© Springer International Publishing AG 2018
S. Masiero, U. Carraro (eds.), Rehabilitation Medicine for Elderly Patients,
Practical Issues in Geriatrics, DOI 10.1007/978-3-319-57406-6_50
P. Di Benedetto
University Tor Vergata, Rome, Italy
Physical Activity and Sexual Function
in Older People
Paolo Di Benedetto
The number of people 65 years of age and older continues to rise in the Unites
States of America (USA) and in the Western countries. In the USA in particular
from approximately 35 million in 2000, the persons aged over 65 by 2030 will be
71 million, 20 million of whom will exceed the age of 80.
Almost 75% of elderly persons have at least one chronic illness, and about 50%
have at least two chronic illnesses. The well-being and quality of life (QoL) of older
people are often seriously compromised even in subjects not complaining of degen-
erative or vascular neurological diseases, psychiatric disorders, or oncological prob-
lems. A healthy lifestyle lowers risks of many diseases and promotes a feeling of
well-being: a balanced diet and regular physical activity can help prevent some of
the health problems associated with aging and reduced mobility.
In this context, multiple studies found that sexuality continues to be an important
aspect of life for many adults throughout midlife and into old age [1–3]. The
American Association of Retired Persons reported in 2005 that 62% of men and
51% of women between ages 60 and 69 believed sexual activity is an important
component of a good relationship and an acceptable QoL: these ﬁgures declined
slightly after age 70. With regard to that, the National Council of Aging (NCOA)
reported that 71% of men in their sixties, over 57% in their seventies, and 27% in
their eighties engaged in sexual activity at least once a month; these percentages
were lower for women (51%, 30%, and 18%, respectively). The study of
Bretschneider and McCoy concluded that the majority of women and men over
eighties continued to fantasize about intimate contact with a partner, even if there
are gender differences (41.2% of males aged 75–85 showed an interest in sex
compared with 11.4% of females the same age [4, 5]). Then, it has been stated that
many elderly persons enjoy an active sex life in contrast with the general perception
of an “asexual” old age and the prevailing myth that aging and sexual dysfunction
(SD) are inexorably linked.
The purpose of this chapter is to provide an overview of aging on the sexual life
of “healthy” men and women and to describe the role of physical activity and exer-
cise training as an important aspect of prevention and treatment of SD in the
50.2 Sexuality in Older Men and Women
Although erectile functioning tends to decline progressively beginning in midlife, it
should not be inferred that erectile failure is an inevitable consequence of aging.
Certainly older men suffer from multiple typical changes in erectile dysfunction
(ED) and ejaculatory and orgasmic disorders: lengthier delay in reaching a full erec-
tion, less rigidity of the erect penis, fewer or no erections during sleep, increase
latency to ejaculation, less forceful ejaculation, reduced volume of sperm expelled
at each ejaculation, and lengthened refractory period following ejaculation (span-
ning sometimes as long as a few days). ED is prevalent among men and its presence
is often an indicator of systemic disease. Risk factors for ED include cardiovascular
disease, hypertension, diabetes mellitus (DM), tobacco use, hyperlipidemia, hypo-
gonadism, lower urinary tract symptoms, metabolic syndrome, and depression.
Addressing the modiﬁable risk factors frequently improves a patient’s overall health
and increases life span. The literature suggests that smoking cessation, treatment of
hyperlipidemia, and increasing physical activity will improve erectile function in
many patients. How the treatment of DM, depression, and hypogonadism impacts
erectile function is less clear. Clinicians need to be aware that certain antihyperten-
sive agents can adversely impact erectile function. Androgen serum levels gradually
decrease in men beginning around age 50 and are often implicated in the decline of
sexual responsiveness; some studies suggest that the beneﬁts of testosterone treat-
ment for improving sexual function are limited to those whose testosterone levels
fall below a relatively low “threshold” value that seems to be necessary to maintain
an adequate sexual function.
