Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0114Sexual DisordersJ. M. KellettSt George’s Hospital Medical School, London, UKTHE CAUSE OF ERECTILE FAILUREAlthough levels of free testosterone fall with age. this does notrelate to levels of sexual activity 1,2 , which correlate closely withage itself. Three hypotheses for the decline remain (althoughwhether loss of interest leads to erectile failure or vice versa is indoubt); these are: (a) that increasing atheroma causes a failure ofvasodilation sufficient to cause an erection; (b) that degenerativechanges in the autonomic system are the cause; and (c) that levelsof self-confidence decline with age, leading to psychogenic failure.Clinical impressions do not support the latter hypothesis, and astudy of 28 men with erectile failure over age 65 compared to 25aged-matched men who were potent showed no differences in theirGHQ 3 .Feldman et al. 4 compared measures of health in 1290 malesaged 40–70 in Massachusetts and found erectile failure to beincreased with heart disease, diabetes, hypertension, depressionand anger, and decreased by high-density cholesterol and by levelsof dihydroepiandrosterone, a breakdown product of testosterone,but not by levels of testosterone itself. They did not measureneuronal ageing. Rowland et al. 5 found that penile sensitivity wasrelated to erectile response. In our study 3 reported above, wefound that only a measure of autonomic neuronal integrity(pilocarpine-induced sweating) distinguished the two groups fully.This might suggest that most elderly men with erectile failurewould respond to corporeal vasodilators, which would be lesseffective if the cause was atheroma. The subject is well covered bySchiavi 6 .TREATMENTCounselling allows the couple to express their fears andinhibitions, whilst the therapist can educate them about thenormal changes of ageing. Elderly men, for example, oftenoverestimate the importance of penetration, compared to petting,in the pleasure they give to their partner. Physical remedies aremore widely used and include vacuum pumps 7 , intracavernosal 8and intraurethral 9 administration of alprostadil, oral sildenafil 10 ,which prolongs the action of cavernosal nitric oxide, andoxpentifylline for vasculogenic failure. Dopaminergic drugs canrestore libido, if fear of prostatic cancer contraindicates testosterone.Disorders of female arousal are reduced by HRT and alsorespond to sildenafil 11 .REFERENCES1. Davidson J, Chen J, Crapo L et al. Hormonal changes and sexualfunction in aging men. J Clin Endocrinol Metab 1983; 57: 71–7.2. Schiavi R, Schreiner-Engel P, White D, Mandell J. The relationshipbetween pituitary–gonadal function and sexual behaviour in healthyaging men. Psychosom Med 1991; 53: 363–74.3. Bandi J, Ford R, Kellett J. Is erectile failure in the elderly caused bypsychological factors? Paper presented to the inaugural meeting ofBEDS, London, 1996.4. Feldman H, Goldstein I, Hatzichristou D et al. Impotence and itsmedical and psychosocial correlates: results of the Massachusettsmale aging study. J Urol 1994; 151: 54–61.5. Rowland D, Greenleaf W, Dorfman L, Davidson J. Aging and sexualfunction in men. Arch Sex Behav 1993; 22: 545–57.6. Schiavi R. Aging and Sexual Function. Cambridge: CambridgeUniversity Press, 1999.7. Cooper AJ. Preliminary experience with a vacuum constrictor device(VCD) as a treatment for impotence. J Psychosom Res 1987; 31: 413–18.8. Linet OI, Ogrine FG. Efficacy and safety of intracavernosalalprostadil in men with erectile dysfunction. N Engl J Med 1996;334: 873.9. Padma-Nathan H, Hellstrom WJ, Kaiser FE et al. Treatment of menwith erectile dysfunction with transurethral alprostadil. N Engl J Med1998; 336: 1–7.10. Booleli M, Gepi-Attee S, Gingell C et al. Sildenafil, a novel effectiveoral therapy for male erectile dysfunction. Br J Urol 1996; 78: 257–61.11. Riley A. Personal communication, 1998.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd