Erectile Failure in the Aged: Evaluation and Treatment

Abstract

With aging, there are changes in both libido and erectile function. Although the majority of aged men remain interested in sex, less than 15% report continued sexual intercourse. The cause of this "libido-potency gap" is due primarily to erectile failure. Penile erection is dependent upon a complex interaction of the autonomic nervous system, cardiovascular system, and local neurotransmitters such as acetylcholine and vasoactive intestinal polypeptide. Sexual stimulation causes augmented blood flow into the corpora cavernosa, and restricted outflow, resulting in penile rigidity. With aging, there is a decline in gonadal steroids, nerve conduction velocity, and vascular compliance, any of which could interfere with normal erections. When disease is superimposed on the normal changes of aging, erectile function is further impaired. Evaluation of an elderly male with impotence may consist of a detailed drug history and trial of alternate therapy, as in the case of adverse drug reactions. More often, evaluation entails hormonal assays, penile vascular assessment, neurologic assessment, and an evaluation of nocturnal erectile function. Based on the results of these assessments, appropriate treatment alternatives can be chosen. With the availability of multiple treatment options, patients and physicians can now choose from a range of noninvasive or invasive alternatives depending upon the etiology, associated disorders, and preference of the patient.

How the Manner of Presentation of Data Influences Older Patients in Determining Their Treatment Preferences

“…Each subject was asked to answer the question as if he or she were the patient in question in the scenario. To control for patient assumptions about what state of mental or physical health they would be in during and after either treatment, all patients were told that (1) their quality of life with each treatment would be the same except for the data (mortality risk) shown in the curves, and (2) their level of mental and physical functioning would be minimally compromised by either treatment.…”

“…The investigator reviewed each curve with each patient identifying: (1) the x‐ and y‐axes of the graph and (2) the labels of the axes and their units of measurement. The investigator then directed each patient's attention to the curves and reviewed each curve individually with the patient as follows: (1) identifying the year‐0 point as the point at which the data were summarized for how many patients were still alive and already dead during treatment and the peri‐treatment period; (2) tracing down the length of each curve and noting the time‐point at which it crossed the other curve and the number of patients still alive and already dead at the cross‐over point; and (3) identifying the 5‐year data point on each curve and noting the number of patients still alive and the number dead. Patients were told survival information beyond year 5 was not available for either treatment group.…”

“…In the past 2 decades, physicians have been faced with the substantial challenge of discussing with patients the uncertainty that is inherent in the decision making related to their medical care. The difficulties in communicating medical uncertainty have been pointed out by psychiatrists, 1 biostatisticians, 2 and statisticians 3 . More recently, attorneys and judges, 4, 5 ethicists, 6, 7 decision analysts, 8 and cognitive psychologists 9 have emphasized the importance of patients’ deliberations about risk‐benefit data.…”

“…The major focus of this study is to determine the factors that influence patients’ treatment preferences and their willingness to change those preferences. This study was designed to answer two questions: (1) whether the ordering of graphic data influences patients’ choices of treatment options, and (2) whether patients are willing to shift their preferences when presented with an increased (or decreased) chance of short‐term survival. Our design allowed us to study whether age, education, and patient beliefs about their own life expectancy influence patients’ treatment preferency.…”

Why Men Are Interested in an Evaluation for a Sexual Problem

“…Sexual dysfunction (primarily erectile failure) may be the most common health disorder to afflict aged males 1 . Diagnostic and therapeutic approaches to erectile sexual dysfunction have been delineated, 2 but Slag et al 3 reported that 50% of men with erectile dysfunction are not interested in pursuing evaluation. Therefore, other factors beyond erectile failure must account for why only a subset of dysfunctional men seek evaluation.…”