Clinical and Biopsychosocial Determinants of Sexual Dysfunction in Middle‐Aged and Older Australian Men

Testosterone Treatment and Sexual Function in Men: Secondary Analysis of the T4DM (Testosterone for Diabetes) Trial

CONTEXT

The combined effects of testosterone treatment and lifestyle intervention on sexual function in men at high risk of type 2 diabetes are unclear.

OBJECTIVE

To assess the effect of testosterone treatment with a lifestyle intervention in men aged 50-74 years at high risk of, or newly diagnosed with, type 2 diabetes (OGTT).

DESIGN

A secondary analysis of the Testosterone for the Prevention of Type 2 Diabetes (T4DM) trial, a double-blind, placebo-controlled trial conducted across six Australian centers.

INTERVENTIONS

Intramuscular testosterone undecanoate (1000 mg) or placebo, 3 monthly for 2 years alongside a community-based lifestyle program.

MAIN OUTCOMES

Sexual function measured using the International Index of Erectile Function (IIEF)-15 questionnaire.

RESULTS

Of 1007 participants, 792 (79%) had complete IIEF-15 data. Baseline domain scores were inversely related to age and waist circumference, but unrelated to serum testosterone or estradiol levels. Testosterone treatment improved all five IIEF-15 domain scores, with stronger effects on sexual desire and orgasmic function in older men, and sexual desire in men with higher depression scores. Testosterone had no impact on depression. Independent of treatment, reductions in waist circumference were associated with improved erectile function, and reductions in depression scores correlated with better sexual function. Clinically significant improvement (CSI) in erectile function and sexual desire occurred in 3% and 10% of men, respectively, and was inversely related to baseline function. CSI improvements in erectile function and sexual desire were greater in younger and older men respectively.

CONCLUSION

Testosterone treatment enhanced sexual desire and, to a lesser extent, erectile function, particularly in older men and those with higher waist circumference or depressive symptoms. Reduced waist circumference and depression independently improved sexual function.

Sexual Difficulties in People 50+: A Content Analysis of Sex-related Queries Posted on Professional Counseling Websites

Although sexual activity has been found to be both important and challenging for people aged 50+, relatively little is known about the concerns that they have with respect to their sexual lives and how help-seeking behavior manifests on counseling platforms. A sample of 293 sex-related queries that Czechs aged 50+ posted on professional counseling websites were subjected to a quantitative and qualitative content analysis. The majority of posts were written by men and their dominant issues were erectile difficulties, partner's lack of interest in sex, and drug use/interaction when treating sexual difficulties and other ailments. Using a thematic analysis, the study showed that sex-related concerns were based within the context of worries about maintaining relationships and re-partnering in mid- and later life, and probing for the normal aspects of aging and the associated changes in sexual health. The online setting of the counseling websites facilitated the posting of both general and personalized queries to get oriented in problems, to triangulate with previous information, and to check the treatability of difficulties when past treatments failed. These findings suggest that online counseling puts a great demand on professionals' knowledge and understanding of the specifics of later-life sexual health.

Individualized identification of sexual dysfunction of psychiatric patients with machine-learning

Sexual dysfunction (SD) is prevalent in patients with mental health disorders and can significantly impair their quality of life. Early recognition of SD in a clinical setting may help patients and clinicians to optimize treatment options of SD and/or other primary diagnoses taking SD risk into account and may facilitate treatment compliance. SD identification is often overlooked in clinical practice; we seek to explore whether patients with a high risk of SD can be identified at the individual level by assessing known risk factors via a machine learning (ML) model. We assessed 135 subjects referred to a tertiary mental health clinic in a Western Canadian city using health records data, including age, sex, physician's diagnoses, drug treatment, and the Arizona Sexual Experiences Scale (ASEX). A ML model was fitted to the data, with SD status derived from the ASEX as target outcomes and all other variables as predicting variables. Our ML model was able to identify individual SD cases-achieving a balanced accuracy of 0.736, with a sensitivity of 0.750 and a specificity of 0.721-and identified major depressive disorder and female sex as risk factors, and attention deficit hyperactivity disorder as a potential protective factor. This study highlights the utility of SD screening in a psychiatric clinical setting, demonstrating a proof-of-concept ML approach for SD screening in psychiatric patients, which has marked potential to improve their quality of life.

