Sexuality among middle-aged and older adults with diagnosed and undiagnosed diabetes: a national, population-based study

Seminal vesicles - an overlooked pair of accessory glands in male sexual dysfunction: a narrative review

The seminal vesicles (SVs) have long been recognized for their role in male fertility, yet their contribution to male sexual function is often underestimated. In recent decades, studies have gradually unveiled an association between SVs and various male sexual dysfunctions (SDs), including diminished libido, erectile dysfunction, premature ejaculation, delayed ejaculation, and orgasmic disorder. We conducted a comprehensive literature search of publications up until April 2024 in PubMed, Google Scholar, and CNKI, focusing on original studies, case reports, and reviews addressing the relationship between SVs and male SDs. The aim was to explore the pathophysiological mechanisms, clinical evaluation, and management of this relationship, providing urologists and andrologists with new insights into diagnosing and treating complex male SDs. Current research suggests that SVs may play a role in male sexual function, but the evidence remains limited. Future large-scale, rigorously designed studies are needed to further validate this relationship.

Asking women with diabetes about sexual problems: An exploratory study of NHS professionals' attitudes and practice: A survey of healthcare professionals regarding communication and silences about sexual problems during the routine care of women with diabetes

AIMS

To explore UK healthcare professionals' practice and attitudes towards asking women with diabetes about sexual health problems, including symptoms of female sexual dysfunction (FSD).

METHODS

An online questionnaire to address the study aims was developed, piloted by ten healthcare professionals (HCPs) and completed by 111 eligible HCPs, recruited via professional networks and social media. Free text data were analysed and reported thematically. Two questions were analysed to test the hypothesis of differences between men's and women's responses.

RESULTS

The majority of respondents did not ask women with diabetes about sexual problems. Multiple barriers to inquiry were reported, including inadequate training, time constraints, competing priorities, the perceived likelihood that questions will cause surprise or distress (especially for certain groups of women), the belief that sexual problems are to be expected as women age, and the belief that FSD is complex or untreatable, with unclear management pathways. Exploratory findings indicated significant differences in men and women's responses (men disagreed more strongly with prioritisation, and fewer reported routine inquiry about sexual problems in their usual practice).

CONCLUSIONS

HCPs reported not asking women with diabetes about sexual problems during routine care. They described multiple factors reinforcing the silence about sexual health, including inadequate education and perceived social risk for individual HCPs who deviate from the patterns of topics usually discussed in diabetes consultations.

Unrecognised orgasmic phase disorders in men presenting with new-onset erectile dysfunction-Findings from a real-life, cross-sectional study

BACKGROUND

Orgasmic phase disorders in men worsen the burden of erectile dysfunction on sexual satisfaction.

OBJECTIVES

To investigate the prevalence of and predictors of unreported orgasmic phase disorder in a cohort of men looking for their first urological assessment for new-onset erectile dysfunction in a real-life setting.

MATERIALS AND METHODS

Data from 1107 heterosexual, sexually active men consecutively assessed for new-onset erectile dysfunction were analysed. Throughout a comprehensive medical and sexual history, all patients were asked to self-report any orgasmic phase disorder and to complete the International Index of Erectile Function and the Beck's Inventory for Depression (depressive symptoms scored as Beck's Inventory for Depression ≥11). Men self-reporting orgasmic phase disorder during the interview were excluded from further analyses. The median value of the International Index of Erectile Function-orgasmic function domain was arbitrarily used to categorise men with (International Index of Erectile Function-orgasmic function ≤5) and without unreported orgasmic phase disorder (International Index of Erectile Function-orgasmic function >5). Circulating hormones were measured in every patient. Descriptive statistics and logistic regression models were used to test the association between clinical variables and unreported orgasmic phase disorder.

RESULTS

Of 1098 patients with non-self-reporting orgasmic phase disorder, 314 (28.6%) had International Index of Erectile Function-orgasmic function ≤5. Patients with erectile dysfunction + unreported orgasmic phase disorder were older (median [interquartile range]: 58 [44-66] years vs. 51 [40-60] years), had higher body mass index [25.8 (23.7-28.1) kg/m2 vs. 25.2 (23.3-27.4) kg/m2 ], higher prevalence of type 2 diabetes (36 [11.5%] vs. 45 [5.7%]) and lower International Index of Erectile Function-erectile function scores (6 [2-10] vs. 18 [11-24]) than men with erectile dysfunction-only (all p < 0.05). Patients with erectile dysfunction + unreported orgasmic phase disorder depicted higher rates of severe erectile dysfunction (75.5% vs. 25%) and Beck's Inventory for Depression ≥11 (22.6% vs. 17.9%) (all p < 0.05). In the multivariable logistic regression analysis, older age (odds ratio: 1.02) and lower International Index of Erectile Function-erectile function scores (odds ratio: 0.83) were independently associated with unreported orgasmic phase disorder (all p < 0.05).

CONCLUSIONS

Almost one in three men seeking first medical help for erectile dysfunction depicted criteria suggestive of unreported orgasmic phase disorder. Men with unreported orgasmic phase disorder were older and had higher rates of severe erectile dysfunction and concomitant depressive symptoms. These real-life findings outline the clinical relevance of a comprehensive investigation of concomitant sexual dysfunction in men only complaining of erectile dysfunction to more effectively tailor patient management.

Shiver Me Tinders and Ring a Ding for a Fling-Sex Tech Use during COVID-19: Findings from a UK Study

Existing research surrounding dating apps has primarily focused on younger people with few studies exploring usage of such apps by middle aged and older adults. The worldwide COVID-19 pandemic challenged social behaviours and forced people to adapt intimacy and wider relationship conduct. The objective of this study was to examine how older adults utilized dating apps during the lockdowns of the UK pandemic (December 2020-May 2021). Findings presented here focus on qualitative data collected from an online survey and eight online, one-to-one interviews with adults aged 40-54 years. The online survey targeted adults across the UK while interviewees were located across England. Employing interpretative phenomenological analysis, findings identified three key themes: 1. Morality, health, and law breaking and COVID-19; 2. Self-surveillance and moral signalling; 3. Loneliness and social isolation. Qualitative findings show engaging with apps was a proxy which alleviated feelings of loneliness and social isolation. Some users used the premise of their social bubble as a way of meeting other people. Using the same premise, others justified breaking the law to engage in physical and sexual intimacy to mitigate their loneliness. The work presented here contributes to the fields of social sciences, gerontology, and human computer interaction. The inter- and multi-disciplinary impact of this study intersects across those fields and offers a cross-sectional insight into behaviours and engagement with technology during one of the most extraordinary global events.

