Fig. 11.1
The landmark Massachusetts Male Aging Study (MMAS) [28], a community-based observational study of nearly 3,000 men, aged 40–70 years, clearly established that ED is highly prevalent, age-related, and progressive. Subjects (n = 1,290) were asked to respond to a sexual activity questionnaire characterizing their level of ED. Minimal ED was defined as “usually able to get or keep an erection”; moderate, as “sometimes able”; and complete, as “never able to get and keep an erection” [1]. Self-rated ED was reflected by higher frequency of erectile difficulty during intercourse, lower monthly rates of sexual activity and erection, and lower satisfaction with sex life and partner. In the MMAS study, 40% of men were estimated to have ED at age 40, but this increased to 67% at age 70. Age was the only variable that proved to be a statistically significant predictor of ED (P < 0.0001) (courtesy of testosteroneupdate.org.)
Ejaculatory dysfunction: Ejaculatory dysfunction in the aging male can be manifest as either rapid or delayed ejaculation. Both entities are difficult to quantitate epidemiologically. Delayed ejaculation, (which is not well-defined in terms of time), in the aging male is most likely a combination of neuropathy of the ejaculatory pathway and a change in the prostatic milieu. The neuropathy may result from diabetes, vitamin deficiency, anatomic spine issues, CNS issues, thyroid issues, posttransurethral resection of the prostate, any pelvic surgery that affects the pelvic nerves such as radical prostatectomy, or combinations thereof. The prostate is predominately a reproductive organ in the young man, and turns into a less glandular, more fibrotic organ with aging, and thus is less secretory. This may result in “delayed” ejaculation, wherein ejaculation is delayed. In the young man, nonorganic, delayed ejaculation is also thought to be psychogenic in origin, while it is assumed that this is less likely in the older man. In general, delayed ejaculation is challenging to treat, as many of the disease processes noted above are chronic, rendering correction of the delayed ejaculation less likely.
Premature ejaculation in the aging male is also enigmatic [29]. The definition of premature ejaculation is somewhat elusive as worldwide studies reflect the disparity in the “normal” ejaculatory period [30]. In a large, multinational study, the intravaginal latency time (the IELT, which is the sine qua nonmeasurement for rapid ejaculation), had a positively skewed distribution, with a geometric mean of 5.7 min and a median of 6.0 min (range: 0.1–52.1 min). Men from Turkey had the shortest median IELT (4.4 min). Men from the United Kingdom had the longest IELT (10.0 min). Circumcision and condom use had no significant impact on the median IELT. Subjects who were discontent with their latency time had slightly lower median IELT values of 5.2 min than the median of the population.
Premature or rapid ejaculation has been historically defined by time. Ejaculation within 1–2 min of erection, combined with distress, is felt to be the two components of the current definition. This definition of rapid ejaculation can be independent of vaginal penetration, in spite of the fact that intravaginal latency time is used as the barometer of rapid ejaculation [31].
Please recall the following data discussed earlier. Laumann et al. [3] detailed both male and FSD in a younger cohort of men and women. Analysis of data came from the National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative, 1992 cohort of the US adults. A national probability sample of 1,749 women and 1,410 men aged 18–59 years at the time of the survey, participated. Sexual dysfunction was more prevalent for women (43%) than men (31%) and was associated with various demographic characteristics, including age and educational attainment. The most common sexual dysfunction in this youngish male cohort was premature ejaculation.
Rapid ejaculation may be a response to erectile dysfunction and may therefore correct itself once the ED is corrected. Alternatively, rapid ejaculation may be lifelong and may only rise to the surface as a problem for the aging male. Rapid ejaculation is thought to be in part genetic in the young man. Jern et al. noted a moderate genetic influence (28%) in rapid ejaculation in a population-based sample of 1,196 Finnish male twins, age 33–43 years. [32]. This genetic relationship has not been established in the aging male.
Hormonal issues: Hormonal issues in the aging male affect sexual desire, erections, and ejaculation [33]. The most common male hormonal issues are related to low testosterone. Other disorders are less common such as thyroid disorders. While data are limited regarding thyroid disorders, however a recent study offered the following data: 48 adult men, 34 with hyperthyroidism, and 14 with hypothyroidism were studied. The mean age of the enrolled subjects was 43.2 +/−12.1 years (range, 22–62 years). No significant difference was found in the age at presentation between hyperthyroid (n = 34) and hypothyroid (n = 14) patients. In hyperthyroid men, the prevalence of hypoactive sexual desire, delayed ejaculation, premature ejaculation, and ED was 17.6, 2.9, 50, and 14.7%, whereas in hypothyroid men, the prevalence of HSD, DE, and ED was 64.3% and of PE was 7.1%. After thyroid hormone normalization in hyperthyroid subjects, PE prevalence fell from 50 to 15%, whereas DE was improved in half of the treated hypothyroid men. Ejaculation latency time doubled after treatment of hyperthyroidism (from 2.4 +/− 2.1 to 4.0 +/− 2.0 min), whereas for hypothyroid men it declined significantly, from 21.8 +/− 10.9 to 7.4 +/− 7.2 (P < 0.01 for both). The cohort in this study was a bit younger, mean age 43, and thus the results may not be fully translatable to the older male [34].
