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1 Kellogg-Spat S, Whitmore K Role of the female urologist/urogynecologist In: Goldstein I, Meston C, Davis S, Traish A, eds Women s Sexual Function and Dysfunction: Study, Diagnosis and Treatment Taylor and Francis: Abingdon, UK, 2006, pp 708 714 2 Raz S Female Urology WB Saunders, Philadelphia, 1983 3 Kursh ED, McGuire EJ Female Urology, JB Lippincott, Philadelphia, 1994 4 Basle K, Schuster B Pregnancy, childbirth and pelvic oor damage In: Bourcier AP, McGuire EJ, Arams P Pelvic Floor Disorders Elsevier Saunders: Philadelphia, 2004, pp 33 42 5 Bourcier AP, McGuire EJ, Arams P Pelvic Floor Disorders Elsevier Saunders: Philadelphia, 2004 6 Graziottin A Treatment of sexual dysfunction In: Bo K, Berghmans B, van Kampen M, Morkved S, eds Evidence Based Physiotherapy for the Pelvic Floor Bridging Research and Clinical Practice, Elsevier: Oxford, UK, 2005 7 Bancroft J Biological factors in human sexuality J Sex Res 2002;39:15 21 8 Pfaus J, Everitt B The Psychopharmacology of Sexual Behaviour In: Bloom FE, Kupfer D, eds Psychopharmacology Raven Press: New York, 1995, chapt 65, pp 743 758 9 Komisaruk B, Whipple B Brain activity imaging during sexual response in women with spinal cord injury In: Hyde J, ed Biological Substrates of Human Sexuality American Psychological Association: Washington, DC, 2005, pp 109 146 10 Meston CM, Frohlich PF The neurobiology of sexual function Arch Gen Psychiatry 2000;57:1012 30 11 Graziottin A Libido: the biologic scenario Maturitas 2000;34(suppl 1):S9 16
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12 Dennerstein L, Hayes R The Impact of Aging on Sexual Function and Sexual Dysfunction in Women: A Review of Population-Based Studies J Sex Med 2005;2: 317 330 13 Dennerstein L, Randolph J, Taffe J, Dudley E, Burger H Hormones, mood, sexuality, and the menopausal transition Fertil Steril 2002;77(suppl 4):S42 8 14 Goldstein I, Berman JR Vasculogenic female sexual dysfunction: vaginal engorgement and clitoral erectile insuf ciency syndromes Int J Impot Res 1998;10 (suppl 2):S84 90; discussion S98 101 15 Bancroft J, Loftus J, Long JS Distress about sex: A national survey of women in heterosexual relationships Arch Sex Behav 2003;32(3):193 204 16 Klausmann D Sexual motivation and the duration of the relationship Arch Sex Behav 2002;31:275 287 17 Liu C Does quality of marital sex decline with duration Arch Sex Behav, 2003;32(1):55 60 18 Basson R, Bertian J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, Goldstein I, Graziottin A et al Report of the International Consensus Development Conference on Female Sexual Dysfunction: De nitions and Classi cations J Urol 2000;163:888 93 19 Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, Graziottin A, Heiman JR, Laan E, Meston C, Schover L, van Lankveld J, Schultz WW De nitions of women s sexual dysfunction reconsidered: advocating expansion and revision J Psychosom Obstet Gynaecol 2003;24:221 9 20 Graziottin A Similarities and differences between male and female sexual dysfunctions In Kandeel F, Lue T, Pryor J, Swerdloff R, eds Male Sexual Dysfunction: Pathophysiology and Treatment New York, Marcel Dekker, 2006 (in press)
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When advising cardiac patients about sexual activity it is important to individualize the advice We have a statistical framework to support our recommendations but each person being advised will have, as well as a general cardiac condition (eg being postmyocardial infarction), varying degrees of effort restriction, determined by, for example, the size of the infarction In addition, each person will have personal issues regarding safety of sex, treatment of erectile dysfunction (ED), and their con dence in returning to normal activities including sex As we advise on sex we need to remember that the problems may have preceded the cardiac event, with important relationship issues as a consequence
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Several studies have been performed using ambulatory electrocardiogram (ECG) and blood pressure (BP) monitoring, comparing the heart rate, ECG, and BP response to sexual activity with other normal daily activities [1] The energy requirement during sexual intercourse is not excessive for couples in a longstanding relationship The average peak heart rate is 110 130 beats per minute and the peak systolic BP is 150 180 mmHg, resulting in a rate pressure product of 16,000 22,000 Expressed as a multiple of the metabolic equivalent (MET) of energy expenditure expanded in the resting state (MET = 1), sexual intercourse is associated with a work load of 2 3 METs before orgasm and 3 4 METs during orgasm Younger couples, who are not usually the individuals we advise, may be more vigorous in their
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activity, expending 5 6 METs The average duration of sexual intercourse is 5 15 minutes Therefore, sexual intercourse is not an extreme or sustained cardiovascular stress for patients in a longstanding relationship who are comfortable with each other Casual sexual intercourse, which must be separated from extramarital sexual intercourse with a longstanding other partner, may involve a greater cardiac workload because of lack of familiarity and age mismatch (usually an older man with a younger woman), with different activities and expectations [2] The incidence of ED increases with age as does the prevalence of coronary artery disease (CAD) [2,3] The heart rate response to exercise decreases with age and the presence of heart rate lowering antiischemic drugs such as the beta blockers The elderly remain sexually active with no evidence of increased cardiovascular risk from sexual activity or treatment with sildena l, providing the relationship is longstanding [38] While sildena l does not have any adverse effect on exercise-induced arrhythmias, cardiopulmonary responses during activity, or QT intervals on the ECG, by facilitating sexual activity sildena l may encourage elderly patients to seek a more challenging casual younger partner [30] Elevated catecholamine levels may result and adversely affect myocardial oxygen demand or overcome the protective action of beta blockers (which work on the basis of competition) and thereby increase the potential for an ischemic event By using our knowledge of MET equivalents in the clinical setting we can advise on sexual safety by comparing sexual intercourse to other activities Some of the daily activities and MET equivalents are shown in Table 281
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