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Sexual dysfunction and the ageing male

  • Author Footnotes
    1 These authors contributed equally to this work.
    Kevan Wylie
    Correspondence
    Corresponding author. Tel.: +44 114 271 8674; fax: +44 114 271 8693.
    Footnotes
    1 These authors contributed equally to this work.
    Affiliations
    Porterbrook Clinic, Sexual Medicine, 75 Osborne Road, Sheffield, South Yorkshire S11 9BF, United Kingdom

    The University of Sheffield, Western Bank, Sheffield S10 2TN, UK
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  • Author Footnotes
    1 These authors contributed equally to this work.
    Gemma Kenney
    Footnotes
    1 These authors contributed equally to this work.
    Affiliations
    The University of Sheffield, Western Bank, Sheffield S10 2TN, UK
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to this work.

      Abstract

      Male sexuality in older age is an important issue but is not fully understood. This review aims to clarify the normal ageing process, the sexual behaviour of ageing men and the prevalence of sexual dysfunction. It identifies conditions affecting male sexuality in older age and highlights areas where more extensive research is required.

      Keywords

      1. Introduction

      Sexual dysfunction in ageing patients can be difficult to assess, often due to embarrassment on the part of the patient or doctor. Medical staff often do not directly ask about sexual problems and patients find it difficult to volunteer personal information. Moreover, many healthcare professionals lack of knowledge of the treatments available.
      Although it is often presumed that ageing patients do not engage in sexual activity and do not see sex as important, especially if they do not currently have a partner, it is, for some, a major factor in quality of life [
      • Moreira E.
      • Glasser D.
      • Nicolosi A.
      • et al.
      Sexual problems and help-seeking behaviour in the United Kingdom and continental Europe.
      ,
      • Bancroft J.
      Sex and aging.
      ,
      • Gott M.
      • Hinchliff S.
      How important is sex in later life? The views of older people.
      ,
      • Gott M.
      Sexual health and the new ageing.
      ].
      Loss of penetrative sexual intercourse may have an impact on intimacy. The centrality of sexual intercourse to many heterosexual intimate relationships was confirmed in a study by Gott and Hinchliff [
      • Gott M.
      • Hinchliff S.
      How important is sex in later life? The views of older people.
      ]. Men may be more affected than women are by a sexual dysfunction, perhaps because sexuality is considered to be crucial to their self-identity [
      • Giddens A
      The transformation of intimacy: sexuality—love and eroticism in modern societies.
      ], although this argument may not be accepted by many. Partnerships may be lost and re-establishing them may be more difficult than it is for younger people. It has been suggested by Jackson and Scott [
      • Jackson S.
      • Scott S.
      Gut reactions to matters of the heart: reflections on rationality, irrationality and sexuality.
      ] that being ‘bad at sex’ is not the same at being bad at gardening or golf!

      2. Normal ageing

      The Massachusetts male ageing study looked into the health of the normal ageing man between 1987 and 2004 [
      • O’Donnell A.
      • Araujo A.
      • McKinnlay J.
      The health of normally aging men: The Massachussets Male Aging Study (1987–2004).
      ]. Over that period, the proportion of over-65s in the USA increased from 1 in 25 to 1 in 8, which is a pattern seen in many other developed countries, and these figures are expected to continue rising. Life expectancy has increased but so too have morbidity, disability and inability to perform normal activities. Hormonal changes demonstrated in the Massachusetts study were decreases in free testosterone, by 1–2% each year, decreased DHEA, increased FSH, LH and SHBG [
      • O’Donnell A.
      • Araujo A.
      • McKinnlay J.
      The health of normally aging men: The Massachussets Male Aging Study (1987–2004).
      ]. The study found that even when serum testosterone levels are normal or high, its availability to tissues, which is the free testosterone, decreases between the ages of 40 and 70 in healthy and non-healthy men. Other hormonal changes were a decrease by 2–3% a year of DHEA and DHEAS (precursors of testosterone, androstenedione and estrone). The significance of this is unknown. Levels of DHT increased with age; it was hypothesised that serum DHT derives from testosterone breakdown in peripheral tissues and so does not decline. 3AAG, which is a metabolite of DHT, decreased in the participants but only by 0.6% a year and was found to be related to prostate cancer, as was a high level of total prostate specific antigen (PSA). Along with all these normal hormonal changes, there may also be vascular damage due to hypertension, diabetes and atherosclerosis, dementia or memory difficulties, arthritis and muscular weakness, pain conditions and polypharmacy.