Symptom Burden before and after Dialysis Initiation in Older Patients

BACKGROUND AND OBJECTIVES

For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality (EQUAL) study is an ongoing, prospective, multicenter study in patients ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m2. Using the dialysis symptom index (DSI), 30 symptoms were assessed every 3-6 months between 2012 and 2021. Scores for symptom number range from zero to 30 and, for burden, from zero to 150, with higher scores indicating more severity. Using mixed effects models, we studied symptoms during the year preceding and the year after dialysis initiation.

RESULTS

We included 456 incident patients on dialysis who filled out at least one DSI during the year before or after dialysis. At dialysis initiation, mean (SD) participant age was 76 (6) years, 75% were men, mean (SD) eGFR was 8 (3) ml/min per 1.73 m2, 44% had diabetes, and 46% had cardiovascular disease. In the year before dialysis initiation, symptom number increased +3.6 (95% confidence interval [95% CI], +2.5 to +4.6) and symptom burden increased +13.3 (95% CI, +9.5 to +17.0). In the year after, symptom number changed -0.9 (95% CI, -3.4 to +1.5) and burden decreased -5.9 (95% CI, -14.9 to -3.0). At dialysis initiation, "fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" had the highest prevalence of 81%, 69%, and 68%, respectively, with a burden of 2.7, 2.4, and 2.3, respectively. "Fatigue" somewhat improved after dialysis initiation, whereas the prevalence and burden of sexual symptoms further increased.

CONCLUSIONS

Symptom burden worsened considerably before and stabilized after dialysis initiation. "Fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" were considered most burdensome, of which only "fatigue" somewhat improved after dialysis initiation.

Prevalence of and risk factors for sexual dysfunctions in adults with type 1 or type 2 diabetes: Results from Diabetes MILES - Flanders

BACKGROUND AND AIMS

The prevalence of sexual dysfunctions in people with diabetes is still debated and understudied in women. This study examines the prevalence of sexual dysfunction in men and women with type 1 or type 2 diabetes (T1D or T2D) and the associations with clinical and psychological variables.

METHODS

Adults with diabetes (n = 756) completed an online survey including questions on sexual functioning (adapted Short Sexual Functional Scale), general emotional well-being (WHO-5), symptoms of anxiety (GAD-7) and diabetes distress (PAID-20).

RESULTS

One third of participants reported a sexual dysfunction. Men reported erectile dysfunction (T1D: 20%; T2D: 33%), and orgasmic dysfunction (T1D: 22%; T2D: 27%). In men, sexual dysfunction was independently associated with, older age (OR = 1.05, p = 0.022), higher waist circumference (OR = 1.04; p < 0.001) and longer duration of diabetes (OR = 1.04; p = 0.007). More men with sexual dysfunction reported diabetes distress (20% vs. 12%, p = 0.026). Women reported decreased desire (T1D: 22%; T2D: 15%) and decreased arousal (T1D: 9%; T2D: 11%). More women with sexual dysfunction reported diabetes distress (36% vs. 21%, p = 0.003), impaired emotional well-being (36% vs. 25%, p = 0.036) and anxiety symptoms (20% vs. 11%, p = 0.026).

CONCLUSION

Sexual dysfunctions are common in both men and women with diabetes. In men, sexual dysfunctions were associated with clinical factors. More women with sexual dysfunction reported low emotional well-being and anxiety symptoms compared to women without sexual dysfunction. For both men and women, sexual dysfunctions were associated with diabetes distress.

Quality of Life, Sexual Functioning and Chronic Disease: A Comparative Study with Portuguese Women without Chronic Disease, and Women with Diabetes Type 1 and 2, and Arterial Hypertension

Aims: Previous research has focused on the impact of chronic diseases on men's sexual functioning and quality of life; however, little is known about the association between chronic disease and women's sexual functioning and quality of life. Current study aimed at exploring the differences in quality of life and sexual functioning between women without chronic disease, and women with type 1 diabetes, with type 2 diabetes, and with arterial hypertension. Methods: A web-survey was completed by 313 Portuguese women (167 without chronic disease, 48 with type 1 diabetes, 48 with type 2 diabetes, and 50 with arterial hypertension). Results: Women without chronic disease scored significantly higher than women with chronic disease in quality of life and sexual functioning, adjusting for age. Conclusions: Quality of life and sexual functioning in women with chronic diseases is impaired.

Decreased Sexual Desire among Middle-Aged and Old Women in China and Factors Influencing It: A Questionnaire-Based Study

Objective

This survey was designed and conducted with an aim to present data on sexual desire and activity in Chinese women.

Methods

Between October 2013 and December 2013, we surveyed 3000 women (aged 40–65 years) at Beijing No. 2 Hospital and the Yuetan Community Health Service Center using a questionnaire. The primary outcomes included determination of sexual desire in the past 4 weeks, reasons for stopping sexual activity, and postmenopausal syndrome. The secondary outcome was determination of factors for low sexual desire.

Results

A total of 2400 women (mean age 54.33 ± 6.25 years; mean menopausal age 50.11 ± 3.31 years) returned the questionnaire, with 58% of women reporting lowered sexual desire and 39.3% reporting stoppage of sexual activity. Compared with the postmenopausal group, the incidence of anxiety, depressive, somatic, and vasomotor symptoms was higher in the perimenopausal group. Muscle and joint pain (45.8%) and vaginal pruritus (21.5%) were the most commonly reported menopausal and vulvovaginal symptoms, respectively. The odds of decrease in sexual desire were significantly higher with older age, menopause, presence of gynecological disease, menopausal depression symptoms, menopausal vasomotor symptoms, and vulvovaginal atrophy; only cesarean delivery (odds ratio = 0.887, P=0.018) was associated with lesser reduction in sexual desire compared with the aforementioned factors.

