SEXUAL HEALTH FOR THE MAN AT MIDLIFE: IN-OFFICE WORKUP
January 1st, 2007Title: SEXUAL HEALTH FOR THE MAN AT MIDLIFE: IN-OFFICE WORKUP , By: Koeneman, Kenneth S., Mulhall, John P., Geriatrics, 0016867X, Sep97, Vol. 52, Issue 9
Section: CME
Normal physiologic changes occur with age that affect male sexuality. The etiology of these problems is often vascular but may be influenced by medications, neurologic conditions, or endocrinopathies, and/or iatrogenic factors. Penile sensitivity and erectile responses decline with age, and patients may present with concerns about ejaculatory disorders and erectile dysfunction. Physicians need to know the pharmacologic, surgical, and educational solutions. Treatment modalities for erectile dysfunction include vacuum erection, devices, intracavernosal or intra-urethral alprostadi injections, and penile implants.
Koeneman KS, Mulhall JP, Goldstein I., Sexual health for the man at midlife: In-office workup. Geriatrics 1997; 52 (Sept): 76-86.
Sexuality is an important quality-of-life issue that is often overlooked by primary physicians who care for midlife and older men. There is no specific age at which sexual activity does or should end, and aging and decline in sexual function are not inexorably linked. Sexual and medical problems are frequently associated in the aging patient, offering a confusing mixture of normal age-related sexual changes, and true physical pathology.
This article reviews the physical and psychosocial alterations that occur in the aging male that may have an impact upon sexuality. Our purpose is to help the primary care physician become comfortable discussing sexual dysfunction, because many patients are reticent to initiate discussion of their problems.
Stressors of midlife may affect sexuality
Life stressors such as a change in social status, divorce, death of spouse, loss of job, or family problems, combined with normal physiologic aging can combine to produce psychopathologic conditions such as major depression. In men, loss of erectile capacity or decline in vigor can produce anger, disgust and anxiety, which negatively impact libido and sexual activity. Marital dissatisfaction with a resultant sexual dysfunction may reflect inadequate communication or boredom, but often may be a symptom of deeper conflict involving power, lack of trust, or commitment.
In addition, previously used coping mechanisms may be less prevalent in midlife: support networks of family and friends are less apparent as time and distance separate. In both men and women, psychosocial issues can manifest as lack of libido, inability to achieve orgasm, or performance anxiety. When a patient presents with sexual complaints, an initial inquiry into these psychosocial issues is advised, with appropriate referral to a sex therapist if a problem is diagnosed.
It is well recognized that both libido and orgasm intensity reduce with aging. Although a number of men present to primary care physicians and/or sexual dysfunction specialists with libido and/or orgasm problems, the only available pharmacologic therapy is testosterone administration for the patient with low libido in association with hypogonadism. If, after a complete workup has been performed, serum testosterone levels are normal and physiologic causes have been eliminated, patients may be referred to a sex therapist for evaluation and management.
Case report: In-office diagnosis
Mr. S, age 52, presents for evaluation and indicates that he has been unable to achieve satisfactory penile erection for 3 years. His wife, age 50, accompanies him to the interview. His risk factors for erectile dysfunction include type 2 diabetes (for which he takes glyburide) and a 40 pack-year history of cigarette smoking, although he has not smoked for the last 10 years. He denies any hypertension, hyperlipidemia, documented cardiac, cerebrovascular, or peripheral vascular problems. He has never had lumbar disc surgery, overt endocrine problems, or urogenital surgeries. The oral hypoglycemic agent is the only prescription medication he is taking.
Examination reveals a well-virilized male, with palpable femoral pulses bilaterally and no pulsatile abdominal masses. The penis is circumcised, has poor penile stretch, but no other palpable abnormality. The scrotal exam is normal. The bulbocavernosus reflex is intact, and a limited lower-limb neurologic assessment is normal. The serum total testosterone is well within the normal reference range.
The pathophysiology of impotence and its association with diabetes and cigarette smoking are discussed with the patient. He was informed that no further investigation is required and that he most probably has vasculogenic erectile dysfunction. (The patient was seen by a psychologist, who confirmed the absence of any overt psychological factors).
Changes in sexuality with normal aging
In midlife, men first begin to experience the physiologic changes that continue into senescence. Thus, in the middle years, lies the opportunity to educate and develop healthy habits that optimize physical, psychosocial, and sexual wellbeing. Indeed, these same habits, such as a healthy diet, regular exercise, and control of hypertension, contribute to overall health and allow the proper hormonal, neural, and vascular environments to promote sexual health.
