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The most common cause of sexual dysfunction in older men is erectile dysfunction (ED). The National Institutes of Health (NIH) defines ED as the consistent inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity. As noted above, more than 60% of men age 70 years are unable to achieve a rigid erection. ED is the most common chronic disease in men, and vascular disease is the most common cause of ED.
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Risk factors for vascular disease include lack of exercise, diabetes mellitus, hyperlipidemia, hypertension, and smoking. In many cases, these diseases are preventable by dietary and lifestyle changes. Because of the correlation between ED and vascular disease, ED is a marker for future vascular events, such as myocardial infarction and stroke. However, ED may be a more powerful predictor of cardiovascular disease in men younger than 60 years of age and in patients with diabetes.
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Diabetes mellitus (DM) has the greatest impact on sexual function in men. The risk of ED in DM is directly related to the duration of diabetes, the A1c level, and increasing age. Early aggressive control of DM may prevent ED or delay its onset.
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The second most common causes of ED are neurogenic. The autonomic dysfunction seen in DM and Parkinson disease prevents penile vasodilatation and erection. DM may cause both vascular and neurogenic ED. Neurogenic ED is frequently seen after prostatectomy or radiation therapy for prostate cancer. Nerve sparing surgery reduces this risk.
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Another common cause of ED is medications. Anticholinergics, such as antipsychotics and oxybutynin, block parasympathetic-mediated vasodilatation. Antihypertensives, including beta blockers and thiazides, also increase the risk of ED. Angiotensin-converting enzyme inhibitors and calcium channel blockers do not have an adverse impact on erections.
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Psychogenic ED is the least-common etiology. Patients with psychogenic ED usually describe the sudden onset of ED related to an event in their lives (argument with their partner, losing a job, etc). Of note, patients with ED caused by a nonpsychogenic etiology may have anxiety and/or depression because of the ED.
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Testosterone’s role in ED is controversial. Low testosterone is associated with decreased libido, but hypogonadal men can still achieve an erection and most men with ED have normal testosterone levels. Studies in animals suggest that testosterone is needed for a rigid erection. Studies also show that testosterone replacement in hypogonadal men improves their response to phosphodiesterase type 5 inhibitors.
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Premature ejaculation (PE) occurs in approximately 30% of men. These patients are also referred to as “rapid ejaculators.” PE is defined as orgasm with minimal stimulation. The most common cause is neurophysiologic. PE may also be psychogenic. Most PE is chronic. Patients with acute onset of PE may have a prostate infection (prostatitis). As men age, PE becomes less of a problem because of changes in penile innervation resulting in decreased penile sensation.
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Retrograde ejaculation is a common complaint in men who have DM or have undergone transurethral prostatic resection. In both cases, the proximal sphincter does not close during ejaculation and semen goes into the bladder.
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Orgasmic failure is uncommon in men. When it does occur, it may be a result of nerve damage (prostate cancer, radical prostatectomy, or DM) or may be medication-induced (gabapentin). With the exception of stopping gabapentin, treatment is usually unsuccessful.
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A decrease in estrogen levels with menopause can have a negative effect on sexuality by causing vaginal dryness. The normal vaginal pH is 3.5–4.5; after menopause it increases up to 7.0–7.39. A pH higher than 5 increases the risk of urogenital atrophy and bladder infections.
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Women with poor self-reported physical health and women with diabetes are less likely to be sexually active than healthy older women.
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These sexual difficulties constitute a “dysfunction” only if they cause significant distress to the woman, so if lack of interest in sex does not bother the woman, she cannot be diagnosed as having sexual dysfunction. Female sexual dysfunction is classified depending on whether the main problem is in one of these 4 areas: arousal, orgasm, desire, or pain.
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Like in men, libido in women is thought to be dependent on testosterone. Estrogen replacement can improve vulvovaginal atrophy symptoms, but it has little effect on libido or sexual satisfaction. The ovaries and adrenals are the main sources of androgens in women. The effects of lack of testosterone in women were originally identified in women treated for advanced breast cancer with oophorectomy and adrenalectomy. When deprived of androgens, these women reported loss of libido. As there are no normative data on plasma total and free testosterone in women and there is no well-defined clinical syndrome of androgen deficiency, the Endocrine Society does not recommend making a diagnosis of androgen deficiency in women.
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In older women, the etiology of sexual dysfunction depends on whether the patient presents with decreased desire, decreased lubrication, delayed or absent orgasm, or pain with intercourse (Table 46–1), but often the cause is multifactorial. For example, the patient may have decreased desire because of poor health and medication side effects and at the same time have painful intercourse.
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Painful intercourse or “dyspareunia” can be caused by psychological or organic factors or a combination thereof. The most common cause of dyspareunia is vaginal atrophy caused by postmenopausal estrogen deficiency. The fear of experiencing pain may perpetuate the dyspareunia as it limits the woman’s ability to become aroused and have adequate lubrication. Other causes of dyspareunia include lack of lubrication, vaginismus, localized vaginal infections, cystitis, Bartholin cyst, or even poor male technique. Pain can occur from pelvic thrusting and can be attributable to the woman’s position during intercourse, retroverted uterus, postoperative adhesions, pelvic tumors, endometriosis, pelvic inflammatory disease, ovarian cysts, or urinary tract infections.