Serum testosterone declines with aging in the male. This decline, termed Testosterone Deficiency (TD) or hypogonadism, in the aging male, is the subject of major interest. Testosterone deficiency in aging men is a condition associated with decreased sexual satisfaction and a decline of general wellbeing. The definition of hypogonadism is as follows [35]: Hypogonadism in men is a clinical syndrome that results from failure of the testis to produce physiological levels of testosterone (androgen deficiency) and a normal number of spermatozoa due to disruption of one or more levels of the hypothalamic-pituitary-testicular axis.
Classification of hypogonadism [35]: Abnormalities of the hypothalamic-pituitary-testicular axis at the testicular level cause primary testicular failure, whereas central defects of the hypothalamus or pituitary cause secondary testicular failure. Hypogonadism also can reflect dual defects that affect both the testis and the pituitary. Primary testicular failure results in low testosterone levels, impairment of spermatogenesis, and elevated gonadotropin levels. Secondary testicular failure results in low testosterone levels, impairment of spermatogenesis, and low or low-normal gonadotropin levels. Combined primary and secondary testicular failure results in low testosterone levels, impairment of spermatogenesis, and variable gonadotropin levels, depending on whether primary or secondary testicular failure predominates [35].
Studies demonstrate both a significant decline in serum testosterone levels of about 1% per year after the age of 30 years and a prevalence of 30% of low serum testosterone in men over age 60 [36, 37]. This has significant implications in terms of cardiac health. Malkin et al. [36] demonstrated a 20.9% prevalence in men with coronary heart disease. The authors showed a substantial decrease in overall and vascular mortality with hypogonadism, highlighting the fact that androgen deficiency may be a part of the underlying pathophysiology of atherosclerotic disease in men (Fig. 11.2a and 11.2b).
Fig. 11.2
Shows a survival curve of (a) all-cause mortality and (b) vascular mortality based on baseline bio-available testosterone (bio-T). The solid line represents patients with baseline bio-T less than 2.6 nmol/l, the broken line represents patients with bio-T greater than 2.6 nmol/l. HR, hazard ratio (from Malkin et al [36])
Recent data confirms that lower serum testosterone levels are associated with significant morbidity and mortality [38]. These authors used a clinical database to identify men older than 40 years with repeated testosterone levels obtained from October 1, 1994, to December 31, 1999, and without diagnosed prostate cancer. A low testosterone level was a total testosterone level of less than 250 ng/dL (<8.7 nmol/L) or a free testosterone level of less than 0.75 ng/dL (<0.03 nmol/L). Men were classified as having a low testosterone level (166 (19.3%)), an equivocal testosterone level (equal number of low and normal levels) (240 (28.0%)), or a normal testosterone level (452 (52.7%)). The risk for all-cause mortality was estimated using Cox proportional hazards regression models, adjusting for demographic and clinical covariates over a follow-up of up to 8 years. There were 452 men (52.7%) with normal testosterone levels, 240 (28.0%) with equivocal levels, and 166 (19.3%) with low levels. Testosterone levels differed significantly between the three groups (Fig. 11.3). Men with low testosterone levels were older, had a greater BMI, and had a greater prevalence of diabetes mellitus compared with men with normal testosterone levels. Men with equivocal testosterone levels had a greater BMI than men with normal testosterone levels. Men with low and normal testosterone levels had more testosterone levels obtained than men with equivocal testosterone levels. There were no significant differences between the groups in marital status; medical morbidity; prevalence of chronic obstructive pulmonary disease, human immunodeficiency virus, CAD, or hyperlipidemia; and treatment with opiates and glucocorticoids.