      3. Sexual dysfunction

      The main areas of sexual dysfunction in men are [
      • Ralph D.
      • Wylie K.
      Ejaculatory disorders and sexual function.
      ,
      • World Health Organization
      The ICD-10 classification of mental and behavioural disorders.
      ,
      • Baldwin D.
      Depression and sexual dysfunction.
      ]:
      • desire—decreased interest in sexual activity, lack of spontaneous sexual thoughts,
      • erection—no spontaneous or nighttime erections, erectile dysfunction (failure to gain or maintain an erection adequate for sexual activity),
      • ejaculation—decreased pleasure from ejaculation, decreased volume of or no ejaculate, premature ejaculation, retrograde ejaculation (where semen passes into the bladder rather than along its usual route down the urethra).
      In the ageing male, the most common dysfunctions described are lack of desire and erectile problems. These can be due to hormonal changes as part of normal ageing or due to underlying conditions such as late-onset hypogonadism, or neurological and vascular disease processes.
      Doctors are known to be uncomfortable asking patients questions about their sex lives, particularly when they differ in terms of age, gender or sexual orientation [

      Maurice ML. Sexual medicine in primary care 1999 - CV Mosby.

      ,

      Moser 2005 (personal communication).

      ]. Most people with sexual problems attending a consultation hope that the doctor will raise the subject [
      • Metz M.
      • Seifert M.
      Differences in men's and women's sexual health needs and expectations of physicians.
      ] and doctors should ask, and be trained to ask, every patient regardless of their age, ‘Do you have any sexual concerns?’ [

      Moser 2005 (personal communication).

      ,

      Kleinplatz PJ. The Profession of Sex Therapy. Systemic Sex Therapy 2008 Routledge.

      ].
      Doctors are very well placed to normalize and affirm the value of fulfilling sexual relations for older patients. When assessing sexual activity in the elderly, however, this tends to be done solely in relation to coitus [
      • Kaiser F.E.
      Sexuality in the elderly.
      ], whereas many older adults engage in other forms of sexual activity, such as touching and caressing [
      • Bretschneider J.G.
      • McCoy N.L.
      Sexual interest and behavior in healthy 80- to 102-year-olds.
      ]. It should also be recognised that conditions which disproportionately affect the elderly may have a bearing on sexual activity. For example, chronic illnesses often affect sexual enjoyment indirectly, typically through anxiety and depression; moreover, general disabilities such as pain and stiffness may lead to changes in sexual repertoires. In addition, loss of privacy, as may be the case within communal residences, is a barrier to sexual activity.
      Sexual dissatisfaction and ejaculatory dysfunction have increased in men over recent decades, probably related to an introduction of erectogenic drugs [
      • Beckman N.
      • Waern M.
      • Gustafson D.
      • Skoog I.
      Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: cross sectional survey of four populations, 1971–2001.
      ]. Satisfaction with sex life, but not the importance attached to sex life, may play a mediating role in the association between erectile dysfunction and mental health. This suggests that if men with erectile dysfunction can learn to be satisfied with their sex lives, then mental health can be preserved [
      • Korfage I.J.
      • Pluijm S.
      • Roobol M.
      • Dohle G.R.
      • Schroder F.H.
      • Essink-Bot M.
      Erectile dysfunction and mental health in a general population of older men.
      ].