Conclusion

This survey showed that a high proportion of Chinese middle-aged and old women have lowered sexual desire and activity. Lack of sexual desire is associated with multiple factors and affects the quality of life of women.

Risk factors for orgasmic and concomitant erectile dysfunction in men with type 1 diabetes: a cross-sectional study

In this study, we sought to determine the burden and characteristics of orgasmic dysfunction (OD) and concomitant erectile dysfunction (ED) in men with type 1 diabetes (T1D) enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. In 2010, we assessed orgasmic and erectile function using the International Index of Erectile Function (IIEF). Sociodemographic, clinical, and diabetes characteristics were compared by OD status (OD only, OD and ED, no ED or OD). Age-adjusted associations between risk factors and OD status were examined. OD and ED information was available from 563 men. Eighty-three men (14.7%) reported OD of whom 21 reported OD only and 62 reported OD and ED. Age-adjusted odds ratios demonstrated that men who reported OD only had higher odds of depression, low sexual desire, and decreased alcohol use compared with men reporting no dysfunction. Men with OD concomitant with ED had greater odds of elevated hemoglobin A1C, peripheral and autonomic neuropathy, and nephropathy. Men reporting both dysfunctions were also more likely to report smoking, lower urinary tract symptoms, and had greater odds of androgen deficiency than men with no sexual dysfunction. Men with longstanding T1D suffer from an increased burden of OD. Psychogenic factors predominate in men reporting OD only while men who present with concomitant ED report increased burden of diabetes severity, characteristics previously observed with incident ED. ED may be the central impediment to sexual function in men with OD and ED. Longitudinal studies to characterize OD and ED experience over time are warranted.

Deterioration of Sexual Health in Cancer Survivors Five Years after Diagnosis: Data from the French National Prospective VICAN Survey

Little is known about cancer survivors' sexual health (SH)-particularly, from well after diagnosis and in cancers unrelated to sexuality. This study aimed to assess SH deterioration five years after diagnosis. We analyzed data from the French national VIe après le CANcer (VICAN) survey. Six items from the Relationship and Sexuality Scale were used to assess SH. Respondents were grouped according to an ascending hierarchical classification in four clusters: strong, moderate, and weak deterioration or stable (WD, SD, MD, or St). Out of 2195 eligible participants, 57.3% reported substantial SH deterioration as either SD (30.8%) or MD (26.5%), while WD and St accounted for 31.2% and 11.5% of respondents, respectively. Substantial deterioration was reported in all cancer sites (from 27.7% in melanoma to 83.1% in prostate). Treatment type, cancer sequelae, and pain, as well as psychological consequences (depression and anxiety, especially for younger patients) were associated with substantial SH deterioration. The same factors were identified after restricting the analysis to survivors of cancers unrelated to sexuality. Five years after diagnosis, the majority of cancer survivors reported SH deterioration. Interventions should be developed to improve SH regardless of cancer site. Particular attention should be paid to depression and anxiety, especially in younger survivors.

The relationship between sexual activity and sexual attitudes among breast cancer survivors in China

Purpose

Less is known about sexual attitudes of breast cancer survivors (BCSs) and its association with sexual activity and sexual dissatisfaction.

Methods

We investigated the proportion of sexual activity and sexual dissatisfaction in a cross‐sectional study among 341 Chinese BCSs aged 30‐75 years old, and we described their association with sexual attitudes, as well as socio‐demographic characteristics, physical health conditions, and mental health problems.

Results

Only 83 (24.3%) individuals reported sexual activity in the past year. More than 50% of BCSs considered that sexual activity had adverse impact on their disease recovery. The sexual attitudes such as “sexual activity may impede disease recovery” (adjusted odds ratio [AOR] = 0.51; 95% confidence interval, 95% CI: 0.30‐0.88), “sexual activity may cause cancer recurrence or metastasizes” (AOR = 0.51; 95% CI: 0.30‐0.87), and “their partner fear contracting cancer by sexuality” (AOR = 0.47; 95% CI: 0.23‐0.98) were significantly associated with decreased likelihood of reporting sexual activity in the past year. Although 201 (58.9%) BCSs reported that breast cancer decreased the frequency of their sexual activity, only 37 (10.9%) had ever discussed sexuality with a doctor to seek advice.

Conclusions

Most Chinese BCSs were sexually inactive. The sexual misconceptions about cancer were great barriers of sexual activity. Professional sexual education and consultation may be regarded as easy and effective intervention measures to correct BCSs' misguided sexual attitudes, and finally improving the overall sexual health for BCSs.

Sexual Inactivity in Methadone Maintenance Treatment Patients

Sexual dysfunction has been extensively studied in methadone maintenance treatment (MMT) patients. However, little data is available regarding sexual inactivity in the MMT patient population. The objectives of this study were to determine the prevalence and putative risk factors for sexual inactivity in the MMT patient population. This cross-sectional study involved 25-71 year old MMT patients recruited from six methadone clinics. Two hundred and seventy-one patients were interviewed for demographic characteristics, comorbidities, concurrent medications used, and sexual activity. The prevalence of sexual inactivity in the MMT population was found to be 47.6%. Increasing age (p < 0.01) and being single/divorced (p < 0.01) were significantly associated with sexual inactivity. In subgroup analysis, increasing age was significantly associated with sexual inactivity in both single/divorced (p < 0.05) and married (p < 0.05) subgroups, while unemployment (p < 0.05) was only significantly associated with sexual inactivity in the earlier subgroup. Our results suggest that sexual inactivity is common in the MMT patient population. The putative risk factors are related to biological and sociocultural factors. Having specific comorbidities or being on certain medications were not correlated with sexual inactivity in the MMT population. Routine assessment of sexual problems is essential, and proper management should be performed for MMT patients.