Fig. 11.3
A study was conducted to determine whether low testosterone levels are a risk factor for mortality in men 40 years of age or older. From the clinical database at the Veterans Affairs Puget Sound Health Care System, 858 male veterans who had repeated measurement of testosterone levels and no history of prostate or testicular cancer or antiandrogen treatment were identified. Testosterone levels were categorized as low if total testosterone was <250 ng/dL or free testosterone was <0.75 ng/dL. Testosterone levels were low in 166 men (19.3%), equivocal (equal number of low and normal levels) in 240 men (28%), and normal in 452 men (52.7%). Cox proportional hazards regression models, adjusted for demographic and clinical covariates over an 8-year follow-up period, were used to compare differences in survival times between men with low, equivocal, and normal testosterone levels. As illustrated by the Kaplan-Meier survival analysis, survival times were shorter in men with low or equivocal testosterone levels than in those with normal testosterone levels. All-cause mortality was 34.9% in men with low testosterone levels, 24.6% in men with equivocal testosterone levels, and 20.1% in men with normal testosterone levels (from Shores et al. [38])
The data demonstrated that mortality in men with normal testosterone levels was 20.1% (95% confidence interval (CI), 16.2%–24.1%) vs. 24.6% (95% CI, 19.2%–30.0%) in men with equivocal testosterone levels and 34.9% (95% CI, 28.5%–41.4%) in men with low testosterone levels. After adjusting for age, medical morbidity, and other clinical covariates, low testosterone levels continued to be associated with increased mortality (hazard ratio, 1.88; 95% CI, 1.34–2.63; P < 0.001) while equivocal testosterone levels were not significantly different from normal testosterone levels (hazard ratio, 1.38; 95% CI, 0.99%–1.92%; P = 0.06).
A decline in serum testosterone in the aging male may be directly associated with a loss of sexual desire and erectile dysfunction [39, 40]. The authors in the EMAS study group [39] surveyed a random population sample of 3,369 men between the ages of 40 and 79 years at eight European centers. Using questionnaires, they collected data with regard to the subjects’ general, sexual, physical, and psychological health. Levels of total testosterone were measured in morning blood samples by mass spectrometry, and free testosterone levels were calculated with the use of Vermeulen’s formula. Data were randomly split into separate training and validation sets for confirmatory analyses.
In the training set, symptoms of poor morning erection, low sexual desire, erectile dysfunction, inability to perform vigorous activity, depression, and fatigue were significantly related to the testosterone level. Increased probabilities of the three sexual symptoms and limited physical vigor were discernible with decreased testosterone levels (ranges, 8.0–13.0 nmol/L (2.3 to 3.7 ng/mL) for total testosterone and 160–280 pmol/L (46–81 pg/mL) for free testosterone). However, only the three sexual symptoms had a syndromic association with decreased testosterone levels. An inverse relationship between an increasing number of sexual symptoms and a decreasing testosterone level was observed. These relationships were independently confirmed in the validation set, in which the strengths of the association between symptoms and low testosterone levels determined the minimum criteria necessary to identify late-onset hypogonadism. Thus, late-onset hypogonadism can be defined by the presence of at least three sexual symptoms associated with a total testosterone level of less than 11 nmol/L (3.2 ng/mL) and a free testosterone level of less than 220 pmol/L (64 pg/mL).
Assessment of Sexual Dysfunction in Aging Men and Women
Sexual Medicine History and Physical Examination [41]
The office evaluation consists of a series of direct questions about the nature of the sexual dysfunction complaint, as delineated in Table 11.1 for the male with sexual dysfunction (adapted from [41]). The interview should take place in a quiet room, in a nonjudgmental fashion. These men and women are embarrassed and often need reassurance that this topic is acceptable to discuss. The questions should be asked in a gentle manner, avoiding any gestures or posturing that might be misconstrued. While, it is worthwhile to for the patient to bring his/her partner into the office for further history, queries, and discussion at the time of the visit, it should be recognized that this is very uncommon. A similar interview paradigm should be employed for the female patient with sexual dysfunction [42].
Characterize the sexual dysfunction |
|---|
What type of sexual problem does the patient complain of? |
For the male |
Does he have ED, low desire, premature ejaculation, and delayed ejaculation? |
If so, how long has he had the problem? |
When was the last time he had intercourse? |
When was the last time he had any sexual activity? |
Does the sexual problem bother him? |
Does the sexual problem bother his partner? |
Did the problem arise suddenly (psychogenic), or has it arisen gradually? |
Did the problem start when he started a new medication? |
Does the problem occur with his partner only, or does it also occur without his partner, for example, with masturbation? |
Does the problem occur because he has no partner or an uninterested partner? |
Does he have a partner outside of his main relationship? |
Can he get an erection? If so, is it firm enough for penetration? |
Can he maintain the erection for intercourse? |
Does he have a problem with sexual desire? |
How long has he lost sexual desire? |
Has he lost sexual desire with all partners? |
Has he lost desire under all circumstances? |
Has he lost desire because he cannot get or maintain an erection? |
Has he lost desire because his partner has lost desire? |
Does the patient complain of other associated symptoms, such as being tired, loss of stamina, loss of strength, loss of muscle mass, loss of muscle tone, recent weight gain, fatigue, or sleep issues? |
Is the patient depressed? |
Does he have a problem with ejaculation? |
What type of ejaculation problem does the patient complain of? |
When did the problem start? |
Is the problem bothersome to the patient? |
Is the problem bothersome to the partner? |
Does the problem occur under all circumstances? |
Suggested laboratory work for the male patient presenting with sexual dysfunction is offered in Table 11.2 [41]. Clinician judgment is used here. For example, if the patient is a known diabetic, a serum glucose many not be needed. Thus, these tests are obtained based upon the clinical scenario.