Unlike men, whose sexual performances generally decrease after early adult-
hood, women’s sexual responsiveness does not show such a consistent pattern over
the life span: the incidence of sexual problems in women may actually decrease
after early adulthood, and sexual satisfaction among older women may remain
somewhat higher that in men. Menopause is characterized by a dramatic reduction
in estrogen, progesterone, and androgen levels. Sexual changes are well known:
low desire (43%), reduction of vaginal lubrication (39%), lining of the vaginal wall
thins, shortening of the vagina, atrophy of the genital tissues, orgasmic dysfunc-
tion, or inability to climax (34%) . All these factors may lead to painful sexual
intercourse (dyspareunia, vaginismus, and vulvar vestibulitis). Age-related changes
P. Di Benedetto
in women somewhat mirror those that occur in men: these changes are related to
vaginal lubrication, clitoral responses, and orgasm that tends to be briefer and asso-
ciated with fewer muscular contractions. These declines in sexual responsiveness
may be reduced sometimes by a regular sexual activity, although the mechanism
of beneﬁt is not understood. The role of estrogen and androgen supplementation in
women is not clear: there are insufﬁcient data for a clear risk-beneﬁt of hormone
treatment . For reducing the risk of systemic estrogen therapy, localized estrogen
preparations can be effective alternatives in order to improve vaginal dryness and
irritation. There is not enough evidence that any of the complementary therapies
available are any better than placebo for menopausal vasomotor symptoms and few
safety data exist .
We have also to consider that women often avoid sexual intercourse because of
pelvic ﬂoor dysfunction: not only overactive bladder and urinary incontinence
(urgency, stress, or mixed urinary incontinence) but also, and more frequently,
chronic pelvic or low back pain conditions may interfere with a good sexuality.
Irrespective of the site of pain, women complaining of chronic pain generally are
depressed, with higher pain scores associated with greater depression.
50.3 Sexuality as an Aspect of Healthy Aging
Clinical studies suggest that many elderly couples discontinue sexual activity due to
illnesses, particularly in the male partner. Some chronic medical conditions among
aged patients (including cardiovascular diseases, hypertension, and DM) are associ-
ated with various sexual problems in men and women. Sexual dysfunction height-
ens anger, frustration, and depression with the involvement of the partners that often
present with similar symptoms. Patients with chronic heart failure (CHF) have sex-
ual dysfunction that impairs QoL: recent trials have demonstrated that exercise
training (ET) improves QoL of CHF patients, but it is not established whether this
beneﬁt may be associated with an improvement in SD.
Moreover, several drugs are commonly associated with sexual dysfunction.
Besides benzodiazepines, tricyclic antidepressants and selective serotonin reuptake
inhibitors (SSRIs), used for the treatment of depression, may have well-documented
side effects: decreased sexual interest, sexual arousal difﬁculties, loss of libido, and
hyporgasmia. Other drugs frequently associated with sexual complaints include
beta-blockers and some diuretics. Consequently, the effects of current medication
used should be considered in the sexual health assessment.
In the last years, there is a more and more growing evidence suggesting that
lifestyle factor (particularly physical activity, eating right, not smoking, getting
enough sleep, and balanced diet) may offer some protection against sexual prob-
lems, frequently associated with health concerns. In this regard, Derby et al. reported
that obesity status was associated with ED, with baseline obesity predicting a higher
risk regardless of follow-up weight loss, whereas physical activity status was asso-
ciated with ED, with the highest risk among men who remained sedentary and the
lowest among those who remained active or initiated physical activity .
50 Physical Activity and Sexual Function in Older People
50.4 Assessment of Sexual Function in the Elderly
A diagnosis should be made when symptoms cause distress or interpersonal problems.
The assessment of SD in elderly should include a sexual history, a discussion of
how sexuality has been experienced over time, laboratory testing, health conditions
(presence of comorbidities), concurrent medications, and psychological and neuro-
logical evaluation . Moreover, in males particular attention must be given to
patients with cardiovascular disease, following the algorithm for determining the
level of sexual activity according to cardiac risk in patients with ED . Actually,
older males who present with complaints of ED should be screened for cardiovas-
cular disease because comorbidity often exists even though most men are asymp-
tomatic prior to the onset of an acute cardiac event. The rate of ED in older adult
men with coronary artery disease (CAD) is increased compared to those without
CAD. ED typically presents about 3 years prior to onset of CAD symptoms, and
older men with ED have a 75% increased risk of developing peripheral vascular
In the medical evaluation of older female patients with sexual problems, it is
important to inquire about early sexual experiences, including childhood sexual
abuse, that impact greatly on their sexuality in later life. Other clinical factors that
impact on older women’s sexuality include breast surgery, urinary incontinence, and
hysterectomy. With regard to this, it is necessary to assess pelvic ﬂoor dysfunction,
particularly pelvic organ prolapse, chronic pelvic pain, and urinary incontinence: all
these conditions signiﬁcantly bother the sexuality. When SDs are related to the
menopause, customized hormone replacement therapy is the treatment of choice.
