Incidence

1. The prevalence of sexual problems in the geriatric population is also frequently underestimated. According to the Global Study of Sexual Attitudes and Behaviors (GSSAB), nearly half of all sexually active respondents aged 40 to 80 reported at least one sexual complaint, including erectile dysfunction, premature ejaculation, lack of sexual interest, lack of sexual pleasure, inability to reach orgasm, and lubrication difficulties. Despite this, less than 19% sought medical attention for such issues.
2. Medical providers frequently underestimate the commonality of sexual activity in the older population.
3. Although sexual complaints are frequently considered specific to certain population genres, most of these diagnoses are actually age bimodal due to the variety of causative etiologies.
4. Although many older adults remain sexually active, they rarely bring up the topic of sexual health with their healthcare providers:
   1. Although 20% of individuals aged 60 to 94 report having had intercourse within the previous 3 months, only 38% of men and 22% of women have discussed sexual behavior with their healthcare provider after the age of 50.
   2. Barriers to pursuing medical care for sexual complaints include the following:
      1. Believing that the problem is not serious.
      2. Not being bothered by the problem.
      3. Belief that menopause-related changes were irreversible.
      4. Lack of awareness of available treatments.
      5. Lack of access or affordability of medical care.
      6. Embarrassment.
5. Across the globe, only 9% of men and women are asked about their sexual health by their healthcare providers, yet more than half of men and women consistently report sexual activity in the previous year. Of a random sample of 500 U.S. NPs regarding taking a sexual history in the 50+-year-old patient population, only 2% reported they always conducted a sexual history and 23.4% never or seldom did. Barriers to sexual health history taking were the following:
   1. Lack of time.
   2. Interruptions.
   3. Limited communication skills.
   4. Inability to cope with issues that arise with sexual history response.
   5. Embarrassment.
   6. Feeling that taking such a history in the older population is not appropriate.

Pathogenesis

1. Although sexuality transforms throughout the life span and varies among individuals, we are typically born with similar constituents: reproductive organs, sex hormones, and a brain wired to receive nerve impulses from erogenous parts of the body.
2. At a very young age, individuals often identify areas of the body that induce pleasure with physical stimulation. Over the course of the first few decades of life, sexual structures and hormones mature, sexual functioning develops, and integration of partnered sexuality and intimacy often occurs.
3. After childbearing years, the aging process can complicate sexual functioning for both men and women. Unfortunately, this frequently terminates sexual activity despite medical capabilities to prevent and treat sexual disorders. If these changes are acknowledged and embraced, individuals can find themselves in just as satisfying a sexual point in their lives as ever. Some even report improvement from past years.

Predisposing Factors

1. Chronic health conditions:
   1. Cardiovascular disease.
   2. Diabetes.
   3. Obstructive sleep apnea (OSA).
   4. Dementia/Alzheimer’s disease.
   5. Parkinson’s disease.
   6. Multiple sclerosis.
   7. Cancer.
   8. Arthritis.
   9. Incontinence.
2. Depression.
3. Intra-partner violence.
4. Postsurgical condition/complication.
5. Physical disabilities.
6. Loss of a spouse/partner
7. Side effects from medications:
   1. Angiotensin-converting enzyme (ACE) inhibitors.
   2. Beta blockers.
   3. Calcium-channel blockers.
   4. Nitrates.
   5. Diuretics.
   6. Cholesterol-lowering drugs.
   7. Antidepressants.
   8. Tranquilizers.

Common Complaints

1. Sexual dysfunction in men encompasses the following problems:
   1. Lack of desire/arousal.
   2. Erectile dysfunction:
      1. Inability to achieve or maintain an erection sufficient for satisfactory sexual performance.
      2. Curvature of the penis with erection (Peyronie’s disease).
      3. Problems with penetration.
      4. Orgasmic disorder.
   3. Ejaculation.
2. Alternately, in women sexual complaints occur in the realms of:
   1. Lack of desire/arousal.
   2. Lack of orgasm.
   3. Sexual/genital pain: Lack of vaginal lubrication.
   4. Urinary:
      1. Dysuria.
      2. Urinary frequency/urgency.

