Sexual Health and Dysfunction in the Elderly Nadya S. Dávila Lourido, MD September 28, 2018
Objectives: To review physiologic changes associated with aging To discuss the importance of the history and examination in the evaluation of sexual dysfunction To learn to identify common issues associated with sexual dysfunction in the elderly and their basic treatment options
Outline Introduction Sexuality of the Older Man Sexuality of the Older woman STD information and prevention Enhancing communication about sexuality Summary
How Often Do you ask your patients about Sexual Health on a routine visit?
Introduction Older Men and Women are still interested in Sex, sexual activity declines with age Massachusetts Male Aging Study >60% of male 70+ reported ED Factors that affect sexual Function in both men and women Physiology changes with aging Lifestyle Choices Psychological Factors Aging-Related Disease and their Treatment
Introduction Evaluation of Sexual Dysfunction Complete Sexual History Review of Medications Physical Exam Lab Tests
Sexuality of the Older Men
Sexuality of the Older Men Sexual behavior with aging is affected by patterns in younger years Causes of Decrease Sexual Activity General decline in health Partner Availability Decrease Libido Sexual Dysfunction
Age Related Physiologic Changes: Men HPG Axis
Age Related Physiologic Changes: Men Alterations in Pituitary-Hypothalamic-Gonadal Axis May result in hypogonadism and decrease libido Changes in penile innervations make it more difficult to achieve an erection Increases time it takes to have an orgasm Prolong the Refractory Period Increase time to Ejaculate may improve sexual function In men who are premature ejaculators
Andropause Testicular function gradually declines with age From age 20, Testosterone (T) ~1%/yr By 80, average serum total T is 100ng/dL less than younger men
Effects of Testosterone Deficiency libido, impotence, energy Depression muscle and bone mass Metabolic syndrome Cognitive impairment
Sexual Dysfunction: Men
Erectile Dysfunction Inability to achieve or maintain an erection adequate for sexual intercourse. Erectile Dysfunction Healthy Aging Most common sexual problem of older men
Erectile Dysfunction: Causes Vascular Disease Neurologic Disease Endocrine Abnormalities Psychogenic Medications Consequence of selected surgical procedures
Causes of Erectile Dysfunction: Vascular Disease Common Risk Factors: Hypertension, DM, HL, Smoking Pathophysiology: Atherosclerosis Blood Flow and Pressure needed to maintain erection Ischemia of trabecular smooth muscle can result in fibrosis and failure of venous closure mechanisms
Causes of Erectile Dysfunction: Neurologic Disease Autonomic Dysfunction i.e. Parkinson s Disease, DM Spinal Cord Injury Impaired Peripheral Autonomic Fibers to the Penis
Causes of Erectile Dysfunction: Endocrine Abnormalities Low testosterone affects mostly libido and males with low testosterone can achieve erection with direct penile stimulation Males with ED and normal Testosterone do not benefit from Testosterone Supplementation Thyroid Abnormalities and Hyperprolactinemia can be associated with ED
Causes of Erectile Dysfunction: Psychogenic Age Causes: Widower s Guilt Relationship Conflicts Performance Anxiety History of Abuse
Causes of Erectile Dysfunction: Medications 5% of cases are medication side effects Common Classes: Anticholinergics, Antidepressants, Antipsychotics, Antihistamines Examples: BB, Clonidine, Thiazides, Cimetidine, Ranitidine
Causes of Erectile Dysfunction: Post Operative GU Procedures in which autonomic nerve supply to penis can be affected (Prostatectomy, Cystectomy), also Proctocolectomy
Sexual Dysfunction: Evaluation Men Sexual History Nature Onset (gradual vs. sudden) Associated Symptoms Presence of Sleep Associated Erections Prior treatment
International Index of Erectile Dysfunction (IIEF-5)
