SEXcessful aging

1. SEXcessful aging Selvalingam Sothilingam Consultant Urologist

2. Closeness, intimacy and touch are lifelong needs that do not get old, even when we do

3. What is the distinction between sex and sexuality? • Sex as what happens below the waist, and in between the legs (behaviors) • Sexuality is the total expression of who we are as human beings.

4. Dennis Daily ‘s“Circles of Sexuality” model.

6. How people experience and express their sexuality will change throughout their lives. • Personal relationships take on an increased importance. • Reports show that the majority of men and women between the ages of 50 and 80 are still enthusiastic about sex and intimacy.

7. Frequency or ability to perform sexually will generally decline

8. Women troubles • Urinary incontinence (when urine accidentally leaks) • More frequent urination • Decreased sexual desire and arousal • Mood swings

9. Men troubles • Less firm or less frequent erections • Increased ‘recovery time’ or time between erections • Decreased force of ejaculation • Urinary incontinence (when urine accidentally leaks) • Decreased sexual desire and arousal • Increased risk of prostate cancer

10. Mr X • Retired Teacher, 73 years old • Lost his wife to Breast Cancer 4 years ago • Recently met another retired teacher, 69 years old, Mdm M who is also a widow. • He has anxiety on this new relationship • He experiences poor erections and has not been sexually active for 8 years since his wife was diagnosed with breast cancer.

11. Mr X has DM, Hypertension and had a cardiac bypass 10 years ago. • He frequently feels tired and does not exercise. • Spends most of his time at home but is ADL independent and does his own shopping. • He has 2 grown children who are currently overseas.

12. Problems • Medical Co morbidities • Late Onset Hypogonadism • Loneliness… • Anxiety with the new relationship • Erectile Dysfunction

13. Optimal erection hardness (e.g. cucumber) : is one of the key factors to satisfying sex life

14. ‘A hard man is good to find’ Mae West

15. Dating Game • Respect yourself • Respect your partner • Communicate • Have fun

16. Steps in managing ED • Laying the foundation • Intervention • Consolidation SHAPE Forum,2009

17. Foundation • Effective assessment • Bio-psycho-social approach • Accurate diagnosis of ED • Consider using a validated PRO, such as the EHS • Identification of contributory factors • Androgen deficiency/ co morbidities • Concomitant medications • Agreement of treatment goals • Goals should be realistic and holistic • What are the goals for the man, his partner and the couple?

18. Bio-psycho-social Assessment of ED

19. All men with ED should be screened for androgen deficiency Porst H & Buvat J (Ed). Standard Practice in Sexual Medicine (2006). Blackwell Publising, Oxford Authoritative, contemporary clinical guidance for ED management recommends that all men with ED have the following blood tests: • Blood sugar • Fasting lipid profile • Total or free morning testosterone • PSA (only where suggested by clinical picture)

20. What is the lower limit of the normal range for testosterone? Total: 11.0 nmol/L Free: 0.225 nmol/L Bioavailable: 5.2 nmol/L Malaysia 2006 Subang Mens health Study 2003 Klang Valley Men’s Health Community Study. 19.1% Men Testosterone< 11 Vermeulen & Kaufman, Aging Male 2002, 5; 3,170-176

21. Men at risk of androgen deficiency Men at high risk of testosterone deficiency include this with: • Type 2 diabetes • History of pituitary pathology/sellar irradiation or surgery • Obesity • Metabolic Syndrome • COPD • Chronic renal disease • HIV disease • Depression • Unexplained fatigue

22. Intervention • Educate patient and partner • How to optimise medication effect • How to integrate medication use into their sexual activity • Discuss partner sexual health and function • Prescribing issues • Ensure use of genuine medication • Discuss risks to health of counterfeit medication • Provide optimal dose • Provide adequate supply • Promote adequate usage

25. Consolidation Follow-up • Enquire about and address sub-optimal response • Consider using a validated PRO, such as the EHS • Dose escalation • Correct sub-optimal usage practices • Address adverse effects • Discuss partner sexual experience and treatment satisfaction