      4. Sexual behaviours in the ageing male

      There is some empirical evidence on the sexual behaviour of the ageing male. The Gothenburg study looked as the changes in sexual activity and views of 560 70-year-old men in four groups between 1971 and 2001 [
      • Beckman N.
      • Waern M.
      • Gustafson D.
      • Skoog I.
      Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: cross sectional survey of four populations, 1971–2001.
      ]. The participants were asked about their first sexual experience, timing in relation to marriage, recent intercourse (frequency and satisfaction) and any sexual dysfunction. All the participants had full general physical and psychiatric assessments. Reasons for exclusion from the study included dementia. Over the 30 years, the number of participants who were divorced and had partners they were not married to increased and the proportion widowed or never married decreased. Those with partners reported being happier with their relationships later in the study. The proportion who were sexually active increased from 47% to 66% over the study period, and the proportion who engaged in sexual activity more than once a week increased from 10% to 31%. High levels of satisfaction were reported by 71% at the end of the study (compared with 58% at the start) and more of the men had positive views towards sexuality in older age (82% in 1971, 97% in 2001). The prevalence of erectile dysfunction in the sample decreased over time (from 18% to 8%), which may be due to advances in treatment. The prevalence of ejaculatory problems increased over the 30 years, from 5% to 12%. The levels of premature ejaculation were consistent among the four groups, at 4%. The reasons for cessation of sexual intercourse were the same over the 30 years, and mainly involved male factors. Changes over the period may be due to higher levels of education, better socioeconomic status, better physical health, longer life expectancy and changes in society, including sex education, contraception and more acceptance of homosexuality.
      Another important study into the sexuality of ageing men also took place in Sweden. It involved 319 men aged between 50 and 80 years [
      • Asgeir R.
      • Helgason
      Sexual desire, erection orgasm and ejaculatory functions and their importance to elderly Swedish Men: A Population-based Study.
      ]. The participants were questioned about desire, erection and orgasm using the Radiumhemmets scale of sexual function, with additional questions on frequency of intercourse and distress due to sexual dysfunction. The men were divided into three age groups: 50–59, 60–69 and 70–80 years. The results from the groups were looked at separately and were also combined to get overall views of sexual function and ageing. The number of men having frequent desire, erections, orgasm and intercourse all decreased as the age of the group increased. The number of men with partners was high, at 83%. Overall, 71% still participated in sexual activity. Many men (68%) reported having adequate erections for sexual intercourse, although the rate of poor maintenance was high, at 72%. When the participants known to have medical conditions causing the erectile dysfunction were excluded, those with erections suitable for intercourse rose to 77%. Many men stated that it was important or very important that they maintained levels of desire, pleasure, erections and ejaculate volume as they got older. The men who had a decrease in sexual function compared with their youth were distressed by this and felt it was very important or important to regain their previous levels of sexual ability. This study shows that large numbers of older men still have the physiological ability to engage in sexual activity and intercourse and can be distressed if their sexual function decreases, with a negative impact on quality of life.
      In the US, the NSHAP study looked at 1455 men aged 57–85 years and their sexual behaviours [
      • Laumann E.O.
      • Das A.
      • Waite L.J.
      Sexual dysfunction among older adults: prevalence and risk factors from a nationally representative U.S. probability sample of men and women 57–85 years of age.
      ,
      • Lindau S.
      • Schumm P.
      • Laumann E.O.
      • et al.
      A study of sexuality and health among older adults in the United States.
      ]. In this study, men were more likely to be sexually active than women as they aged, but did not always report any problems to their doctor, instead ignoring the problem, taking measures such as stopping medication they believed was responsible for sexual dysfunction or buying medication off the internet. This can result in depression, social withdrawal and delayed diagnosis of underlying medical conditions, as well as possible worsening of medical conditions or the side-effects of unknown drugs. Once again there were three age groups in the study and across these groups involvement in sexual intercourse, oral sex and masturbation decreased as age increased. The numbers still involved in sexual activity were as follows: 83.7% of 57–64-year-old, 67% of 65–74-year-old and 38.5% of 75–85-year-old. Of those who did not partake in sexual activity, 55% blamed their poor physical health, including arthritis, cardiovascular disease and diabetes. The most common sexual problems reported by the men are shown below as combined averages for the three age groups, with the percentage who were bothered by these problems in parentheses: lack of interest, 28% (65%); erectile dysfunction, 37% (90%); anxiety about performance, 27% (75%); and inability to climax, 27% (73%). The prevalence of all these increased with age, but this was not the case for premature ejaculation, which affected 28% overall (71% of whom were bothered by the problem) and which was more prevalent among the lower age groups. Only 38% of the patients had discussed sex with their doctor since the age of 50 and 14% of the men took non-prescribed supplements or drugs for sexual problems. This study shows that high numbers of men still engage in sexual activity as they age, with many reporting problems that cause them bother but for which they have not sought help.
      Finally, the MSHHP study also found that sexual problems among the elderly were not invariably purely physical in origin, and could be, rather, responses to stresses in multiple life domains other than illness or disease states. The mechanism linking life stresses with sexual problems is likely to be poor mental health and relationship dissatisfaction. Physicians treating older adults with sexual problems should take into account both physical and psychosocial health, as well as intimate relationship issues [
      • Laumann E.O.
      • Das A.
      • Waite L.J.
      Sexual dysfunction among older adults: prevalence and risk factors from a nationally representative U.S. probability sample of men and women 57–85 years of age.
      ].
      Psychological relational and especially psychosexual skill factors become more important for men in their 40s and above. Establishing positive, realistic expectations are likewise important. The key to sexual desire is positive anticipation and feeling that ‘I deserve sex to be satisfying at this point in my life and relationship’. Sex generally changes from being automatic and autonomous to being intimate and interactive. Rather than sex being about predictability and control, sexual desire is about comfort, anticipation and receptivity and/or responsitivity [
      • McCarthy B.
      • McDonald D.
      Sex therapy failures; a crucial, yet ignored, issue.
      ]. The prime intervention for clinicians is to cognitively restructure sexuality and desire as an intimate interactive process and so to adopt the ‘good-enough sex’ model.