Subjective Data

1. Sexuality integrates into many layers of the individual and nearly always requires collaboration with a multidisciplinary team. Functioning as a sort of “gatekeeper” in this realm of medicine can help manage treatment recommendations from multiple providers for complicated, multifaceted, and sensitive health matters.
2. When addressing patients with potential sexual issues, a variety of questionnaires and assessment tools can help facilitate efficient communication in a busy medical setting. They can also aid in “breaking the ice” with potential uncomfortable topics. A study conducted in the United Kingdom identified that general practitioners do not discuss sexual health with their older patients because they feel it is not appropriate to discuss such issues with this age group and because they feel sexual health equates with younger people. Interestingly, these beliefs were found to be based on stereotypes versus actual patient experience. In this circumstance, questionnaires would not only identify the presence of sexual complaints irrespective of age, but also foster patient–provider communication. See Table 17.11 for a list of questionnaires that can help to identify sexual dysfunction in men and women.
3. Mailing the questionnaire prior to the appointment: Not all questions are pertinent to each patient, and it is important to identify this in the cover letter.
   1. Mailed questionnaires offer the opportunities for the following:
      1. Answering sensitive questions in a private setting.
      2. Some patients like to include their partners’ input in the answering of questions, which is also helpful when paperwork is mailed prior to the appointment.
   2. Allowing patients to leave questions blank indicates the following:
      1. The question does not pertain to their situation.
      2. They do not understand the question.
      3. They would rather discuss them in the office.
4. In your interview, it is important to be considerate of the patient’s comfort level when addressing sensitive topics such as this, and potentially modify assessment techniques and terminology.
5. During the patient interview, consider factors that play a role in the patient’s potential belief structure regarding sexuality, such as age, culture, ethnicity, religious affiliation, and sexual orientation.