A systematic review of Indian studies on sexual dysfunction in patients with substance use disorders

BACKGROUND AND AIMS

Sexual dysfunction is often associated with substance use disorders. This study aimed to synthesize Indian literature on sexual dysfunction among patients with substance use disorders.

MATERIALS AND METHODS

Electronic search engines were used to identify studies of the last 20 years that reported sexual dysfunction with different substance use disorders. Information was extracted using a predefined template. Quality appraisal of the included studies was carried out using Joanna Briggs Institute checklist.

RESULTS

Twenty-seven relevant papers were identified that pertained to 24 distinct studies. Most of them were in patients with alcohol dependence, and fewer were in patients with opioid dependence. The study designs were primarily single-group cross-sectional, though many case-control, cross-sectional studies were also identified. The proportion of participants with sexual dysfunction ranged from 22.2% to 76% for studies related to alcohol dependence and 40% to 90% for studies pertaining to opioid dependence. Varied types of sexual dysfunctions were identified, including poor satisfaction, lack of desire, premature ejaculation, and erectile dysfunction. Efforts to address bias and confounders were not reported in most studies.

CONCLUSION

Sexual dysfunction affects a substantial proportion of patients with substance use disorders. Clinicians can make an effort to ascertain and address sexual dysfunction in their routine clinical practice while dealing with patients with substance use disorders.

Trends in reported male sexual dysfunction over the past decade: an evolving landscape

We investigated changes in patterns of reported male SDs at a single academic centre over a 10-year time frame. Comprehensive data of 2013 patients consecutively assessed for the first time by a single Sexual Medicine expert between 2006 and 2019 has been analysed. All patients were assessed with a thorough sexual and medical history. Primary reason for seeking medical help at first assessment was recorded for all patients and categorized as: erectile dysfunction (ED), premature ejaculation (PE), low/reduced sexual desire/interest (LSD/I), Peyronie's disease (PD), and other SDs. Linear and logistic regression models tested the association between different reasons for seeking medical help and the time at first evaluation. Local polynomial regression model explored the probability of reporting different SDs over the analysed time frame. Median (IQR) age at first clinical assessment was 50 (38-61) years. Overall, most patients were assessed for ED (824; 41%), followed by PD (369; 18%), PE (322; 16%), LSD/I (204; 10%) and other SDs (294; 15%). Significant changes in terms of reported SD over the analysed time frame were observed. The likelihood of assessing patients for ED significantly increased up to 2013, with a decrease in the past 5 years (p < 0.001). PE assessment at presentation linearly decreased over time (OR: 0.94; 95% CI: 0.91-0.96; p < 0.001). Patients assessed during the past few years were more likely to report PD (OR: 1.20; 95% CI: 1.15-1.25; p < 0.001) and LSD/I (OR: 1.21; 95% CI: 1.16-1.26; p < 0.001), with a linear increase over the evaluated time frame. Likewise, patients were also more likely to report other SDs (Coeff: 1.06; 95% CI: 1.02-1.10; p = 0.004), with a linear increase over time. These results may reflect real changes in SD incidence, increased public awareness towards different SDs and the possible impact of novel treatments available on the market throughout the same time frame.

Steroid secretion in healthy aging

Nowadays, people spend a considerable amount of their lives as older adults, but this longer lifespan is often accompanied by an increase in chronic conditions and disease, resulting in reduced quality of life and unprecedented societal and economic burden. Healthy aging is therefore increasingly recognized as a healthcare priority. Physical and mental adaptations to changes over the life course, and the maintenance of well-being, represent pivotal challenges in healthy aging. To capture the complexity of healthy aging, we propose a specific phenotype based on body composition, cognition, mood, and sexual function as indicators of different dimensions of healthy aging. With increasing age, sex hormones as well as glucocorticoids undergo significant alterations, and different patterns emerge for women and men. This review describes age-related patterns of change for women and men, and sheds light on the underlying mechanisms. Furthermore, an overview is provided of the challenges for healthy aging resulting from these age-related steroid alterations. While clinical practice guidelines recommend hormonal treatment only in the case of consistently low hormone levels and symptoms of hormone deficiency, physical exercise and a healthy lifestyle emerge as preventive strategies which can counter age-related hormonal changes and at best prevent chronic conditions.

