1. Selvalingam Sothilingam Consultant Urologist
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
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 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

18. 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

19. 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

20. What is the lower limit of the normal range for testosterone?
Total: 11.0 nmol/L
Free: 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, 20

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 21

22. 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

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 25

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
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:

31. Hardness score correlates with maintenance of erection
EHS Maintain rigidity % %
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)
EHS SSI
0.5 <5%
3 60% % %
Goldstein I et al , J Sex Med 2008;1:1-7

33. 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

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 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

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.

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