Sexual Health for Older Patients Essay

Sexual health is presumably the most under-discussed topic in the history of human health. Discussions between patients and medical providers shy away from bringing up issues around sexual health, probably because they assume that it is not as significant (Flynn et al., 2016). Physicians tend to think that if their patients had problems with their sexual health, they would talk about it during their routine visits without a prompt. On the other hand, female patients barely know that their health issues could stem from sexual dysfunctions. Dr. Shapiro’s emphasizes the importance of sexual health discussions and the need to highlight such problems to rule out rather known conditions and perhaps narrows down to the patient’s issues. This way, clinic visits will record higher patient satisfaction and patients’ top quality of life.
The most surprising information I got from the NAMS videos is that studies have revealed that at least 1 in 10 women could be living with sexual dysfunction. A majority of physicians assume that women barely have sexual health issues and are in control of their sexual desires and satisfaction. If I would take a survey on the prevalence of sexual health issues among females, I would positively rate it at almost 2%, when it is indeed at a staggering 10%! The information that caught me by surprise highlights the need for sexual health conversations between health providers and their female patients.
Genitourinary Syndrome of Menopause (GSM)
GSM is a sexual syndrome that encompasses the entire urinary tract and vagina, which is evident in most post-menopausal women. The symptom is under-diagnosed owing to the very few discussions surrounding female sexual health (Faubion, Sood, & Kapoor, 2017). One of the boldest effects of the rather un-discussed symptom is painful sex for women beyond menopause. GSM is the leading cause of discomfort during sex in post-menopausal women, with up to 80% of these women recording symptoms of the condition (Faubion, Sood, & Kapoor, 2017).
Following advances in technology and research, there have been significant steps towards evaluating GSM’s evaluation, clinical presentation, diagnosis, and management. Genitourinary syndrome of menopause has various interventions in place. These interventions include moisturizers and lubricants, controlled amounts of vaginal estrogen, sex therapy, and specialized physiotherapy (Faubion, Sood, & Kapoor, 2017). Dr. Shapiro recommends low doses of estrogen for women with GSM. She recounts that the therapy is locally available, and comes in various forms, including vaginal tablets, creams, and easy-to-use vaginal rings (Dr. Shapiro).Sexual Health for Older Patients Essay.  Despite having multiple treatments for Genitourinary Symptom of Menopause, very few women are receiving therapy because clinicians barely hold these conversations (Dr. Shapiro). All physicians must ask their patients beyond menopause about their sexual health and satisfaction to ensure that patients live a quality life.

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The conversation around sexual health and dysfunction has been missing in clinical visits for so long. The discomfort around the topic is evident and can be attributed to its little potency to pose a life threat (Flynn et al., 2016). However, in the wake of time, the essentiality of these discussions continues to rise. As a clinician, my level of comfort in taking a complete sexual history has grown over time. I cannot overlook the impact of progressive experience in holding such discussions. As such, I would comfortably note that I can confidently initiate sexual conversations with post-menopausal patients.
Sexual health in older females is a conversation physicians have been shying away from holding with their patients for far too long. Usually, the assumption is that if patients had these issues, they would bring them up without having to be asked about them. Well, patients often shy from this conversation, perhaps because they have been convinced that sexual dissatisfaction should not be a concern at that age. The much-needed discussion was timely and will play a key role in improving the quality of life for post-menopausal patients, and enhancing their patient satisfaction.

References
Flynn, K. E., Lin, L., Bruner, D. W., Cyranowski, J. M., Hahn, E. A., Jeffery, D. D., … & Weinfurt, K. P. (2016). Sexual satisfaction and the importance of sexual health to quality of life throughout the life course of US adults. The journal of sexual medicine, 13(11), 1642-1650.
Faubion, S. S., Sood, R., & Kapoor, E. (2017, December). Genitourinary syndrome of menopause: management strategies for the clinician. In Mayo Clinic Proceedings (Vol. 92, No. 12, pp. 1842-1849). Elsevier. Sexual Health for Older Patients Essay.