50.5 Physical Activity as a Treatment Modality of Sexual
Dysfunction in the Elderly
Sedentary lifestyle predisposes to metabolic syndrome (MetS), a clustering of meta-
bolic disorders: visceral obesity, hypertension, dyslipidemia, and DM. MetS com-
prises a high risk for CVD events even in the absence of DM. Mechanisms that link
MetS to increased CVD risk are, however, incompletely understood. Many of the
physiological changes of aging as well as those secondary to physical inactivity are
reversible or retarded by exercise. Bone density, muscle mass, aerobic conditioning,
and ﬂexibility can also be increased through an appropriate exercise program.
Physical activity and strength/ﬂexibility exercises can also reduce the fatigue and
improve quality of sleep, stress, depression, weight control, gastrointestinal func-
tion, and sexuality.
Regarding this latter, many studies report a clinical evidence of beneﬁts induced
by physical activity on ED and, in general, on sexual responsiveness both in men
and women. The literature shows that ED in middle- aged men is often an early
event in endothelial damage and has been associated with cardiovascular diseases
. Physical activity (in association with Mediterranean diet) is able to improve
both sexual responses and overall cardiovascular health in men and women .
P. Di Benedetto
There are conﬂicting data regarding the effects of exercise on androgen or estrogen
status, but in clinical practice it would be recommended to add regular physical
activity to balanced diet and drugs to achieve better therapeutic results. Regarding
the ED in males, besides the well-known phosphodiesterase type 5 (PDE5) inhibi-
tors, it is recently reported that statins could be considered as adjuvant or alterna-
tive therapy, because of their protective effect on the dyslipidemia and reduction of
endothelial damage .
In men and women with pelvic ﬂoor dysfunction (overactive bladder, urinary
incontinence, pelvic organ prolapse, constipation and fecal incontinence, chronic
pelvic pain), it is mandatory also to organize a correct pelvic ﬂoor muscle training,
in association with other pelvic ﬂoor treatment modalities (as biofeedback, func-
tional electrical stimulation, and behavioral modiﬁcations) and pharmacological
50.5.1 Physical Activity
Many authors stated that it is never too late to start an exercise program or a generic
physical activity. To stay healthy or to improve health, older adults need to do two
types of physical activity each week: aerobic and strength exercises.
Patients aged 65 or older, who are generally ﬁt and have no health conditions that
limit their mobility, should try to be active daily in accordance with the recommen-
dations from the American College of Sports Medicine (ACSM) and the American
Heart Association (AHA) .
The older people should do:
– At least 150 min of moderate aerobic activity such as cycling or walking every
– Strength exercises on 2 or more days a week that work all the major muscles
(legs, hips, back, abdomen, chest, shoulders, and arms)
Two alternatives are possible in the context of aerobic activity, in association
with strength exercises:
– 75 min of vigorous aerobic activity such as running or a game of singles tennis
– A mix of moderate and vigorous aerobic activity every week (e.g., two 30-min
runs, plus 30 min of fast walking, equates to 150 min of moderate aerobic
A rule of thumb is that 1 min of vigorous activity provides the same health ben-
eﬁts as 2 min of moderate activity.
Examples of activities that require moderate effort for most people include walk-
ing, water aerobics, ballroom and line dancing, riding a bike on level ground or with
few hills, playing doubles tennis, canoeing, and volleyball.
50 Physical Activity and Sexual Function in Older People
Instead, examples of activities that require vigorous effort are jogging or running,
aerobics, swimming fast, riding a bike fast or on hills, singles tennis, energetic
dancing, and martial art.