A Life Course Perspective on the Ways Older Men and Women Discuss Sexual Issues

The present study examined how older adults communicate about sexual issues in light of the tremendous societal changes that have taken place with regard to sexuality in the past few decades. We relied on interviews with 47 Israelis 60 years of age and older who were instructed to discuss sexuality in old age and its unique characteristics, using semi-structured interviews. Analysis consisted of repeated comparisons and contrasts to identify common themes. A common thread of "secrets and lies" characterized the discussion of sexual issues throughout the life course of respondents. The findings showed that although older adults have been aware of the limited information provided to them during their upbringing and of the limited room allowed to sexuality in their emerging adulthood years, many have continued to find it difficult to address sexual issues, even in later life. Moreover, many perceived the information currently available about sexuality and the contemporary approach to sexuality brought by the media or their children and grandchildren as being somewhat inadequate. Implications for practice are discussed.

Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial

PURPOSE

Time during primary care visits is limited. We tested the hypothesis that a waiting room health information technology (IT) tool to help patients identify and voice their top visit priorities would lead to better visit interactions and improved quality of care.

METHODS

We designed a waiting room tool, the Visit Planner, to guide adult patients through the process of identifying their top priorities for their visit and effectively expressing these priorities to their clinician. We tested this tool in a cluster-randomized controlled trial with usual care as the control. Eligible patients had at least 1 clinical care gap (eg, overdue for cancer screening, suboptimal chronic disease risk factor control, or medication nonadherence).

RESULTS

The study (conducted March 31, 2016 through December 31, 2017) included 750 English- or Spanish-speaking patients. Compared with usual care patients, intervention patients more often reported "definitely" preparing questions for their doctor (59.5% vs 45.1%, P <.001) and "definitely" expressing their top concerns at the beginning of the visit (91.3% vs 83.3%, P = .005). Patients in both arms reported high levels of satisfaction with their care (86.8% vs 89.9%, P = .20). With 6 months of follow-up, prevalence of clinical care gaps was reduced by a similar amount in each study arm.

CONCLUSIONS

A simple waiting room-based tool significantly improved visit communication. Patients using the Visit Planner were more prepared and more likely to begin the visit by communicating their top priorities. These changes did not, however, lead to further reduction in aggregate clinical care gaps beyond the improvements seen in the usual care arm.

"My wife's mistrust. That's the saddest part of being a diabetic": A qualitative study of sexual well-being in men with Type 2 diabetes in sub-Saharan Africa

Introduction

Sexual dysfunction is a common complication for men with diabetes, yet little is known about the lived experiences of sexual difficulties within the context of diabetes, particularly in low-and-middle-income countries. This study explores how men with type 2 diabetes in three sub-Saharan African settings (Cape Town and Johannesburg, South Africa; Lilongwe, Malawi) perceive and experience sexual functioning and sexual well-being, and the biopsychosocial contexts in which these occur and are shaped.

Methods

We used a qualitative research design, including individual interviews (n = 15) and focus group discussions (n = 4). Forty-seven men were included in the study. We used an inductive thematic analysis approach to develop our findings. A biopsychosocial conceptual model on the relationship between chronic illness and sexuality informed the interpretation of findings.

Results

Men across the study settings identified sexual difficulties as a central concern of living with diabetes. These difficulties went beyond biomedical issues of erectile dysfunction, comprising complex psychological and relational effects. Low self-esteem, related to a sense of loss of masculinity and reduced sexual and emotional intimacy in partner relationships were common experiences. Specific negative relational effects included suspicion of infidelity, mutual mistrust, general unhappiness, and fear of losing support from partners. These effects may impact on men’s ability to cope with their diabetes. Further stressors were a lack of information about the reasons for their sexual difficulties, perceived lack of support from healthcare providers and an inability to communicate with partners about sexual difficulties.

Conclusion

More in-depth research is needed to better understand sexual functioning and well-being within the context of diabetes, and its potential impact on diabetes self-management. Holistic and patient-centered care should include raising awareness of sexual problems as a potential complication of diabetes amongst patients, their partners and care providers, and incorporating sexual well-being as part of routine clinical care.

Delayed Ejaculation: Pathophysiology, Diagnosis, and Treatment

Delayed ejaculation (DE) is a poorly defined and uncommon form of male sexual dysfunction, characterized by a marked delay in ejaculation or an inability to achieve ejaculation. It is often quite concerning to patients and their partners, and sometimes frustrates couples' attempts to conceive. This article aims to review the pathophysiology of DE and anejaculation (AE), to explore our current understanding of the diagnosis, and to present the treatment options for this condition. Electronic databases were searched from 1966 to October 2017, including PubMed (MEDLINE) and Embase. We combined “delayed ejaculation,” “retarded ejaculation,” “inhibited ejaculation,” or “anejaculation” as Medical Subject Headings (MeSH) terms or keywords with “epidemiology,” “etiology,” “pathophysiology,” “clinical assessment,” “diagnosis,” or “treatment.” Relevant sexual medicine textbooks were searched as well. The literature suggests that the pathophysiology of DE/AE is multifactorial, including both organic and psychosocial factors. Despite the many publications on this condition, the exact pathogenesis is not yet known. There is currently no single gold standard for diagnosing DE/AE, as operationalized criteria do not exist. The history is the key to the diagnosis. Treatment should be cause-specific. There are many approaches to treatment planning, including various psychological interventions, pharmacotherapy, and specific treatments for infertile men. An approved form of drug therapy does not exist. A number of approaches can be employed for infertile men, including the collection of nocturnal emissions, prostatic massage, prostatic urethra catheterization, penile vibratory stimulation, probe electroejaculation, sperm retrieval by aspiration from either the vas deferens or the epididymis, and testicular sperm extraction.

Mobile application for diabetes self-management in China: Do they fit for older adults?

OBJECTIVES

Despite the exponential proliferation of Chinese diabetes applications, none are designed to meet the needs of the largest potential user population. The purpose of this study is to examine the features and contents of Chinese diabetes mobile applications in terms of their suitability for use by older adults with diabetes.

METHODS

A search of the Apple application store and the 360 Mobile Assistant was conducted to identify Chinese diabetes applications. Next, we compared the features and contents of all the included and most popular diabetes applications with both the International Diabetes Federation (IDF) clinical guideline and recommended usability criteria for older adults respectively.