Kennedy-Malone, L., Plank, L. M., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed.). Philadelphia: F.A. Davis Company.
• Chapter 5: Symptoms and Syndromes (Urinary Incontinence section only) p. 83-87 (WO6.1)
URINARY INCONTINENCE Description:
Urinary incontinence (UI) is an involuntary loss of urine (Gibson & Wagg, 2014). It is common in the older individual but often underreported. It can be distressing and affect a person’s overall quality of life (Berardelli, 2013). Acute UI is generally a result of illness or the effects of medications and is self-limiting when the cause is determined and addressed. Chronic UI has different forms, including stress incontinence, urge incontinence, overflow incontinence, and functional incontinence. Many older women manifest a combination of urge and stress symptoms resulting in mixed incontinence. Tables 5-10 and 5-11 describe the various types of UI and management strategies. Etiology: The causes and management of UI are multifactorial, depending on the type of incontinence and also the severity and impact on quality of life for the individual. Anatomical changes, factors related to the individual’s medical history, lifestyle, and acute and chronic illnesses, in addition to medications, can result in incontinence that can be either reversible or a permanent condition. Cognitive as well as chronic mental illness, depression, and functional barriers to continence can also affect an individual’s ability to maintain urinary continence. TABLE 5-10 Types of Urinary Incontinence
TYPE SYMPTOMS TREATMENT OPTIONS Stress incontinence Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors increasing abdominal pressure Lifestyle interventions Behavioral therapies Urge incontinence Urine leakage associated by or immediately preceded by the feeling of an urgent need to void Lifestyle interventions Behavioral therapies Consider trial of antimuscarinic medications Mixed incontinence A combination of stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing See Management of Stress Incontinence and Urge Incontinence Overflow incontinence Urine leakage when the bladder is over-distended and may result in incomplete bladder emptying Symptoms can present as constant dribbling, frequency, hesitation when initiating urination, and nocturia Often associated with bladder outlet obstruction, such as benign prostatic hypertrophy in men and pelvic organ prolapse in women Neurogenic bladder can also present as overflow UI Assess for the cause such as medication usage and fluid intake Double voiding to empty residual urine from bladder Functional incontinence The inability to hold urine due to reasons other than neurological and lower urinary tract dysfunction including delirium, psychiatric disorders, UTI, impaired mobility Treat underlying cause Source: Vasavada (2016); Luckacz (2016); Wagg et al. (2015). Occurrence: Urinary incontinence is often underreported, with the prevalence of UI being more common in women and increasing with age. Greater than 60% of older individuals experience UI, with the highest occurrence in women (Gibson et al., 2014; da Silva et al., 2012). In the long-term care setting, this rate increases to an average of 85% of the population and is the cause of approximately one in ten nursing home admissions (Vasavada, 2016). UI is not a cause, but it is associated with frailty and functional decline in the older individual (Gibson et al., 2014; da Silva et al., 2012; Omli et al., 2013; Wagg et al., 2015). TABLE 5-11 Lifestyle Measures and Behavioral Therapies for UI Management Lifestyle measures Weight loss Fluid management-restricting fluids Avoiding alcohol, caffeine, and carbonated beverages Avoiding constipation Behavioral therapies Pelvic floor exercises including Kegel exercises: • 1 dentify the muscle that starts and stops urination through attempts to start and stop urinating • Contract the identified muscle for approximately 8–10 seconds, and then relax the muscles • Perform 8 to 12 contractions • Repeat 3–4 sets of repetitions daily Bladder training: • Prompted toileting: Ask the individual to void more often • Habit training: Identifying the toileting pattern including UI episodes, schedule toileting routine to prevent UI episodes • Timed toileting: Scheduled toileting at fixed intervals • Combined toileting and exercise therapy: Sexual Health for Older Patients Essay.  