Sexuality in the Aging Couple, Part II: The Aging Male

Irwin W. Kuzmarov, MD, FRCSC; Jerald Bain, BScPhm, MD, MSc, FRCPC

Disclosures

Geriatrics and Aging. 2009;12(1):53-57. 

In This Article

Erectile Dysfunction and PDE-5 Inhibitors

The incidence of erectile dysfunction (defined as the inability to develop and sustain an erection sufficient for satisfactory sexual intercourse in 50% or more attempts at intercourse) is well documented particularly in the Massachusetts Male Aging study, where greater than 50% of men had some degree of symptom.[12] The relationship with diseases such as diabetes mellitus, cardiovascular disease, hypertension, neurological disorders, and psychiatric conditions such as depression, as well as medication, has been well described.

The introduction of PDE-5i's for erectile dysfunction has changed the profile of sexual functioning in aging men. The increasing use of PDE-5i's, the emerging understanding of the role of testosterone decline in men as they age, and the availability and use of adjunctive testosterone therapies have played a role in restoring men's sexual potency and libido.

The use of PDE-5 inhibitors has proven very effective in alleviating the physical effects of reduced erectile function in many men. This has generally been a constructive addition to the management of sexual dysfunction and relationship issues concerned with sexuality. It has, however, created consternation in some female partners who have interpreted the use of these agents as a sign of diminished interest in sex in general or with them specifically. The addition of a foreign agent, namely a drug to produce an erection, has been perceived as a sign that the partner is no longer attractive and is not desirable. The misperception is that the drug is preventing rather than promoting a healthy sexual relationship. For the first time, women who have never required their partners to be artificially stimulated to become erect are placed in this situation. The lack of understanding about the erectile response of their partner, and the role that medication or other devices play fuels this negative response. There are many couples who face this catch-22 situation in which the male partner's libido remains at a level satisfactory to him but who for largely organic reasons has erectile dysfunction remediable by a PDE-5i. In such a circumstance it would be useful to invite your male patient to return with his partner for a brief discussion about the causes of erectile dysfunction. In only a small minority of instances is the male's loss of libidinous interest in his wife the major cause of his ED. If this is the case he is usually aroused to erection by other stimuli.

The family physician, the urologist, the sex therapist, or the psychologist who deals with erectile problems in couples must explain the role and function of the erectile aids. The provision of PDE-5i's to aging patients necessitates a discussion of these factors.

Specific PDE-5 Inhibitors

Sildenafil (Viagra®), vardenafil (Levitra®), and tadalafil (Cialis®) are the three oral PDE-5i's currently approved for clinical use and have become the preferred first-line ED therapy for most men due to their efficacy, safety, and ease-of-use. Published clinical trial data suggest an efficacy of ~70% for all three PDE-5i's across a wide range of causes of ED and patient subgroups.[16]

The arrival of PDE-5 inhibitors and the increased awareness of the need to evaluate potential hypogonadal states in this cohort of men has greatly improved the management of this problem, and has also increased awareness of the need by primary care physicians to evaluate both partners, individually and as an interactive unit. It is important that the primary care physician take initiative and discuss these matters with patients: patients themselves may avoid addressing issues of sexual dysfunction in a forthright matter, either asking about it at the end of a visit in passing, in connection with a separate matter, or not at all. If the physician fails to inquire, these concerns may go ignored.

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