Introduction: Sexual Function and Dysfunction in Men
Evaluation of sexual responsiveness in older men and women has shown that sexuality and sexual activity continue well into later life, and that age-related changes do not necessarily prohibit sexual activity. While research has shown that sexual activity decreases with age, particularly among women, sexual activity in both men and women continues well into the senior years.[1,2,3,4] For example, Marsiglio et al., showed that 24% of people over age 75 were having sexual relations more than twice per month.
Normal Sexual Response in Older Men
The normal male sexual response cycle is shown in Figure 1. There is a period of excitement followed by a plateau period, an orgasmic phase, a resolution, and a refractory period. As men age, there are many changes that occur in their sexual response. This is shown in Table 1 .
In the previous article in this series, we discussed an emerging paradigm of women's sexual responsiveness that replaced a cycle of libido (desire)-arousal-orgasm-resolution with a model of intimate experience emphasizing that, while libido is maintained until quite late in the aging process, sexual arousal and response involve a sense of intimacy, bonding, commitment, love, affection, acceptance, etc., all of which may enter the sexual response equation, and result in pleasurable resolution, in which orgasm may or may not play a part. Similarly, with advancing age, some men may experience sexual response that is less orgasmically driven and more attached to a broader experience of intimacy.
While sexual desire and response continue into late life, there are numerous physical alterations that can affect sexual activity. With age, men experience a decrease in the number of spontaneous and morning erections. The rigidity of the erection diminishes, the force and volume of the ejaculate diminishes, and there is faster detumescence. The preejaculatory sensation also diminishes. These changes often lead to distress in men unless they can be made aware of the fact that they are the normal changes of aging.
Many of these changes can be related to or exacerbated by several causes other than normal aging. These include lifestyle factors as well as cardiovascular, psychosocial, and psychiatric causes such as depression, all of which are prevalent in the aging population. These changes can lead to erectile problems and the development of erectile dysfunction. Antihypertensive drugs represent the single largest medication group implicated in the development of sexual side effects, including difficulties in attaining orgasm for both women and men. Counselling of men as they age by their family physicians on the physiologic changes in their sexual performance, on the side effects that medications and other interventions may induce, and other intervening psychosocial factors may be helpful. This should be part of the annual visit, as well as part of the explanation given to men as medication or interventions are recommended and instituted.
Such counselling can start with simple information. Many men do not know what to expect as they age. Men may have less anxiety about the changes they are experiencing if they are made aware that they are normal and expected.
Sexual dysfunction occurs when the normal pattern of sexual interaction between partners becomes interrupted and creates discontent in one or other of the partners or in the couple. In the female it is defined as any disorder related to sexual desire, arousal, orgasm, and/or sexual pain that results in significant personal distress and may impair the quality of life. Figure 2 shows the prevalence for male sexual dysfunction. Loss of libido, erectile dysfunction, and rapid ejaculation are the three most significant and prevalent sexual complaints in this population.
Decrease in libido with age can be associated with various factors. These factors can relate to the psychosocial aspects of aging, which include the mental and physical status of both parties; the nature of their interpersonal relationship; marital conflicts and unresolved issues; and their overall lifestyles quality, including financial, social and, most important, communication issues.
Other psychosocial stresses seen in older men that correlate with sexual dysfunction include the "Widower's Syndrome," which men may experience with the resumption of sexual activities after a period of celibacy. When a man has had the same sexual partner for many years, particularly a partner with whom he has enjoyed a satisfying marital life in general, and the partner dies, he may enter a new relationship with some trepidation. The trepidation may be amplified by erectile dysfunction, which he might not have experienced with his late wife. This may, of course, be due to newly manifested organic factors but it may also be due to the powerful impact of his psyche related to unconscious guilt that he is betraying the fidelity and happiness he enjoyed with his wife. These and other factors require more intense sexual and/or psychological counselling.
Note that alcohol consumption, poor physical fitness, diet, and lifestyle as well as concomitant comorbidities can also exert a negative pressure on libido. The loss of libido can also be related to low testosterone levels, which may be remediable through supplementation with exogenous testosterone.
Geriatrics and Aging. 2009;12(1):53-57. © 2009 1453987 Ontario, Ltd.
Cite this: Sexuality in the Aging Couple, Part II: The Aging Male - Medscape - Jan 01, 2009.