Clinical Geriatrics

Case Presentation
A 72-year-old male who is a retired CEO of a major company and a long-time patient complains of erectile dysfunction (ED) on a routine office visit. He was married for 30 years when his wife died of cancer three years ago. He was depressed initially and often thought of his late wife. On the insistence of his children and friends, he began to socialize again and recently met an attractive female, with whom he started an intimate relationship. However, he failed to obtain sufficient erection at the moments that mattered. He feels very frustrated and seeks help. The patient currently acts as a consultant to several companies, exercises daily, and is an avid golfer and an active member of his country club. He has a history of coronary artery disease with a myocardial infarction five years ago, well-controlled hypertension for the last ten years, diabetes mellitus for 15 years, benign prostatic hypertrophy, exertional angina, and hyperlipidemia. He is taking the following medications: enalapril; aspirin; isosorbide mononitrate; doxazosin; lovastatin; and insulin glargine. His physical examination is unremarkable except for diminished peripheral pulses, and he appears to be in good spirits.

Discussion
An erection is initiated by the parasympathetic division of the autonomous nervous system and is accomplished by engorgement of corpora cavernosa with venous blood in response to various physiological stimuli, resulting in hardening, swelling, and enlargement of the penis as a prelude to sexual intercourse. This hemodynamic event results primarily from relaxation of smooth muscles of the arterial vasculature, distension of the corpora cavernosa and the surrounding sinuses, and compression of the venules influenced by the neurotransmitter nitric oxide released by the endothelial lining. Nitric oxide eventually increases the tissue concentration of a potent smooth muscle relaxant cyclic guanosine monophosphate (cGMP), which is ultimately neutralized by the enzyme phosphodiesterase-5 (PDE-5).

Aging affects the sexuality of men in various manners. A man’s sexual response begins to slow down after age 30. However, a man’s sexual drive is more likely to be affected by his health and his attitude about sex and intimacy than by his age. An aging man may find that it takes longer to achieve an erection. His erection may not be as firm or as large as it used to be. The amount of ejaculate may be smaller. The loss of erection after orgasm may happen more quickly, or it may take longer before an erection is again possible. Some men may find that they need more foreplay.

Stages of sexual response also change with aging. There is delayed erection, decreased tensing of the scrotal sac, and loss of testicular elevation during the excitement phase. The plateau stage is prolonged, and pre-ejaculatory secretion is decreased. Orgasm is diminished in duration and intensity, characterized by decreased quantity and force of seminal emission. There is rapid detumescence and testicular descent during the resolution phase. The refractory period between erections is also prolonged.

The frequency of sexual intercourse and the prevalence of engaging in any sexual activity also decrease. Young men report having intercourse two to three times per week, whereas only 7% of men age 60-69 years and 2% of those age 70 years and older report the same frequency. Fifty percent to 80% of men age 60-70 years engage in any sexual activity, a prevalence rate that declines to 15-25% among those age 80 years and older.1

A man’s level of sexual activity, interest, and enjoyment in younger years often determines his sexual behavior with aging. In most healthy adults, pleasure and interest in sex do not diminish with age.