RESULTS

Seventy-one diabetes apps were randomly selected (from a pool of 552 diabetes apps) and reviewed. The features of most apps failed to include content areas of known importance for managing diabetes in older adults. Usability of all tested applications was rated moderate to good.

CONCLUSIONS

Designing maximally effective medical applications would benefit from attention to both usability and content guidelines targeted for the largest potential user population. Despite the preponderance of older adults in the potential user group, failing to consider the relevance of content, in addition to usability for the specific population will ultimately limit the usefulness of the app.

The pathophysiology of delayed ejaculation

Delayed ejaculation (DE) is probably least studied, and least understood of male sexual dysfunctions, with an estimated prevalence of 1–4% of the male population. Pathophysiology of DE is multifactorial and including psychosexual-behavioral and cultural factors, disruption of ejaculatory apparatus, central and peripheral neurotransmitters, hormonal or neurochemical ejaculatory control and psychosocial factors. Although knowledge of the physiology of the DE has increased in the last two decade, our understanding of the different pathophysiological process of the causes of DE remains limited. To provide a systematic update on the pathophysiology of DE. A systematic review of Medline and PubMed for relevant publications on ejaculatory dysfunction (EjD), DE, retarded ejaculation, inhibited ejaculation, and climax was performed. The search was limited to the articles published between the January 1960 and December 2015 in English. Of 178 articles, 105 were selected for this review. Only those publications relevant to the pathophysiology, epidemiology and prevalence of DE were included. The pathophysiology of DE involves cerebral sensory areas, motor centers, and several spinal nuclei that are tightly interconnected. The biogenic, psychogenic and other factors strongly affect the pathophysiology of DE. Despite the many publications on this disorder, there still is a paucity of publications dedicated to the subject.

Predictors of impact of vaginal symptoms in postmenopausal women

OBJECTIVE

This study aims to identify factors associated with greater impact of vaginal symptoms on the functioning and well-being of postmenopausal women.

METHODS

Postmenopausal women who reported vaginal dryness, itching, irritation, or pain with sexual activity completed the multidimensional Day-to-day Impact of Vaginal Aging (DIVA) questionnaire and underwent assessment of multiple sociodemographic and clinical factors that have the potential to influence the impact of vaginal symptoms. Multivariable linear regression analyses examined relationships between selected participant characteristics and DIVA scale scores assessing symptom impact on activities of daily living, emotional well-being, self-concept and body image, and sexual functioning.

RESULTS

Among 745 symptomatic participants, the mean (SD) age was 56 (9) years, and 66% were racial/ethnic minorities. Women with comorbid depression reported greater impact of vaginal symptoms on all dimensions of functioning and well-being measured by the DIVA questionnaire (11%-22% estimated increase in impact scores associated with every three-point increase in Hospital and Anxiety Depression Scale scores). Women with urinary incontinence also reported greater impact of vaginal symptoms on activities of daily living, emotional well-being, and self-concept and body image (27%-37% estimated increase in impact scores). Age, partner status, frequency of sexual activity, general health, and body mass index also predicted greater impact on at least one domain.

CONCLUSIONS

Findings suggest that special efforts should be made to identify and treat vaginal symptoms in postmenopausal women known to have depression or urinary incontinence, as these women may experience greater impact of vaginal symptoms on multiple domains of functioning and quality of life.

Factors Related to Coital Frequency of Women in Their Thirties

This cross-sectional study aimed to identify factors related to coital frequency (CF) among 254 women in their 30s using a semistructured interview to collect sociodemographic, anthropometric, reproductive, clinical, and relationship data. CF was characterized as (a) never, (b) rarely (≤1 times/month), (c) occasionally (≤1 times /week), (d) regularly (2-3 times/week), or (e) frequently (>3 times/week). The mean age was 34.38 ± 0.43 years, mean body mass index (BMI) was 27.86 ± 6.52 kg, mean family income was US$1,044.18 ± 796.19, mean number of children was 1.71 ± 0.89, and mean relationship duration was 8.87 ± 5.11 years. Eighty-seven women (35.2%) were taking hormonal contraceptives, 143 (98.0%) were employed, 239 (96.48%) had a secondary or higher education, and 9 (3.62%) had primary schooling. CF was classified as >3 times/week in 22 (8.66%), 2-3 times/week for 98 (38.58%), ≤1 times/week in 40 (15.75%), ≤1 times/month in 14 (5.51%), and never in 5 (1.97%). Women who reported having coitus >3 times/week a week had significantly higher body mass index (BMI; 32.72 ± 7.42 kg/m(2)) than those who had coitus 2-3 times/week (28.45 ± 6.76 kg/m(2)) and ≤1 times /week (26.81 ± 5.39 kg/m(2)) (p < 0.01 for both comparisons). Thus, coital frequency varies in women in their 30s. Obese women had a higher CF than normal-weight and overweight women.

Type 2 Diabetes Patients' Needs and Preferences for Care Concerning Sexual Problems: A Cross-Sectional Survey and Qualitative Interviews

Sexual dysfunction is highly prevalent among patients with type 2 diabetes; however, little is known regarding these patients' needs and preferences for care for sexual problems. A cross-sectional survey and 25 semistructured interviews were therefore conducted among 40- to 75-year-old type 2 diabetes patients to explore this. We learned from the survey and interviews that most participants were unaware of the association between type 2 diabetes and sexual problems. Although certain barriers for discussing sexual problems with a care provider were identified (e.g., feelings of embarrassment), patients still reported a need for discussing their problems, because sex was viewed as an important part of their relationship. Some patients had sought help, but were dissatisfied with the offered care. Patients experienced a lack of attention and information from diabetes care providers. Improving this, together with a care provider-initiated conversation, was suggested to lower the threshold for discussion. Moreover, patients preferred a care provider with whom they have a close relationship, whereas age, gender, and medical specialty were regarded to be less important. An important recommendation was to make care for sexual problems an integral part of routine diabetes care. Future research should look into these recommendations.

Antihypertensive therapy causes erectile dysfunction

PURPOSE OF REVIEW

Erectile dysfunction is a common sexual disorder affecting 40% of men in the United States. However, the pathophysiologic mechanism involved in the causation of erectile dysfunction is multifactorial and not well delineated.