Incorporates pelvic floor strengthening exercises and bladder training interventions • Double voiding: Empty bladder, relax for 1–2 minutes, then lean forward and/or press on bladder and attempt to void again, emptying the remaining urine from the bladder Source: Luckanz (2016); Wagg et al. (2015). Age: Urinary incontinence affects all age groups, with the highest prevalence in older adults who are institutionalized, have cognitive impairment, and are physically frail with functional limitations. Despite popular belief, lifestyle measures and behavioral therapies can be effective interventions when used for individuals, even in individuals with cognitive impairment. Gender: UI is twice as prevalent in women as in men, and the incidence increases with age, with institutionalized individuals, and those who have at least one deficit in ADLs (Wagg et al., 2015; da Silva et al., 2012). Women are at higher risk for stress incontinence; however, overflow incontinence is more prevalent in men as a result of hyperplasia of the prostate gland. Ethnicity: Ethnicity is not significant with regard to incontinence in general; however, some data indicate a higher prevalence of stress incontinence among Caucasian women, whereas African American women were found to be at higher risk for urge incontinence. Contributing Factors: The many contributing factors for UI include pelvic muscle weakness, multiparity, estrogen depletion, pelvic organ prolapse, diabetes, stroke, multiple sclerosis, Parkinson’s disease, spinal cord injury, benign prostatic hyperplasia, UTI, fecal impaction, poor fluid intake or excessive fluid intake, smoking, cognitive impairment, depression, immobility or impaired mobility, environmental barriers, impaired dexterity, visual impairment, obesity, and high-impact physical activities. Incontinence can be a side effect of many medications, including cholinergics, anticholinergics, diuretics, antispasmodics, opiates, hypnotics, calcium channel blockers, ACE inhibitors, alcohol, and caffeine. Signs and Symptoms: In screening for UI it is important to evaluate whether symptoms are transient or persistent in nature. A thorough history should include: ■ The severity and quantity of urine lost, including use of pads or adult briefs ■ Onset and duration of the problem and whether the UI is worsening ■ Triggering factors or events, including sneezing, coughing, laughing, or during activity ■ Constant versus intermittent urine loss ■ Associated frequency, urgency, dysuria, pain with a full bladder ■ History of UTIs ■ Association with fecal incontinence or pelvic organ prolapse ■ Additional medical problems, including current or past cancers of the pelvic organs, congestive heart failure, COPD, cognitive impairment, and connective tissue disorders ■ Obstetrical history, including difficult deliveries, multiparity, and large babies ■ History of pelvic surgeries or other urological procedures, including use of indwelling urinary catheters ■ History of spinal or CNS problems and/or surgeries ■ Lifestyle issues, including use of tobacco, alcohol, or caffeine; occupational or recreational factors causing severe or repetitive increases in intra-abdominal pressure ■ Medications, including use of the following medications that have been associated with UI: cholinergic or anticholinergic agents, alpha blockers, OTC allergy medications, estrogen replacement, beta-mimetics, sedatives, muscle relaxants, diuretics, and ACE inhibitors ■ Effect of these symptoms on ADLs, socialization, and relationships, including sexual activity (Vasavada, 2016) Considering that approximately 10% of nursing home admissions are a result of UI, discussion with patients and caregivers before long-term care placement about symptoms has the potential to prolong the individual’s ability to be maintained at home for an extended period of time. Physical examination should include functional assessment with special attention to mobility, including ability to ambulate to the toilet and dexterity, including the person’s ability to remove necessary clothing in time to use the toilet. Vital signs should be completed, looking for the presence of an elevated temperature. Respiratory rate and the presence of dyspnea on exertion may affect continence due to limited stamina to complete necessary tasks for maintaining continence. Mental status, including cognition and evidence of depression, should be assessed. The abdomen should be examined for clues such as bladder distention, pelvic masses, inguinal lymphadenopathy, or tenderness in the suprapubic region. Bladder distention can be found in overflow incontinence secondary to obstruction. In women, malignancy, uterine fibroids, or organ prolapse in the pelvic region creates pressure on the bladder seen in urge, stress, or mixed incontinence. A vaginal examination may also reveal poor perineal hygiene, skin breakdown from urine soaking, or redness and thinning of tissue typical of atrophic changes. Prolapse of genitourinary structures or the rectum may also be seen. To assess for pelvic floor muscle strength and relaxation, instruct the patient to bear down as though having a bowel movement, then tighten or squeeze by pulling up with the pelvic floor muscles. In patients with pelvic floor relaxation, you can see the inability to