#94974: Sexual Dysfunction in Patients with Diabetes

Diabetes, known clinically as diabetes mellitus, is a progressive disease process affecting the fuel metabolism functioning within the body [2]. According to the American Diabetes Association (ADA), the prevalence of diabetes has increased eightfold since 1958, with the sharpest increase occurring in the 2000s [3]. As of 2023, 11.6% of the U.S. population, or 38.4 million Americans, had diabetes [4]. Unfortunately, 8.7 million of these individuals were unaware of their diabetes diagnosis [4]. Diabetes has been considered epidemic since the 1970s, and the percentage of Americans expected to have diabetes or prediabetes is estimated to reach 15.5% and 30%, respectively, by the year 2030 [5]. Genetics, race, age, and lifestyle significantly influence the onset and progression of diabetes [7]. The scope of the problem is vast and diverse.

Although people of all races and ethnicities develop the disease, the prevalence is slightly greater among Black, Puerto Rican, and Native American/Alaska Native people [4,8,9,10]. The incidence of diagnosed diabetes is estimated to be 12.7% among non-Hispanic Black Americans, 18 years of age and older, compared with the overall U.S. rate of 11.3%. The prevalence of diabetes among persons of Hispanic descent who are 18 years of age or older is 11.1% [4]. Among the subdivisions of Hispanic groups, diabetes prevalence rates are 13.3% for Puerto Ricans, 11.1% for Mexicans or Mexican Americans, 9.0% for Cubans, and from 5.0% to 7.3% for Central American, South American, and other Hispanic, Latino, or Spanish adults. However, Native Americans/Alaska Natives present the greatest risk for the development of type 2 diabetes; their risk is nearly three times greater than that of White Americans [10]. Approximately 13.6% of Native Americans/Alaska Natives 18 years of age and older have type 2 diabetes [4].

Despite the higher prevalence in certain racial or ethnic groups, diabetes is everywhere in America. The most rapid increase in diabetes prevalence in the last decade has been among adolescents. Historically, children and adolescents with hyperglycemia have been diagnosed with type 1 diabetes, a result of the body being unable to produce adequate amounts of insulin. However, it is now estimated that as many as 46% of juvenile-onset cases of diabetes are type 2, although cases of both types have increased significantly since 2000 [12]. Furthermore, it has been predicted that children born in this millennium will have a one in three chance of developing diabetes in their lifetime; among high-risk groups, the estimate is as high as one in two [13].

As discussed, the most common types of diabetes are type 1 and type 2. However, gestational diabetes is also relatively common and is a source of significant morbidity and mortality. Gestational diabetes is first recognized in pregnancy, usually around the 24th week of gestation, and typically resolves after the birth of the child [3]. Other less common types of diabetes include [14,15]:

All adults older than 45 years of age should be screened for type 2 diabetes every three years or every three years if they have any risk factors [3]. In addition, individuals of any age who are at risk for or are suspect of having diabetes should be screened. Established risk factors for type 2 diabetes include [16]:

The diagnostic criteria for type 2 diabetes are fairly straightforward and are based on fasting plasma glucose, postprandial plasma glucose levels, or glycosylated hemoglobin (HbA1c) testing (Table 1). After a diagnosis of type 2 diabetes has been definitively made, education on self-care management is necessary in order to obtain euglycemia and prevent complications related to the detrimental effects of hyperglycemia [3]. It is estimated that as many as 90% of patients with type 2 diabetes will require oral medications to achieve adequate glucose control within five years of diagnosis [3]. When glucose levels cannot be adequately controlled with oral medications, the use of injectable medications is necessary. If elevated blood glucose levels are untreated and continue to rise, the result can be hyperosmolar hyperglycemic nonketotic syndrome (HHNS) and ultimately death [17].

Blood flow is directly related to driving pressure and inversely related to arteriolar resistance, which is dependent on the net effects of systemically circulating substances, such as catecholamines, angiotensin, and prostaglandins [23]. Vascular endothelial thickening and its consequences are most associated with chronic cardiovascular diseases such as coronary artery disease and peripheral vascular disease, the presence of which greatly increases the risk for myocardial infarction and stroke [1]. In patients with diabetes, atherosclerosis is often present, as evidenced by fatty streaking, intimal plaques, and calcification of vessels. Changes in platelet activity, with an increase in adhesiveness and tendency to aggregation, have been observed in patients with diabetes, although it is not clear whether this is a primary alteration as a consequence of diabetes or if it occurs secondary to occlusive arterial disease [24].

When the vasculature is weakened due to narrowing related to fatty streak formation or rupture, the result is ischemia. Ischemia is the reversible cellular injury that occurs when tissue demands for oxygen exceed the supply. The result is an imbalance in oxygen supply and demand that results in tissue hypoxia, decreased energy substrate, and the buildup of toxic metabolites. Ultimately, ischemia results in alteration in tissue function [23].

