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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #9

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LEARNING OBJECTIVES

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Learning Objectives

  • Identify the factors affecting sexual function in the older man, including changes in sexual physiology, coexisting medical problems, and psychosocial issues.

  • Describe the initial evaluation of erectile dysfunction (ED) in an older man, using knowledge of possible etiologies to guide evaluation and treatment recommendations.

  • Recognize the components necessary for the diagnosis of testosterone deficiency in an older man and be able distinguish the expected outcome(s) of testosterone replacement therapy.

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Key Clinical Points

  1. Male sexual activity declines with aging, due to social factors and changes in physical and psychological health; yet many older men are sexually active into late life.

  2. The most common causes for ED in older men are vascular in origin, not hormonal, and thus current predominant therapies are phosphodiesterase-5 (PDE-5) inhibitors and vacuum devices.

  3. The diagnosis of testosterone deficiency in an older man requires both low testosterone levels and symptoms of hypogonadism. Consideration for testosterone replacement therapy should involve a careful discussion of possible benefits and risks.

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Sexuality is a basic human need which exists throughout life in one form or another and is a significant component to quality of life of many older individuals. Although 70% of adult patients in a large sample study considered sexual matters to be an appropriate topic for a general clinician or geriatrician to discuss, sexual problems are noted in fewer than 2% of primary care physicians’ notes. It is not easy to find physicians and other health care providers who are knowledgeable about sexuality in general and among the aging population in particular. Sexuality and sexual function in the aging female is addressed in Chapter 41. Sexuality, sexual function, and dysfunction in the aging male will be addressed in the first part of this chapter, with the second part of the chapter being devoted to androgen replacement therapy in the older man.

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SEXUALITY AND SEXUAL FUNCTION IN OLDER MEN

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Sexual Behaviors

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Idealized societal concepts of older people do not include sex or the facility for sexual function. A poll conducted by the National Council on Aging, regarding attributes of people over 65 years, reported that older persons were frequently thought of as being “warm and friendly” (74% of respondents) or “wise from experience” (70% of respondents), but being “sexually active” was attributed to older persons by only 5% of the survey respondents. Nonetheless, numerous cross-sectional and longitudinal epidemiologic studies of sexuality and aging report that, although sexual activity decreases with age, many older adults are sexually active. These surveys have reported that, by all measures evaluated, men have a stronger sex drive than women; sexual activity, good-quality sex life, and interest in sex were higher for men than for women and this gender gap widened with age. Sexual expression can encompass many forms, including sexual intercourse, oral sex, masturbation, ...

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