Key learning points:
- It is important for health professionals to recognise that older people, despite illness and disability, may want to express their sexuality
- With age often comes physical sexual difficulties
- Older people can also have psychosexual and relationship problems
People in the Western world are living longer and generally enjoying many more years of good health. A woman may now expect to live as much as a third of her life post menopause. Our society has changed and the concept of one mate for life is not so common. Older people may find themselves in new relationships and generally expect more from their sex lives. In America, the National Survey of Sexual Health and Behavior 2010 showed that by the age of 60-69, 54% of men and 43% of women had reported having vaginal intercourse in the past year. By the age of 70 this had dropped to 42% and 22% respectively.1 A survey of sexual dysfunction in older adults aged 57-64 showed that women were less likely than men to report sexual activity. About half the men and women who were sexually active reported at least one bothersome problem.2
Sexual activity into older age has many benefits. There is often more time and less stress. There is usually no fear of pregnancy and contraception is rarely necessary. Sadly many people may not have a partner at this age, but the health professional must not forget that help is sometimes needed to enable them to masturbate. Older people may find it more difficult to discuss sexual difficulties, and healthcare professionals who are much younger than their patients may not see them as sexual and neglect to discuss the topic.
While discussing male and female problems as different entities it must be remembered that there can be couple of relationship problems at any stage of life. A person’s health or sexual problems can also have an impact on their partner. If the patient is in a new or casual relationship, safe sex must be discussed. Men may find condom use difficult if they have any erectile dysfunction (ED).
Age is the biggest risk factor for ED in men. Various disease processes also contribute. One study showed that 40% of 40-year-old men had occasional erectile problems and likewise 70% of 70-year-olds. Complete erectile failure increased from 5% at the age of 40 to 15% at the age of 70.3 In addition to asking men with long-term illnesses about sexual dysfunction, it is important to screen men who present with sexual dysfunction for diabetes and cardiovascular disease. Up to 10% of men with ED have undiagnosed diabetes. One study of men with insulin-dependant diabetes mellitus (IDDM) showed that 47% of them at the age of 43 years had erectile problems.4 Testosterone levels reduce with ageing, although it is not always associated with ED, and this may affect libido and general wellbeing. Those with type 2 diabetes and other overweight men have an increased risk of androgen deficiency.
General illness will also contribute to sexual difficulties both in terms of loss of desire and ED. Urinary problems and prostate surgery will have an impact. Some men have complete loss of erectile function after prostatectomy and most have retrograde ejaculation. Anti-androgenic drugs used in treatment of prostate cancer often affect libido. Antihypertensive medication may cause ED and it is therefore important to find out when a problem started. Antidepressants may cause sexual difficulties, with selective serotonin reuptake inhibitors (SSRIs) often causing delayed ejaculation. Sometimes it is difficult to work out whether the sexual dysfunction is due to the mental health problem or the medication. It is also important to ask about alcohol and recreational drug use.
People of any age can have psychosexual or relationship problems and these can interact with physical difficulties. It is always worth asking when the problem started exactly and why the patient has presented now. Men can develop problems associated with other factors in their life, such as sudden unemployment, life changes associated with retirement, bereavement and other life events.
Treatment in men
If the erectile problem is considered to be physical then phosphodiesterase type 5 (PDE5) inhibitors can be used with the usual caveats. These do not work in many diabetics or after some radical prostate surgery. Vacuum pumps or penile rings are helpful in many older men but their partner has to be in agreement. They can be used together with PDE5 inhibitors. Pumps can be prescribed by GPs and are free of charge for diabetics and men who have had prostate surgery. Some men will need more specialist help and use MUSE (medicated urethral system for erection) or Caverject injections.
Whether the problem is physical or psychological there needs to be sensitive discussion regarding their needs and those of their partners. Many men and their partners worry about the effects of exertion during sexual activity. Generally if a man can climb two flights of stairs without angina or severe dyspnoea then intercourse should be safe. Warnings need to be in place to stop if any problems arise. It is often important to examine the patient as you may find an undisclosed physical problem, or deep-seated emotional problems and fears that are only discussed at this time. Psychosexual counselling or couple therapy may be necessary.
As with men, female sexual dysfunction increases with age. This may or not be associated with the menopause. Some women experience a loss of libido after the menopause while others find no change. A lot of women develop problems with vaginal dryness, soreness and lack of lubrication. This tends to get worse with increased age. Occasionally it will cause secondary vaginismus, where the muscles around the vagina contract upon penetration causing pain. If there is difficulty doing a cervical smear then sexual activity should be discussed. On the other hand, for many women there is the relief of not having to worry about periods or contraception. Gynaecological disorders such as prolapse may impair enjoyment and many women will have had a hysterectomy. Often it is the fear associated with these physical problems that impairs sexual function. Genital examination and discussion by a sensitive health professional can help the patient dismiss unnecessary fears. Physical examination may also reveal an undisclosed vulval condition such as lichen sclerosus. Women can also develop general physical and mental health problems. Urinary incontinence may have an adverse effect on desire and ability to achieve orgasm.5 Fear of urine leaks during sexual activity may be inhibitory. There is far less research on the effect of diseases such as diabetes or heart disease in women. Increasing disability may make sexual intercourse more difficult and a health professional can help the women to be more imaginative in her sexual expression.