      5. Androgen deficiency

      Large numbers of older men have symptoms of androgen deficiency and could benefit from replacement therapy. Each year, testosterone production decreases naturally by 1–2%; more marked falls can lead to symptoms such as mood changes, low energy, decreased strength, increased sweating, decreased sex drive and erectile dysfunction [
      • Bhasin S
      • Enzlin P.
      • Coviello A.
      • et al.
      Sexual dysfunction in men and women with endocrine disorders.
      ]. This can be due to primary hypogonadism, when no testosterone is produced (for example in Klinefelter's syndrome), trauma and cancer treatment; no secondary sexual characteristics develop and blood tests show testosterone to be low and LH and FSH to be high.
      More commonly, low testosterone is due to low FSH, LH or GnRH, resulting from secondary gonadal failure [
      • Bhasin S
      • Enzlin P.
      • Coviello A.
      • et al.
      Sexual dysfunction in men and women with endocrine disorders.
      ]. This can be caused by, for instance, pituitary tumours, drug and alcohol abuse, systemic illness, haematological conditions and use of steroids. Changes in hormone levels can provide information on the cause. For example, low LH is seen in hypothalamic and pituitary conditions, whereas the level is usually normal or high with testicular defects. Prolactin measurements and MRI scans are useful in detecting brain tumours that cause hyperprolactinaemia. Although the correlation between sexual function and testosterone level is poor, with low levels there can be a decrease in spontaneous sexual thoughts, sexual desire, arousal, and early-morning and nighttime erections, as well as delayed orgasm and low volume of ejaculate.
      Testosterone replacement therapy can be used if testosterone is repeatedly low on early-morning blood tests, with a low bioavailable testosterone level calculated from the free testosterone, albumin and SHBG levels and there is clinical significance [
      • Bhasin S
      • Enzlin P.
      • Coviello A.
      • et al.
      Sexual dysfunction in men and women with endocrine disorders.
      ]. In studies of healthy older men, trials of testosterone have improved libido, increased lean muscle mass, increased strength and increased lumbar bone density. There is limited evidence to suggest improvement of sexual dysfunction after testosterone replacement but frequently other symptoms of androgen deficiency resolve. It can be used in most patients except those with prostate cancer, breast cancer, erythrocytosis, hyperviscosity and uncontrolled heart failure. It can be given as several treatment options, including patches, gel and injections. Whilst a patient is on testosterone treatment, a test for prostate specific antigen (PSA) level, assessment of lower urinary tract symptoms and digital rectal examination should be regularly performed, along with blood tests. The most significant side-effects of treatment are erythrocytosis, breast tenderness and enlargement, depression, sleep apnoea and prostate problems. The full international guidelines have recently been revised [
      • Wang C.
      • Nieschlag E.
      • Swerdloff R.
      • et al.
      Investigation, treatment and monitoring of late onset hypogonadism in males: ISA, ISSAM, EAU, EAA AND ASA recommendations.
      ].