Moderate activity will raise the heart rate and make breathe faster and feel warmer;
exercising at moderate level signiﬁes that people can still talk, but cannot sing the
words to a song. Daily chores such as shopping, cooking, or housework do not count
toward the 150 min of moderate activity, because the effort is not enough to raise
the heart rate, but they are important nonetheless, as they break up periods of sitting.
Older adults at risk of falls, such as people with weak legs, poor balance, and
some medical conditions, should do exercises to improve balance and coordination
on at least 2 days a week (yoga, tai chi, and dancing).
Vigorous activity makes the breath hard and fast. Working at this level, the peo-
ple will not be able to say more than a few words without pausing for breath. In
general, 75 min of vigorous activity can give similar health beneﬁts to 150 min of
moderate activity, and there is a good evidence that vigorous activity can bring
health beneﬁts over and above that of moderate activity.
Regarding activities that strengthen muscles, whose good function is necessary
for all daily movement, maintaining strong bones, regulating blood sugar and blood
pressure, and maintaining a healthy weight, they include carrying or moving heavy
loads, dancing, heavy gardening, exercises that use body weight for resistance (such
as push-ups or sit-ups), yoga, and lifting weights. There are many ways for strength-
ening muscles, whether at home or in the gym; in these programs also, ﬂexibility
exercises are recommended.
Muscle-strengthening exercises are not an aerobic activity; then they have to be
done in addition to 75–150 min of aerobic activity. It is possible to do activities that
strengthen muscles on the same day or on different days as aerobic activity.
Some vigorous activities count as both an aerobic activity and a muscle-
strengthening activity and include circuit training, aerobics, and running.
Moreover, to maintain the ﬂexibility necessary for regular physical activity,
older adults should perform activities that maintain or increase ﬂexibility on at least
2 days each week for at least 10’ each day. Balance exercises are also indicated to
reduce risks of injury from falls.
Obviously modiﬁcations of the exercise prescription are advisable in selected
aging-related chronic conditions, as degenerative joint diseases, CHF, diabetes mel-
litus, low back pain, osteoporosis, chronic obstructive lung disease, hypertension,
and orthostatic hypotension . Many randomized controlled studies have shown
that physical activity and exercise have a beneﬁcial effect on physical performance,
pain, and disability; there is also a strong evidence that resistance training is the
most effective strategy to counter and prevent age-related muscle weakness.
50.5.2 Physical Activity and Sexual Function
Many studies demonstrated the presence in men of ED and METs. Physical activity
is a strong and independent predictor of normal erectile function among all as well
as among only MET subjects. Thus, especially MET patients presenting with ED
P. Di Benedetto
should be considered at high risk for CVD. Consequently, physical activity is very
important in the management of METs, ED, and concomitant diseases, leading the
researchers to conclude that enhanced sexuality is directly correlated with the
improvement in physical ﬁtness .
Obviously, balanced diet, reducing stress, cessation of smoking, and getting
enough sleep are all important for having a satisfying sex life, but physical activity
determines the release of endorphins, opioids, and sex hormones, elevating the
mood and lowering hearth rate and blood pressure. These positive effects of regular
physical activity are seen on menopausal women through an increase of synaptic
transmission of monoamines, which supposedly functions in the same manner as
antidepressants . Active elderly women obtained the highest total scores on all
Female Sexual Function Index (FSFI) domains (desire, arousal, lubrication, orgasm,
satisfaction, and pain), compared to moderately active and sedentary subjects.
Aging continues to rise in the USA and in all Western countries. Older people are
at risk for several chronic conditions that interfere and, sometimes, exacerbate
SD both in men and women.
Many studies demonstrated that adopting or increasing regular physical activ-
ity may be beneﬁcial to sexuality of elderly people improving cardiovascular
ﬁtness, ﬂexibility, mobility, mood, and self-image. Physical activity consists of
moderate or vigorous aerobic and strength exercises (see guidelines suggested by
American College of Sports Medicine), in association with pelvic ﬂoor rehabili-
tation, when necessary .
