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Essentials of Diagnosis

  • Sexual dysfunction is common among older men and women, and is caused by a combination of physiologic changes, lifestyle choices, psychological factors, and aging-related disease.

  • 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 in men.

General Principles in Older Adults

Although older men and women are still interested in sex, sexual activity declines with age. In the Massachusetts Male Aging Study, more than 60% of men age 70 years reported erectile dysfunction and in the Rancho Bernardo Study, 32% of women age 65 years or older reported sexual activity in the previous 4 weeks but only 13% of women age 80 years or older reported being sexually active. This decrease in sexual activity may negatively impact quality of life. Fortunately, there are effective treatments for sexual dysfunction in men and women.

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 make it more difficult to achieve an erection, increase the time it takes to have an orgasm, and prolong the refractory period (the time it takes to have an erection after ejaculation). The increased time to ejaculate may actually improve sexual function in men who are premature ejaculators.

In women, the 4 phases of sexual response (excitement, plateau, orgasm, and resolution) change with aging. During the excitement phase, there is decreased genital engorgement. Vaginal lubrication is decreased and the woman may need longer foreplay and gentle stimulation to achieve sufficient lubrication for intercourse. During the plateau phase, there is less expansion and vasocongestion of the vagina. During orgasm, there are fewer and weaker contractions, although older women can still achieve multiple orgasms. During the resolution phase, vasocongestion is lost more rapidly. As in younger women, the 4 phases may vary in sequence, overlap, or some may be absent. For example, desire does not always precede arousal. An older woman may engage in sexual activity not out of desire for sex but out of desire for closeness with her partner. If the stimulation is appropriate and she stays focused, her arousal and sexual desire intensifies. A positive experience increases her motivation for future encounters whereas a negative one (eg, from dyspareunia) may decrease her interest in sex.

In addition to the physiologic changes that occur with aging, lifestyle choices, psychological factors, and aging-related diseases and their treatment may affect sexual function in both men and women.

Prevention

Men

The most common cause of sexual ...

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