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Physical Activity and Sexual Function in Older People

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Abstract

By the year 2030, nearly 20% of people in the USA and in Western countries will be 65 years of age or older. Many studies showed that a balanced diet and a regular physical activity can help prevent some of the health problems associated with aging and reduced mobility. Among these problems related to aging, the sexual function continues to be an important aspect of the quality of life of elderly people.
495
© 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
e-mail: mrsart@libero.it
50
Physical Activity and Sexual Function
in Older People
Paolo Di Benedetto
50.1 Introduction
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 [13]. 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
496
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
elderly.
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%) [6]. All these factors may lead to painful sexual
intercourse (dyspareunia, vaginismus, and vulvar vestibulitis). Age-related changes
P. Di Benedetto
497
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 [7]. 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 [8].
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 [9].
50 Physical Activity and Sexual Function in Older People
498
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 [1]. 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 [10]. 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
disease.
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
[11]. Physical activity (in association with Mediterranean diet) is able to improve
both sexual responses and overall cardiovascular health in men and women [12].
P. Di Benedetto
499
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 [13].
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
therapy.
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) [14].
The older people should do:
At least 150 min of moderate aerobic activity such as cycling or walking every
week
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
every week
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
activity)
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
500
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 [15]. 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
501
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 [11].
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 [16]. 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.
Conclusions
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 [14].
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.
Key Points
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
sexuality.
50 Physical Activity and Sexual Function in Older People
502
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Full-text available
Objective: To investigate the relationship between physical activity level and sexual function in middle-aged women. Methods: A cross-sectional study with a sample of 370 middle-aged women (40-65 years old), treated at public health care facilities in a Brazilian city. A questionnaire was used containing enquiries on sociodemographic, clinical and behavioral characteristics: the International Physical Activity Questionnaire (IPAQ), short form, and the Female Sexual Function Index (FSFI). Results: The average age of the women studied was 49.8 years (± 8.1), 67% of whom exhibited sexual dysfunction (FSFI ≤ 26.55). Sedentary women had a higher prevalence (78.9%) of sexual dysfunction when compared to active (57.6%) and moderately active (66.7%) females (p = 0.002). Physically active women obtained higher score in all FSFI domains (desire, arousal, lubrication, orgasm, satisfaction and pain) and total FSFI score (20.9), indicating better sexual function than their moderately active (18.8) and sedentary (15.6) counterparts (p <0.05). Conclusion: Physical activity appears to influence sexual function positively in middle-aged women.
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The prevalence of erectile dysfunction is high in men of all ages and increases greatly in the elderly. In particular, severity and prevalence both increase with aging. Because erectile dysfunction is a symptom, physicians should diagnose underlying pathologies that might lead to it instead of focusing only on finding a viable treatment. Physical inactivity negatively impacts on erectile function; experimental and clinical exercise interventions have been shown to improve sexual responses and overall cardiovascular health. Several studies have confirmed that combining 2 interventions (Mediterranean diet and physical activity) provides additional benefit to erectile function, likely via reduced metabolic disturbances (eg, inflammatory markers, insulin resistance), decreased visceral adipose tissue, and improvement in vascular function (eg, increased endothelial function). This brief review shows the main clinical evidence of benefits induced by physical activity on erectile and endothelial dysfunction. The literature shows that erectile dysfunction in middle-aged men is often an early event in endothelial damage, and physical activity is able to improve both erectile and endothelial dysfunction. There are conflicting data regarding the effects of exercise on androgen status. In clinical practice it would be recommended to add regular physical activity to balanced diet and drugs to achieve better therapeutic results.
