Travis Glenn MD; Monica Chaung MD; Darlene Moyer MD; HonorHealth Family Medicine Residency, Phoenix, AZ
July 2020
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TIPS FOR HELPING OLDER ADULTS WITH THEIR SEXUAL HEALTH
In the first of our two-part series on sexual health in older adults, we addressed the importance of taking a sexual history and how to effectively do so in a culturally appropriate and sensitive way. In this edition of Elder Care, we focus on common sexual health issues in older adults and how to address them - an important concern given the increasing percentage of older adults in our communities and practices. |
Common Performance Concerns
Physiologic changes associated with aging can lead to sexual performance concerns for both men and women (Table 1).
In women, decreasing estrogen causes changes in the vaginal epithelium, sometimes leading to dyspareunia. Treatment can include lubricants, vaginal estrogens, toys, or vaginal dilators. If patients opt for vaginal estrogens, it is important to counsel them appropriately on systemic absorption, risks, and benefits.
In men, erectile dysfunction (ED) is the main performance concern. ED can have organic, psychogenic, or mixed causes and treatment differs depending on the cause. Common organic causes of ED include low testosterone levels or microvascular disease. Microvascular disease can be treated with phosphodiesterase inhibitors while low testosterone may respond to hormone replacement therapy (HRT). Men should be counseled, however, on the potential risks of HRT such as further enlarging the prostate or possibly increasing the risk of cardiovascular events.
Both men and women can suffer from “widower syndrome,” which is a period of abstinence after the loss of a long-term partner. Another common complaint is decreased libido. Given many causes for this, it is important to take a comprehensive history and rule out behavioral concerns such as depression and anxiety.
Chronic Disease and Sex
Rising rates of obesity, cardiovascular disease (CVD), and diabetes combined with longer life expectancy have revealed an interesting interplay of chronic disease and sex (Table 2). As noted, microvascular disease is one of the common reasons for ED, and it is often caused by poorly controlled CVD risk factors like hypertension or diabetes. A key to preventing ED is early and sufficient control of those risk factors. Discussing these issues with patients when CVD risk factors are identified may provide patients with additional “incentives” for controlling those risk factors to prevent or delay development of ED.
Furthermore, men with a history of CVD may ask if their heart is healthy enough for sex. Current studies suggest that CVD carries a relative risk of myocardial infarction of 1.5% per sexually active men per year. Appropriate counseling should take place about what to do if patients experience chest pain during intercourse.
Another barrier may be chronic pain from arthritis or other causes. For patients whose sexual activity is being limited by pain, clinicians should discuss options for adequate pain control during intercourse.
Benign prostate hyperplasia (BPH) can cause some men to experience urinary incontinence during intercourse. If this occurs, providing adequate BPH treatment can help relieve the symptoms and the associated psychological distress. Women may also experience incontinence during sexual activity. For older women, the incontinence can be stress, urge, or mixed incontinence, any of which can be combined with pelvic organ prolapse. For women experiencing these symptoms, conduct a POP-Q to assess for level of prolapse and guide therapy as needed.
While dementia and cognitive impairment do not always correlate with decreased libido, there is sometimes concern about whether such individuals have the ability to consent to sexual activity. It is recommended to have early and frequent conversations about this with patients while they still have adequate cognitive capacity. Additionally, some memory care institutions have developed policies regarding consent to sexual activity. The references and resource list contains a link to one of the first such policies.
Sexually Transmitted Infections in the Elderly
There are increasing rates of syphilis, gonorrhea, chlamydia, and HIV in older adults, likely due to several factors. One is that as part of the aging process, the immune system has decreases in multiple immunologic cell lines, thus inhibiting the ability to fight infections. Another reason is that current condom use is estimated at only 15% overall and significantly less for older adults. This is thought to be due to today’s older adults not experiencing sex education in school during their youth, plus a lack of concern about pregnancy. Undiagnosed and untreated STIs can be mistaken as normal aging. Testing should be undertaken when screening is indicated or STI is suspected, and infections should be reported and treated. The references and resources list contains a link to the CDC’s treatment guidelines.
Final Comment
Sexual health is an important aspect of well-being that is commonly under-evaluated and under-treated in older adults. It is a multifaceted issue, encompassing physical and emotional concerns as well as raising ethical questions in those with dementia. As discussed, physical and emotional factors should be addressed as they can be improved through treatment.
Clinicians can also alleviate distress regarding sexual dysfunction by raising awareness about common symptoms. Teaching our patients about these symptoms normalizes the aging process in sexual health. In engaging our patients in open dialogue and providing a safe space to discuss their sexual health, clinicians will be better able to improve their patients’ quality of life and care for the whole person.
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Table 1. Common Sexual Performance Concerns |
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| Concern | Cause | Treatment |
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Dyspareunia |
Loss of estrogen causing vaginal atrophy, stenosis, or thinning of epithelial lining | Vaginal estrogen or lubricants |
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Widower Syndrome |
Death of long-term partner, often followed by a period of abstinence | Reassurance, behavioral therapy, and addressing misconceptions |
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Erectile Dysfunction
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Medications: Phosphodiesterase-5 inhibitors Devices: vacuums or implants Therapy: behavioral or couples counseling |
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Decreased Libido |
Usually multifactorial |
Treat underlying causes (e.g., depression) |
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Table 2. Chronic Conditions That Commonly Cause Sexual Dysfunction |
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Condition |
How it affects sexual health |
Way to treat or mitigate |
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Hypertension and cardiovascular disease |
Erectile dysfunction via vascular insufficiency and reduced endothelial integrity | Individual counseling based on known risk level and health conditions along with symptoms |
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Diabetes |
Erectile dysfunction via microvascular changes similar to hypertension and cardiovascular disease | Controlling diabetes in younger men |
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Benign Prostatic Hyperplasia |
Outflow obstruction which can lead to: erectile dysfunction, ejaculatory dysfunction, and hypoactive sexual disease Outflow obstruction which can lead to: erectile dysfunction, ejaculatory dysfunction, and hypoactive sexual disease |
Medications: alpha-1-blockers and 5-alpha-reductase inhibitors Office procedures: prostate steaming Surgeries: TURP and stents |
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Dementia |
Cognitive impairment does not correspond to decreased sexual desire | Most issues surround consent, but some nursing homes are addressing this concern with patients and their families |
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Arthritis |
Pain limits mobility | Treat chronic pain and discuss as-needed pain options |
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Lower Urinary Tract |
Often causes embarrassment about intimacy, but can also lead to dyspareunia if pelvic organ prolapse is present |
Providing reassurance and treating causes of incontinence Prolapse can be managed surgically or with pessaries |
References and Resources
- 2015 Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment/default.htm
- America Urologynecologic Society. POP_Q Tool. https://www.augs.org/patient-services/pop-q-tool/
- Inelmen Em, et al. The importance of sexual health in the elderly: breaking down barriers and taboos. Aging Clin Exp Res. 2012;24(3 Suppl):31-4
- Nursing Home Sexual Expression Policy. https://www.riverspringhealth.org/wp-content/uploads/2019/08/Sexual-Expression-Policy-1-17.pdf
- Sex After 50. American Sexual Health Association. 2019. http://www.ashasexualhealth.org/sexual-health/sex-after-50/
- Sexual Rights for Seniors. American Sexual Health Association. 2019. http://www.ashasexualhealth.org/sexual-rights-for-seniors/
- Sexuality in Later Life. National Institute for Aging. 2019. https://www.nia.nih.gov/health/sexuality-later-life