Table 11.2
Common laboratory work for a man complaining of sexual dysfunction, ED in particular (from [41])
Fasting lipid profile |
Fasting glucose |
TT and FT (morning testing preferred) |
PSA: mandatory if considering testosterone supplementation; otherwise, it may be optional |
Optional laboratory tests |
Prolactin |
Creatinine |
Estradiol |
Thyroid-stimulating hormone (TSH) |
Follicle-stimulating hormone (FSH) |
Luteinizing hormone (LH) |
Dehydroepiandrosterone (DHEA) |
25-hydroxyvitamin D level |
SHBG |
Albumin |
Urinalysis |
The objective assessment of male and female sexual function has been challenging. Most regulatory agencies have allowed self-reported, validated instruments to be used as surrogate markers for sexual activity endpoints. Many instruments have been published that meet or fulfill these needs. It is important to bear in mind that to our knowledge, these instruments are not specific to the aging male or female population, but rather are for general use. Data for the aging male and female is extrapolated from these instruments.
The instrument that has been used most often used to capture the severity of general male sexual function, and male erectile function in specific is the International Index of Erectile Function (IIEF, Table 11.3). This instrument was developed as an adjunctive sexual function measure for the sildenafil clinical trials [43] and has since gained universal acceptance as the leading instrument to assess male erectile function. A five question–shorter form was subsequently developed, which has been utilized quite widely as well ([44], Table 11.4). The IIEF and its shorter version have been used for all the clinical phosphodiesterase type 5 (PDE5) inhibitor trials along with numerous non-pharma-sponsored trials. The IIEF contains 15 questions which ask the patient to recall sexual activity for the previous 4 weeks. The 15 questions are answered on a Likert-type scale which allows the instrument to be graded numerically. Questions 1–5 and 15 are termed the erectile function domain of the IIEF.
Table 11.3
IIEF questionnaire
Instructions: These questions ask about the effects your erection problems have had on your sex life, over the past 4 weeks. Please answer the following questions as honestly and clearly as possible. In answering these questions, the following definitions apply: | |||
Definitions: Sexual activity includes intercourse, caressing, foreplay, and masturbation. Sexual intercourse is defined as vaginal penetration of the partner (you entered the partner). Sexual stimulation includes situations like foreplay with a partner, looking at erotic pictures, etc. Ejaculate is defined as the ejection of semen from the penis (or the feeling of this) | |||
Mark ONLY one circle per question | |||
1. Over the past 4 weeks, how often were you able to get an erection during sexual activity? | |||
0 No sexual activity | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
2. Over the past 4 weeks, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? | |||
0 No sexual stimulation | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
Questions 3, 4, and 5 will ask about erections you may have had during sexual intercourse. | |||
3. Over the past 4 weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? | |||
0 Did not attempt intercourse | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
4. Over the past 4 weeks, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? | |||
0 Did not attempt intercourse | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
5. Over the past 4 weeks, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? | |||
0 Did not attempt intercourse | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
6. Over the past 4 weeks, how many times have you attempted sexual intercourse? | |||
0 No attempts | |||
0 1–2 attempts | |||
0 3–4 attempts | |||
0 5–6 attempts | |||
0 7–10 attempts | |||
0 11 or more attempts | |||
7. Over the past 4 weeks, when you attempted sexual intercourse how often was it satisfactory for you? | |||
0 Did not attempt intercourse | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
8. Over the past 4 weeks, how much have you enjoyed sexual intercourse? | |||
0 No intercourse | |||
0 Very highly enjoyable | |||
0 Highly enjoyable | |||
0 Fairly enjoyable | |||
0 Not very enjoyable | |||
0 Not enjoyable | |||
9. Over the past 4 weeks, when you had sexual stimulation or intercourse how often did you ejaculate? | |||
0 Did not attempt intercourse | |||
0 Almost always or always | |||
0 Most times (more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
10. Over the past 4 weeks, when you had sexual stimulation or intercourse how often did you have the feeling of orgasm or climax (with or without ejaculation)? | |||
0 No sexual stimulation or intercourse | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