International Index of Erectile Dysfunction (IIEF-5) 22-25: No erectile dysfunction 17-21: Mild erectile dysfunction 12-16: Mild to moderate erectile dysfunction 8-11: Moderate erectile dysfunction 5-7: Severe erectile dysfunction
Sexual Dysfunction: Evaluation Men Physical Exam Hypogonadism Gynecomastia, decrease body hair, scant pubic hair Vascular Checking for bruits, palpating pedal pulses Neurologic Rectal sphincter tone, bulbocavernosous reflex, DTRs Prostate Exam, nodules Examine Penis for Plaques (Peyronie s disease)
Sexual Dysfunction: Evaluation Men
Lab tests Sexual Dysfunction: Evaluation Men HbA1C, Lipid, Testosterone (Total) T low, repeat + LH T low/lh high, problem at the level of testes T low/lh low or nl, further testing (hypothalamic or pituitary disorder)
Sexual Dysfunction: Men Treatment
Sexual Dysfunction: Treatment Male Stop/Change offending drugs Psychogenic ED Discussion, reassurance, sex therapy referral Decrease Libido If Hypogonadal consider T No T if hx of polycythemia, hx of Prostate Ca, severe LUTS, OSA Neurophysiologic PE Meds that delay ejaculation (SSRI, Alpha blockers, topical anesthetics, abx for prostatitis) Retrograde Ejaculation Reassurance
Sexual Dysfunction: Treatment of Male Erectile Dysfunction (ED) Is it safe for the patient to engage in sexual intercourse? Energy needed to climb 2 flights of stairs Evaluate CV risk factors (HTN, DM, HL tobacco use)
Sexual Dysfunction: Treatment of Male Erectile Dysfunction (ED) Multiple effective therapeutic options are available and Treatment should be individualized
Sexual Dysfunction: Treatment of Erectile Dysfunction (ED) Non Pharmacologic Pharmacologic Stop Medications that can be potentially contributing Psychotherapy Vacuum tumescence device Surgery Penile Prosthesis Penile revascularization Phosphodiesterase-5 inhibitor Vasoactive drugs Medicated Urethral System for Erection (MUSE) Testosterone supplementation
Treatment of Erectile Dysfunction: PPDE-5 INHIBITORS Start working when sexual stimulation occurs Enhance penile response to stimulation, improve rigidity and duration Contraindicated with Nitrate use and use at the same time with α-blocker
Treatment of Erectile Dysfunction: PPDE-5 INHIBITORS Sildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) Avanalafil (Stendra)
Treatment of Erectile Dysfunction: PPDE-5 INHIBITORS Side Effects: Sildenafil: Transient Visual Disturbance Rhinitis Headache Flushing Dyspepsia
Treatment of Erectile Dysfunction: Other Pharmacologic Options Intracavernous Injection of Vasoactive Drug Alprostadil Phentolamine + Alprostadil or Papaverine or both Medicated Urethral System for Erection (MUSE) Alprostadil pellet placed in urethra Testosterone for men with true hypogonadism
Sleep Disorders Associated with Higher Odds of Erectile Dysfunction
Sexuality in Older Women
Sexuality in Older Women Frequency of intercourse decrease with aging in females but most report that sexuality is still important Causes of Decrease Sexual Activity Menopause Decline in Health Relationship Problems ED more common in older men Depression Many women outlive their spouses Issues with privacy
Age Related Physiologic Changes: Women The 4 Phases of Sexual Response Change with Aging
Age Related Physiologic Changes: Women Estrogen post Menopause can cause vaginal dryness, increase Ph, effect in sexuality, increases risk of urogenital atrophy and bladder infections Estrogen Replacement can improve vulvovaginal symptoms but little effect on libido or sexual satisfaction Endocrine Society does NOT recommend making a dx of Adrogen Deficiency in women
Menopause LH, FSH rise Oestrone (weakner estrogen synthesized in cortex of adrenal gland) estradiol Increase risk of CV events LDL, Tchol HDL Bone Loss Vasomotor instability Psychological sx s Vaginal Mucosa Atrophy = bleeding Dysuria, urinary frequency, incontinence due to low estrogen Loss of Libido (due to fall in both estrogen and testosterone levels)
