Erectile dysfunction

Although the frequency of erectile dysfunction increases with advancing age, societal attitudes have discouraged older men from seeking treatment. Interest in sex was considered appropriate for young men only; the “dirty old man” was an object of derision.

While physicians now recognize sexuality as a legitimate concern for men regardless of their age, as a gerontologist, I often encounter men in their 70s or 80s who are embarrassed to bring up the subject. (Those who are in a longstanding marriage may be more willing to mention it than those who are trying to start a new relationship.) Yet, as Wierman’s case histories illustrate, when patients do come forward, the physician often can provide effective treatment not only for the erectile dysfunction itself, but also for underlying disorders.

The disorders I see most often in my practice are endocrine, particularly thyroid disease. Both hyperthyroidism and hypothyroidism can cause erectile dysfunction as well as subtle problems such as confusion, depression, sleep disruption, and weight loss or gain. All of these symptoms could be written off as “just old age”–but as with many other complaints in the elderly, that is not an acceptable answer. The patient whose physician says “It’s just your age” should seek a second opinion.

I have had several patients who presented with impotence as their chief complaint–sometimes their only complaint–who proved to have hypothyroidism. Moreover, there is a syndrome among the elderly called apathetic hyperthyroidism, which stands in strong contrast to the hyperactivity, insomnia, and jitteriness seen in the typical young patient with hyperthyroidism.

Indeed, because thyroid disorders occur so commonly with age–affecting perhaps 10% of the elderly population–I order a thyroid panel almost routinely whenever I see a new patient. Thyroid function often is abnormal, and correcting it makes the patient feel and function better in many dimensions, including sexuality.

I would also underscore Wierman’s point that drug side effects are an important cause of erectile dysfunction. Antihypertensive agents, as in the second case, are a frequent offender, but many other drugs–and many drug interactions–can cause impotence or loss of libido. In geriatric medicine, it is standard practice to review every single one of a patient’s medications and its potential side effects to make sure that the complaint is not drug-related. That practice also applies in erectile dysfunction, especially since the advent of sildenafil. Indeed, I worry that some patients may be receiving sildenafil as a treatment for erectile dysfunction that is in fact the result of another medication that the patient is taking. In general, it is a bad idea to prescribe a new medication in order to counteract the side effect of a current medication. Instead, the physician should try to carefully withdraw the offending medication and then substitute a different class of drug.

Circumspection is especially important with a newly released drug such as sildenafil. Although relatively few side effects of this drug have been reported, a complete understanding of the side-effects of any new drug cannot be established until it has been used by a large number of patients for an extended period. Even if sildenafil turns out to have no as yet unknown side effects, those currently reported (e. g., decreased blood pressure) may cause adverse interactions with other medications. Wierman’s caution about that possibility is well taken.

The case of the diabetic patient provides an excellent example of what we hope to prevent with the new emphasis on tight control of blood glucose levels in patients with this disease. It had always been assumed that diabetes leads more or less inexorably to neuropathy and vasculopathy and their resulting dismal array of complications, including impotence. Recent studies have shown, however, that very tight blood glucose control can slow or even halt the progression of diabetic complications.

While erectile function was not used as an outcome measure in those studies, pathophysiology and common sense argue that because tight blood glucose control prevents other neurologic and vascular complications, it will also prevent erectile dysfunction. I would not hesitate to use that argument as a motivational tool in a diabetic patient.

Finally, I would reinforce Wierman’s observation about the psychological component in all men with erectile dysfunction. Physicians need to be more willing to talk with patients about this issue, or–if they do not wish to talk about it themselves–to set up a clear and easy system of referral to a skilled counselor. If the psychologic component can be addressed, then even a slight improvement in the physiologic component may be all it takes to restore erectile function.

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