contract or weak contractions, and feel a lack of muscle tone when testing during the vaginal examination. Have the patient cough and determine if leakage occurs. Urethral discharge in male patients should also be assessed. Positive neurological findings in the perineal area include hypersensation, hyposensation, or absence of the bulbocavernosus (anal wink) reflex. A rectal examination may reveal fecal impaction, rectal prolapse, hemorrhoids, masses, or, in men, prostatic enlargement. Whenever possible, the examiner should observe the patient voiding, having the patient void into a measurable receptacle. This should be followed by evaluation of a post-void residual (PVR) urine by catheterization or ultrasound of the bladder. Studies are inconclusive with respect to the amount of PVR that is significant, with values ranging from greater than 50 mL to greater than 200 mL. Diagnostic Tests: Initial evaluation for UI should include a urinalysis to rule out infection and renal abnormalities. This has great significance when UI has an acute onset. The presence of nitrites and leukocyte esterase in the urinalysis is usually indicative of an infectious process. When a UTI is suspected, a culture and sensitivity should be ordered to ensure appropriate antimicrobial therapy. Hematuria may indicate a number of differential diagnoses, including infection, obstruction, kidney stones, or malignancy. Proteinuria is revealing for renal disease and is often associated with poorly controlled diabetes. When renal, metabolic, or obstructive causes of urinary tract dysfunction are suspected, a basic metabolic panel is recommended to evaluate elevated BUN and creatinine levels, and calculate estimated glomerular filtration rate (eGFR) to evaluate for renal disease. Measurement of PVR may reveal incomplete bladder emptying. When symptoms and basic noninvasive evaluation does not clearly indicate the type of urinary tract dysfunction, and the individual indicates that UI is problematic enough to warrant further treatment, urodynamic testing and referral to a urologist or urogynecologist is indicated. Urodynamic testing evaluates all stages of lower urinary tract function, including filling and storage, as well as bladder outlet abnormalities. Subjective reporting by the patient of sensation such as urgency can also be evaluated with respect to bladder wall compliance, detrusor overactivity, pressure, and flow measurements during testing. Cystoscopy is indicated for evaluation of hematuria to visualize the bladder wall when cancer is suspected, and also when stricture or prostate enlargement is suspected with symptoms of urinary retention. Differential Diagnosis: UI is a symptom, not a diagnosis. The two mnemonics DRIP and DIAPERS often are used to differentiate transient (acute) from persistent urinary incontinence: Mnemonic: DRIP ■ Delirium ■ Restricted mobility ■ Infection ■ Pharmaceuticals, polyuria Mnemonic: DIAPERS ■ Delirium ■ Infection, impaction, inflammation ■ Atrophic vaginitis ■ Psychological, pharmaceuticals, psychotropics ■ Endocrine problem ■ Restricted mobility ■ Stool impaction Treatment: Management of UI will depend on the type of incontinence; the patient’s preference with regard to his or her perception of how UI affects his or her lifestyle; and the patient’s physical condition to tolerate treatments, surgical procedures, and risk for adverse effects, as well as complications due to medications or treatment regimens. For transient UI, treating, eliminating, or modifying the cause usually alleviates the symptom. Delirium or a mild elevation in temperature from the patient’s baseline, rather than a fever, may be the first indication of a UTI in the older adult. Sexual Health for Older Patients Essay.  Appropriate antimicrobial therapy will generally resolve the UI as a result of the infection. Lifestyle management using behavioral therapies and pelvic muscle exercises or Kegel exercises can be an effective treatment for stress and urge incontinence, performed alone or in combination with biofeedback, to help strengthen periurethral muscles. Toileting programs (see Table 5-11) can be effective interventions for decreasing the impact of or controlling UI, even in patients with cognitive impairment. Nocturia can be a very annoying problem and cause significant issues where quality of life is concerned. Control of comorbidities and symptoms such as edema, in addition to limiting fluids before bedtime, can be helpful to improve sleep hygiene. Pharmacological treatment for urge incontinence with anticholinergic drugs is effective for symptoms; however, they are not without side effects, especially constipation, blurred vision, and cognitive changes in older adults. These medications, such as tolterodine (Detrol) and oxybutynin (Ditropan), seem to be better tolerated in long-acting