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in the same class. PDE‐5 inhibitors will not improve erections in men with disrupted penile vasculature. When choosing a PDE‐5 inhibitor for a patient, the timing of medication is important to consider, with avanafil having the shortest onset of action as well as shortest effectiveness time (15–30 minutes and 6 hours, respectively), and tadalafil having the slowest onset of action but longest effectiveness time (60–120 minutes and 36 hours, respectively).²⁶ Men may have to trial several different PDE‐5 inhibitors to identify which meets their needs.

For men who cannot or choose not to use PDE‐5 inhibitors, other options are available. Prostaglandin E1, which can be injected or inserted as a pellet through a catheter in the meatus, can be considered, with good efficacy, ease of use, tolerance, and improved sex performance reported among users.^27,28 Vacuum tumescence devices and penile prostheses have been shown to be effective and satisfactory for men and their partners. These may be especially effective for men whose ED is due to previous prostate surgery.²⁶ Men receiving treatment for ED by any method should be counselled to seek emergency management for priapism (an erection lasting more than four to six hours) if this occurs, due to the risk of permanent corporal fibrosis.

      To treat other male sexual disorders, including lack of interest in sex, climaxing too quickly, and anxiety about performance, the physician should evaluate for contributing factors, such as comorbid anxiety and depression. Sleep deprivation and psychological stress may also contribute to these disorders and should be addressed. Certain medications (such as SSRIs and antipsychotics) can diminish libido, and the risks versus benefits of continuing these medications should be considered.²⁹ Patients may benefit from marital counselling to address relationship problems and/or sex‐positive counselling with a trained therapist to address issues at an individual level.

      Andropause

      Beginning around age 30, serum testosterone levels decrease at a rate of about 1–2% per year. Andropause, or late‐onset hypogonadism, is defined as an age‐related reduction in serum testosterone levels to below the normal range, as determined in young males, with associated sexual symptoms such as erectile dysfunction, decreased sexual thoughts, and decreased morning erections.^30,31 Men may report additional symptoms, such as insomnia, depression, muscle weakness, and irritability, although these symptoms are not used to clinically define andropause.³¹ Late‐onset hypogonadism, or andropause, is relatively rare. A study of community‐dwelling males aged 40–79 across eight European countries found that only 2.1% of men suffered from andropause.³² Some factors affecting andropause, such as obesity and cigarette smoking, may be modifiable.³³

      The benefits of treating a low testosterone level in older men without sexual symptoms are not established. Management of andropause consists of testosterone replacement therapy (TRT) and/or lifestyle modifications (weight loss and smoking cessation). Testosterone can be administered in oral, buccal, transdermal, subcutaneous, or intramuscular forms. TRT has been demonstrated in some studies to reduce depression and improve quality of life and sexual function, but in older men specifically, no improvement was noted in measurements of vitality or walking distance.^34,35 Different formulations were not found to significantly affect depression or erectile function, while testosterone gel was demonstrated to be better at improving libido than testosterone delivered either orally or by a patch.³⁴ There have been contradictory data about the risk of adverse cardiovascular events with TRT, and more research is needed in this area. At this time, prostate cancer is considered a contraindication for TRT.³⁶ Men with andropause are at increased risk of secondary osteoporosis and should be screened accordingly.

Sexuality and disease

      Sexuality is closely linked to health at an older age, and people who consider themselves to be in good health are more likely to have an intimate relationship and engage in sexual activity with a partner.⁵ Older adults who are in good to excellent health may gain up to seven additional years of sexual activity compared to those in fair or poor health.⁴

      A number of diseases have known impacts on sexual activity. Diabetes is associated with reduced sexual activity in women and erectile dysfunction in men and is also associated with less frequent masturbation in both men and women.⁵ Neurological conditions, including multiple sclerosis, Parkinson’s disease, and peripheral neuropathy, can affect sexual functioning. Renal failure is associated with sexual dysfunction in both men and women due to physical changes and psychological changes such as negative self‐image and anxiety.³⁷ Urinary incontinence is associated with worrisome reduced sexual activity and function in both men and women.³⁸ Depression and sexual activity are closely linked, with some evidence that older adults who are sexually active and report having more frequent and better‐quality sex have better mental health outcomes and higher quality of life.^1,3 Conversely, older adults with increased anxiety report more sexual difficulties and lack of interest in sexual activity.^39,40

      Hip arthritis pain can limit mobility during sexual intercourse, but this may be mitigated by oral pain medication and changing of positioning. For patients who have undergone total hip replacement, rehabilitation facilitated by physical therapists can help improve pain, range of motion, and self‐confidence during sexual intercourse.⁴¹ Other disorders such as prior stroke or post‐polio syndrome may result in impaired mobility. Physical therapists or sex‐positive counsellors can provide patients with assistance in sexually functioning with impaired mobility. Additionally, a wealth of online resources and forums are available to patients with disability.

Studies have shown high levels of concern about sexual health among survivors of breast and prostate cancer, with prostate cancer survivors being most concerned about being able to satisfy their partners, and breast cancer survivors most concerned regarding changes in their bodies and sexual function.⁴² Prostate cancer treatment, including surgery, radiotherapy, and brachytherapy, can cause urinary incontinence and erectile dysfunction.^43,44 Frequent issues among survivors of breast or gynaecologic cancers include dyspareunia, vaginal dryness, and loss of libido. Other issues affecting patients with breast cancer include pain, grief, altered body image, self‐perception, and fatigue.⁴⁵ A number of barriers to addressing unmet needs exist, including oncology clinicians’ focus on treating and monitoring the cancer itself, feelings of embarrassment on the part of patients, and logistical issues such as busy clinics and lack of resources.⁴⁶

Dementia

      There are many barriers to healthy expression of sexuality in older adults with dementia. As these adults lose functional independence and require more assistance, their personal privacy and ability to engage in sexual activities is diminished. There may also be ethical issues surrounding the ability of older adults with dementia to consent to sexual activity. People with more advanced cognitive decline may not be able to comprehend the ramifications of sexual activity and are at increased risk of sexual abuse. On the other hand, restricting sexual activity may be unfairly infringing upon their autonomy.⁴⁷ For older adults living in the community, caregivers who are familiar with their lifelong habits and beliefs, who may be surrogate decision‐makers in other aspects of their lives, can help provide a safe space for appropriate sexual activity. The situation becomes more complex for those who reside in long‐term care settings, which will be explored later in the chapter.

      Sexually inappropriate behaviours may be a manifestation of dementia in some older adults. Some behaviours may be interpreted as misguided displays of affection or intimacy‐seeking (e.g. mistaking a person for their spouse, handholding), while others are disinhibited and inappropriate in most contexts (e.g. groping, lewd outbursts).⁴⁸ Older adults with dementia may not be able to understand the context behind their actions, such as the difference between touching an arm and touching a breast or why it is inappropriate to disrobe in public when it is fine to do so in one’s bedroom. They may also misinterpret the actions of others: for example, when a caregiver is assisting with personal hygiene, the patient may interpret these actions as sexual advances.⁴⁹

      Initial management of

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