Sexual dysfunction in old age

Abstract

The sexual behaviour of older people is more often the target of jocularity or ridicule than the subject of serious scientific research. As a consequence, relatively little is known about the sexual behaviour of the over-65s and such information as is available shows a polarisation according to gender, male sexual behaviour and dysfunction being viewed very much in the light of physical problems, whereas women's sexual behaviour revolves around attitudes towards sexuality and the psychological effects of ageing. This review will address the biological changes associated with ageing, the psychological and social concomitants, the prevalence of sexual dysfunction, its aetiological factors, and the management of common sexual problems including those found in an institutional setting. Biological changesMasters and Johnson described the physiology of coitus as having four components. Excitement, plateau, orgasm and resolution, all of which show age related changes. As ageing increases, desire may not always result in sexual excitement. The triggers for sexual excitement become more specifically sexual and may require intimate body contact and manual stimulation. The intensity of sexual fantasies decreases and it may take a man longer to achieve an erection and following ejaculation more time before an erection is possible. The physiological changes are listed in Box 1. In addition, older men experience anatomical changes, including thinning of the pubic hair, laxity of scrotal tissue, atrophy of the perineal muscles, loss of collagen tissue and occasionally weight gain. The phase of ejaculation undergoes changes which result in a decline in the intensity of orgasm and in the propulsive force of ejaculation. The volume of the ejaculate may be reduced by 50%. Sex drive and performance vary widely between individuals of the same group and the maintenance of sexual activity depends on factors such as regular sexual activity, the presence of a willing sexual partner, the absence of a major physical illness and the integrity of the relationship.Age-related changes in women (see Box 2) include thinning of the pubic hair, shrinkage of the labia, thinning of the vaginal mucosa and laxity of the perineal muscle. The thinning of the vaginal mucosa and the reduced lubrication may lead to dyspareunia and bleeding during intercourse. Orgasmic contractions may become painful.The ageing male experiences a reduction in the activity of the cells of Leydig with an associated drop in testosterone of 0.4-0.8% per year after the age of 50. Interested readers are referred to a Box 1. Physiological changes in ageing men Sexual organ atrophy Diminished testosterone level Delay in attaining erectionErection of poor quality Longer delay in achieving and maintaining a full penile erection Decline in intensity of orgasm Decreased hormone levels are associated with reduced desire

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