26. Treatment Options • Non-pharmacologic • Counseling and/or sex therapy • Pharmacologicall • Non-invasive • Minimally invasive • Invasive

27. Medications (PDE5 Inhibitors) • Viagra, Levitra, Cialis • Mechanism of Action: • PDE inhibitor and increases the cGMP that promotes and sustains smooth muscle relaxation • Indications: • Psychogenic ED • Mild vasculogenic ED • Neurogenic ED

28. Erection Hardness Score A new, simple and validated measure of erection hardness

30. The EHS Provides a Clear Treatment Goal Towards Optimal Erection Hardness (e.g. cucumber) Severe Erection Dysfunction Moderate Erection Dysfunction Suboptimal Erection Optimal Erection Penis is larger but not hard Impotent Penis is hard but not hard enough for penetration Soft Penis is hard enough for penetration but not completely hard Half-rigid Penis is completely hard and fully rigid Rigid Goldstein I, et al.N Engl J Med 1998;338:1397-1404.

31. EHSMaintain rigidity 4 68% 3 25% Hardness score correlates with maintenance of erection

32. Multinational, double-blinded, placebo-controlled trial of Viagra in men with ED 307 men (mean-based modelling) EHSSSI 0.5 <5% 3 60% 3.5 78.5% 4 93.1% Goldstein I et al , J Sex Med 2008;1:1-7

33. Penile Injection TherapyCaverject, Edex, Tri/Bi-Mix • Mechanism of action: smooth muscle vasodilator • Administration: 10, 20, 40ug • Inject directly into corporeal bodies of the penis • Results: 70%-90% • Dropout rates: 25%-60% • Side effects: pain (36%), priapism (4%), fibrosis

34. Vacuum constriction devices, such as the ErecAid, are often used in the treatment of ED. A man places his penis in the cylinder and vacuum suction increases blood flow to the penis.

35. Vacuum Constriction Device

36. Malleable Prosthesis

37. Inflatable penile implant

39. Treatment OptionsGoal directed therapy3 • Find out what the patient wants • Try to tailor the treatment to the patients needs and wants • Aetiology rarely affects treatment choice for the patient 3 Lue TF, World J. Urol 8:67,1990

40. How important is sexual satisfaction? AP Show Survey

41. AP SHOW Survey Conducted over 13 countries 3, 957 sexually active men (2, 016) and women (1, 941) Online self-administrated method or face-to-face interview (self completed questionnaire) May to July 2008 In Malaysia, 102 males and 100 females nationwide

42. Importance vs. Satisfaction Satisfaction with sex is as good as or even better than satisfaction with top rated life priorities Men consider sex to be the next most important life priority # 8 out of 17

43. Importance vs. Satisfaction Satisfaction with sex is as good as or even better than satisfaction with top rated life priorities Women consider sex to be #14 out of 17 on list of life priorities

44. Satisfaction with Sex and Overall Outlook on Life

45. Sexual Satisfaction and Overall Health

46. Importance and satisfaction by age

47. Summary

48. Causes of decreased sexual interest in older adults • General Physical health • Psychological Causes • Male Sexual Dysfunction- ED/Testosterone deficiency • Female sexual dysfucntion-reduced desire, dyspareunia, body image • Practical problems- no partner, institutionilized • Delay in seeking help- Geriatric Sexuality Breakdown Syndrome

49. Our role as physicians • Start intervention early • Take a sexual history from your patients especially those with risk factors (DM,Hypertension ,hypercholesterolemia, IHD,BPH, obesity,smokers) • Warn patients that ED is a risk factor for cardiovascular disease- encourage behavioural modification (stop smoking,exercise)- it may prevent your pt from future CV morbidity and mortality

50. Our role as physicians • Use available tools (IIEF questionaire, EHS) to evaluate ED • Try to interview both partners. • Recognise EHS 3 as ED • Understand that good sexual health equals satisfaction with other aspects of life including family life.