Introduction

"Inability to perform" was the delicate term once used. Then came "impotence", and now it's "erectile dysfunction" (ED). The problem is the same. However, since a drug - sildenafil (Viagra) - has become available that can treat many forms of ED effectively, the numbers of men complaining of difficulty in getting and maintaining an erection have skyrocketed; 30 million men in the USA alone, according to recent NIH estimates.

Sexual function in men changes with age. In healthy men the time it takes to get an erection, and the time needed to "recover" between erections, gets longer with passing years. More direct stimulation of the penis is needed than in youth. By the time they are 40, as many as 50% of US men have occasional ED.

Causes

What are the causes? Too often, an aging endocrine system is automatically - and incorrectly - blamed. Aging is accompanied by a gradual fall in testosterone (the male hormone) levels, but they remain in the normal range in 70% of older men (see " The Male Menopause - Back in Fashion?"). On the other hand, aging is obviously associated with a number of conditions that impact significantly on sexuality - heart disease (myocardial infarction, angina), stroke, diabetes, prostatism, rheumatoid and osteoarthritis, Parkinson's disease, and chronic obstructive pulmonary disease (COPD) are examples. ED itself is often related to changes in the blood vessels supplying the penis, with atherosclerotic changes (exacerbated by diabetes) leading the list.
Medications are among the most common causes of ED. At one time almost all antihypertensives were likely to cause ED, but this has changed with the availability of drugs with more specific actions. ED remains a rare side effect of drugs from a number of different classes, but there are no clues as to which patient may experience this distressing response. Surgery is another reason for lessened sexuality activity in age - prostatectomy and orchiectomy may be associated with ED, while colostomy, ileostomy and rectal cancer surgery can induce emotional reactions that affect potency.

About 90% of cases of ED are due to physical causes, such as atherosclerosis of vessels supplying the pelvis and genitalia, diabetic neuropathy of pelvic nerves, and endocrine syndromes (thyroid disorders, diabetes, and low testosterone levels). Unfortunately, physical conditions can themselves produce emotional changes that affect sexual ability. Thus men with heart disease may worry that sex will precipitate an infarct, and they become impotent.

A psychological or emotional cause - diagnosed largely by exclusion - is responsible in about 10% of ED. If nocturnal tumescent testing shows the existence of erections during sleep, it is unlikely that the main cause of ED is physical.

Treatment

A careful history and examination, if necessary with special tests, will reveal any underlying physical disorder, which should then be treated vigorously. It's also important to ensure that the physical disorder isn't associated with an additional psychological cause of ED. Nocturnal tumescent testing may help here.

In general, a healthy lifestyle - no smoking, only moderate drinking, a healthy diet and plenty of regular exercise may assist in improving ED, and can also help make the sufferer more attractive to his partner.

Provided a psychological cause can been excluded as the primary etiology, and there are no contraindications to it's use, sildenafil (Viagra) offers a safe and often effective way of overcoming ED. Used as prescribed, there should be no side effects to speak of - slight headache, flushing and indigestion are the most common. Unfortunately, the drug has been used by people who shouldn't take it - either it's been prescribed incorrectly or bought "on the street" or "through the Net" without a full physical examination beforehand. This has led to reports of occasional serious adverse events (myocardial infarction) in men using vasodilators such as nitroglycerine concomitantly with sildenafil.

Newer medications that promise to be equally effective or even better than sildenafil are being developed, and will soon be available. Some of them have the same method of action (specific inhibition of cyclic-GMP phosphodiesterase), while others have different mechanisms (prostaglandin analogs, morphine derivatives, alpha-adrenergic blockers), so that they may be effective where sildenafil fails.

The effectiveness of medication to treat ED has pushed devices such as penile vacuum pumps and penile implants into the background. Many people ask about alternatives to prescription medication, such as herbs and food supplements. In general, these are much less likely to be effective than approved medications. There is good, comprehensive discussion of such approaches in the book "The Viagra Alternative".¹

Premature ejaculation

This is a fairly common complaint in men of all ages. However, it is not considered a severe impediment to subjective sexual enjoyment² It may be associated with a history of urinary tract symptoms, general health problems, and emotional stress. Certain psychotherapeutic drugs (e.g. phenothiazines) list premature ejaculation as a fairly common adverse effect.

Comment

It should be remembered that, while a focus on genital contact is appropriate for young people, it is insufficient in older persons - it should make place for intimacy, mutual trust, love and romance, friendship, and caring. Older people are interested in sex, and want to remain sexually active. Their physicians should help them in this respect, without being judgmental.

Physicians have two new opportunities to help their patients in connection with the present-day interest in sexual performance. First, when a patient visits to request medication to help treat ED, the physician should use the occasion to search for underlying physical conditions - it may be the first time the man has visited his doctor for some time. Second, physicians treating men for symptoms related to atherosclerosis or diabetes should enquire about ED - many men are too shy to report this distressing problem, which is now, in many cases, amenable to specific treatment.

The Internet has found good acceptance by older people, and this site has developed several articles aimed at the older visitor who may have questions about sex and aging. These can be found at " Aging and Sexuality".

Click here to read the article "Sexual Problem in Women"