Treatment in women
Hormone replacement therapy (HRT) is not the panacea for menopausal women’s sexual difficulties, but has been shown to help some women. Systemic oestrogen, especially administered transdermally, can have significant effects and local oestrogen can prevent vaginal/vulval ageing and the subsequent discomforts.6 Tibolone can also help with libido but the jury is still out on the effect of testosterone. There are no longer any topical preparations licensed for women in this country.
It is equally important to explore the emotional factors and listen to the patient’s agenda. Genital examination can reassure a woman that her anatomy is normal and sometimes self-examination or use of vaginal trainers can help her regain her confidence. Women who do not want to use HRT can use vaginal moisturisers regularly and lubricants during intercourse. Listen to the patient’s agenda in the consultation and notice the feelings in the room.
Case study: John and Mary
John attended the special sexual dysfunction clinic run by his local diabetic unit. He had confessed to his diabetic specialist nurse that he could no longer get an erection and seemed very distressed. He was 63 years old and had been married to Mary for 32 years. He had type 2 diabetes, diagnosed when he was 58 years old, although he feels that it may have started several years before this. He was overweight. He did not smoke and was on no other medication apart from his diabetic pills. Initially he was embarrassed when talking to the female doctor, although a bit of him was pleased that he did not have to admit his deficiencies in front of another man. His erections had gradually become weaker over the last few years but they still managed to have some penetrative sex and ‘did other things’. Suddenly it had become much worse. He was quite surprised when the doctor asked him about masturbation. This was fine he said guiltily, although his erections were not quite what they were.
The doctor asked to examine him and he agreed. She said that nothing was wrong but he plucked up enough courage to ask about the size of his penis. She pointed out that it may appear shorter because of his pubic fat pad. He sat down and the doctor explained about the effect of the diabetes on his nerves and blood supply. She said that she was curious as to why masturbation was better than sex with his wife. He denied any relationship problems. To his surprise the doctor then remained quiet and waited for him to speak.
After a while he admitted that he was terrified of hurting his wife. She had recently had surgery for a prolapse and he did not know what to expect. She seemed ‘a bit tight’ and he was worried that she could split. His GP had prescribed some Viagra but he did not want to use it. The doctor reflected that he was afraid of hurting Mary if he got a strong erection with Viagra.
Mary was 60 years old. She had suffered with a vaginal prolapse for years. Despite this she and John had maintained their sex life. It wasn’t what it was and they used to joke about his erections - she knew that it was due to his diabetes and never blamed him. Her surgery was unpleasant - complicated by a post-operative infection. They did not attempt sex for several months. When they did John lost his erection completely. He got very upset and has not tried again. Mary did not want to push him as she thought that it was due to his diabetes.
As time went on she became more upset and was delighted when he agreed to go to the special clinic. When he came back he was very quiet but then explained what had happened with the doctor. Mary agreed to go to her own GP for an examination. Everything was fine and she came back with advice regarding use of lubricants. John agreed to try the Viagra and take it gently.
John’s initial problems were due to the diabetes. The ED had come on gradually – the usual pattern for a physical illness. The doctor had been surprised by the sudden change and the fact that masturbation was alright. She stopped asking questions and stuck with his agenda and the feelings in the room. She also examined him and that helped him air some fears. John reported back to Mary and they then took ownership of the problem as a couple and set about working it out.
Association of Psychosexual Nursing
1. National Survey of Sexual Health and Behavior (NSSHB). School of Health and Physical Education and Recreation, Indiana University: Bloomington; 2010.
2. Lindau ST, et al. A Study of Sexuality and Health Among Older Adults in the United States. N Engl J Med 2007;357:823.
3. Johannes CB, Araujo AB, Feldman HA, et al. Incidence of erectile dysfunction in men 40 to 69 years old: Longitudinal results from the Massachusetts Male Aging Study. J Urol 2000;163:460–463.
4. Klein R, Klein BEK, Lee KE et al: Prevalence of Self-Reported Erectile Dysfunction in People With Long-Term IDDM : Diabetes Care 1996;19(2):135-141.
5. Cohen BL, Barboglio P, Gousse A. The impact of lower urinary tract symptoms and urinary incontinence on female sexual dysfunction using a validated intstrument. J Sex Med 2008;5:1418-23.
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