Effects of Medical Disorders on Sexuality

Several medical disorders common in the elderly can affect sexual functioning, and physicians should discuss sexuality when treating patients with such disorders.

Persons who have had a myocardial infarction and those with angina or heart failure may avoid sexual activity because of concerns about risk to life. However, cardiac death during or after sexual activity is rare, and sexual activity provides an opportunity for mild exercise and release of physical and emotional tension. Cardiac evaluation can generally estimate the risk, and a physician's support and encouragement can greatly help patients for whom sexual activity is safe.

After a myocardial infarction, patients are usually advised to avoid sexual activity for 8 to 14 weeks, although no data support such a long abstinence. The duration of abstinence depends primarily on the patient's desire, general fitness, and conditioning. A patient's general fitness for sexual activity can be determined in several ways (eg, stress tests, ability to walk certain distances or up two flights of stairs).

Patients with angina may be anxious and require reassurance. Sexual activity should occur in a relaxed atmosphere; it may be best in the late morning, after a full night of sleep. A supine position during intercourse can reduce the level of activity to a level of energy expenditure equivalent to climbing one flight of stairs or walking one city block. Nitroglycerin can be used to prevent or treat angina. However, men who may need to use nitrates cannot use sildenafil to treat erectile dysfunction.

When heart failure is managed effectively, the physical exercise and emotional release associated with sexual activity may contribute to a patient's improvement. After an episode of pulmonary edema, patients are usually advised to avoid sexual activity for 2 to 3 weeks or until normal exertion (eg, climbing two flights of stairs) is possible without symptoms.

Patients with serious arrhythmias, which can occur after exercise or exertion, may need the reassurance of successfully performing a treadmill test to overcome anxiety about engaging in sexual activity. In rare cases, arrhythmias preclude sexual activity.

Persons with hypertension need not restrict sexual activity. However, untreated hypertension and the use of some antihypertensives increase the prevalence of erectile dysfunction. The effects of hypertension and antihypertensives on sexuality in women are not as well studied as those in men. Antihypertensives should be selected to avoid impairing sexual arousal whenever possible in elderly persons who are sexually active.

Sexual activity has not been shown to cause stroke or to increase neurologic deficit after stroke. Sexual functioning is likely to be affected, but sexual desire is not unless brain damage is severe. Some male stroke patients experience erectile dysfunction; male partners of stroke patients may also experience erectile dysfunction because they fear causing injury during sexual activity. Reassurance and advice by a physician may help the patient and partner. The unaffected side of the body should be the focus of physical stimulation during sexual activity. Patients in whom motor activity is compromised may benefit from the use of pillows, headboards, or overhead chain grips for support during sexual activity.

Men with diabetes mellitus experience erectile dysfunction two to five times more often than does the general population, although sexual desire is unaffected. Good control of the diabetes may reestablish potency. However, if the diabetes is already well controlled, erectile dysfunction is likely irreversible.

Hypothyroidism may reduce potency.

The discomforts and disabilities of osteoarthritis or rheumatoid arthritis may affect sexual function. A program of exercise, rest, and warm baths reduces arthritic discomfort and facilitates sexual performance. Experimenting with sexual positions that do not aggravate joint pain is often helpful. Because osteoarthritis tends to be less severe in the morning and rheumatoid arthritis less severe in the afternoon and evening, sexual activity can be planned for times of the day when pain and stiffness are least severe. Some rheumatoid arthritis patients find that regular sexual activity relieves their pain for 4 to 8 hours, possibly because of hormone production, release of endorphins, or the physical activity involved.

The pain of chronic or recurrent prostatitis may decrease sexual desire. Mild prostatitis may cause perineal pain after ejaculation. Therapy for chronic or recurrent prostatitis (eg, antibiotics, warm sitz baths, periodic gentle prostatic massage) may alleviate the problem.

Some women experience recurrent episodes of cystitis and urethritis after intercourse. Although these problems are usually due to the introduction of bacteria into the urethra during thrusting and are exacerbated by mucosal changes caused by atrophic urethritis, the cause may be unclear. Age-related estrogen decline may be a factor. A urologic or gynecologic evaluation is indicated to determine the cause and to plan preventive options or treatment.

About 50% of men with Peyronie's disease experience pain during intercourse. When the penis is angled too sharply, penetration may be impossible. However, tumescence is preserved in about 90% of patients, although some pain may occur. Treatment of Peyronie's disease may facilitate intercourse.

Men and women with chronic renal failure may have reduced levels of serum testosterone, although the mechanism is unknown. Patients with chronic renal failure often have diminished libido and erectile dysfunction, especially if testosterone levels are reduced. When the erectile dysfunction is associated with anxiety or depression, psychotherapy and couples counseling can be helpful. Kidney transplantation often restores potency in dialysis patients with erectile dysfunction.

In patients with Parkinson's disease, advanced neurologic involvement may cause erectile dysfunction. Patients with Parkinson's disease are commonly depressed, which may also lead to erectile dysfunction in men and reduced sexual desire in men and women. Sexual drive and performance improve in some men and women treated with levodopa, probably because of greater mobility and an increased sense of well-being; little evidence supports an aphrodisiac effect.

Shortness of breath in patients with chronic emphysema and bronchitis hinders physical activity, including sexual activity. Patients may improve sexual activity by resting at intervals, finding the least taxing ways to have sexual contact, and using oxygen.