Physical Examination

1. Physical examination is dependent on the type of sexual dysfunction and other chronic medical conditions.

Diagnostic Tests

1. Diagnostic testing is dependent on the type of sexual dysfunction and other chronic medical conditions.

Plan

1. It is incredibly important to consider the entire individual when evaluating sexual health, utilizing a holistic approach inclusive of the mind, body, and spirit when addressing concerns and implementing treatment plans. An individualized approach includes consideration of age-related factors. It is also critical to involve partner(s) when appropriate and agreed upon by the patient.
2. LGBT elderly:
   1. More than two million older adults identify as LGBT. In addition, the National Social Life, Health and Aging Project (NSHAP) indicated approximately 4% of the 3,005 respondents reported at least one same-sex sexual relationship (SSSR). Although the age of the respondents fell between 57 and 85 years of age, those reporting at least one SSSR tended to be younger, more educated, in better health, and more likely to be actively working.
   2. Rates of the LGBT population are generally considered to be underestimated, especially in the elderly population, due to fears of social stigmas and discrimination. Keeping in mind the age of this population, it is important to remember that up until the early 1970s homosexuality was considered a mental disorder in the DSM of the American Psychiatric Association (APA). In addition, many individuals may identify as heterosexual but still engage in some same-sex sexual contact.
   3. Use of nonspecific and nonoffensive terms on paperwork and in an office encounter can help to facilitate rapport between a medical provider and patient. Considering that a patient experience begins in the waiting room, medical providers should make sure to include posters, handouts, books, magazines, and television shows that do not convey derogatory opinions of any patient population. Also, use of patient questionnaires that can be filled out privately prior to a face to face encounter allows patients to share personal details in a safe manner.
   4. In the older LGBT community, most respondents identify as gay men (61%), followed by lesbian (33%), transgender (7%), bisexual men (3%), bisexual women (2%), and “queer” (1%).
   5. As previously stated, homosexual contact is the most commonly reported sexually transmitted infection (STI) risk behavior in individuals older than 50. Although age differences in gay men do not seem to make a significant difference in likelihood of engaging in sexual or risk behavior, those with significantly older partners tend to take the receptive position more during anal intercourse.
3. Use of aids/toys /products:
   1. Use of sexual aids and toys may be a taboo subject for many older persons. At the same time, changes that occur to sexual functioning with age often warrant modification and inclusion of products into sexual activity that may not have been necessary in the past. The conversation of such products with patients should be approached with sensitivity.
   2. It can be helpful to compare use of sexual aids to other more socially acceptable therapies used on the body, such as weights to strengthen weak muscles. This analogy can normalize a previously uncomfortable concept.
   3. As previously reviewed, changes occur to vaginal mucosa with age, including tissue thinning, dryness, and inelasticity:
      1. Vaginal moisturizers and lubricants can drastically improve the quality of sexual encounters and potentially alleviate vaginal discomfort.
      2. Women should be instructed to avoid products with flavoring, dyes, and perfumes, because many of these ingredients can irritate sensitive vulvovaginal mucosa.
   4. Women should be aware of personal allergies and sensitivities. Available lubricant and moisturizing products contain a variety of potential irritants that should be reviewed by the patient before purchasing and using.
   5. For men with problems getting and maintaining erections, there are over-the-counter (OTC) options such as constrictive rings that fit at the base of the penis and help to hold blood in the erect penis. There are also masturbation sleeves that assist in enhancing sensation during self-stimulation and partnered manual stimulation. OTC penis pumps enhance blood flow in the penis, although the prescription versions are of better quality and sometimes covered by insurance.
   6. Vibrators are a popular choice for enhancing vulvovaginal sexual response for women reporting arousal and orgasm difficulties. There are many different shapes, sizes, speeds, colors, and compositions, which can be daunting for a woman looking for her first vibrator. If possible, it can be helpful to have some examples to show patients in the office or even a safe website to view together so that an explanation of each type can be reviewed.
   7. For women in heterosexual relationships, there are constrictive penis rings with small vibrators attached to provide clitoral stimulation during penetration. There are also a variety of arousal creams, gels, oils, and so forth available, although, once again, they should be used with caution as there is always a potential for contact dermatitis.
   8. Many elderly individuals are either not going to have transportation to get to a store that sells sexual aids and toys or they are not going to feel comfortable making that trip. Providing patients with resources such as safe websites or a local product representative can help facilitate ease of purchase. Another option that some clinics utilize is selling these products on site. This is a mutually beneficial endeavor, as it offers an additional revenue stream while providing patients the opportunity to purchase sensitive items in a safe and private manner.
   9. Older patients will not be familiar with use of certain sexual aids and toys. Drawings and demonstrations on anatomical models in the medical office setting can help with proper use at home.

