Sexual dysfunction and its psychiatric associations in the elderly

Normal ageing changes. Men — slower erection, reduced rigidity, longer refractory period, reduced ejaculatory volume. Women — vaginal dryness, atrophy, dyspareunia, reduced elasticity (genitourinary syndrome of menopause, GSM). Sexual desire persists into late life — ageing alone does not abolish sexual interest.

Classification. Desire disorders (hypoactive sexual desire), arousal disorders (erectile dysfunction, female arousal disorder), orgasmic disorders, and sexual pain disorders (dyspareunia, vaginismus).

Organic causes. Diabetes, cardiovascular and peripheral vascular disease, hypertension, prostate surgery and pelvic radiotherapy, neurological disease (Parkinson's disease, stroke, neuropathy), hypogonadism (testosterone in ng/dL), hyperprolactinaemia, CKD, arthritis, and obesity. Erectile dysfunction is an early marker of endothelial dysfunction and predicts future cardiovascular events.

Drug causes. SSRIs and SNRIs (commonest — delayed orgasm, reduced desire), antipsychotics (hyperprolactinaemia), beta-blockers, thiazides, spironolactone, finasteride, anticholinergics, opioids, and alcohol.

Psychiatric associations. Depression — a bidirectional relationship (both a cause and a consequence, and its drug treatment worsens it further); anxiety and performance anxiety; dementia — disinhibition, inappropriate sexual behaviour, and difficult capacity-to-consent questions in care homes; alcohol misuse; and bereavement and widowhood — lack of a partner is the commonest reason for sexual inactivity in older women.

Management. Use the PLISSIT model (Permission → Limited Information → Specific Suggestions → Intensive Therapy). Optimise chronic disease; review and switch the offending drug (e.g. SSRI → bupropion or mirtazapine). PDE-5 inhibitors (sildenafil, tadalafil) are first-line for ED — absolutely contraindicated with nitrates, caution with alpha-blockers. Low-dose vaginal oestrogen ± lubricants for GSM. Couple and psychosexual counselling. Testosterone only in biochemically confirmed hypogonadism.

2023–2025 guidance. AUA/EAU reaffirm PDE-5 inhibitors as first-line for ED at any age, with cardiovascular risk stratification before resuming sexual activity (Princeton consensus low / intermediate / high-risk categories). Menopause society guidance (NAMS / IMS 2023–24) endorses low-dose vaginal oestrogen, prasterone (intravaginal DHEA) and ospemifene as safe and effective for GSM — including in most breast cancer survivors after discussion with the oncologist — as systemic absorption is negligible. If asked for 15 marks, add: physiology of the sexual response cycle and its age-related changes; detailed history-taking and examination framework; investigations (fasting glucose, lipids, testosterone ng/dL, prolactin, TSH, PSA ng/mL); management of inappropriate sexual behaviour in dementia (behavioural first, then SSRI, antiandrogen as last resort); capacity and consent in institutional settings; sexuality in LGBT+ elders; and Indian cultural attitudes and the near-absence of sexual history-taking in geriatric practice.