This process of weakening vasculature and alteration of tissue function can lead to obstruction of the genital arteries and consequent symptomatic sexual dysfunction in both men and women [1]. Diffuse atherosclerosis, a common finding in patients with diabetes, may affect the penile, clitoral, or vaginal vasculature in addition to the circulatory beds of the heart, brain, and lower extremities. There may be a discrete narrowing in the external iliac artery that diverts the blood supply from penile circulation [25].

In women, estrogen acts as a vasoprotector, which diminishes the effects of atherosclerotic disease on female sexuality in the childbearing years. However, as estrogen levels drop, often during perimenopause and menopause, arterial blood flow to the pelvis may be compromised. This is termed clitoral and vaginal vascular insufficiency syndrome and may cause delayed vaginal engorgement, diminished vaginal lubrication, pain or discomfort with intercourse, diminished vaginal sensation, diminished vaginal orgasm, and diminished clitoral sensation or orgasm [26,27]. There is some evidence that hormone replacement therapy in postmenopausal women increases clitoral blood flow, but this must be weighed against the possible risks associated with the therapy [28].

Although erectile dysfunction is associated with cardiovascular risk factors and atherosclerosis, it is not known whether the presence of erectile dysfunction is predictive of future cardiovascular events. In one study, all-cause deaths occurred in 11.3% of individuals who reported erectile dysfunction at baseline, but in only 5.6% of individuals who reported no or mild erectile dysfunction [29].

Individuals with diabetes (particularly type 2) tend to be overweight or obese, and this may be a confounding factor for patients experiencing sexual dysfunction. Vascular, endothelial, neurogenic, endocrine, and psychologic factors may all play a role [32]. Obesity and sexuality is a prevailing area of study for researchers, although many studies have been small in scale and focus primarily on the obese male with erectile dysfunction or obese women awaiting bariatric surgery. One study of 12,364 French men and women between 18 and 69 years of age revealed that obese men and women were at a greater risk of negative sexual outcomes than their nonobese counterparts [33]. The research uncovered the fact that obese women were 30% less likely to report a sexual partner in the previous 12 months than women of a healthy weight. Obese men were 70% less likely to report more than one partner in the same time period and greater than 2.6 times more likely to report erectile dysfunction than their nonobese counterparts [33]. However, the study did not determine the cause of sexual inactivity/dysfunction, and the actual etiology may be physical or psychologic (or both) in nature. When an individual views him/herself as visually unappealing, the emotion may be internalized and result in sexual avoidance, even when the individual is in a committed relationship [32].

Obesity is often the result of insulin resistance in diabetes and is associated with dyslipidemia and endothelial and smooth muscle dysfunction, each of which is associated with sexual dysfunction [34]. A strong inverse relationship has been identified between the incidence of metabolic syndrome and testosterone levels (total and unbound, or "free") as well as sex hormone-binding globulin levels. The association is strongest for the dyslipidemia and waist circumference components of metabolic syndrome when compared with elevated triglycerides, hypertension, or glucose intolerance [35]. As such, diminished levels of testosterone should also be considered, along with vascular and neuropathic etiologies, when evaluating erectile dysfunction in overweight patients with poorly controlled diabetes [32].

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.

The first step in addressing sexual dysfunction in most patients is to make changes in one's lifestyle, particularly for women, for whom pharmacologic and surgical options are limited. This includes obtaining adequate rest, engaging in effective stress management techniques, and regular exercise [38]. Regular physical activity is protective against the development of sexual problems in patients with diabetes [36,39]. Weight loss may also be helpful for some patients. In fact, obesity nearly doubles the risk of erectile dysfunction, and even modest improvement in weight may result in better sexual functioning [36]. Smoking is associated with an increase in the risk of erectile dysfunction, and given the implications of smoking for all patients, cessation should be encouraged.

Engaging in noncoital intimacy (e.g., sensate-focus exercises) and enhancing stimulation and eliminating routine, with the use of erotic materials, masturbation, and devices, may improve sexual response, particularly among women [40]. Some women have experienced success with pelvic floor muscle training (Kegel exercises), a process for strengthening the pubococcygeus and levator ani muscles [41]. With this training, the individual should alternate constriction and release of the muscles of the pelvic floor. These exercises should be done rapidly 10 to 20 times [31].

Steps should also be taken to decrease pain associated with intercourse by changing positions, ensuring full arousal, or practicing biofeedback [40]. Topical lubricants can improve the comfort of sex, especially for those experiencing vaginal dryness, and many over-the-counter products are available [32]. Lubricants add temporary moisture to vaginal tissue, allowing for easier penetration, but these products do not increase blood flow to the genitals and may not improve disorders of desire. Only water- or silicone-based (not oil-based) products should be utilized. Silicone-based lubricants are not absorbed by the skin, resulting in longer efficacy compared to water-based formulations. However, because these products are not absorbed, they must be washed completely off with soap and water following sexual activity [19].