16,000 women followed for ave. 5.2 yrs ½ took placebo, ½ took medroxyprogsterone+conjugated equine estrogen combination == Breast Cancer Heart Attack Stroke
Issues with Sexuality in the Older Woman
Issues with Sexuality in the Older Woman: Dyspareunia Difficult or Painful sexual intercourse Cause can be of organic or psychological or a combination of both Most common: atrophic vaginitis due to estrogen deficiency Other causes: cystititis, vaginismus, Bartholin s cyst, uterine prolapse, inadequate lubrication
Issues with Sexuality in the Older Woman: Libido Libido depends on Testosterone rather than Estrogen Estrogen replacement has little effect on libido but can improve vaginal lubrication
Sexual Dysfunction: HYPOACTIVE SEXUAL DESIRE DISORDER Decreased libido that causes personal distress Low Testosterone Rx. Flibanserin (Addyi) Only for pre menopausal women
Medications that Contribute to Sexual Dysfunction in Females SSRIs Antipsychotics Antihypertensives Antiestrogens Antiandrogens Alcohol Recreational Drugs Anticholinergics- decrease nl vaginal lubrications Chronic Opioids- opioid-induced androgen deficiency
Sexual Dysfunction: Evaluation Women History Identify issue: Arousal, Desire, Orgasm, Pain or a combination 3 screening questions: Are you sexually active? Any problems? Do you have pain with intercourse?
Sexual Dysfunction: Evaluation Women History Duration, consistency of problem Quality of couple relationship Vaginal lubrication Symptoms of depression History of negative experiences Chronic illnesses Medications Self Image
Sexual Dysfunction: Evaluation Women Physical Exam Pelvic BP, pulses MSK exam Thyroid exam Screen for neuropathy
Labs Sexual Dysfunction: Evaluation Women No routine labs recommended Testosterone levels do NOT correlate with sexual dysfunction Do Prolactin/TSH only if hx or exam suggest possible abnormalites
Sexual Dysfunction: Treatment Female
Sexual Dysfunction: Treatment Female Non Pharmacologic Treat chronic disease when appropriate Psychological Depression Marital Counseling Kegel exercises CBT Stop offending Agent Lubricants Pharmacologic Low dose topical estrogens SERMs: Ospemifene No long term safety data available Testosterone OFF label use for libido, Endocrine Society does not recommend Sildenafil Not FDA approved for women Flibanserin (Addyi) For premenopausal females only
Addyi (Flibanserin) For treatment of Hypoactive Sexual Desire Disorder (HSDD) Pre Menopausal Women Side effects: Hypotension, Syncope due to an interaction with alcohol
STD Risk in the Elderly
STDs in Retirement Communities Sex and the Single Senior The number of Medicare enrollees who took advantage of free S.T.D. tests is about the same as the number who received free colonoscopies to screen for colon cancer (5% ) Rise in STDs in the elderly, Between 2007 and 2011, chlamydia infections among Americans 65 and over increased by 31 percent, and syphilis by 52 percent Numbers are similar to STD trends in 20-24 group (chlamydia 35% and syphillis 64%)
Causes for Increase Rates of STD s in the Elderly Retirement communities and assisted living facilities are becoming like college campuses Older people are living longer and are in better health=> remaining sexually active for longer Unfamiliarity with condoms and Viagra On a study Condoms used in 40% of sexual encounters; only in 6% of encounters aming ppl >61 Lack of Medical Provider Awareness
SUMMARY Although sexual activity decreases with age, most older adults are still interested Sexuality in the Older Adult is affected by Age related changes as well as medical conditions that become more prevalent Sexual history is key in the evaluation of sexual dysfunction Sexually active older adults are at risk for STDs and should be tested Healthcare providers are encouraged to discuss sexual health with their geriatric patients