Questions 11 and 12 ask about sexual desire. Let’s define sexual desire as a feeling that may include wanting to have a sexual experience (for example, masturbation or intercourse), thinking about having sex or feeling frustrated due to lack of sex | |||
11. Over the past 4 weeks, how often have you felt sexual desire? | |||
0 Almost always or always | |||
0 Most times (much more than half the time) | |||
0 Sometimes (about half the time) | |||
0 A few times (much less than half the time) | |||
0 Almost never or never | |||
12. Over the past 4 weeks, how would you rate your level of sexual desire? | |||
0 Very high | |||
0 High | |||
0 Moderate | |||
0 Low | |||
0 Very low or none at all | |||
13. Over the past 4 weeks, how satisfied have you been with you overall sex life? | |||
0 Very satisfied | |||
0 Moderately satisfied | |||
0 About equally satisfied and dissatisfied | |||
0 Moderately dissatisfied | |||
0 Very dissatisfied | |||
14. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner? | |||
0 Very satisfied | |||
0 Moderately satisfied | |||
0 About equally satisfied and dissatisfied | |||
0 Moderately dissatisfied | |||
0 Very dissatisfied | |||
15. Over the past 4 weeks, how do you rate your confidence that you can get and keep your erection? | |||
0 Very high | |||
0 High | |||
0 Moderate | |||
0 Low | |||
0 Very low | |||
All items are scored in five domains as followsa: | |||
Domain | Items | Range | Max score |
Erectile function | 1, 2, 3, 4, 5, 15 | 0–5 | 30 |
Orgasmic function | 9, 10 | 0–5 | 10 |
Sexual desire | 11, 12 | 0–5 | 10 |
Intercourse satisfaction | 6, 7, 8 | 0–5 | 15 |
Overall satisfaction | 13, 14 | 0-5 | 10 |
Table 11.4
The International Index of Erectile Function (IIEF-5) questionnaire (from Rosen et al. [44])
Over the past 6 months | |||||
|---|---|---|---|---|---|
1. How do you rate your confidence that you could get and keep an erection? | Very low 1 | Low 2 | Moderate 3 | High 4 | Very high 5 |
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? | Almost never/never 1 | A few times (much less than half the time) 2 | Sometimes (about half the time) 3 | Most times (much more than half the time) 4 | Almost always/always 5 |
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? | Almost never/never 1 | A few times (much less than half the time) 2 | Sometimes (about half the time) 3 | Most times (much more than half the time)4 | Almost always/always 5 |
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? | Extremely difficult 1 | Very difficult 2 | Difficult 3 | Slightly difficult 4 | Not difficult 5 |
5. When you attempted sexual intercourse, how often was it satisfactory for you? | Almost never/never 1 | A few times (much less than half the time) 2 | Sometimes (about half the time) 3 | Most times (much more than half the time) 4 | Almost always/always 5 |
Male ejaculatory function may be assessed by a variety of instruments. A recent, noteworthy instrument is the Male Sexual Health Questionnaire, which has been shortened to a 4-question instrument ([45], Table 11.5 and Table 11.6).
Table 11.5
Male sexual health questionnaire (MSHQ)
Erection scale* |
1. In the last month, without using drugs like Viagra, how often have you been able to get an |
erection when you wanted to? (check only one) |
5 All of the time |
4 Most of the time |
3 About half of the time |
2 Less than half of the time |
1 None of the time |
0 Used Viagra or similar drug with every sexual encounter |
2. In the last month, if you were able to get an erection, without using drugs like Viagra, how |
often were you able to stay hard as long as you wanted to? (check only one) |
5 All of the time |
4 Most of the time |
3 About half of the time |
2 Less than half of the time |
1 None of the time |
0 Used Viagra or similar drug with every sexual encounter |
3. In the last month, if you were able to get an erection, without using drugs like Viagra, how |
would you rate the hardness of your erection? (check only one) |
5 Completely hard |
4 Almost completely hard |
3 Mostly hard, but can be slightly bent |
2 A little hard, but bends easily |
1 Not at all hard |
0 Used Viagra or similar drug with every sexual encounter |
INTRODUCTION: The following questions concern various aspects of your ability to have sex. In answering these questions, please think about all aspects of the sexual activity you have had with your main partner, with other partners, or masturbating. |
By sexual activity, we mean any type of sex you may have had, including intercourse, oral sex, or other sexual activities that could lead to ejaculation. Some of these questions might be difficult to answer. Please answer as many as possible, and be as honest as you can when answering them. Please remember that all of your answers are confidential. The first questions concern your erections, which some people refer to as “hard-one.” In the last month have you taken Viagra or any similar drugs for problems with your erection? Yes No |