and transdermal forms. Drugs that are more selective for muscarinic-3 receptors, such as darifenacin (Enablex), solifenacin (Vesicare), and trospium (Sanctura), which do not appear to cross the blood-brain barrier, appear to have a better side effect profile, and are better tolerated in the older adult population. In the STAR trial, with 70% of subjects more than 65 years old, efficacy and tolerability of solifenacin was found to have better outcomes with regard to incontinence than long-acting tolterodine. Comorbidities such as narrow-angle glaucoma and potential interactions with other medications are always a concern in the geriatric population and should be considered before prescribing a drug regimen for UI. Topical estrogen therapy (one-quarter applicator nightly) for 2 weeks, then three times a week ongoing, can be an effective remedy for UI as a result of vaginal atrophy. Studies have also indicated that the antidepressant duloxetine can be an effective treatment for stress UI, with approximately a 50% reduction in incontinence episodes and improved quality of life; however, nausea as a significant adverse effect may reduce compliance with this treatment regimen. For patients with overflow incontinence secondary to prostatic hypertrophy, 5-alpha-reductase inhibitors, finasteride (Proscar), or dutasteride (Avodart) are effective to reduce prostate volume by preventing the conversion of testosterone to dihydrotestosterone. These drugs should not be handled by women of childbearing age, because they can be harmful to the development of a male fetus. Selective alpha-adrenergic antagonists such as tamsulosin (Flomax) relax smooth muscle to reduce urethral resistance and improve urine flow. Nonselective alpha-1 blockers such as doxazosin (Cardura) and terazosin (Hytrin) are effective for UI and can also be used in patients who also require antihypertensive therapy. The provider should consider, however, the cardiovascular side effects due to their nonselectivity, because orthostatic hypotension is an adverse reaction that can have serious consequences, such as increased fall risk and injuries, in the older adult patient. Post-prostatectomy incontinence can be treated long after surgery with behavioral therapy such as pelvic floor muscle training. Studies have found an average of 55% reduction in incontinence using these strategies. Other treatments for UI include bulking agents such as collagen for stress incontinence, botulinum toxin, sacral nerve stimulation for urge incontinence, and surgical interventions for stress incontinence in women and for prostatic hypertrophy in men. Referral to urology or urogynecology for surgical intervention is appropriate if the patient is inclined to consider surgical intervention and is physically able to tolerate the procedure. Surgical management for pelvic organ prolapse to improve organ support, such as retropubic suspension, sling procedures, and vaginal mesh, are viable options; however, patient education with regard to the high failure rate (5% to 12%) should be discussed when considering these options. In 2008, the FDA warned of potentially serious complications associated with the use of surgical mesh, and in 2016 they changed the classification from moderate risk to high risk when used for pelvic organ prolapse, a frequent cause of stress incontinence. When surgical treatment for UI as a result of pelvic organ prolapse is contraindicated, a pessary is a viable option. In addition to incontinence pads and briefs, pessaries, when properly fitted within the vaginal vault to correct organ prolapse and reduce stress UI, can often be managed by the patient or cared for by a qualified nurse at regular intervals. Nonsurgical management of persistent urinary overflow incontinence includes clean intermittent catheterization. Although the Centers for Medicare and Medicaid Services now reimburses for a single-use sterile catheter, there is no evidence to support a reduction in UTIs with the use of sterile versus clean urinary catheter. Follow-Up: Follow-up visits will depend on the acuity and severity of symptoms. Treatment of infection and symptoms related to urinary retention requires closer and more frequent follow-up until the problem is resolved due to renal complications that can result. Initially, medication management should be attempted but monitored closely for adverse effects, especially with anticholinergic medications. Side effects of these medications can result in significant complications for the geriatric patient, such as blurred vision, dizziness, and somnolence, as well as contribute to fall risk. Long-acting medications appear to have a lower risk profile, but individual monitoring is necessary to ensure patient safety. Additionally, dementia exacerbation can occur with the use of anticholinergic medications, resulting