      6. General medical conditions

      Many medical conditions have an effect on sexuality and have been linked to sexual dysfunction. The normal sexual response can be altered by a change in central or peripheral physiology seen in common disease pathways [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. Problems with desire, arousal and orgasm can all be predisposed to, precipitated by or maintained by medical factors. It is important to investigate those presenting with sexual difficulties for serious underlying conditions, as these may be present in up to a third of cases. Patients known to have chronic illness should also periodically be asked if they have any sexual problems, as they are common in many conditions.

      6.1 Cardiovascular disease

      In cardiovascular disease there is endothelial dysfunction leading to changes in the structure of the penile tissues and impaired vascular supply [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ,
      • DeBusk R.
      • Drory Y.
      • Goldstein I.
      • et al.
      Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel.
      ,
      • Kostis J.
      • Jackson G.
      • Rosen R.
      • et al.
      Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference).
      ]. Erectile dysfunction may be present in 44–65% of ageing men with cardiovascular disease. In cardiac failure, erectile dysfunction may affect up to 80% of men and risks of treatment for this include hypotension. In patients with hypertension, there is increased prevalence of erectile dysfunction due to endothelial dysfunction, along with structural changes to blood vessels decreasing the flow to the area.
      Those who present with erectile dysfunction may have unknown serious underlying cardiovascular disease and have a twofold increase in risk of myocardial infarction (MI) in 1 year [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. Erectile dysfunction is therefore an important sign of cardiovascular disease in ageing men. In a study of 132 men requiring coronary angiography, 45% had erectile dysfunction, and 58% of these had an earlier diagnosis of coronary heart disease [
      • Solomon H.
      • Man J.W.
      • Wierzbicki A.S.
      • Jackson G.
      Relation of erectile dysfunction to angiographic coronary artery disease.
      ]. Drugs used to treat cardiovascular disease can also lead to sexual dysfunction, including beta blockers and thiazide diuretics [
      • DeBusk R.
      • Drory Y.
      • Goldstein I.
      • et al.
      Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel.
      ]. Treatment for an erectile dysfunction should not be given until any cardiac condition is stabilised and an exercise test is normal, although there is little evidence to suggest an increased risk of MI during sexual activity. After MI, many men (10–54%) decrease sexual activity or do not resume it due to fears of further MI, lack of knowledge about treatment options for erectile dysfunction, or concomitant depression [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. Those taking nitrates should not be treated with PDE5 inhibitors and care should be taken with alpha blockers.

      6.2 Diabetes mellitus

      It has been reported that 49% of men with type 2 diabetes over the age of 66 have erectile dysfunction [
      • Fedele D.
      • Bortolotti A.
      • Coscelli C.
      • et al.
      Erectile dysfunction in type 1 and type 2 diabetics in Italy.
      ]. This is even more common in those with a long duration of diabetes, poor glycaemic control, high BMI, smokers and those with diabetic complications. Mechanisms for erectile dysfunction in diabetic men include neuropathy, endothelial dysfunction and smooth-muscle changes. Low NO is common in ageing diabetic men and is important for relaxation of penile smooth-muscle, necessary for engorgement of the penis during erection [
      • Zheng H.
      • Bidasee K.
      • Mayhan W.
      • et al.
      Lack of central nitric oxide triggers erectile dysfunction in diabetes.
      ]. In studies, PDE5 inhibitors were effective treatment in 56% of elderly men with diabetes and intracavernosal injection in 83%, with similar rates of side-effects to the general population [
      • Penson D.
      • Wessells H.
      Erectile dysfunction in diabetic patients.
      ,
      • Wagner G.
      • Montorsi F.
      • Auerbach S.
      • et al.
      Sildenafil citrate (VIAGRA(R)) improves erectile function in elderly patients with erectile dysfunction: a subgroup analysis.
      ]. Older men with diabetes and poor glycaemic control as well as metabolic syndrome also have higher rates of hypogonadism, retrograde ejaculation and low desire.