Testosterone and Dehydroepiandrosterone Treatment in Ageing Men: Are We All Set?

Although demographic statistics show that populations around the world are rapidly ageing, this rising life expectancy is accompanied by an increase in the number of people living with age-related chronic conditions, such as frailty, cognitive decline, depression, or sexual dysfunction. In men, a progressive decline in androgens occurs with increasing age, and low androgen levels are associated with age-related chronic conditions. However, androgen administration studies are inconclusive, showing differing results according to the androgen used (testosterone [T], dehydroepiandrosterone [DHEA]), the group of men examined (younger vs. older; eugonadal vs. hypogonadal) and the conditions studied (frailty, cognitive decline, depression, sexual dysfunction). In this review, the current state for the use of T and DHEA therapy in men for the age-related conditions is examined. Due to the progressive age-related decline in androgens leading to a higher rate of older men having low androgen levels, the effects of androgen treatment in elderly males will be of particular interest in this review. Dose-response relationships, the role of potential moderators, and the androgen treatment-related risk for adverse events will be discussed. Studies have suggested that T treatment - more so than DHEA treatment - may be an effective therapy against age-related chronic conditions in men with low T levels; especially older men. Such conditions include frailty, depression, or sexual dysfunction. However, T treatment does not emerge as an effective therapy against cognitive decline. Nevertheless, more high-quality, randomised controlled trials using T treatment for age-related chronic conditions are necessary if further conclusions are to be made.

Erectile dysfunction is independently associated with apnea-hypopnea index and oxygen desaturation index in elderly, but not younger, community-dwelling men

OBJECTIVE(S)

To examine the association between obstructive sleep apnea (OSA) and other sleep indices using polysomnography (PSG) data and erectile dysfunction (ED) in a representative cohort of men.

DESIGN

Cross-sectional.

SETTING

Community-based.

PARTICIPANTS

Aged 40+ years (n=734; mean age [SD], 60.8 [10.9]).

MEASUREMENTS

Men with no prior OSA diagnosis who underwent in-home PSG (Embletta X100; 2010-11) and ED assessment (Global Impotence Rating) were selected. Un-adjusted and multi-adjusted regression models of ED were fitted against PSG measures, along with qualifying sociodemographic, lifestyle, and health-related covariates. Mediation effects were examined using the Baron-Kenny method.

RESULTS

Of the men examined, 24.7% (n=181) had ED, most notably in men older than 65years (cf. men 35-49 and 50-64years; P<.001). There was no significant association between ED and any of the PSG measures for allaged men. Given an observed ageinteraction within OSA categories (P=.005), analyses were repeated in age-stratified samples (<65 years; 65+ years). In men younger than 65years, only severe OSA was found to have an association with ED (2.01; 1.13-4.69) in unadjusted models. For men aged 65+ years, an independent association with ED was found for apnea-hyponea index (AHI; 1.55;1.02-2.36), moderate (AHI:10.0-19.9; 1.79;1.18-2.43), and severe (AHI:20.0+; 4.84;2.56-9.93) OSA, and oxygen desaturation index (ODI; both continuous [1.48;1.03-1.99] and >16 seconds [2.79;1.23-6.32]). The effect of AHI on ED was shown to be primarily mediated through ODI (63.4%, Sobel P value=.29).

CONCLUSIONS

In younger, community-based men, there appeared no independent relationship between objective measures of sleep and ED. However, there appears a strong, independent relationship between OSA, ODI, and ED in men 65 years and older.

Hypertension might be a risk factor for erectile dysfunction: a meta-analysis

The study aimed to evaluate whether hypertension was a risk factor for erectile dysfunction (ED). Databases including PubMed and Embase were retrieved to identify studies related to hypertension in ED patients. Odds ratio (OR) and 95% confidence interval (CI) were used as the effect size. Subgroup analyses stratified by total number of enrolled subjects and research regions were performed. Sensitivity analysis was performed by removing a single study at one time. Egger's test was used to evaluate the publication bias. Totally, 40 studies including 121,641 subjects were included in the meta-analysis. As a result, hypertension was closely related to ED (OR = 1.74, 95% CI, 0.63-0.80, p < .01). Subgroup analysis indicated hypertension was the risk factor for ED whatever the participants numbers. When stratified by different regions, hypertension was a risk factor for ED in Africa (OR = 3.35, 95% CI, 1.45-7.77, p < .01), Americas (OR = 1.97, 95% CI, 1.68-2.31, p < 0.01), Asia (OR = 1.46, 95% CI, 1.16-1.84, p < .01) and Europe (OR = 1.83, 95% CI, 1.34-2.49, p < .01), but not in Australia. Hypertension may be a potential risk factor for ED.

