Ejaculatory dysfunction in men with diabetes mellitus

Table 4 Assessment steps in the evaluation of diabetes mellitus-related ejaculatory dysfunctions

History
Asking about the period from vaginal intromission to ejaculation (intravaginal ejaculatory latency time).
Is the patient unable to advance his ejaculatory response?
Is the patient or his partner distressed or bothered by the situation?
Is the symptom occurring since the first sexual experience or occurring after a period of normal ejaculatory performance?
Onset and duration of the symptom.
Is the symptom occurring on every/almost every attempt and with every partner?
Presence or absence of premonitory ejaculatory sensation.
The duration of thrusting before the suspension of intercourse.
Reasons for delay of intercourse (e.g., fatigue, loss of erection, a sense of ejaculatory futility, or partner request).
Presence of post-coital self- or partner-assisted masturbation.
Psychogenic anejaculation/anorgasmia can be suspected when there is a history of nocturnal emission.
Patient's ability to get an erection, relax, sustain, and heighten sexual arousal.
Exclude anorgasmia by asking about lack of orgasm.
Whether orgasm is present but there is a lack of external ejaculation that may indicate retrograde ejaculate.
Feeling before ejaculation/orgasm: The inadequate combination of “friction and fantasy” may exacerbate DE.
Intercourse frequency.
Presence of other sexual dysfunctions such as ED (ability to initiate or maintain an erection), low libido.
Other symptoms of hypogonadism (such as lack of energy, depressed mood).
Masturbation habits
The life events/circumstances related to the complaint.
Sexual communication abilities.
Paraphilic inclinations/interests (may be related to DE and anejaculation).
Cultural or religious beliefs (if any).
History of a psychiatric disorder (may be the etiologic factor).
History of previous treatment for this symptom.
History of neurologic disorders, spinal cord injury, medical diseases, trauma, abdominal/pelvic operations, drug intake, or pelvic radiotherapy.
History of pelvic or testicular pain (may indicate inflammation).
History of dysuria, burning micturition, or any urinary symptom (indicate inflammation).
Clinical examination
Signs of diabetic complications and co-morbidities.
Signs of hypogonadism.
Rule out systemic disorders that contribute to ejaculation dysfunction as neurological impairment, endocrine/ urological diseases.
Examination for secondary sexual characteristics, penile and testicular abnormalities.
Examination of the epididymis, and vas deferens on each side.
PR examination to determine the prostate size, anal sphincter tone, and quality of the bulbocavernosus reflex.
The cremasteric reflex: measures intact L1-2 spinal segments, also mediating emission and psychogenic erection.
Perineal reflexes (bulbocavernosus and anal reflex) mediated by sacral segments, also mediating reflex erection (for intact S2–4 pathway).
Examination of pinprick and temperature sensations in the saddle area (perineal) and glans penis for healthy sacral cord segments.
Inability to feel testicular squeeze: measures the integrity of T11 to T12 spinal nerves via the sympathetic nervous system.
Examination of lower abdominal cutaneous reflex: measures intact Th11-12.
Penile biothesiometry.
Investigations
Blood levels of glucose, HbA1c, serum testosterone, thyrotropin, and prolactin to exclude other endocrine disorders.
Post-masturbation first-void urine if we suspect retrograde ejaculation to search for spermatozoa and fructose content to confirm retrograde ejaculate
Microbiological examination of expressed prostatic secretion and urine to verify or exclude associated genital infections.
Urine cytology to exclude bladder cancer
Serum prostate-specific antigen to exclude prostate cancer
Neurophysiologic investigations (bulbocavernosus evoked response and dorsal nerve somatosensory evoked-potentials): If there is clinical evidence of neurologic lesions. These tests are little used in clinical practice and usually do not affect management.
Trans-rectal ultrasound examination if we suspect ejaculatory duct obstruction, prostatic or seminal vesicle abnormalities or stones.
CT or MRI scans to assess pelvic anatomy if we suspect major pelvic lesions.

CT: Computed tomography; MRI: Magnetic resonance imaging.