      6.3 Urological conditions

      Those with lower urinary tract symptoms may have an increased smooth-muscle tone, reduced NO in nerves and fibrosis of penile tissue [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. These can cause erectile dysfunction and ejaculatory problems such as painful ejaculation, seen in 20% of men with these symptoms [
      • Nickel J.C.
      • Narayan P.
      • McKay J.
      • Doyle C.
      Treatment of chronic prostatitis/chronic pelvic pain syndrome with tamsulosin: a randomized double blind trial.
      ]. Treatment of lower urinary tract symptoms may increase the prevalence of ejaculatory disorders, although alfuzonsin has a lower risk than tamsulosin [
      • Kaplan S.A.
      • Gonzalez R.R.
      • Alexis E.T.
      Combination of Alfuzosin and Sildenafil is Superior to Monotherapy in Treating Lower Urinary Tract Symptoms and Erectile Dysfunction.
      ]. Erectile dysfunction can be treated with PDE5 inhibitors.
      Low desire is a common feature of renal failure. It can be due to many factors, including Leydig cell dysfunction, low GnRH, low zinc, high LH and FSH levels, anaemia and depression [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. Erectile dysfunction is due to endothelial damage, structural changes and low NO due to uraemia, and is precipitated by hypertension and diabetes. Limited research is available on the best methods of treatment to improve sexual function. PDE5 inhibitors may work to magnify the action of the NO present, to give an erection.
      Many surgical procedures in the pelvis commonly performed in ageing men can damage the nerve supply and lead to retrograde ejaculation or erectile dysfunction [
      • Rees P.
      • Fowler C.
      • Maas C.
      Sexual function in men and women with neurological disorders.
      ]. Nerve-sparing surgical techniques tested in radical prostatectomy and cystoprostatectomy allowed early recovery of sexual function in 62% and 96% of participants, respectively, and in those still with erectile dysfunction there was an increased response to sildenafil [
      • Rees P.
      • Fowler C.
      • Maas C.
      Sexual function in men and women with neurological disorders.
      ].

      6.4 Depression

      Depression may be present alone or commonly presents concomitantly with diseases of the older population, such as dementia, stroke and cardiovascular disease [
      • Baldwin D.
      Depression and sexual dysfunction.
      ,
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ,
      • Ko D.
      • Hebert P.
      • Coffey C.
      • et al.
      Beta-blocker therapy and symptoms of depression, fatigue and sexual dysfunction.
      ,
      • Kennedy S.
      • Rizvi S.
      Sexual dysfunction, depression and the impact of antidepressants.
      ]. Common types of sexual dysfunction present in ageing depressed patients are low desire, delayed ejaculation and erectile dysfunction (in 26–50% untreated depressed patients) due to a change in limbic neurotransmitters [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. The dysfunction can be due to the depression or the treatment, although it is not always clear which [
      • Baldwin D.
      Depression and sexual dysfunction.
      ,
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. It is important to ask depressed patients about sexual problems and to screen those with sexual difficulties for signs of low mood. SSRIs are the most commonly prescribed type of antidepressant, although they can cause new-onset erectile dysfunction in 22–41% of older men and have a similar effect on desire [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. They are known to delay ejaculation, and indeed have commonly been used as a treatment for premature ejaculation [
      • Kennedy S.
      • Rizvi S.
      Sexual dysfunction, depression and the impact of antidepressants.
      ]. There is evidence to show that if erectile dysfunction is treated, depressive symptoms may resolve, decreasing the need for treatment of the mental health condition [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ]. (A similar finding has been shown for pain disorder.) In those who do require medical treatment for depression, the drug should be carefully chosen to decrease the risk of causing or aggravating sexual dysfunctions [
      • Basson R.
      • Schultz W.
      Sexual sequelae of general medical disorders.
      ,
      • Ko D.
      • Hebert P.
      • Coffey C.
      • et al.
      Beta-blocker therapy and symptoms of depression, fatigue and sexual dysfunction.
      ,
      • Kennedy S.
      • Rizvi S.
      Sexual dysfunction, depression and the impact of antidepressants.
      ].