in hallucinations, psychosis, or changes in behavior that can lead to injury to the individual or others. Constipation, a common adverse effect of anticholinergics, can exacerbate UI by causing a fecal impaction. Polypharmacy issues also need to be monitored closely with any medication change, requiring close follow-up when starting a new drug regimen. Sequelae: Possible complications include UTI, hydronephrosis (with overflow or obstruction), renal failure, adverse drug events, or failure of behavioral therapy. Skin breakdown is a significant complication with persistent UI. Urosepsis can occur with unrecognized UTIs. Falls due to UI result from environmental factors or as a side effect of medication management. Social isolation may be a result of uncontrolled UI having a significant impact on quality of life and may lead to depression. Prevention/Prophylaxis: Ways to help prevent incontinence include: ■ Early identification of acute or transient UI ■ Teaching patients and family members/caregivers that UI is not a normal part of the aging process and that treatment options are available ■ Referral to appropriate specialists for treatment options ■ Regular rectal examination in men to detect and treat early prostatic hypertrophy ■ Recognition of polypharmacy and adverse reactions when initiating new medications in the geriatric population Referral: Referral to urogynecology for the female patient to explore treatment options is appropriate if behavioral interventions and medication management are unsuccessful. It is also appropriate to refer to a specialty practice if the diagnosis is uncertain. Refer men with overflow incontinence for urological evaluation urgently if PVR urine volume is significant, to prevent renal complications, and for surgical intervention, if indicated. Certified continence nurse specialists may be an appropriate referral for behavioral therapies, such as biofeedback or for electrical stimulation treatments to improve continence. Further work-up and referral to urology would be indicated if abnormalities in the urinalysis do not resolve after treatment for infection, such as persistent hematuria or proteinuria, and if the patient has a past medical history that includes surgeries for genitourinary diagnoses, or a history of pelvic cancer with or without radiation therapy. Patients with neurogenic bladder as a result of injury or a chronic neurological condition should be followed by a neurologist in collaboration with the primary care provider. Education: Teach patients, family, caregivers, and healthcare providers, as well as the community, that UI is not a normal part of aging and it is a treatable medical problem in many individuals. Behavioral therapy can be provided in the primary care setting, such as Kegel exercises, as well as self-catheterization techniques. Written instructions given to the patient with possible adverse drug effects when starting a new medication can prevent serious consequences of drug effects/complications. Teach patients, especially women and men with bladder outlet obstruction, the signs and symptoms of UTI, including delirium as an indication of acute illness, and that in an older adult a fever may not occur even when there is a UTI. Dietary issues such as adequate fluid intake, limiting bladder irritants such as caffeine and alcohol, and prevention of constipation to avoid fecal impaction can help avoid bladder symptoms and infections. The importance of good perineal hygiene, especially for women and patients who do self-catheterization, should be emphasized. When incontinence cannot be completely avoided, attention to skin care and instruction in the use of skin barriers such as zinc oxide or dimethicone-based products should be taught to the patient or caregivers to prevent skin breakdown. DIAGNOSIS CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES Urinary incontinence Combination behavioral therapy and medication management A da Silva et al., 2012 Omli et al., 2013 Gibson & Wagg, 2014 Vasavada, 2016 Wagg et al., 2015 Stress urinary incontinence Alpha-adrenergic medications, serotonin-norepinephrine reuptake inhibitors A Gibson & Wagg, 2014 Wagg et al., 2015 Stress urinary incontinence Surgical procedures A Omli et al., 2013 Urge urinary incontinence Anticholinergic medications (antimuscarinic agents) A Gibson & Wagg, 2014 Wagg et al., 2015 Overflow urinary incontinence Treatment of underlying cause of bladder outlet obstruction, urinary catheterization C Lucacz, 2016 Functional urinary incontinence Scheduled toileting A Gibson & Wagg, 2014 Wagg et al., 2015 Mixed urinary incontinence Anticholinergic medications (antimuscarinic agents) A Gibson & Wagg, 2014 Wagg et al., 2015 A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to www.aafp.org/afpsort.xml. Sexual Health for Older Patients Essay.

