La tarea educativa

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comparisons with analogous measures from the Derogatis Interview for Sexual Functioning (DISF). It has been validated in English and Spanish and is rated based on available evidence as Grade B and Level 3 evidence.

Golombok Rust Inventory of Sexual Satisfaction (GRISS) ¹³⁹

The GRISS was developed by Rust and Golombok. It is a 56-item questionnaire (28 items for women and 28 items for men) self-report instrument, designed to assess the existence and severity of sexual problems in the context of sexually active individuals and heterosexual couples. Internal consistency of the subscales was acceptably high and ranged from 0.61 to 0.83.

It is rated based on available evidence as Grade B and Level 3 evidence.

2.8 MANAGEMENT OF SEXUAL DYSFUNCTION IN TYPE 2 DIABETES

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Masturbation before anticipation of sexual intercourse is a technique used by many younger men with premature ejaculation. Following masturbation, the penis is desensitized resulting in greater ejaculatory delay after the refractory period is over.⁶²

Clinical experience suggests that improvements achieved with these techniques are generally not maintained in the long term.

Pharmacotherapy

Phosphodiesterase Type 5 Inhibitors (PDE5 inhibitors):

PDE5 hydrolyses cGMP in the cavernosum tissue. Inhibition of PDE5 results in smooth muscle relaxation with increased arterial blood flow, leading to compression of the subtunical venous plexus and penile erection. Three potent selective PDE5Is have been approved by the European Medicines Agency (EMA) for the treatment of erectile dysfunction. They are not initiators of erection and require sexual stimulation to facilitate an erection. They may reduce performance anxiety due to better erections and may down-regulate the erectile threshold to a lower level of arousal so that greater arousal is required to achieve the ejaculation threshold. ⁶²

Sildenafil was launched in 1998 and was the first PDE5I available in the market. It is effective from 30-60 minutes after administration. Its efficacy is reduced after a heavy, fatty meal due to prolonged absorption. The recommended starting dose is 50 mg and should be adapted according to the patient’s response and side effects. Efficacy may be maintained for up to 12 hours. The other PGE5I are Tadalafil and Vardenafil. Choice of drug will depend on the frequency of intercourse and the patient’s personal experience.⁶² The side effects common among them are headache, flushing, dyspepsia nasal congestion , dizziness and abnormal vision.

Topical anaesthetic agents:

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The use of topical anaesthetic desensitizing agents reduces the sensitivity of the glans penis so delaying ejaculatory latency, but without adversely affecting the sensation of ejaculation. In a randomized, double-blind, placebo-controlled trial, lidocaine -prilocaine cream increased the IELT from 1 minute in the placebo group to 6.7 minutes in the treatment group.¹⁴⁹

Selective Serotonin Reuptake Inhibitors (SSRI):

Ejaculation is mediated by a spinal ejaculation generator and by descending supraspinal modulation from several brain regions. The neurotransmitter 5-hydroxytryptamine (5-HT, serotonin) is also involved in ejaculatory control. As in depression, SSRIs must be given for 1 to 2 weeks to be effective in premature ejaculation. SSRIs were expected to increase the geometric mean IELT by 2.6-fold to 13.2-fold. Dapoxetine is currently the first and only drug approved for premature ejaculation. Other commonly used SSRIs include citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline, all of which have a similar pharmacological mechanism of action.⁶²

Intracavernous injections of Alprostadil:

Intracavernous Alprostadil is most efficacious as monotherapy at a dose of 5-40 μg. The erection appears after 5-15 minutes and lasts according to the dose injected. An office-training programme is required for the patient to learn the correct injection process. The efficacy rates for intracavernous Alprostadil of greater than 70% have been found in general ED populations, as well as in patient subgroups (e.g., diabetes or cardiovascular disease), with reported sexual activity after 94% of the injections and satisfaction rates of 87-93.5% in patients and 86-90.3%

in partners.¹⁴⁹ Complications of intracavernous Alprostadil include penile pain, prolonged erections, priapism, and fibrosis.

VACUUM ERECTION DEVICES

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Vacuum Erection Devices (VEDs) provide passive engorgement of the corpora cavernosa, together with a constrictor ring placed at the base of the penis to retain blood within the corpora.

Thus, erections with these devices are not normal because they do not involve the physiological erection pathways. Efficacy, in terms of erections satisfactory for intercourse, is as high as 90%, regardless of the cause of ED and satisfaction rates range between 27% and 94%.¹³⁹ Men with a motivated, interested, and understanding partner report the highest satisfaction rates. Long-term use of VEDs decreases to 50-64% after 2 years. The commonest adverse events include pain, inability to ejaculate, petechiae, bruising, and numbness

SHOCKWAVE THERAPY

Recently, the use of low-intensity extracorporeal shock wave therapy was proposed as a novel treatment for ED. The feasibility and tolerability of this treatment, coupled with its potential rehabilitative characteristics make it an attractive new therapeutic option for men with ED.

However, current data are limited and clear recommendations cannot be given. Data regarding the mechanism of action of this procedure are still lacking.⁶²

PENILE PROSTHESES

The surgical implantation of a penile prosthesis may be considered in patients who do not respond to pharmacotherapy or who prefer a permanent solution to their problem. The two currently available classes of penile implants include inflatable and malleable devices. Prosthesis implantation has one of the highest satisfaction rates (92-100% in patients and 91-95% in

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partners) among the treatment options for ED based on appropriate consultation. The two main complications of penile prosthesis implantation are mechanical failure and infection.⁶²

2.8.2 MANAGEMENT OF FEMALE SEXUAL DYSFUNCTION IN TYPE 2 DIABETES MELLITUS

No specific guidelines are currently available for the treatment of female sexual dysfunction in diabetes. Therefore, therapeutic possibilities for sexual dysfunction in diabetic women refer to lifestyle changes, optimal diabetic control, psychotherapy, and selected medications when appropriate.¹⁶¹

CHAPTER THREE

MATERIALS AND METHOD 3.1 STUDY AREA

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The study was carried out in the General Outpatient Clinic (GOPC), Ahmadu Bello University Teaching Hospital (ABUTH), Shika-Zaria, Kaduna State of Nigeria. Ahmadu Bello University Teaching Hospital Shika is a tertiary hospital established with the tripartite mandate of service delivery, training and research. It serves as a referral centre for primary and secondary public health institutions as well as private hospitals within Zaria, Kaduna State and other neighbouring states of Kano, Plateau, Zamfara, and Bauchi.¹⁶²

The GOPC serves as a care clinic within the hospital for outpatients and NHIS enrollees. All adults and paediatric patients excluding those who need emergency health care services and antenatal care services are first seen at the GOPC. Patients who need primary and secondary care are managed and followed up in this clinic while those who need other specialist care are referred to the respective specialist clinics for further management. Patients with chronic diseases like diabetes mellitus and hypertension who are relatively stable are referred to the GOPC for continuing care. In the GOPC, about 60,000 adult patients are seen per year of which about 4,781 patients are diabetics (Appendix A). ¹⁶²