      7. Neurological disorders

      Conditions affecting the neurological system can have a huge effect on sexuality at all ages [
      • Rees P.
      • Fowler C.
      • Maas C.
      Sexual function in men and women with neurological disorders.
      ]. Below, we have focused on two common conditions which affect predominantly ageing men. Often there is a decrease in sexual desire due to changes in the brain and spinal tract damage can reduce the ability for sexual arousal, erection and ejaculation. Problems such as decreased mobility, personality changes and incontinence can cause further problems in the ability to engage in sexual activity, so this is a controversial area.

      7.1 Stroke

      There is a decline is sexuality in many ageing men after a stroke, which may be due to vascular disorders, depression, physical disability or adverse effects of drug treatment [
      • Rees P.
      • Fowler C.
      • Maas C.
      Sexual function in men and women with neurological disorders.
      ]. Depending on the area of brain affected and the severity of the stroke, the patient can have different sexual problems. There may be deficiencies in growth hormone and gonadotrophins, causing decreased desire and other sexual dysfunction. An increased libido and disinhibited sexual behavior occur in around 10% of patients after a stroke, although more common complaints are decreased desire and erectile dysfunction. Treatment of physical problems such as spasticity may improve the ability for sexual contact and PDE5 inhibitors or intracavernosal injections can be improve erectile function. However, even if patients do appear to recover well physically after a stroke, many ageing men do not return to their previous level of sexual activity, as they have fears about its medical adverse effects.
      A study by Buzzelli et al. [
      • Buzzelli S.
      • di Francesco L.
      • Giaquinto S.
      • Nolfe G.
      Psychological and medical aspects of sexuality following stroke.
      ] examined the sexual life after stroke of 72 patients, with a mean age of 63.7 years. They found a decline in sexual activity; at an individual level, the decline was about 35% in the frequency of performance, but the percentage of patients experiencing a decline was quite high (83.3%). Neither gender nor injured hemisphere accounted for the sexual decline and there was a lack of correlation with age, education, disability and depression. The data agreed with existing opinion that psychological issues rather than medical ones account for disruption of sexual function in stroke survivors. A recent study by Jung et al. [
      • Jung J.H.
      • Kam S.C.
      • Choi S.M.
      • Jae S.U.
      • Lee S.H.
      • Hyun J.S.
      Sexual dysfunction in male stroke patients: correlation between brain lesions and sexual function.
      ] found that ejaculation disorder was likely after lesions of the right hemisphere, whereas a decrease in sexual desire was more likely in patients with lesions of the left hemisphere. A decrease in sexual desire may be secondary to depression rather than a direct result of brain damage.

      7.2 Parkinson's disease

      There is little research into changes in the sexuality of men with Parkinson's disease. These men have been reported to have higher rates of dissatisfaction sexually and erectile dysfunction than the general population in some studies [
      • Rees P.
      • Fowler C.
      • Maas C.
      Sexual function in men and women with neurological disorders.
      ]. Changes in sexual behavior may be due to dopamine having a role in desire, erection, reward-seeking behavior and sexuality. Dopamine replacement may improve these symptoms and this treatment may cause the hypersexuality seen in some patients with Parkinson's disease. Treatment of erectile dysfunction is the usual route, although PDE5 inhibitors can increase the risk of hypotension. An improvement in physical symptoms such as mobility may increase sexual activity.
      In a study by Yu et al. [
      • Yu M.
      • Roane D.M.
      • Miner C.R.
      • Fleming M.
      • Rogers J.D.
      Dimensions of sexual dysfunction in Parkinson disease.
      ], 21 patients with Parkinson's disease and their partners completed the Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR). Seventeen male patients demonstrated profound impairment in the dimension of sexual arousal, behaviour, orgasm and drive. Over half the patients (53%) scored above 50% in sexual fantasy subscale scores, and those subscale scores were positively correlated with the duration of Parkinson's disease. This demonstrated that the patients with advancing disease remained interested in sex. Thus, sexual dysfunction is clinically relevant to this group and, as such, must have attention from attending physicians.

      Provenance

      Commissioned and externally peer reviewed.

      Conflict of interest

      None declared.

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