Level of activity. It is well documented that sexual interest, activity, and desire decline slowly with age. One study found 95% of men age 46 to 50 had intercourse weekly, which decreased to 28% of men age 66 to 71.(n1)Another report revealed that 68% of women and 83% of men age 39 to 50 had weekly sexual activity.(n2) In postmenopausal women,42% described having no sexual contact.(n1)
It appears that men and women with a higher degree of sexual function in youth tend to maintain this through midlife.(n3,n4) Women who continue to be sexually active in midlife seem to maintain better vaginal health and have fewer sexual problems when compared with women who become sexually abstinent.(n5) Similarly, men impotent after radical prostatectomy who start using penile self-injection therapy early post-operatively to promote erection appear to be more likely to regain erectile function than those who undergo a prolonged period of erectile absence.(n6)
Physiologic changes. A decline in vascular, neural, and hormonal responsiveness occurs with aging, and these factors seem to be interwoven with maintaining sexual function. In women, these alterations are more obvious and abrupt than in men, and primarily involve the decline of ovarian hormonal function. In men, changes may be experienced as decreased vascular and muscular responsiveness, with decreased penile and scrotal vasocongestion and diminished duration and force of orgasm. Penile sensitivity and erectile responses decline and become more dependent on direct physical stimulation and less dependent on visual or psychologic pathways.(n5)
Mean testosterone levels decrease 1% per year in men, but a decrease in sexual function has not been shown to correlate with testosterone production or testosterone levels.(n7)
Dehydroepiandrosterone (DHEA), an adrenal steroid, declines progressively and markedly with age, in contrast with other adrenal steroids such as glucocor-ticoids and mineralocorticoids. In one study, oral DHEA, 50 to 100 mg/d, appeared to induce anabolic growth factor, activate immune function, increase muscle strength and lean body mass, and enhance quality of life in men and women age 40 to 70, with no significant adverse effects.(n8)
DHEA effects appear to be pleotrophic, and when levels are restored to those found in youth some individuals report an increased sense of well-being and libido. Althought some researchers predict, albeit with caution, a potential future therapeutic role for DHEA as a hormone replacement therapy,(n9) long-term analysis of the efficacy and safety for such a form of management is required.
Male sexual dysfunction: Two major problems
In men, the two major areas of sexual concern are ejaculatory problems and erectile dysfunction.
Ejaculatory disorders. Ejaculation is a highly coordinated, complex neurophysiologic event, involving the emission of semen from the prostate, seminal vesicles, and vas deferens into the pro-static urethra and propulsion of this fluid bolus in an antegrade direction along the urethra.(n10) Closure of the bladder neck coincident with fluid emission into the pro-static urethra prevents the backward flow of the seminal fluid.(n11)
Retrograde ejaculation may occur following operations that prevent full bladder neck closure, such as transurethral resection of the prostate (TURP). Bladder neck closure may also be impaired by neurogenic mechanisms such as those affecting diabetic men or men having undergone operations that interrupt the sympathetic nerves traveling to the bladder neck (eg, retroperitoneal lymph node dissection for testicular cancer. Sympathomimetic drugs can in many cases alleviate this problem, if it has a neural etiology.(n10)
Premature ejaculation was previously believed to represent a form of subtle psychopathology. Recently, however, it is postulated that an underlying organic basis exists in some men with a definite secondary psychological component.(n12) Some men have been shown to have a hypersensitivity syndrome in the penis. Premature ejaculation can be treated with sex therapy, selective serotonin reup-take inhibitor (SSRI) medications (eg, sertraline, paroxetine, fluoxetine, or fluvoxamine, or the tri-cyclic compound clomipramine HCl. It is our philosophy to utilize a combined therapeutic regimen of psychological counseling (involving education regarding behavioral modification exercises) and pharmacologic manipulation. This approach has proven to be effective at least in the short to medium term.
Retarded (delayed) ejaculation is a far more vexing phenomenon for the clinician. This condition, where men fail to reach orgasm and ejaculate despite the maintenance of a rigid erection for a prolonged period of time, is poorly understood. It is incumbent upon the physician to rule out any underlying organic etiology for this problem, such as a neurologic deficit either at the gross level involving the S2-4 roots or at the peripheral level on the glans penis. The other increasingly common etiology is the use of SSRI antidepressants, which as stated above prolong ejaculatory latency. Once these potential etiologies have been explored and discounted, patients should be referred to a sex therapist in an effort to ameliorate this difficult problem.
Erectile dysfunction ( impotence ). Erectile dysfunction is the inability to achieve and/or maintain a penile erection of sufficient rigidity to permit satisfactory sexual relations.(n13) The prevalence of erectile dysfunction ranges from 52% in men age 40 to 70, to greater than 95% in men over age 70 with diabetes.(n7) The etiology is often vascular but may be multifactorial, with medication, neurologic, endocrine, and iatrogenic factors each potentially playing a part.