Erectile dysfunction in the elderly: an old widespread issue with novel treatment perspectives

Erectile dysfunction (ED) is one of the most common chronic diseases affecting men and its prevalence increases with aging. It is also the most frequently diagnosed sexual dysfunction in the older male population. A number of different diseases potentially worsening sexual function may occur in elderly people, together with polypharmacy. Related causes of ED are variable and can include arterial, neurogenic, hormonal, cavernosal, iatrogenic, and psychogenic causes. The aim of the present review was to examine the main aspects of erectile dysfunction going through epidemiology and pathophysiology and revise most of ED in elderly disabled men and in those affected with psychiatric disorders. Lastly we tried to focus on the main aspects of nonpharmacological and pharmacological treatments of ED and the recreational use in the elderly. Phosphodiesterase-5 inhibitors (PDE5-I) are commonly used for on-demand or chronic treatment of ED. It is widely known that PDE5-I have lower response rates in older men than in younger patients, but they have the advantages of ease of use and excellent safety profile, also in the elderly. The old and new PDE5-I as well as the alternative treatments for ED are extensively discussed.

Predictors of sexual dysfunction incidence and remission in men

INTRODUCTION

The progress and determinants of sexual dysfunction in middle-aged and elderly men remain unclear.

AIM

To describe the incidence or remission and biopsychosocial predictors of erectile dysfunction (ED) and low sexual desire (SD).

MAIN OUTCOME MEASURES

Erectile function (International Index of Erectile Function) and sexual desire (Sexual Desire Inventory 2) were assessed at follow-up. Sociodemographic, lifestyle, and health-related factors were examined in multivariate models of ED and low SD.

METHODS

Data were collected from 810 randomly selected men residing in northern and western Adelaide, Australia, and aged 35-80 years at baseline, who made clinic visits 5 years apart.

RESULTS

At baseline, 23.2% (n = 123) of men had ED. ED incidence and remission were observed in 31.7% (n = 179) and 29.0% (n = 71) of eligible men, respectively. At baseline, 19.2% (n = 165) had low solitary sexual desire, and 6.0% (n = 50) had low dyadic sexual desire; incidence of low sexual desire occurred in 17.6% (n = 83) (solitary) and 8.3% (n = 51) (dyadic), while remission occurred in 15.4% (n = 68) (solitary) and 22.6% (n = 40) (dyadic) of men. In the final regression models, predictors of incident ED were higher age, lower income, higher abdominal fat mass, low alcohol intake, higher risk of obstructive sleep apnea (OSA) risk, voiding lower urinary tract symptoms (LUTS), depression, and diabetes. Predictors of ED remission were lower age, current employment, and absence of voiding LUTS, angina, diabetes, and dyslipidemia. Predictors of low dyadic SD incidence included higher age, never having been married, widowhood, being unemployed, being retired, insufficient physical activity, and low alcohol intake. Predictors of low dyadic SD remission were being married, not being widowed, higher income, lower abdominal fat mass, lower OSA risk, and higher plasma testosterone. Predictors of low solitary SD included never having been married, being unemployed, low alcohol intake, lower testosterone, storage LUTS, and hypertension. Predictors of low solitary SD remission were being married, being employed, higher income, higher physical activity, moderate alcohol intake, and depression.

CONCLUSIONS

Sexual dysfunction in aging men is a dynamic disorder whose incidence and remission are predicted by a range of modifiable risk factors.