ED Bother Item |
4. In the last month, if you have had difficulty getting hard or staying hard without using drugs |
like Viagra, have you been bothered by this problem?… (Check only one) |
5 Not at all bothered/Did not have a problem with erection |
4 A little bit bothered |
3 Moderately bothered |
2 Very bothered |
1 Extremely bothered |
Ejaculation (Ej) scale |
INTRODUCTION: The next section deals with male ejaculation and the pleasure you have with ejaculation. |
Ejaculation or “cumming” is the release of semen or “cum” during sexual climax. These questions concern all |
of your ejaculations when having sexual activity. These could include ejaculations you have had with your |
main partner, as well as with other partners, or ejaculations you have had when masturbating. |
5. In the last month, how often have you been able to ejaculate when having sexual activity? |
(check only one) |
5 All of the time |
4 Most of the time |
3 About half of the time |
2 Less than half of the time |
1 None of the time/could not ejaculate |
6. In the last month, when having sexual activity, how often did you feel that you took too long |
to ejaculate or “cum”? (check only one) |
5 None of the time |
4 Less than half of the time |
3 About half of the time |
2 Most of the time |
1 All of the time |
0 Could not ejaculate |
7. In the last month, when having sexual activity, how often have you felt like you were |
ejaculating (“cumming”), but no fluid came out? |
5 None of the time |
4 Less than half of the time |
3 About half of the time |
2 Most of the time |
1 All of the time |
0 Could not ejaculate |
8. In the last month, how would you rate the strength or force of your ejaculation? |
5 As strong as it always was |
4 A little less strong than it used to be |
3 Somewhat less strong than it used to be |
2 Much less strong than it used to be |
1 Very much less strong than it used to be |
0 Could not ejaculate |
9. In the last month, how would you rate the amount or volume of semen when you ejaculate? |
5 As much as it always was |
4 A little less than it used to be |
3 Somewhat less than it used to be |
2 Much less than it used to be |
1 Very much less than it used to be |
0 Could not ejaculate |
10. Compared to ONE month ago, would you say the physical pleasure you feel when you |
ejaculate has… |
5 Increased a lot |
4 Increased moderately |
3 Neither increased nor decreased |
2 Decreased moderately |
1 Decreased a lot |
0 Could not ejaculate |
11. In the last month, have you experienced any physical pain or discomfort when you |
ejaculated? Would you say you have… |
5 No pain at all |
4 Slight amount of pain or discomfort |
3 Moderate amount of pain or discomfort |
2 Strong amount of pain or discomfort |
1 Extreme amount of pain or discomfort |
0 Could not ejaculate |
(EjD) bother item |
12. In the last month, if you have had any ejaculation difficulties or have been unable to ejaculate, have you been bothered by this? |
5 Not at all bothered |
4 A little bit bothered |
3 Moderately bothered |
2 Very bothered |
1 Extremely bothered |
Satisfaction scale |
These next few questions ask about your relationship with your main partner over the last month. |
Some of these questions concern your sexual relationship, while others are about your overall |
relationship. |
13. Generally, how satisfied are you with the overall sexual relationship you have with your main partner? (check only one) |
5 Extremely satisfied |
4 Moderately satisfied |
3 Neither satisfied nor unsatisfied |
2 Moderately unsatisfied |
1 Extremely unsatisfied |
14. Generally, how satisfied are you with the quality of the sex life you have with your main |
partner? |
5 Extremely satisfied |
4 Moderately satisfied |
3 Neither satisfied nor unsatisfied |
2 Moderately unsatisfied |
1 Extremely unsatisfied |
15. Generally, how satisfied are you with the number of times you and your main partner have |
sex? |
5 Extremely satisfied |
4 Moderately satisfied |
3 Neither satisfied nor unsatisfied |
2 Moderately unsatisfied |
1 Extremely unsatisfied |
16. Generally, how satisfied are you with the way you and your main partner show affection during sex? |
5 Extremely satisfied |
4 Moderately satisfied |
3 Neither satisfied nor unsatisfied |
2 Moderately unsatisfied |
1 Extremely unsatisfied |
17. Generally, how satisfied are you with the way you and your main partner communicate about sex? |
5 Extremely satisfied |
4 Moderately satisfied |
3 Neither satisfied nor unsatisfied |
2 Moderately unsatisfied |
1 Extremely unsatisfied |
18. Aside from your sexual relationship, how satisfied are you with all other aspects of the relationship you have with your main partner? |
5 Extremely satisfied |
4 Moderately satisfied |
3 Neither satisfied nor unsatisfied |
2 Moderately unsatisfied |
1 Extremely unsatisfied |
