Clinical Geriatrics

Erectile dysfunction (ED) is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Although ED is not a normal change of age, it is very common. While not a life-threatening problem, it nevertheless is a source of significant stress to many men. Regardless of the man’s age, it is likely to have a significant effect on self-esteem and quality of life. While there are some normal changes in sexual function with healthy aging, these changes are not so severe that enjoyment of sexual activity must be abandoned. Unlike younger men, psychological causes for ED are less frequent (but must still be considered), and organic causes are much more likely. With the advent of the phosphodiesterase type 5 (PDE5) inhibitors, treatment, after an initial evaluation for reversible causes, will be successful in 65-70% of patients.¹ Of those who initially respond to PDE5 inhibitors, only about 30% will be using them 6-12 months later.¹ Hence, a fairly large percentage of men with ED may wish to consider other alternative treatments.

Sexual health is related to overall health and function. Older men need to understand that while impairment of erectile function is common with aging, it is not inevitable and is often a sign of underlying medical conditions that may have been inadequately addressed. Erectile dysfunction can have a profound effect on emotional well-being and interpersonal relationships with the patient’s partner. A thorough evaluation is critical to successful management. It is recommended that questions about satisfaction with one’s sexual life and ED should be included in the routine assessment of functional status of all elderly men.

PREVALENCE AND ETIOLOGY
Erectile dysfunction affects 20-30 million men in the United States. From 52-70% of men over age 60 have one or more episodes of ED per month.² The prevalence increases with advancing age³ (Figure). In those who have a sudden onset of ED, psychogenic or adverse drug events are the most likely causes. But, the more common scenario in older men is the gradual onset of ED, in which vascular or neurogenic causes are more common.

Vascular diseases, which are frequent causes of ED, include atherosclerotic cardiovascular disease, hypertension, and diabetes. Men presenting with ED have been shown to have a high risk of subsequent development of cardiovascular conditions (eg, angina, myocardial infarction, transient ischemic attack, stroke).⁴ A comprehensive assessment of cardiovascular risk should be part of the general evaluation. Neurological conditions such as stroke, neuropathies, Parkinson’s disease, and Alzheimer’s disease are also common causes. In addition, substance abuse (especially alcohol and cocaine), obesity, cigarette smoking, depression, chronic renal disease, trauma or spinal cord injuries, and radical pelvic surgery can all cause or worsen ED. Perhaps surprisingly, hypogonadism, or low serum testosterone, is an uncommon cause of ED. Of course, medications are always a concern (Table I).

Normal erections are a complex event. They require psychosexual stimulation, and usually some physical stimulation as well. The arterial and venous supply of the penis must be functioning well. Nervous innervations must function normally. The man must have adequate hormonal function. And finally, the erectile tissues of the penis must function normally. It is not difficult to see how a multiplicity of factors may be involved in the etiology of ED in a particular patient.

Sexual functioning does change with age, even in normal circumstances. Older men have a prolonged latency period (the time required to develop a full erection). Erections are generally less turgid and ejaculations are less forceful. There is also a decrease in volume of the ejaculate and penile sensitivity.