Longitudinal trajectory of sexual functioning after hematopoietic cell transplantation: impact of chronic graft-versus-host disease and total body irradiation

This prospective study described the trajectory of sexual well-being from before hematopoietic cell transplantation (HCT) to 3 years after in 131 allogeneic and 146 autologous HCT recipients using Derogatis Interview for Sexual Function and Derogatis Global Sexual Satisfaction Index. Sixty-one percent of men and 37% of women were sexually active pre-HCT; the prevalence declined to 51% (P = .01) in men and increased to 48% (P = .02) in women at 3 years post-HCT. After HCT, sexual satisfaction declined in both sexes (P < .001). All sexual function domains were worse in women compared with men (P ≤ .001). Orgasm (P = .002) and drive/relationship (P < .001) declined in men, but sexual cognition/fantasy (P = .01) and sexual behavior/experience (P = .01) improved in women. Older age negatively impacted sexual function post-HCT in both sexes (P < .01). Chronic graft-versus-host disease was associated with lower sexual cognition/fantasy (P = .003) and orgasm (P = .006) in men and sexual arousal (P = .05) and sexual satisfaction (P = .005) in women. All male sexual function domains declined after total body irradiation (P < .05). This study identifies vulnerable subpopulations that could benefit from interventional strategies to improve sexual well-being.

The "Aging Males' Symptoms" (AMS) Scale assesses depression and anxiety

OBJECTIVE

Emotional distress may be associated with severe aging symptoms. This study aimed to investigate aging symptoms in male psychiatric outpatients and their relationship with anxiety and depression.

METHOD

About 176 male psychiatric outpatients aged 40-80 years were enrolled into this single-center cross-sectional study, and completed self-reported questionnaires including "Aging Males' Symptoms" (AMS) scale and the Hospital Anxiety and Depression Scale (HADS).

RESULT

Age was correlated with less anxiety (r = -0.23), less psychological (r = -0.16) and more sexual symptoms (r = 0.31). After controlling demographic variables, the partial correlation coefficients of HADS and AMS scores ranged from 0.30 to 0.73. Four groups were defined by HADS: control (C; n = 103), depression (D; n = 18), anxiety (A; n = 26) and mixed anxiety and depression (M; n = 29). The M group had the most severe aging symptoms, and the C group the least. The A group had more psychological and less sexual symptoms than the D group. "Impaired sexual potency" was the only aging symptom in males not significantly different among the four groups.

CONCLUSIONS

Anxiety and depression was associated with more severe aging symptoms in male psychiatric outpatients. Sexual dysfunction could be regarded as the core manifestation to differentiate aging symptoms from syndromal emotional distress.

The Erectile Performance Anxiety Index: scale development and psychometric properties

INTRODUCTION

Erectile dysfunction is a highly publicized and prevalent condition with marked adverse effects on men's social, emotional, and quality of life. Although several instruments have emerged for assessing erectile dysfunction and its impact on men's quality of life, none of the existing instruments provide a specific assessment of men's erectile performance anxiety.

AIM

This article reports on the development and psychometric evaluation of the Erectile Performance Anxiety Index (EPAI)--a 10-item self-report scale designed to fill an important gap in the assessment of male erectile dysfunction.

METHODS

A total of 207 men ranging in age from 18 to 79 took part in the study. All subjects completed an online battery consisting of the EPAI, along with measures of related sexual functioning, social anxiety, state anxiety, and depressive symptoms. A small subset of study participants (N = 42) completed the EPAI a second time for determining test-retest reliability.

MAIN OUTCOME MEASURE

Test-retest reliability was determined by Pearson's product-moment correlations. Internal reliability was assessed using Cronbach's alpha. Factor validity was evaluated by a maximum likelihood factor analysis with oblique rotation. Convergent and discriminant validity was assessed by comparing the strength of association between the EPAI and measures varying in their hypothesized shared variance with the construct of erectile performance anxiety.

RESULTS

The EPAI demonstrated excellent internal consistency, with Cronbach's alpha = 0.93 and excellent test-retest reliability (r = 0.85) over an average period of 3.5 weeks. Results of an exploratory factor analysis revealed a one-factor solution that accounted for 63% of the total variance. Preliminary evidence supports the convergent and discriminant validity of the EPAI.

CONCLUSION

Results support the use of the EPAI as a reliable, valid, and efficient instrument for the assessment of erectile performance anxiety. Potential research and clinical applications are discussed.