasize the continued importance of lifestyle interventions. At the end of the visit, Patient K and his wife feel comfortable with the new arrangement and commit to calling if any further questions arise or if adverse effects are experienced.

In six months, Patient K returns to his primary care provider for follow-up. When Dr. G enters the examination room, he is met by a more confident appearing patient. He is calm, at ease, and sitting with a relaxed smile on his face. Patient K tells Dr. G that his relationship with Mrs. K is improving, and they have been able to engage in sexual activity regularly. In addition, Patient K has lost 25 pounds and has cut back on his smoking. His HbA1c level is normal on medications, and he seems very happy.

Patient N is a postmenopausal Latina woman, 59 years of age. She has a history of depression (2 years), fibromyalgia (11 years), diabetes (12 years), hypertension (3 years), osteoarthritis (6 years), and hypercholesterolemia (6 years). She has two adult children, both born by cesarean delivery. Her past surgical history is positive for bilateral knee replacement (nine years ago), cholecystectomy (20 years ago), and appendectomy (47 years ago). She has a family history of diabetes, cardiovascular disease, hypertension, stroke, and prostate and breast cancer.

Patient N uses alcohol (beer, wine, and liquor) occasionally and socially, consuming approximately three drinks per week or less. She has no history of tobacco use. Her diet consists primarily of convenience foods due to a lack of desire to cook and availability of the items. She has gained 20 pounds over the past year, and she denies engaging in any form of exercise.

At her routine gynecologic visit, Patient N is free of initial complaints. Although she has a strong professional relationship with her gynecologist, Patient N presents with a flat affect and withdrawn behavior. Dr. J questions the patient regarding her disposition, but she dismisses the behavior as "nothing." Dr. J continues to pursue the cause of the mood change and inquires regarding Patient N's relationship with her husband of 37 years. Patient N begins crying and states that she has been separated from her husband for the past five months, a fact that is all her own fault.

Dr. J comforts Patient N and asks her to describe what happened. At first, the patient is reluctant to discuss the problems, but Dr. J reassures Patient N that many couples experience problems and it is nothing to be ashamed of. He lets the patient know that he would like to help her. While continuing crying, Patient N claims she is no longer desirable to her husband. She admits to a noticeable change in her attitude toward sexual intimacy, pain with intercourse, and vaginal dryness, all of which have occurred gradually over the past six years. Patient N states that she still loves her husband and finds him attractive, but no longer knows how to demonstrate that love.

Dr. J assures the patient that this is a common complaint for many women, especially those who are postmenopausal and/or diabetic. Dr. J tells Patient N that when women progress through menopause, their estrogen levels decrease, and estrogen plays an important role in sexual health and desire in women. Furthermore, Dr. J educates the patient regarding the neuropathic aspect of diabetes and sexual function.

Initially, Dr. J advises Patient N to exercise and adopt a healthier diet to promote better glycemic management and weight loss. Patient N agrees to try this approach and to contact her primary care provider for assistance. Dr. J also encourages her to inquire about possible adjustment of her depression medication during this period in her life, which the patient also agrees to.

Patient N feels encouraged to talk with her husband regarding their situation and determine if the relationship was something they wanted to salvage or dissolve. Although she believes she already knows the answer and is confident to take the first step, she is unsure of what to say. Dr. J encourages the patient to engage in a frank conversation regarding what she is going through and determine if her husband is willing to attend counseling.

Patient N returns for a follow-up visit in six months, and Dr. J notes a slightly brighter affect to the patient's demeanor. Dr. J evaluates Patient N's progress and finds that she and her husband are meeting with a therapist to attempt to overcome their issues. During therapy, Mr. N stated that he felt responsible for Patient N's lack of sexual desire. Although Patient N and her husband have started to work past some of their issues, pain with intercourse and persistent vaginal dryness continue to be problems. Dr. J suggests utilizing an over-the-counter, silicone- or water-based lubricant. He cautions the couple to avoid oil-based products and to be cautious with application due to the potential risk for falls. Enhancing the sensual experience (through erotic massage or viewing erotic materials) is also suggested.

Patient N continues to follow-up with Dr. J for the next six months and reports progression in her sexual relationship with her husband. She states that while things are not perfect, she and her husband are committed to finding their optimal comfort level with each other.