Drug-related impotence has a variable cited incidence in the literature. Whether the erectile difficulties that appear to coincide with commencement of the medication are the result of the treatment or of the underlying pathology (eg, hypertension or depression) is unclear. In the medical outpatient setting, an incidence of 25% has been reported.(n14) The drug classes that are most likely to impair erections include antihypertensives, all psychotropic medications, and digoxin (table). Phenothiazines may elevate serum prolactin levels, which reduce active testosterone levels and may result in impotence .
Diabetes affects autonomic nervous function and microvasculature and accelerates atherosclerosis in large vessels, all of which can contribute to diminishment in erectile spontaneity, rigidity, and sustaining capability. Thus, erectile dysfunction may be a presenting symptom of diabetes. In the Massachusetts Male Aging Study, the age-adjusted probability of complete impotence was 28% in treated diabetes, compared with 9% in the overall population.(n7)
Men with a history of diabetes should be educated about the increased risk of erectile dysfunction. Some evidence suggests that control of serum glucose may delay impotence .(n15)
Atherosclerotic vascular disease accounts for greater than 60% of erectile dysfunction in men age 50 and older.(n16) Because erectile dysfunction of vascular origin may be a harbinger of generalized atherosclerosis, a comprehensive history and examination focusing on heart disease or extremity lesions is warranted. In midlife for men at risk for early atherosclerosis, a plan to control hypertension and reduce dietary cholesterol is advisable.
Endocrinopathies may be associated with erectile impairment. These endocrine disorders include hypopituitarism, hyperprolactinemia, hyperthyroidism, hypothyroidism, and hypogonadism. After a thorough history and physical exam, the specific hormonal evaluation should be tailored to the individual patient and may include, testosterone (free and total), luteinizing hormore (LH), prolactin, thyroxine (T4), and TSH levels. A suspected pituitary problem would warrant MRI imaging.
Treatment options for erectile dysfunction
The management of erectile dysfunction in men should be referred to a urologist specializing in these problems. If the problem falls into the most common category of diabetes or diffuse vascular disease, then four main treatment options exist: a vacuum erection device, intracavernosal self-injection, intraurethral alprostadil, and prosthetic penile implants.
Vacuum erection devices help the corpora cavernosa engorge with blood. This is followed by the placement of a constriction ring at the base of the penis to sustain the erection during intercourse. This mechanical method gives a satisfactory result in many men, is simple to use and generally well reimbursed by insurance carriers, but it may be perceived as cumbersome. Some patients complain of discomfort, sensory changes, and poor cosmetic appearance of the penis, which feels cool and appears dusky while the ring is in place.
Introcavernosal self-injection therapy typically utilizes an insulin-type syringe with a 28-gauge needle, which places vaso-active drug directly into the corpus cavernosum of the penis. An erection satisfactory for intercourse will eventuate in approximately 60 to 90% of men, depending upon the vasoactive agent used.
The main vasoactive medications utilized are papaverine, phentolamine, and prostaglandin El. These can be used alone, although they are frequently used in combination (papaverine/phentolamine, papaverine/phentolamine/ prostaglandin). Multiple other vasoactive agents have been or are being investigated (vaso-active intestinal polypeptide, calcitonin gene-related peptide, linsidomine).
The only injectable medication that is formally approved for use in erectile dysfunction is alprostadil (Caverject, Edex). Patient satisfaction rate is high, but proper patient education is important.
Self-injection therapy should be initiated only after the patient’s competence in the procedure has been demonstrated during the office visit, and follow-up should be continuous. Patients should be seen at least annually while undergoing self-injection therapy, as prolonged use of penile injections has been suggested to cause corporal fibrosis and tunical nodule formation. The use of newer medications and more careful patient education and supervision has decreased the occurence of these problems (to 5% of men) and has improved the efficacy and safety.(n17)
Priapism (prolonged erection) occurs in 0.5 to 5% of men using penile injection therapy, depending on the series reviewed. Appropriate patient instruction with regard to the steps that need to be taken in this situation will avoid any long-term detrimental effects.
Intrauethral alprostadil system (Muse) does not require the use of a needle and is therefore preferred by some patients over the injectable form of the alprostadil.(n18) The therapy involves the placement of a small (3-mm) pellet approximately 3 cm into the anterior urethra using a small applicator. In studies to date, approximately 40% of men develop an erection rigid enough for sexual intercourse.(n15)
The system causes penile pain in at least 10% of men, urethral bleeding in 5%, and (although no cases are documented in the literature) priapism has occurred anecdotally. The cost of this therapy is significant, and many insurance carriers do not cover it. In our experience, more men for whom aprostadil is appropriate will opt for injection therapy, which is frequently covered by health insurance.