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The challenge in the field of sexual medicine is to develop evidence-based principles for clinical evaluation and create a uniform, widely accepted diagnostic and treatment approach for all sexual problems and dysfunctions, for both genders. To provide recommendations for the broad approach for assessing sexual problems in a medical practice setting; to develop an evidence-based diagnostic and treatment algorithm for men and women with sexual dysfunctions. The PubMed literature was reviewed. Expert opinion was based on the grading of evidence-based medical literature and the Delphi consensus process. The Committee determined three principles for clinical evaluation and management: (i) adoption of a patient-centered framework, with emphasis on cultural competence in clinical practice; (ii) application of evidence-based medicine in diagnostic and treatment planning; (iii) use of a unified management approach in evaluating and treating sexual problems in both men and women. The International Consultation in Sexual Medicine-5 stepwise diagnostic and treatment algorithm was developed for that purpose. According to this algorithm, sexual, medical, and psychosocial history is mandatory, whereas physical examination and laboratory tests are highly recommended in most cases. Furthermore, the Brief Sexual Symptom Checklist (BSSC) for Men and BSSC for Women, and more recently the Sexual Complaints Screener (SCS) for Men and SCS for Women, were all endorsed for screening purposes. A classification system was also defined; clinically, sexual dysfunctions are categorized in three types according to their etiology (Type I: psychogenic; Type II: organic; Type III: mixed). Final recommendations on specialized diagnostic tests were based on level of evidence. A unified diagnostic and management strategy in sexual medicine, irrespective of condition and gender, would improve patients' sexual well-being. It would also lead to the development of academic curricula to provide practicing physicians across specialties with the needed skills to meet contemporary patients' needs in sexual medicine health-care delivery.
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Sexual interest and behavior of 100 white men and 102 white women ranging in age from 80-102 were studied using an anonymous 117-item questionnaire. Subjects were healthy and upper middle-class, and living in residential retirement facilities; 14% of the women and 29% of the men were presently married. For both men and women, the most common activity was touching and caressing without sexual intercourse, followed by masturbation, followed by sexual intercourse. Of these activities, only touching and caressing showed a significant decline from the 80s to the 90s, with further analyses revealing a significant decline in this activity for men but not for women. Except for past enjoyment of sexual intercourse and of touching and caressing without sexual intercourse, all analyses revealed sex differences reflecting more activity and enjoyment by men. Current income and past guilt over sexual feelings showed very low but significant correlations with some frequency and enjoyment measures, and marital status, extramarital sex, and church attendance were significantly associated with continuing to perform and enjoy some sexual behaviors. Past importance of sex was significantly correlated with present frequency and enjoyment of both sexual intercourse and touching and caressing without sexual intercourse. Correlations between past and present frequency of sexual behaviors were substantial and significant for all but frequency of sexual intercourse, suggesting that current physical and social factors play an overriding role in this area.
Article
To prospectively examine whether changes in smoking, heavy alcohol consumption, sedentary lifestyle, and obesity are associated with the risk of erectile dysfunction. Data were collected as part of a cohort study of a random sample of men 40 to 70 years old, selected from street listings in the Boston Metropolitan Area, Massachusetts. In-home interviews were completed by 1709 men at baseline in 1987 to 1989 and 1156 men at follow-up in 1995 to 1997 (average follow-up 8.8 years). Analyses included 593 men without erectile dysfunction at baseline, who were free of prostate cancer, and had not been treated for heart disease or diabetes. The incidence of moderate to complete erectile dysfunction was determined by discriminant analysis of responses to a self-administered sexual function questionnaire. Obesity status was associated with erectile dysfunction (P = 0.006), with baseline obesity predicting a higher risk regardless of follow-up weight loss. Physical activity status was associated with erectile dysfunction (P = 0.01), with the highest risk among men who remained sedentary and the lowest among those who remained active or initiated physical activity. Changes in smoking and alcohol consumption were not associated with the incidence of erectile dysfunction (P >0.3). Midlife changes may be too late to reverse the effects of smoking, obesity, and alcohol consumption on erectile dysfunction. In contrast, physical activity may reduce the risk of erectile dysfunction even if initiated in midlife. Early adoption of healthy lifestyles may be the best approach to reducing the burden of erectile dysfunction on the health and well-being of older men.
Article
Recently, interest has grown in the use of androgen replacement therapy for postmenopausal women. Androgen replacement in women improves libido, bone density, and body composition. The adverse effects, like hirsutism, are generally mild, and the safety profile of transdermal testosterone replacement is more favorable than that of other modes of androgen therapy. Further studies may help to determine the effect of lipid changes on cardiac outcomes. We believe that long-term studies are necessary to observe the potential effect of androgen replacement on cardiovascular mortality, breast and endometrial tissues, and mood and anger before this therapy can be used routinely in women.