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INTRODUCTION

ESSENTIALS OF DIAGNOSIS

  • Sexual dysfunction is common among older persons and is caused by a combination of physiologic changes, lifestyle choices, psychological factors, and agingrelated diseases.

  • In older men, the most common type of sexual dysfunction is erectile dysfunction, and the most common etiology is vascular disease.

  • In older women, sexual dysfunction is often multifactorial, including lack of estrogen causing vaginal dryness and lack of testosterone decreasing libido.

  • Evaluation of sexual dysfunction consists of a complete sexual history, review of medications, a targeted physical exam, and selected laboratory tests.

GENERAL PRINCIPLES

Older men and women are still interested in sex, yet sexual activity can decline with age. In the National Social Life, Health, and Aging Project (NSHAP), Lindau and colleagues found that self-reported sexual activity decreased with age; 73% of respondents aged 57 to 64 years described themselves as being “sexually active,” as compared to 26% of those aged 75 to 85. It is of interest, however, that of those who identified as being sexually active, the frequency of sexual activity was similar to that of younger counterparts; 54% reported sexual activity at least two to three times month, with 25% stating frequency of at least weekly. These findings run counter to the stereotypes of older adults who are often mislabeled as sexless and uninterested in intimacy.

In men, age-related physiologic changes impact sexual function. Alterations in the pituitary–hypothalamic–gonadal axis may result in hypogonadism and decreased libido. Changes in penile innervation reduce penile sensitivity to touch, make it more difficult to achieve a rigid erection, increase the time it takes to reach orgasm, diminish forcefulness and volume of ejaculation, and prolong the refractory period (the time it takes to have an erection after ejaculation). The prolonged time to orgasm may be beneficial in men with a history of premature ejaculation.

Masters and Johnson in 1966 first described the sexual response in four distinct stages: excitement, plateau, orgasm, and resolution. The female physiologic response may change with aging in the setting of hypoestrogenism following menopause. During the excitement phase, there is decreased genital engorgement. Vaginal lubrication may decrease, necessitating longer foreplay and use of supplemental lubrication for penetrative intercourse. During the plateau phase, there is less expansion and vasocongestion of the vagina. During orgasm, the strength and frequency of the perineal muscle contractions may diminish, although the ability to achieve multiple orgasms is retained. During the resolution phase, vasocongestion is lost more rapidly.

In women, for whom the stages may overlap or even be absent, the characterization of “normal” sexual response as one that culminates in orgasm is a limiting lens through which to view satisfactory sexual intimacy. Some older persons may engage in sexual activity not out of desire for sex but out of desire for closeness with their partners. A positive experience may increase motivation for future encounters, whereas a negative one (eg, ...

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