Differential Diagnosis

1. Sexual dysfunction in the elderly:
   1. Currently, there are 26 Food and Drug Administration (FDA)-approved pharmaceutical agents that treat male sexual dysfunction, including phosphodiesterase 5 inhibitors (PDE-5i) and testosterone replacement.
   2. The FDA has yet to approve a single medication for the treatment of female sexual dysfunction outside of two medications used to treat dyspareunia related to menopausal changes: conjugated estrogen creams and ospemifene oral tablets.
   3. Female sexual complaints involving interest, arousal, and orgasm must be addressed with alternative and off-label options.
2. Sexual interest/arousal disorders in men and women:
   1. Consider a variety of etiologies in patients reporting bothersome sexual dysfunction, including physical health, relationship status, and psychosocial factors to best individualize the treatment regimen.
      1. Although 33% of mature adult women in the United States (defined as 40–80 years of age) report decreased sexual interest, only 18% of men report the same complaint.
      2. Similarly, more women (21%) report vaginal lubrication difficulties than inability to reach orgasm or nonpleasurable and painful sex. This is consistent with the general female population.
   2. Depression consistently coincides with interest/arousal disorders in both men and women. Approximately 40% of individuals with a sexual disorder have depression. Unfortunately, the most common treatment for depression, serotonin-specific reuptake inhibitors (SSRIs), frequently result in sexual side effects in both men and women. Although men report higher rates of sexual dysfunction related to SSRIs, women tend to experience more severe dysfunction.
   3. There is no current FDA-approved pharmaceutical agent specifically for sexual interest/arousal disorder in either men or women; treating underlying cause(s) will frequently improve sexual functioning.
   4. Consider collaboration with a multidisciplinary team such as sex therapists, sexuality educators, medical specialists and subspecialists, physical therapists, and alternative health providers to capture all aspects of these conditions.
3. Erectile dysfunction (ED):
   1. Male ED is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.
   2. Frequency of ED increases with age and comorbidities.
   3. ED can be a symptom of more concerning etiologies, including diabetes and cardiovascular disease, and should be considered when evaluating male patients.
   4. ED is a known comorbidity of testosterone deficiency. Additional comorbidities of testosterone deficiency include increased body weight, adiposity and increased waist circumference, insulin resistance, type 2 diabetes mellitus (DM), hypertension, inflammation, atherosclerosis/cardiovascular disease, and increased incidence of mortality. More severe testosterone deficiency–related symptoms correlate with higher cardiovascular risk in men.
   5. Common prescriptive treatment for ED includes the following:
      1. Phosphodiesterase 5 inhibitors (PDE5I):
         1. Despite available options, only about 25% of men with ED are treated and PDE-5is are the most frequently utilized medication. Interestingly, men older than the age of 60 are much less likely to be treated than men age 40 to 59.
      2. Injectable or urethral prostaglandins.
      3. Exogenous testosterone replacement when applicable.
      4. Additional treatment options include constrictive penis rings, vacuum erection devices (VED), and surgical placement of penile prostheses.
      5. Some literature even suggests the benefit of pelvic floor muscles (PFMs) physical therapy for men experiencing ED.
4. Orgasmic disorder:
   1. Of women between 57 and 85 years of age, 35% to 38.2% were unable to achieve orgasm, comparable to 16.1% to 33% of men in the same age category. Both men and women experienced more of a prevalence with advancing age. In women, this complaint ranked second only to low desire and trouble lubricating. In men, inability to achieve orgasm ranked fifth to lack of interest in sex, anxiety about performance, trouble maintaining or achieving an erection, and climaxing too early.
   2. For men or women to be diagnosed with orgasmic dysfunction, a delay in or absence of orgasm must happen following sufficient sexual stimulation.
   3. Simple explanation of sexual physiology and average time to orgasm can help some patients identify a misunderstanding of expectations.
   4. In cases of true orgasmic dysfunction, especially acute onset, patients should be worked up for underlying causes such as cardiovascular and/or neurologic etiologies.
   5. Visual examination of the genitals can help to rule out skin changes that can impede sensation.
5. Premature ejaculation:
   1. Premature ejaculation (PE) occurs in approximately 21% to 30% of men, with less prevalence in older men. This data coincides with worsening incidences of ED with advancing age.
   2. The consensus on the definition of premature ejaculation as stated by the International Society for Sexual Medicine (ISSM) is “ejaculation which always or nearly always occurs prior to or within about 1 minute.” The typical ejaculatory latency in men is between 4 and 8 minutes.