• Chapter 11: Urological and Gynecological Disorders (atrophic vaginitis, cystitis and ED only)
o Atrophic vaginitis p. 282-284 (WO6.2)
o Cystitis p.289-291 (WO6.1)
o Erectile dysfunction p.297-299 (WO6.2)
ATROPHIC VAGINITIS Signal Symptoms: Vaginal dryness, dysuria, vulvar and vaginal itching, urinary frequency, blood-tinged vaginal discharge, dyspareunia. Description: Atrophic vaginitis, also called vulvovaginal atrophy, urogenital atrophy, or adhesive vaginitis, is a noninfectious, sometimes inflammatory, postmenopausal process in which the female genital and urological tissue thins and becomes fragile. Changes in vaginal pH due to a hypoestrogenic state present a more favorable environment for bacterial invasion by trichomonas, candida, and bacterial vaginosis, as well as by resident skin and rectal flora. Dysuria, increase in UTIs, and urinary frequency, as well as dyspareunia, are potential consequences (Bachmann & Santen, 2011a). This can have a significant negative effect on a woman’s sexual health and quality of life (North American Menopause Society [NAMS], 2013). Up to 70% of women do not address this issue with health-care providers due to its personal nature (Nappi & Kokot-Kierepa, 2010; Pearson, 2011; Reimer & Johnson, 2011). Unlike vasomotor symptoms associated with menopause, atrophic vaginitis will not resolve with time and without treatment (Wysocki, Kingsberg, & Krychman, 2014). Left untreated, these symptoms can cause not only discomfort and have a negative impact on sexuality, they can negatively impact quality of life, including sexual relationships and emotional well-being (NAMS, 2013). Etiology: Estrogen deprivation leads to atrophy of the vaginal and vulvar epithelium. Atrophic vaginitis, a common disorder in postmenopausal women, can be surgically induced, created by the natural aging process, or brought on through primary ovarian failure. Postmenopausal estrogen depletion can cause deterioration of tissue, decrease in blood flow, loss of elasticity, decreased rugae, thinning of tissues and epithelium, and increased pH, and these lead to the symptoms (Lester et al., 2015). Occurrence: This disorder affects all postmenopausal women to some degree, unless estrogen therapy is provided. Women who experience earlier menopause, have diabetes, or have lower body mass may experience more pronounced symptoms (Pearson, 2011). Moreover, symptoms are prevalent in menopausal women but more so in postmenopausal breast cancer survivors (Lester, Bernhart, & Ryan-Wenger, 2012). This may be due to premature menopause with associated symptoms in young breast cancer survivors or due to chemotherapy or enodocrine therapy, such as aromatase inhibitors (Lester et al., 2015). Age: Atrophic vaginitis is predominantly a problem of postmenopausal women. The average age of natural menopause in the

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Post-Menopausal and Sexuality Issues in the Maturing and Older Adult

Total Points Possible: 70

Requirements:

Ageism and gender bias can affect to whom and how we ask about sexual health, sexual activity, and concerning symptoms. Depending on your own level of comfort and cultural norms this can be a tough conversation for some providers but this is an important topic. As this week’s required NAMS videos discussed, women are wanting us to ask about sexual concerns. This week we also reviewed sexually transmitted diseases and the effects of ageism on the time to diagnosis so it is necessary to ask these questions and provide good education for all patients. You will not know any needs unless you ask.

Discussion Questions:

• Review the required NAMS videos. What was the most surprising statement or topic that you heard in the videos? Explain why this was surprising to you.
• What is GSM? What body systems are involved? How does GSM affect a woman’s quality of life?
• Review one aspect of treatment that Dr Shapiro recommends for GSM and include an EBP journal article or guideline recommendation in addition to referencing the video in your response.

Sexuality and the older adult

• What is your level of comfort in taking a complete sexual history? Is this comfort level different for male or female patients? If so, why?
• How will this week’s information impact the way you will interact with your mature and elderly clients in the future? Sexual Health for Older Patients Essay.

Sexual Health for Older Patients Essay