Additional items (sexual activity and desire) |
19. In the last month, how often have you had sexual activity, including masturbating, intercourse, oral sex, or any other type of sex? (check only one) |
5 Daily or almost daily |
4 More than 6 times per month |
3 4−6 times per month |
2 1−3 times per month |
1 0 times per month |
If your answer is “0” for item 19, please answer the following questions: |
A. When was the last time you had sex? (check only one) |
5 1−3 months ago |
4 4−6 months ago |
3 7−12 months ago |
2 13−24 months ago |
1 More than 24 months ago |
B. What are the reasons you have not had sex? |
I could not have sex because I could not get an erection: Yes No |
I could not have sex because I could not ejaculate or “cum”: Yes No |
I had no partner: Yes No |
Other (specify): __________________________________________________ |
20. Compared to ONE month ago, has the number of times you have had sexual activity |
increased or decreased? |
5 Increased a lot |
4 Increased moderately |
3 Neither increased nor decreased |
2 Decreased moderately |
1 Decreased a lot |
INTRODUCTION: The next set of questions concern the sexual activity you have had in the last month. In answering these questions, we want to know about all of the sexual activity you have had with your main partner, with other partners, or masturbating. By sexual activity, we mean any type of sex you may have had, including intercourse, oral sex, or any other sexual activities that could lead to ejaculation. |
21. In the last month, have you been bothered by these changes in the number of times you |
have had sexual activity? |
5 Not at all bothered |
4 A little bit bothered |
3 Moderately bothered |
2 Very bothered |
1 Extremely bothered |
INTRODUCTION : These next questions ask about your urge or desire to have sex with your main partner. Some people refer to this as “feeling horny.” These questions concern the sexual urges you have felt toward your main partner, and not whether you actually had sex |
Do you have a “main partner”? : Yes No |
IF YOU DO NOT HAVE A MAIN PARTNER, PLEASE ANSWER ALL QUESTIONS WITHOUT REFERENCE TO A “MAIN PARTNER” |
22. In the last month, how often have you felt an urge or desire to have sex with your main |
partner? |
5 All of the time |
4 Most of the time |
3 About half of the time |
2 Less than half of the time |
1 None of the time |
23. In the last month, how would you rate your urge or desire to have sex with your main |
partner? |
5 Very high |
4 High |
3 Moderate |
2 Low |
1 Very low or none at all |
24. In the last month, have you been bothered by your level of sexual desire? Have you been… |
5 Not at all bothered |
4 A little bit bothered |
3 Moderately bothered |
2 Very bothered |
1 Extremely bothered |
25. Compared to ONE month ago, has your urge or desire for sex with your main partner |
increased or decreased? |
5 Increased a lot |
4 Increased moderately |
3 Neither increased nor decreased |
2 Decreased moderately |
1 Decreased a lot |
Thank You for Your Cooperation |
Table 11.6
MSHQ-EjD short form for assessing EjD*
In the past month: | |
1. How often have you been able to ejaculate or “cum” when having sexual activity? | |
All the time | 5 |
Most of the time | 4 |
About half the time | 3 |
Less than half the time | 2 |
None of the time/could not ejaculate | 1 |
2. How would you rate the strength or force of your ejaculation? | |
As strong as it always was | 5 |
A little less strong than it used to be | 4 |
Somewhat less strong than it used to be | 3 |
Much less strong than it used to be | 2 |
Very much less strong than it used to be | 1 |
Could not ejaculate | 0 |
3. How would you rate the amount or volume of semen or fluid when you ejaculate? | |
As much as it always was | 5 |
A little less than it used to be | 4 |
Somewhat less than it used to be | 3 |
Much less than it used to be | 2 |
Very much less than it used to be | 1 |
Could not ejaculate | 0 |
4. If you have had any ejaculation difficulties or have been unable to ejaculate, have you been bothered by this? | |
No problem with ejaculation | 0 |
Not at all bothered | 1 |
A little bothered | 2 |
Moderately bothered | 3 |
Very bothered | 4 |
Extremely bothered | 5 |
Testosterone deficiency in the male can be assessed by a variety of instruments. The Androgen Deficiency in the Aging Male (ADAM) questionnaire is widely used but unfortunately is not validated [46]. Further, the ADAM questionnaire (Table 11.7) seems to be sensitive but not specific for the diagnosis of hypogonadism. An answer of YES to questions 1 or 7 or any 3 other questions, suggest that the patient may be experiencing androgen deficiency (low testosterone level). The Aging Males’ Symptom (AMS) questionnaire is often utilized as well [47]. Recently, the NERI hypogonadism screener has been published, but has not yet found its way into routine clinical practice [48].