RECENT FINDINGS

Several recent studies disclose that erectile dysfunction is the result of multiple interrelated comorbid conditions that include hypertension, coronary artery disease (CAD), heart failure, and diabetes mellitus among them. In addition to comorbid conditions, certain cardiovascular and antihypertensive drugs are also involved in the development of erectile dysfunction, with the most prominent being the thiazide type diuretics, the aldosterone receptor blockers, and the β-adrenergic receptor blockers. Also, knowledge by the patient of the drug and its action on erectile dysfunction may increase the incidence of erectile dysfunction (Hawthorn effect). Before treatment is initiated, patients should be screened for the presence of erectile dysfunction, because this condition is associated with hypertension, CAD, heart failure, diabetes mellitus, and their treatment and an appropriate treatment regimen should be selected. If that fails, the addition of phosphodiesterase 5 inhibitors to the treatment regimen is recommended. The only exception is a patient with CAD treated with organic nitrates, in which the coadministration of phosphodiesterase 5 inhibitors is strictly prohibited.

SUMMARY

Knowledge of the various comorbid conditions and their treatment associated with the development of erectile dysfunction will help the caring physician to treat his patients appropriately and safely. All these aspects will be discussed in this review.

Prevalence of sexual desire and satisfaction among patients with screen-detected diabetes and impact of intensive multifactorial treatment: results from the ADDITION-Denmark study

OBJECTIVE

Sexual problems are common in people with diabetes. It is unknown whether early detection of diabetes and subsequent intensive multifactorial treatment (IT) are associated with sexual health. We report the prevalence of low sexual desire and low sexual satisfaction among people with screen-detected diabetes and compare the impact of intensive multifactorial treatment with the impact of routine care (RC) on these measures.

DESIGN

A cross-sectional analysis of the ADDITION-Denmark trial cohort six years post-diagnosis.

SETTING

190 general practices around Denmark.

SUBJECTS

A total of 968 patients with screen-detected type 2 diabetes.

MAIN OUTCOME MEASURES

Low sexual desire and low sexual satisfaction.

RESULTS

Mean (standard deviation, SD) age was 64.9 (6.9) years. The prevalence of low sexual desire was 53% (RC) and 54% (IT) among women, and 24% (RC) and 25% (IT) among men. The prevalence of low sexual satisfaction was 23% (RC) and 18% (IT) among women, and 27% (RC) and 37% (IT) among men. Among men, the prevalence of low sexual satisfaction was significantly higher in the IT group than in the RC group, p = 0.01.

CONCLUSION

Low sexual desire and low satisfaction are frequent among men and women with screen-detected diabetes, and IT may negatively impact men's sexual satisfaction.

Diabetes mellitus and sexual function in middle-aged and older women

OBJECTIVE

Diabetes mellitus is an established risk factor for sexual dysfunction in men, but its effect on female sexual function is poorly understood. We examined the relationship of diabetes to sexual function in middle-aged and older women.

METHODS

Sexual function was examined in a cross-sectional cohort of ethnically diverse women aged 40-80 years using self-administered questionnaires. Multivariable regression models compared self-reported sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (difficulty with lubrication, arousal, orgasm, or pain) among insulin-treated diabetic, non-insulin-treated diabetic, and nondiabetic women. Additional models assessed relationships between diabetic end-organ complications (heart disease, stroke, renal dysfunction, and peripheral neuropathy) and sexual function.

RESULTS

Among the 2,270 participants, mean±standard deviation age was 55±9.2 years, 1,006 (44.4%) were non-Latina white, 486 (21.4%) had diabetes, and 139 (6.1%) were taking insulin. Compared with 19.3% of nondiabetic women, 34.9% of insulin-treated diabetic women (adjusted odds ratio [OR] 2.04, 95% confidence interval [CI] 1.32-3.15) and 26.0% of non-insulin-treated diabetic women (adjusted OR 1.42, 95% CI 1.03-1.94) reported low overall sexual satisfaction. Among sexually active women, insulin-treated diabetic women were more likely to report problems with lubrication (OR 2.37, 95% CI 1.35-4.16) and orgasm (OR 1.80, 95% CI 1.01-3.20) than nondiabetic women. Among all diabetic women, end-organ complications such as heart disease, stroke, renal dysfunction, and peripheral neuropathy were associated with decreased sexual function in at least one domain.

CONCLUSION

Compared with nondiabetic women, diabetic women are more likely to report low overall sexual satisfaction. Insulin-treated diabetic women also appear at higher risk for problems such as difficulty with lubrication and orgasm. Prevention of end-organ complications may be important in preserving sexual activity and function in diabetic women.

LEVEL OF EVIDENCE

II.

Sexual activity and function among middle-aged and older men and women with hypertension

OBJECTIVE

To determine the association of hypertension (HTN) and its treatment with sexual function in middle-aged and older adults.

METHODS

We studied a nationally representative sample of community-residing adults aged 57-85 years (n = 3005) from the National Social Health, Life and Aging Project. Adults were categorized by HTN status (treated, untreated, and no HTN). Antihypertensive medication use was classified into calcium channel blocker; β-blocker; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; diuretic; and α-blocker. For each HTN and medication group, we determined the prevalence and adjusted odds of being sexually active and of having any sexual problem.

RESULTS

Among men, comparing treated HTN with untreated HTN and no HTN, sexual activity was less prevalent (66.5 vs. 75.9 vs.71.5%, P <0.01) and sexual problems were more prevalent (69.1 vs. 57.7 vs. 54.3%; P ≤ 0.01). There was no association between treated HTN and sexual activity [odds ratio, OR = 0.86 (95% confidence interval 0.51-1.45)] and a nonsignificant association between treated HTN and sexual problems [OR = 1.49 (0.94-2.37)]. Among women, the prevalence of sexual activity was lower in the treated and untreated HTN groups than the no HTN group (35.2 vs. 38.3 vs. 58.0%, P <0.01); the prevalence of sexual problems was similar (73.7 vs. 65.3 vs. 71.7%; P = 0.301). Women in the treated HTN [OR = 0.61 (0.39-0.95)] and untreated HTN [0.54 (0.30-0.96)] groups had a lower odds of sexual activity compared with no HTN. There were no significant associations between antihypertensive medication class and sexual activity or problems in men or women.