   3. Although there is no clearly defined cause for PE, some research suggests a correlation with multiple causes, including genetic predisposition, serotonin receptor activity, elevated penile sensitivity, and nerve conduction atypias. More recent evidence has shown a connection with PE, ED, and folate deficiency, possibly due to the effect of folic acid on the metabolism of nitric oxide.
   4. Men with PE often report embarrassment over their condition and frequently avoid sexual relationships because of it. Pharmaceutical treatment options utilized over the years include topical anesthetics, PDE-5is, and antidepressant medications.
   5. Combining pharmaceutical intervention with behavioral, cognitive, and sex therapy techniques is the most likely regimen to prove efficacious for premature ejaculation.
6. Genito-pelvic pain/penetration disorder:
   1. In the general female population, anywhere from 7% to 58% of women report pain with intercourse. Specifically in the older population, 12.7% of women between the ages of 40 to 80 report pain with sex, comparable to only 3.1% of men.
   2. There are many potential causes for painful intercourse in older women including the following:
      1. Genitounitary symptoms of menopause (GSM).
      2. Disuse atrophy.
      3. Pelvic floor dysfunction.
      4. Changes to vaginal anatomy due to surgery, such as vaginal hysterectomy.
      5. Vulvovaginal skin conditions and infections.
      6. In addition, physical disabilities, chronic pain, and cognitive changes can negatively impact the sexual response cycle, leading to pain during vaginal penetration.
   3. Estrogen plays a direct role in vulvovaginal epithelial cell maturation, which subsequently maintains healthy vulvovaginal pH and appropriate vaginal flora. During the perimenopausal period and following both natural and surgical menopause, significant changes occur to the vaginal microbiota in response to loss of endogenous estrogen. Symptoms of VVA occur in approximately 50% of postmenopausal women, including burning with urination, painful intercourse, bleeding with intercourse, vaginal discharge, vulvovaginal soreness, itching, and burning. Given the prevalence of this condition in older women, this population should be screened for signs and symptoms of VVA.
   4. There are many FDA-approved treatment options for VVA including local estrogen replacement and an oral selective estrogen receptor modulator (SERM):
      1. Not all women are candidates for treatment with hormones and/or estrogen agonists. Patients should be counseled and treated on a case by case basis, taking into consideration their medical history.
      2. In certain situations, collaboration with the patient’s other healthcare providers can help weigh risk versus benefit of traditional hormonal treatment for VVA.
   5. Vaginal surgeries such as hysterectomies and prolapse repairs can lead to scarring, strictures, and shortening of the vaginal canal. These surgical complications combined with VVA can result in tremendous pain with vaginal penetration, including intercourse, use of sexual aids and toys, and even pelvic examinations. If appropriate, 6 weeks of preoperative local vaginal estrogen can improve tissue integrity, including synthesis of mature collagen, decreased degradative enzyme activity, and increased thickness of the vaginal wall. This suggests improved tolerance for suturing and maintenance of connective tissue integrity for prolapse repair without significant changes to circulating estrogen levels.
   6. Pain with intercourse for any reason can result in avoidance of sexual contact:
      1. Avoidance of sexual contact can lead to disuse atrophy, further worsening painful sex.
      2. Fear of pain further compounds the problem and frequently the PFMs become involved. Muscle tension is a natural guarding response that occurs as a protective mechanism in the presence of pain. PFM dysfunction frequently accompanies pelvic pain and painful intercourse.
      3. Incorporation of PFM rehabilitation with a trained pelvic floor physical therapist is crucial to properly addressing these issues.
      4. Although sexual pain for men is not classified in the DSM, pelvic floor physical therapy (PFPT) can benefit men with pelvic floor dysfunction as well.
   7. Given recent changes to the recommendations for annual Pap testing in the older female population, many women are receiving less frequent routine pelvic medical care:
      1. Because the vulva and vagina are not overtly visible without intentional inspection, this area of the body can easily be missed, especially if conditions occur that are asymptomatic. For example, vulvar skin changes, vaginal pH shifts, and asymptomatic vaginal infections will not be identified without medical evaluation.
      2. It is important to maintain vulvovaginal inspection and pelvic examination in older women at least on an annual basis to identify changes from baseline:
         1. Use of colposcopy for the vulva and vagina can be helpful to better visualize mild skin changes.
         2. If consent is obtained, photography is a great way to document anatomical variances for future reference.
         3. There should be a low threshold for performing a biopsy with any concerning and grossly unidentifiable tissue findings.
7. Peyronie’s disease:
   1. Although male sexual pain is not classified in the DSM, Peyronie’s disease is an incurable condition involving fibrotic plaques of the penis that can result in a palpable plaque, curvature of the penis with erection, and pain with sexual activity. Penetrative intercourse can also result in partner discomfort due to the curvature.