The patient in our case report accepted the intraurethral al-prostadil system, after therapeutic options for patients with a diagnosis of vasculogenic erectile dysfuntion were discussed. He failed to respond to this first-line therapy and proceeded to injection therapy.
After in-office training, the patient was successful in using a multicomponent vasoactive medication at home. He has been using the injection therapy for 2 months without any adverse effects, administering it approximately twice a week and obtaining a 90% erection for 30 minutes following each injection.
Prosthetic penile implants are generally offered to men who refuse one of the above forms of therapy or for whom these methods fail. The modern prosthetic devices use biomaterials and prosthetic design that have markedly reduced an earlier incidence of mechanical malfunction and have increased their ease of use.
Implants are either malleable (semi-rigid) or inflatable (hydraulic). Most surgeons who are familiar with implant placement are now utilizing the inflatable devices.
There is approximately a 2 to 5% incidence of infection with a primary implant. The infection rate is somewhat higher in the spinal cord-injured population and in patients with poorly-controlled diabetes.(n19) There is approximately a 10 to 20% chance of reoperation at 10 years post-implant. Patient and partner satisfaction rates are in the 90% range.(n20)
Summary
Sexual health in midlife involves a global concern for the health of the individual, with special consideration for the physiologic changes accompanying aging. Sexuality reflects the interplay of biologic, social, psychologic, and interpersonal factors.
The primary care physician can help the individual in midlife with sexual problems by eliciting a complaint and obtaining a careful sexual history. Diagnosis of a psychosocial or physiologic problem will direct what intervention is needed.
The predictable physiologic effects of aging need not lead to a cessation of satisfying sexual relations. Several treatment options are available for various dysfunctions. Patient education or hormone replacement may be indicated. In some cases, referral to a sex therapist, urologist, or other specialist in the field of sexual dysfunction may be necessary.
Preventive maintenance for the midlife patient
The articles presented in this year’s “CME in GERIATRICS” series offer physicians an analysis of common problems in midlife–from ages 45 to 65. Experts in a variety of disciplines discuss timely clinical actions that can pay off for the patient and society in terms of wellness and functional vitality.
Series Editor Fredrick T. Sherman, MD, MSc, oversees the quality of the series and ensures that the articles are practical and useful for the primary care physicians who read GERIATRICS. Dr. Sherman is vice chairman for clinical affairs, department of geriatrics and adult development, Mount Sinai Medical Center, New York.
The Page and William Black Post-Graduate School of the Mount Sinai School of Medicine (CUNY) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians and designates this Continuing Medical Education activity for 1 hour in Category 1 of the Physician’s Recognition Award for the American Medical Association.
TABLE DRUGS THAT MAY BE ASSOCIATED WITH ERECTILE DYSFUNCTION
Cardiac Digoxin
Gemfibrozil
Antihypertensives Thiazides
Spironolactone
Beta blockers
Clonidine
Alpha blockers
Ganglion blockers
Antidepressants Tricyclics
MAO inhibitors
Lithium
Selective serotonin reuptake inhibitors
Sedatives Phenothiazines
Opiates
Benzodiazepines
Antiandrogens Estrogen
Flutamide
5 Alpha reductase inhibitors
LH-RH agonists
Ketoconazole
Cimetidine
MAO: Monoamine oxidase
LH-RH: Luteinizing hormone-releasing hormone
Source: Prepared for GERIATRICS by Kenneth S. Koeneman,
MD, John P. Mulhall, MD, and Irwin Goldstein, MD
PHOTO (BLACK & WHITE): Dr. Sherman
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Fallon B. Intracavernous injection therapy for male erectile dysfunction. Urol Clin North Am 1995; 22:833-45.
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Padma-Nathan H, Hellstrom WJG, Kaiser F, Labasky R. Treatment of men with erectile dysfunction with transurethral alprostadil. NEngl J Med 1997; 336:1-7.
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Wilson SK, Delk JR. Inflatable penile implant infections: Predisposing factors and treatment suggestions. J Urol 1995; 153:659-61.
(n20.)
Goldstein I, Bertero EB, Kaufman JM, et al. Early experience with the first pre-connected 3-piece inflatable penile prosthesis: The Mentor Alpha-1. J Urol 1993; 150(6):1814-8.
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By FREDERICK T. SHERMAN, MD, MSc EDITOR and KENNETH S. KOENEMAN, MD JOHN P. MULHALL, MD IRWIN GOLDSTEIN, MD
Dr. Koeneman is chief resident and Dr. Mulhall is assistant professor, department of urology, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL. Dr. Goldstein is professor, department of urology, Boston University Medical Center, Boston.
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Source: Geriatrics, Sep97, Vol. 52 Issue 9, p76, 6p
