Office evaluation of sexual function and complaints.

The maintenance of sexual function is becoming a concern of patients as they live longer. Because over 80% of sexual complaints can be successfully managed in the primary care setting, it is important for physicians to include an evaluation of sexual health in the routine health examination. Physicians need to appreciate the spectrum of sexual function among older patients, which includes emotional intimacy, touching, and caressing as sexual activity as well as intercourse. For the majority of older people, sexual function may continue into their ninth and tenth decades. As people age, the prevalence of sexual dysfunction increases, most often because of the unavailability of a healthy partner, the prevalence of comorbid physical and psychologic problems, and the interaction of medications and substances used; thus, common sexual complaints of the elderly are multifactorial. To evaluate the older patient effectively, physicians must overcome a number of barriers, including their lack of formal training in therapy and counseling, personal myths regarding sexual function in old age, time and financial restraints, and a lack of patient comfort in discussing sexual problems. The sexual history should be nonthreatening, include general questions followed by more specific ones to elicit specific sexual concerns, and incorporate a thorough review of medications. The physical examination should concentrate on identifying signs of androgen deficiency, estrogen excess, vascular disease, and neurologic dysfunction. Few laboratory tests are required for the routine evaluation of common complaints. This problem-oriented evaluation approach is usually sufficient to identify one or more of the causes of sexual problems: the normal aging climacteric, disuse, physiologic dysfunction or physical illness, psychologic illness, or iatrogenic causes. Initial treatment by the primary care physician often begins with general counseling and education. Counseling should focus on eliminating medications that can interfere with sexual function, granting permission to patients to express themselves sexually in a variety of ways, educating patients on more comfortable positions for sexual activity and other lifestyle changes to make sexual expression safer and more comfortable. It also is important for the primary physician to know when to refer patients for further treatment.