Marriage counseling or sex therapy may be required for cases in which sexual dysfunction has been long standing in the relationship [7]. In severe cases, individuals have reported the absence of a sexual physical relationship with their significant other for more than 10 years. Truth, honesty, and openness are essential goals for therapy in order to initiate the healing process. Because the task may seem insurmountable to the couple, encouragement regarding the re-establishment of a healthy relationship will be fundamental [32].

Discussion of the issues related to sexual dysfunction can potentiate an already fragile state. Stress increases relationship friction and can worsen sexual dysfunction; therefore, management of stress is crucial [32]. Stress is subjective in nature, and a patients' self-described stress level should not be discounted. Members of the healthcare team have an important role assisting patients and their partners to modify their appraisals of typical and atypical stressors related to diabetes and complications associated with the disease process. Providing individuals with more effective coping strategies is often necessary [42].

When education and control of modifiable factors do not result in improvements or resolution, medical treatments will be required [32]. In general, pharmacotherapy is used for male sexual dysfunction, but research into drugs for female sexual dysfunction is ongoing. Prior to the initiation of any therapeutic option, the individual should be mandated to refrain from the use of alcohol and all forms of tobacco. The patient's current medications should also be assessed for the presence of medication that might contribute to sexual dysfunction [30]. If possible, these medications should be eliminated or replaced.

The National Institute for Health and Care Excellence recommends that clinicians consider a phosphodiesterase-5 inhibitor to treat problematic erectile dysfunction in men with type 2 diabetes, initially choosing the drug with the lowest acquisition cost and taking into account any contraindications.

(https://www.nice.org.uk/guidance/ng28 Last Accessed: March 22, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

The ability of a man to initiate and maintain an erection is dependent on the presence of nitric oxide and cyclic guanosine monophosphate. Phosphodiesterase-5 enzyme inhibitors used to address erectile dysfunction, including sildenafil, vardenafil, tadalafil, and avanafil, act by increasing nitric oxide and cyclic guanosine monophosphate levels, both of which may be diminished in men with diabetes [30]. These medications are absolutely contraindicated in individuals being treated with nitroglycerine or other nitrate-containing medications due to the potential for severe hypotension and fatal cardiac events [7].

Phosphodiesterase-5 enzyme inhibitors have also been studied for improvements in sexual arousal and functioning in women, although their use is off-label. One systematic review and meta-analysis found significant increases in adverse events with these agents compared with placebo, but concluded that they were a relatively safe and potentially effective treatment modality for female sexual dysfunction [43]. Additional research is necessary before they can be recommended [44].

Vacuum pump devices or constrictors are a viable alternative to medication therapy or medication failure. They are non-invasive, have few side effects, and are generally well tolerated [17]. To use, the vacuum tube is lubricated and placed over the penis, with a constriction band situated over the end. A battery- or hand-operated pump is initiated, and a vacuum is produced. Sitting back or lying down may improve the tightness of the seal. For patients with larger abdomens who are unable to visualize the pelvic area, assistance applying the pump may be necessary. When significant tumescence is produced, the band is moved to the base of the penis, the vacuum is released, and the cylinder is removed. The band can safely remain in place for 30 minutes. These devices do not produce a full erection, and the base will remain flaccid; however, sufficient rigidity is obtained for sexual activity in 80% to 90% of cases [25].

Thorough education regarding appropriate application and use of vacuum devices is essential for successful outcomes and prevention of injury. Patients should be encouraged to practice the application process to gain confidence and to use sufficient lubrication to avoid friction injury. It may be necessary for patients to remove hair from their pubic area in order to obtain the tightest seal possible.

The implantation of an inflatable penile prosthesis is a surgical option for the treatment of impotence in men who have not responded to first- or second-line therapies [17]. The prostheses are implanted by a urologist as a pair and are made primarily of a silicone polymer. The three main types of prostheses are malleable, inflatable, and mechanical [25]. The cost varies significantly based on the type of prosthesis selected.

After it is implanted, the individual or his significant other may inflate the prosthesis by pressing on the pump, which transfers fluid from the reservoir to the cylinders within the penis. The implant may be deflated after sexual activity by pressing on the deflation valve at the base of the device. This will cause the device to return the fluid from the implant to the reservoir [32].

Patients should be instructed to watch for signs and symptoms of infection and to alert their healthcare provider of any discharge or seepage from the tip of the penis. In addition, patients should be aware of potential signs of complications, such as mechanical failure, extrusion of the device, pain, and bruising. These discoveries should be communicated to a primary care provider without delay [25].

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.