Most studies suggest also that physical activity and exercise training are asso-
ciated with better QoL and health outcomes. Therefore, assessment and promo-
tion of physical activity may be beneﬁcial in achieving desired beneﬁts across
older people, including a satisfying sexuality.
Understanding the effects of physical activity on sexuality can potentially
have a positive inﬂuence on the clinical practice of physicians. Physicians rarely
recommend that their older patients exercise more, despite the documented
advantages of systematic physical exercise. This could possibly promote a more
satisfactory QoL and prevent SD.
• Sexuality continues to be an important aspect of life for many adults
throughout midlife and into old age. Unlike men, whose sexual perfor-
mances generally decrease after early adulthood, women do not show such
a consistent pattern over the life span.
• Physical activity (in association with Mediterranean diet) is able to improve
both sexual responses and overall cardiovascular health in men and women.
• Physical ﬁtness is very important in the management of patients with
metabolic syndrome and erectile dysfunction and is related to enhanced
50 Physical Activity and Sexual Function in Older People
1. Montorsi F, Basson R, Adaikan G et al (eds) (2010) Sexual medicine: sexual dysfunctions in
men and women. In: Proceedings of the 3rd International Consultation on Sexual Medicine,
2. Araujo AB, Mohr BA, McKinlay JB (2004) Changes in sexual function in middle-aged and
older men: longitudinal data from the Massachusetts Male Aging Study. J Am Geriatr Soc
3. Addis IB, Van Den Eeden SK, Wassel-Fyr CL, Vittinghoff E, Brow NJS, Thom DH (2006)
Sexual activity and function in middle-aged and older women. Obstet Gynecol 107:755–764
4. Bretschnider JG, McCoy NL (1988) Sexual interest and behavior in healthy 80- to 102-years-
olds. Arch Sex Behav 17:109–129
5. Taylor A, Gosney MA (2011) Sexuality in older age: essentials considerations for healthcare
professionals. Age Ageing 40:538–543
6. Lindau ST, Schumm LP, Laumann EO, Wendy Levinson W, O’Muircheartaigh CA, Waite LJ
(2007) A study of sexuality and health among older adults in the United States. N Engl J Med
7. Basaria S, Dobs AS (2004) Safety and adverse effects of androgens: how to counsel patients.
Mayo Clin Proc 79:S25–S32
8. Hichey M, Davis SR, Sturdee DW (2005) Treatment of menopausal symptoms. What shall we
do now? Lancet 366:409–421
9. Derby CA, Mohr BA, Goldstein I, Feldman HA, Johannes CB, McKinlay JB (2000) Modiﬁable
risk factors and erectile dysfunction. Can lifestyle changes modify risk? Urology 56:302–306
10. Hatzichristou D, Rosen RC, Derogatis LR et al (2010) Recommendations for the clinical eval-
uation of men and women with sexual dysfunction. J Sex Med 7(1 pt 2):346
11. Pohjantähti-Maaroos H, Palomäki A, Hartikainen J (2011) Erectile dysfunction, physical
activity and metabolic syndrome: differences in markers of atherosclerosis. BMC Cardiovasc
Disord 11:36. doi:10.1186/1471-2261-11-36
12. Belardinelli R, Lacalaprice F, Faccenda E, Purcaro A, Perna G (2005) Effects of short-term
moderate exercise training on sexual function in male patients with chronic stable heart failure.
Int J Cardiol 101:83–90
13. La Vignera S, Condorelli R, Vicari E, D’Agata R, Calogero AE (2012) Physical activity and
erectile dysfunction in middle-aged men. J Androl 33(2):154–161
14. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Jo J, King AC, Macera CA, Castaneda-
Sceppa C (2007) Physical activity and public health in older adults: recommendation from the
American College of Sports Medicine and the American Heart Association. Med Sci Sports
15. Capodaglio P, Narici MV, Rutherford OM, Sartorio A (2000) Physical exercise in the elderly:
its effects on the motor and endocrine system. Eur Med Phys 36:205–219
16. Cabral PU, Canario AC, Spyrides MH, Uchôa SA, Eleuterio Juniorn J, Giraldo PC, Gonçalves
AK (2014) Physical activity and sexual function in middle-aged women. Rev Assoc Med Bras
P. Di Benedetto