CONCLUSION

The relationship between HTN and sexual health is different for older men and women. Prospective, comparative effectiveness trials are needed.

Erectile dysfunction in patients with diabetes mellitus: its magnitude, predictors and their bio-psycho-social interaction: a study from a developing country

BACKGROUND

Persons suffering from diabetes mellitus (DM) are at higher risk of developing erectile dysfunction (ED). Several factors contribute to ED in patients of DM. Only few studies have attempted to explore physical, psychological and social factors in a single study. The aim of the index study was to measure the prevalence of ED in patients of DM and to determine the contributory role of various socio-demographic, physical, and psychological variables.

METHOD

One hundred and thirteen (N = 113) consenting consecutive male married diabetic patients were assessed on International Index of Erectile Function Questionnaire (IIEFQ-5), Dyadic Adjustment Scale (DAS) and Beck's Depression Inventory (BDI) to measure erectile performance, quality of marriage and depressive symptoms respectively. Pretested Bengali versions of these scales were used in the index study.

RESULTS

Prevalence of ED was 38.94%. ED group significantly differed from non-ED group in current age, family type, type of treatment for diabetes, presence of micro/macrovascular complications, history of current tobacco use, quality of marriage, and presence of depressive symptoms. In logistic regression analysis current age, body mass index (BMI) and presence of depressive symptoms had significant predictive role on occurrence of erectile dysfunction.

CONCLUSION

Prevalence of ED among diabetic patients is high compared to general population. Both physical and psychosocial factors predict the occurrence of ED in this group. So, both physicians and psychiatrists should remain aware about the multi-faceted causative role of ED in DM.

Childbirth and female sexual function later in life

OBJECTIVE

To examine relationships among parity, mode of delivery, and other parturition-related factors with women's sexual function later in life.

METHODS

Self-administered questionnaires examined sexual desire, activity, satisfaction, and problems in a multiethnic cohort of women aged 40 years and older with at least one past childbirth event. Trained abstractors obtained information on parity, mode of delivery, and other parturition-related factors from archived records. Multivariable regression models examined associations with sexual function controlling for age, race or ethnicity, partner status, diabetes, and general health.

RESULTS

Among 1,094 participants, mean (standard deviation) age was 56.3 (±8.7) years, 568 (43%) were racial or ethnic minorities (214 African American, 171 Asian, and 183 Latina), and 963 (88%) were multiparous. Fifty-six percent (n=601) reported low sexual desire; 53% (n=577) reported less than monthly sexual activity, and 43% (n=399) reported low overall sexual satisfaction. Greater parity was not associated with increased risk of reporting low sexual desire (adjusted odds ratio [OR] 1.08, confidence interval [CI] 0.96-1.21 per each birth), less than monthly sexual activity (adjusted OR 1.05, CI 0.93-1.20 per each birth), or low sexual satisfaction (adjusted OR 0.96, CI 0.85-1.09 per each birth). Compared with vaginal delivery alone, women with a history of cesarean delivery were not significantly more likely to report low desire (adjusted OR 0.71, CI 0.34-1.47), less than monthly sexual activity (adjusted OR 1.03, CI 0.46-2.32), or low sexual satisfaction (adjusted OR 0.57, CI 0.26-1.22). Women with a history of operative-assisted delivery were more likely to report low desire (adjusted OR 1.38, CI 1.04-1.83).

CONCLUSIONS

Among women with at least one childbirth event, parity and mode of delivery are not major determinants of sexual desire, activity, or satisfaction later in life.

LEVEL OF EVIDENCE

II.

Establishing visit priorities for complex patients: A summary of the literature and conceptual model to guide innovative interventions

With the aging of the population and continuing advances in health care, patients seen in the primary care setting are increasingly complex. At the same time, the number of screening and chronic condition management tasks primary care providers are expected to cover during brief primary care office visits has continued to grow. These converging trends mean that there is often not enough time during each visit to address all of the patient's concerns and needs, a significant barrier to effectively providing patient-centered care. For complex patients, prioritization of which issues to address during a given visit must precede discrete decisions about disease-specific treatment preferences and goals. Negotiating this process of setting priorities represents a major challenge for patient-centered primary care, as patient and provider priorities may not always be aligned. In this review, we present a synthesis of recent research on how patients and providers negotiate the visit process and describe a conceptual model to guide innovative approaches to more effective primary care visits for complex patients based on defining visit priorities. The goal of this model is to inform interventions that maximize the value of available time during the primary care encounter by facilitating communication between a prepared patient who has had time before the visit to identify his/her priorities and an informed provider who is aware of the patient's care priorities at the beginning of the visit. We conclude with a discussion of key questions that should guide future research and intervention development in this area.

Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

BACKGROUND

Physical and mental health could greatly affect sexual activity and fulfilment, but the nature of associations at a population level is poorly understood. We used data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) to explore associations between health and sexual lifestyles in Britain (England, Scotland, and Wales).

METHODS

Men and women aged 16-74 years who were resident in households in Britain were interviewed between Sept 6, 2010, and Aug 31, 2012. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data for self-reported health status, chronic conditions, and sexual lifestyles, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures.

FINDINGS

Interviews were done with 15,162 participants (6293 men, 8869 women). The proportion reporting recent sexual activity (one or more occasion of vaginal, oral, or anal sex with a partner of the opposite sex, or oral or anal sex or genital contact with a partner of the same sex in the past 4 weeks) decreased with age after the age of 45 years in men and after the age of 35 years in women, while the proportion in poorer health categories increased with age. Recent sexual activity was less common in participants reporting bad or very bad health than in those reporting very good health (men: 35·7% [95% CI 28·6-43·5] vs 74·8% [72·7-76·7]; women: 34·0% [28·6-39·9] vs 67·4% [65·4-69·3]), and this association remained after adjusting for age and relationship status (men: adjusted odds ratio [AOR] 0·29 [95% CI 0·19-0·44]; women: 0·43 [0·31-0·61]). Sexual satisfaction generally decreased with age, and was significantly lower in those reporting bad or very bad health than in those reporting very good health (men: 45·4% [38·4-52·7] vs 69·5% [67·3-71·6], AOR 0·51 [0·36-0·72]; women: 48·6% [42·9-54·3] vs 65·6% [63·6-67·4], AOR 0·69 [0·53-0·91]). In both sexes, reduced sexual activity and reduced satisfaction were associated with limiting disability and depressive symptoms, and reduced sexual activity was associated with chronic airways disease and difficulty walking up the stairs because of a health problem. 16·6% (95% CI 15·4-17·7) of men and 17·2% (16·3-18·2) of women reported that their health had affected their sex life in the past year, increasing to about 60% in those reporting bad or very bad health. 23·5% (20·3-26·9) of men and 18·4% (16·0-20·9) of women who reported that their health affected their sex life reported that they had sought clinical help (>80% from general practitioners; <10% from specialist services).