Table 11.7
Saint Louis University
Adam questionnaire* |
|---|
Androgen deficiency in aging males |
1. Do you have a decrease in libido (sex drive)? |
2. Do you have a lack of energy? |
3. Do you have a decrease in strength and/or endurance? |
4. Have you lost height? |
5. Have you noticed a decreased “enjoyment of life”? |
6. Are you sad and/or grumpy? |
7. Are your erections less strong? |
8. Have you noted a recent deterioration in your ability to play sports? |
9. Are you falling asleep after dinner? |
10. Has there been a recent deterioration in your work performance? |
Female Sexual Function
There are several well-done, validated, instruments that assess female sexual function [50]. One such instrument that seems to be gaining in popularity is the FSFI. The FSFI is a brief multidimensional scale for assessing sexual function in women. The scale has received psychometric evaluation, including studies of reliability, convergent validity, and discriminant validity. The authors’ found an FSFI total score of 26.55 to be the optimal cut score for differentiating women with and without sexual dysfunction [51]. The FSFI has been recently validated for use in cancer survivors [52].
While this validated cutpoint for the total FSFI scale score of 26.55 enables one to classify women into groups with and without sexual dysfunction, there was no sexual desire (SD) domain-specific cutpoint for assessing the presence of diminished desire in women with or without a sexual desire problem. Gersterberger et al. noted that the use of a diagnostic cutpoint for classifying women with SD scores of 5 or less on the SD domain of the FSFI as having HSDD and those with SD scores of 6 or more as not having HSDD maximized diagnostic sensitivity and specificity. In the development sample, the sensitivity and specificity for predicting HSDD (with or without other conditions) were 75% and 84%, respectively, and the corresponding sensitivity and specificity in the validation sample were 92% and 89%, respectively [53].
It is important to recognize that many clinicians find these questionnaires somewhat cumbersome to use during the office visit. Rather than using the full instrument, clinicians have adopted their practices so that they utilize a modified version of a specific instrument. This seems to suit them well.
There are many other wonderful instruments that have been developed to assess male and female sexual function. The authors of these fine instruments deserve recognition and we offer our apologies for our inability to include them and credit them in this section. Finally, there are many instruments that evaluate mood, depression, cognition, strength, quality of life, amongst other areas, in the aging male and female. Discussion of these instruments is beyond the scope of this chapter.
Cardiovascular evaluation of the male and female patient with sexual dysfunction: Consensus guidelines have provided algorithms to the clinician as to which patients with cardiovascular risk factors may safely reengage in sexual activity. The Princeton II consensus guidelines document discusses the approach for men with a variety of CV risk factors and their ability to reengage in sexual activity ([54], Fig. 11.4). Low risk patients are those with less than three CV risk factors, controlled hypertension, etc. The reader should review ref [54] to gain a better understanding of the risk assessment algorithm. The Princeton III conference was recently convened to continue the discussion of evaluating CV risks and sexual health [55]. Importantly, data from that meeting has surfaced that reviews CV risk and female sexual health [56]. Other, recent guidelines have been offered to assist the clinician with counseling patients who have various CV issues and wish to reengage in sexual activity [57].
Fig. 11.4
Risk assessment algorithm for men with cardiovascular risk factors who wish to reengage in sexual activity (from Kostis et al. [54])
Pathophysiology of ED
This area has studied in depth and thus data on erectile dysfunction (ED) is well-represented in the literature. Erectile dysfunction is defined as the consistent inability to achieve or maintain an erection adequate for satisfactory sexual function [58]. Age alone is the single most profound variable associated with erectile dysfunction and impotence. Feldman et al. showed that the rate of complete impotence tripled from 5 to 15% as men aged from the 40 to 70 [28]. After adjustment for age, a higher probability of ED was directly correlated with cardiovascular disease, hypertension, diabetes mellitus (DM), and depression, and inversely correlated with serum dehydroepiandrosterone (DHEA), high density lipoprotein cholesterol and an index of dominant personality. ED can significantly decrease the quality of life as well as a man’s mental and physical wellbeing. The cause of ED is primarily organic but can have a psychogenic etiology as well [28, 41].
ED can be caused by endocrine abnormalities, most commonly DM, but also hypogonadism and hyperprolactinemia [41, 59, 60]. DM causes changes in neurotransmitters like nitric oxide and vasoactive intestinal peptide resulting in poor erectile ability; tight glycemic control has been shown to dramatically reduce the prevalence of ED (Fig. 11.5, [61–63]). Complications of smooth muscle and endothelial dysfunction are sequelae of DM, which can exacerbate the severity of ED by direct pathophysiology.
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