By definition, erectile dysfunction is the inability to achieve or maintain an erection of sufficient rigidity for satisfactory sexual relations (
12). Erectile dysfunction is common among older men. According to the consensus statement on impotence issued by the National Institutes of Health, the rate of erectile dysfunction among men aged 65 and older is 15 to 25 percent (
13). These figures would be higher if men with mild cases were included. The Massachusetts male aging study found that 52 percent of men between the ages of 40 and 70 had some degree of erectile dysfunction (
14).
Common causes of erectile dysfunction are diabetes, side effects of medication, arteriosclerosis, heart disease, hypertension, endocrinopathy, traumatic injury, herniated disc, and surgical complications (
9,
15). Some of the medications that may impair erection include certain antihypertensives, medications to counter hair loss, antidepressants, mood stabilizers, benzodiazepines, and heartburn medications (
9,
15). The antidepressants that are not likely to produce sexual side effects are nefazodone (Serzone), bupropion (Wellbutrin), trazodone (Desyrel), and mirtazepine (Remeron) (
1). The antihypertensives that are least likely to produce sexual side effects are the ACE inhibitors (
16). For diabetic men, good control of glucose reduces the risk of erectile dysfunction (
17).
Medical evaluation and treatment
Men who in later life develop erectile dysfunction that is persistent and not situational should be referred to a urologist for a medical evaluation (
15). After a thorough history and physical examination, laboratory tests that should be considered include a complete blood count, urinalysis, renal function tests, lipid profile, fasting blood sugar, and the hormonal studies noted above (
9). In the urological setting, a number of tests are available to assess erectile functioning, such as nocturnal penile tumescence monitoring and intracavernosal injection with vasoactive medication (
2). Often treatment is initiated before such testing is completed (
9).
Numerous treatment options are available for men with erectile dysfunction. Briefly, these include oral medications, such as sildenafil citrate (Viagra), yohimbine (Yocon), and apomorphine (Uprima); Food and Drug Administration approval is pending for apomorphine (
18). Although testosterone supplementation primarily affects libido, it may improve erectile functioning in some men (
8). Vacuum erection devices and constrictive bands are helpful for men with less severe symptoms (
19).
Intracavernosal injection therapy is very effective, but unless patients are given proper education and encouragement, discontinuation rates are high (
20). Transurethral suppositories are also effective. Prosthetic penile implants (
15), although they have been improved, are reserved for refractory cases.
Psychosexual therapy for erectile dysfunction
Men with erectile difficulties often react with feelings of failure and loss of self-esteem. These feelings may be compounded by their partner's disappointment or anger. To prevent exacerbation, it is often advisable to address erectile dysfunction as soon as it is brought to the clinician's attention. If the patient and his partner are interested and willing to undergo specific sex therapy, referral to a trained professional is recommended.
Often psychosexual therapy is useful in helping couples adjust to the various medical treatments that can be prescribed for erectile dysfunction. For example, the partner may object to the treatment recommendation, whether it is a pill, a suppository, an injection, or a vacuum device, ostensibly because it is "too mechanical," "too frightening," or "too unnatural" or because it takes "too long." In speaking with the partner, it may become clear that she has other, more pertinent objections to the treatment, of which she may or may not be consciously aware, such as a fear that she will be left for a younger woman, ambivalence about resuming sex at all, or a multitude of other concerns.
Not uncommonly, a modicum of sex therapy or counseling given simultaneously with the course of urological treatment can improve the outcome. Many urologists provide this treatment themselves or assign it to a nurse. For more complex problems, referral to a specialist in sex therapy is advisable.
Some common sex therapy treatment interventions that are particularly helpful for older men with erectile disorder are listed below (
2).
• Sex in the morning when erection is more likely. Avoid times when the male partner is stressed or tired.
• Ample amount of vigorous penile stimulation, manually or orally, before and for intervals during intercourse as needed.
• Positions in which vaginal tension is increased for heightened penile stimulation.
• Spending more time on sexual activities other than intercourse. For instance, rather than relying on intercourse alone, as was customary when the couple was younger, it may be helpful for both partners to achieve orgasm via other techniques. Some older individuals need encouragement to try new sexual activities outside of their usual repertoire.
• Encouraging the partner to experience sexual pleasure after erectile difficulty has occurred. Encouragement often serves to reduce both the partner's frustration and performance pressure. Not uncommonly, such encouragement results in a pleasurable experience for both partners.
• Taking turns at giving or receiving sexual pleasure. For example, one time for him and then another, different time for her.