   2. In addition to the physical sequelae, men frequently report embarrassment and psychological distress over the aesthetic changes and sexual implications. Younger men are prone to this condition due to the frequency and intensity of intercourse, although there is a peak of incidence in older men likely due to weaker erections; this causes more opportunity for tunical trauma secondary to erectile dysfunction.
   3. Treatment is available, including injectable therapies, interferon alpha-2b, and collagenase clostridium histolyticum, as well as surgery, although efficacy varies based on the severity of symptoms.
8. STIs:
   1. The medical provider should never assume potential for STIs based on patient age. It has been stated that sexual activity does not terminate at a certain age. Therefore, it is important to consider the fact that most sexually active individuals will contract an STI at some point in their lives.
   2. Many cases of STIs remain undiagnosed and many STIs can have long-term sequelae especially if left undiagnosed and untreated. The most common risk behaviors in individuals older than 50 include the following:
      1. Homosexual contact.
      2. Intravenous drug use.
   3. Although STIs predominately occur in the younger population, rates of STI episodes in the older population have been on the rise:
      1. More than 20% of STIs reported in the United States occur in the 15- to 24-year-old age group, yet British researchers found that STI rates have doubled in less than 10 years in the 45-and-older patient population. In the British study of STI trends in older people, rates of all five chosen STIs—Chlamydia trachomatis (CT), genital herpes, genital warts, gonorrhea (GC), and syphilis—increased. With nearly 4,500 reported episodes, genital warts and genital herpes were identified as the most common STIs, accounting for 45% and 19% of reported infections, respectively. The age group between 55 and 59 was most likely to be affected, and men were more likely than women.
      2. Among the general U.S. population, there was only a slight increase in STI incidents between 2000 and 2008, from 18.8 million to 19.7 million. Human papillomavirus (HPV) and trichomoniasis were the two STIs showing the sharpest increase in estimates of incidence. Trichomoniasis has the highest prevalence in women over the age of 40, whereas CT and GC have the lowest prevalence in this age category:
         1. HPV:
            • Although the prevalence rates of new HPV infection decline with age, there is still a significant prevalence in the older population.
            • The rate of progression from new infection to cervical intraepithelial neoplasia (CIN) 2+ or CIN 3+ was not higher for women aged 34 years and older comparable to younger women after 3 years of follow-up. Newly detected HPV infection does not typically persist or progress onto CIN 2 or worse disease regardless of age.
            • See Section III: Patient Teaching Guide “Herpes Simplex Virus.”
         2. Trichomoniasis:
            • Approximately 50% to 60% of trichomonas infections are asymptomatic in women.
            • Whereas some of the adverse health outcomes from infection with Trichomonas vaginalis (TV) are not a concern in the older patient population, such as preterm birth and low birth weight infants, trichomoniasis has been shown to increase the risk of HIV infection.
            • Refer to the Chapter 17 Patient teaching: See Section III: Patient Teaching Guide “Trichomoniasis.”
         3. HIV:
            • Despite comparable rates of reported sexual risk factors in the younger versus older population, late middle-age (50–59 years old) and old adults (60–75 years old) are less likely to use condoms and to have ever had an HIV test. HIV/AIDS knowledge and risk perception, perceived behavioral control, and behavioral intentions toward condom use are lower among older adults compared to their younger counterparts.
            • According to the Centers for Disease Control and Prevention (CDC), adults 50 years and older account for 45% of all Americans living with HIV:
              • People with HIV are living longer.
              • Older adults are more likely to be diagnosed with HIV later in the course of their disease, usually because they are unaware of risk factors.
            • Adults older than 60 are less likely to discuss HIV/AIDS with family, friends, and medical providers.
            • See Section III: Patient Teaching Guide “Reference Resources for Patients With HIV/AIDS.”
         4. Herpes simplex virus (HSV):
            • Painful ulcers result from HSV presentation; asymptomatic HSV type 2 shedding can contribute to chronic inflammation in the genital tract and painful intercourse.
            • The social stigma associated with HSV infection complicates those entering into new sexual relationships. Older patients with clinically diagnosed genital herpes should be counseled on preventive measures as well as ways to approach the topic with potential partners. Informing patients of the prevalence of this STI can help to lessen the fear and shame often associated with HSV.
            • See Section III: Patient Teaching Guide “Herpes Simplex Virus.”