INTERPRETATION

Poor health is independently associated with decreased sexual activity and satisfaction at all ages in Britain. Many people in poor health report an effect on their sex life, but few seek clinical help. Sexual lifestyle advice should be a component of holistic health care for patients with chronic ill health.

FUNDING

Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and Department of Health.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men

INTRODUCTION

A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.

OBJECTIVES

The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.

METHODS

A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.

RESULTS

A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.

CONCLUSION

There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.

Undercarboxylated osteocalcin is positively associated with free testosterone in male patients with type 2 diabetes mellitus

Although a recent study showed that undercarboxylated osteocalcin (ucOC) is important for male fertility and testosterone production by testes, little is known about the relationship between ucOC and testosterone in humans. We found for the first time that ucOC is positively associated with free testosterone in men with type 2 diabetes.

INTRODUCTION

The ucOC has been shown to play a key role in energy metabolism as an endocrine hormone. Although a recent animal study demonstrated that ucOC is also important for male fertility and testosterone production by the testes, association between serum osteocalcin and testosterone levels has not been understood in humans.

METHODS

Sixty-nine male patients with type 2 diabetes were recruited and chemical bone markers [total osteocalcin (TOC), ucOC, bone-specific alkaline phosphatase (BAP), and urinary N-terminal cross-linked telopeptide of type I collagen (uNTX)], gonadotropic hormones [luteinizing hormone (LH) and follicle-stimulating hormone (FSH)], and free testosterone (FT) were measured.

RESULTS

Multiple regression analysis showed that ucOC and ucOC/TOC ratio were associated positively with FT and negatively with LH (for ucOC, β = 0.30, p = 0.042 and β = -0.52, p = 0.048; for ucOC/TOC ratio, β = 0.31, p = 0.031 and β = -0.54, p = 0.036, respectively) independently of age, duration of diabetes, body mass index, and hemoglobin A1c. ucOC and ucOC/TOC ratio were significantly associated with FT even after adjusting for LH and FSH (β = 0.24, p = 0.042 and β = 0.25, p = 0.031, respectively). However, neither TOC, BAP, nor uNTX was associated with the gonadotropic hormones or FT levels.

CONCLUSIONS

The present study indicates for the first time that ucOC is associated positively with FT and negatively with LH in type 2 diabetes. These findings support the recent evidence that ucOC is involved in testosterone production in male subjects.

Sexuality among Spanish adults with diabetes: a population-based case control study

OBJECTIVES

To describe and compare sexuality between subjects with diabetes with matched non-diabetic controls.

METHODS

Population based case control study using individual data from the Spanish National Sexual Health Survey. Diabetes status was self reported, we selected type 2 patients. We identified 461 diabetes sufferers. Two controls were matched by age, sex and sexual partner for each diabetic case. Sexuality measures included: sexual activity, importance of sex, satisfaction with partner, bothersome with one's sexual life and self-rated sexual health. Independent variables included: socio-demographics, physical health, chronic diseases and medications use.

RESULTS

No differences were found in "Sexually activity", "Importance of sex" or "Bothersome" between those with and without diabetes. Dissatisfaction with partner was 25% in women with diabetes and 12.9% in non-diabetic controls (Adjusted-OR 1.82 95%CI 1.02-4.85). Diabetes sufferers reported sexual health as "fair/poor/very poor" more than their non-diabetic control, 58.1% vs. 45.1% for women (Adjusted-OR 1.74 95%CI 1.15-2.63) and 54.3% vs. 38% for men (Adjusted-OR 1.88 95%CI 1.29-2.75). Among diabetes sufferers "fair/poor/very poor" sexual health was associated with poorer physical health, not having a sexual partner and among men taking heart medications.

CONCLUSIONS

Women and men with diabetes have significantly worse sexuality measures than non diabetic controls.

Patterns and loss of sexual activity in the year following hospitalization for acute myocardial infarction (a United States National Multisite Observational Study)

A multisite observational study of sexual activity-related outcomes in patients enrolled in the TRIUMPH registry during hospitalization for an acute myocardial infarction (AMI) was conducted to identify patterns and loss of sexual activity 1 year after hospitalization for AMI. Gender-specific multivariable hierarchical models were used to identify correlates of loss of sexual activity including physician counseling. Main outcome measurements included "loss of sexual activity" (less frequent or no sexual activity 1 year after an AMI in those who were sexually active in the year before the AMI) and 1-year mortality. Mean ages were 61.1 years for women (n = 605) and 58.6 years for men (n = 1,274). Many were sexually active in the year before and 1 year after hospitalization (44% and 40% of women, 74% and 68% of men, respectively). One third of women and 47% of men reported receiving hospital discharge instructions about resuming sex. Those who did not receive instructions were more likely to report loss of sexual activity (women, adjusted relative risk 1.44, 95% confidence interval 1.16 to 1.79; men, adjusted relative risk 1.27, 95% confidence interval 1.11 to 1.46). One year mortality after AMI was similar in those who reported sexual activity in the first month after AMI (2.1%) and those who were sexually inactive (4.1%, p = 0.08). In conclusion, although many patients were sexually active before AMI, only a minority received discharge counseling about resuming sexual activity. Lack of counseling was associated with loss of sexual activity 1 year later. Mortality was not significantly increased in patients who were sexually active soon after their AMI.