Selvalingam Sothilingam Consultant Urologist SEXcessful aging Selvalingam Sothilingam Consultant Urologist

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

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.

Dennis Daily ‘s“Circles of Sexuality” model.

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.

Frequency or ability to perform sexually will generally decline

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

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

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.

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.

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

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

‘A hard man is good to find’ Mae West

Dating Game Respect yourself Respect your partner Communicate Have fun

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

Foundation Effective assessment Accurate diagnosis of ED 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? 17

Poor past sexual experiences Bio-psycho-social Assessment of ED Biomedical Psychological Social Chronic diseases Intra-individual Inter-personal Predisposing Factors Hypertension Dyslipidaemia Diabetes Hypogonadism Poor past sexual experiences Religion-based restrictions on sex? Guilt? Precipitating Medication Smoking Stressful life event Younger partner Loss of wife New relationship Maintaining Vascular disease Anxiety Fear Problems with Communication 18

All men with ED should be screened for androgen deficiency 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) Porst H & Buvat J (Ed). Standard Practice in Sexual Medicine (2006). Blackwell Publising, Oxford 19

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 20

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 21

Intervention Educate patient and partner Prescribing issues 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 22

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 25

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

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

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

The EHS Provides a Clear Treatment Goal Towards Optimal Erection Hardness (e.g. cucumber) Severe 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 Moderate Erection Dysfunction Goldstein I, et al. N Engl J Med 1998;338:1397-1404.

Hardness score correlates with maintenance of erection EHS Maintain rigidity 4 68% 3 25% Hardness score correlates with maintenance of erection

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

Penile Injection Therapy Caverject, 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

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.

Vacuum Constriction Device

Malleable Prosthesis

Inflatable penile implant

Treatment Options Goal 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

How important is sexual satisfaction? AP Show Survey

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

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

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

Satisfaction with Sex and Overall Outlook on Life

Sexual Satisfaction and Overall Health

Importance and satisfaction by age

Summary

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

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

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.

Overall, Malaysians are interested in improving their sexual experience Recognize Erectile Dysfunction as a problem in Malaysia