Acne, Hormones, and Treatment

neuropathy almost guarantees that the impotence is organic and irreversible. If tests of autonomic function are normal erectile capacity may usefully be measured directly by recording nocturnal erections during rapid eye movement sleep.8 9 With this technique a mercury-in-rubber strain-gauge is placed round the base of the penis and connected to a device which records erections during dreaming. When impotence is psychogenic nocturnal erections are normal, whereas patients with organic impotence have either absent or reduced erections during sleep. In one English study9 two-thirds of diabetic patients with "impotence" had nocturnal erections though this does not necessarily mean that their impotence was psychogenic, since the test cannot measure the quality of the erection. What is measured may be penile tumescence which does not produce a sufficiently rigid erection for penetration. In well-financed centres overseas8 this difficulty is circumvented by having an observer who assesses the quality of the erection by hand. Organic impotence due to diabetes is irreversible, and many doctors adopt a nihilistic approach to its treatment. Despite an early report by Schoffling et al'0 that testosterone and chorionic gonadotrophin were effective, it is now generally agreed that all testosterone does is to increase libido without improving performance-making it a cruel treatment. Many diabetic specialists also regard formal psychiatric treatment as a waste of time, perhaps because in the past they have referred unsuitable cases. Nevertheless, psychological treatment, whether administered by the physician, psychiatrist, or sex therapist, has much to offer; Schiavi6 makes the point that mutual sexual satisfaction is possible without penetration and his therapeutic approach includes trying to change the attitude of the couple by emphasising sexual intimacy rather than performance." Some diabetic men respond to sexual counselling with a marked improvement in erectile capacity, presumably because performance anxiety and "spectatoring" have been reduced." Finally, there are couples for whom sexual satisfaction is inseparable from erection and penetration, and in such cases some form of penile prosthesis'2 may be the only acceptable solution. Nevertheless, surgery should be undertaken only after careful preoperative evaluation. Osborne'3 suggests that one approach is to ask the patient: "How will your life be different if you undergo this procedure ?" The answer may indicate those patients who have unrealistic expectationsand in whom the results of surgery are usually poor. In the past the problem of impotence has been neglected in diabetic clinics. Many clinics are so busy and open that patients are inhibited from talking about their intimate problems. I suggest that the onus is on the diabetic physician to ask routine questions about sexual potency and that not to do so is just as negligent as not asking about chest pain or visual symptoms. ROBERT TATTERSALL Consultant Physician, University Hospital, Nottingham NG7 2UH