Erectile dysfunction isn’t just ‘all in the head’

Doctors understand that many older men retain an interest in sexual activity as they age. Some primary-care physicians think that sexual potency in older men is the norm, and that if it is lacking, it is “all in the head.”

This viewpoint has not been supported by current literature. The Massachusetts Male Aging Study (MMAS) found that 52 percent of men between 40 and 70 years old reported having some form of erectile dysfunction (ED), or impotence. The reality is that ED is a natural part of aging and that the prevalence increases with age. The MMAS found that roughly 50 percent of men at 50 years old, 60 percent of men at 60, and 70 percent of men at 70 had ED. Thus, nearly all men who live long enough will develop ED. 

ED happens when a man has ongoing problems getting and keeping an erection. Without treatment, ED can make sex difficult.  According to Dr. Culley C. Carson III, a distinguished professor emeritus of urology at the UNC School of Medicine, men who have trouble getting and maintaining erections should see a doctor. The etiology for this decline in sexual activity is multifactorial and is, in part, due to the fact that most female partners undergo menopause at 52 years of age, with a significant decline in their libido, or desire to engage in sexual activity. But why see a doctor, then? That is because ED is sometimes caused by serious systemic disease issues (cardiovascular like hypertension, atherosclerosis, hypercholesterolemia, diabetes [nerve damage, impaired blood flow and hormone level problems], neurological disorders like stroke, brain tumor, Parkinson’s, etc.).

Other causes: metabolic syndrome, lower urinary tract infection, emotional problems like depression, anxiety, history of sexual abuse, marital problems, alcoholism, tobacco use, and use of certain drugs (anti-hypertensives, antihistamines like diphenhydramine, antidepressants, cytotoxic drugs like methotrexate, anti-arrhythmics, chemotherapy drugs, prostate cancer medications etc.), venous leaks and a history of pelvic irradiation or surgery can also lead to ED. That is why it’s very important to get to the bottom of what’s causing it.

One in five men report the problem, and that number gets bigger with age. Nearly every primary-care physician, internist and geriatrician will be called upon to manage this condition or make referrals to urologists, endocrinologists and cardiologists, who will assist in the treatment of ED. However, ED in men under the age of 40 — once thought to be entirely psychogenic — is now passé. Although psychogenic ED (“it’s all in the mind”) is more prevalent in the younger population, at least 15 to 20 percent of these men have an organic, actual cause. Organic ED has been a predictor of increased future morbidity and mortality. As such, any man with complaints of sexual dysfunction should undergo a thorough workup.

Erectile dysfunction is the most common sexual problem affecting middle-aged and older men, afflicting up to one-third of men throughout their lives. It causes a substantial negative impact on intimate relationships, quality of life and self-esteem. History and physical examination are sufficient to make a diagnosis of ED in most cases, because there is no preferred, first-line diagnostic test.  Clues to ED include altered or impaired partner sexual function (so it’s not always the mistress), decreased appearance and volume of ejaculate, decreased libido, impaired quality and timing of orgasm, including anorgasmia, and sexually induced genital pain. In their physical examinations, doctors should also include:

•Assessment for central obesity (a big tummy, Cushing’s syndrome, diabetes mellitus, metabolic syndrome)

•Decreased perineal sensation (spinal problems like Cauda Equina syndrome, spinal stenosis, trauma, surgery of pelvis)

•Decreased peripheral pulses (atherosclerosis, peripheral vascular disease)

•Elevated blood pressure (cerebrovascular disease)

•Enlarged prostrate upon digital examination

•Curved penis

•Tachycardia

•Testicular abnormalities

•Thyroid, goiter

An initial diagnostic workup should usually be limited to a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test and morning total testosterone level.

First-line therapy for ED consists of lifestyle changes, modifying drug therapy that may cause ED, and phosphodiesterase type 5 inhibitor drugs (for example, Viagra).

Obesity, a sedentary lifestyle (lack of exercise), and smoking greatly increase the risk of ED. Phosphodiesterase type 5 inhibitors are the most effective oral drugs for treatment of ED, including ED associated with diabetes mellitus, spinal cord injury, and antidepressants, but not without side effects.

When Phosphodiesterase type 5 inhibitors fail, alternative therapeutic options include intra-urethral and intra-cavernosal injection of a drug called Alprostadil (painful and can permanently damage the penis when improperly used), vacuum-pump devices (can produce pain, bruising and have a lot of contraindications), and surgically implanted penile prostheses (an invasive procedure).

Testosterone supplementation in men with hypogonadism (decreased testosterone) improves ED and libido, but requires interval monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels because of an increased risk of prostate cancer. Cognitive behavior therapy and therapy aimed at improving relationships may help improve ED.

Screening for cardiovascular risk factors should be considered in men with ED, because symptoms of ED present, on average, three years earlier than symptoms of coronary artery disease. Men with ED are at increased risk of heart disease, stroke and peripheral vascular diseases (blood circulation disorders that cause the blood vessels outside of your heart and brain to narrow, block, or spasm).

New clinical trial results show that Human Mesenchymal Stem Cells (HSMC) can restore sufficient erectile function to help impotent men have spontaneous intercourse. It restores one’s energy and overall performance, has no side effects or complications and is simple to carry out. Most of all, the HSMC come from a young and healthy human donor. However, although promising, this is in the early trial stages. Although not marketed for treatment, HSMC shows very encouraging results in those with cardiovascular diseases, diabetes, stroke patients, Parkinson’s, degenerative disc diseases, spinal cord injuries, cancer, and multiple sclerosis, which are all possible causes of ED, so it would be most helpful to address this particular problem of impotence.

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