Hypoandrogenism of senescence and sexual activity

Aging in men is accompanied by a decrease in libido and sexual activity. Mean coital frequency was reported to be about four times a week at age 20-25 years and decreases to less than twice a month between 75 and 80 years (Masters 1986; Tsitouras-Bulat 1995). Nevertheless, only 15% of men over 60 years old deny any sexual interest (Verwoerdt et al. 1969) and 80% of men over 60 years old remain sexually active (Kaiser 1992).

Whereas normal libido requires adequate testosterone levels, as shown by the effect of testosterone withdrawal (Bagatell etal. 1994; Basaria etal. 2002) the testosterone concentration required to sustain sexual activity and maintain libido appears to be rather low (Gooren 1987; Schiavi 1996), and there is good evidence that healthy adults have substantially higher androgen levels than required for normal sexual behavior (Buena etal. 1993; Udry etal. 1985).

Several authors reported differences in parameters of sexual desire or activity according to endogenous serum testosterone levels (Davidson et al. 1983; Schiavi etal. 1988; 1990; Tsitouras etal. 1982; Udry etal. 1985), but there is a broad overlap of serum testosterone levels in sexually less or more active elderly men in these studies. Moreover, other studies failed to find an association between androgen levels and the perception of sexual functioning (Perry etal. 2001; T'Sjoen etal. 2003) (see also Chapters 4 and 11). Although potency and nocturnal penile tumescence (NPT) require adequate testosterone levels and although several studies show that hormonal alterations might play some role in 6 to 45% of cases (Morley 1986), most frequently the cause of impotence in elderly males is non-hormonal.

Nocturnal penile tumescence is clearly androgen-dependent, but Schiavi et al. (1990) did not observe any correlation between NPT and erectile problems in the elderly, suggesting that their erectile problems are largely non-hormonal in origin. Similarly, several studies failed to find a relationship between erectile dysfunction and serum testosterone levels in elderly men (Feldman etal. 1994; Korenman etal. 1990; Rhoden etal. 2002). This maybe explained by alow threshold of serum testosterone required for maintenance of normal erectile function. Among nonhormonal factors that may influence the frequency of impotence in elderly men are:

• the overall health status of both partners, diabetes mellitus being a common cause of impotence at any age;

• boredom with, or loss of attractiveness of the (same) sexual partner, as well as monotony of sexual life;

• low level of sexual activity in young age, the activity of the aging male being strongly correlated with the activity in younger age (Martin 1975; Pfeiffer 1974);

• medications (Tsitouras and Bulat 1995) such as psychotropic drugs (tricyclics; MAO inhibitors; phenothiazines; hypnotics), antihypertensive compounds (P-blockers; guanethidine; prazozine; angiotensin-converting enzyme inhibitors), H2-antihistaminics, drug abuse (alcohol; heroin; cannabis) (Kligman 1991; Tsitouras and Bulat 1995);

• psychopathology such as stress and depressive states;

• atherosclerosis and cardiovascular disease, being the most frequent cause of erectile dysfunction in the elderly and accounting for about 50% of cases (Kaiser 1992; Virag etal. 1985);

• neurological factors with decreased sensory, neural and autonomic functioning, an important cause of impotence in the elderly and together with atherosclerosis the most frequent cause in diabetics.

In conclusion, whereas adequate testosterone levels are required for libido and NPT, it appears that testosterone levels required for normal sexual activity are rather low (below the lower end of the reference range for young men, i.e. below 11 nmol/l or 320 ng/dl for total serum testosterone), and although testosterone codetermines potency, the factors most commonly involved in erectile dysfunction in elderly men are not hormonal. Nevertheless, there have been recent reports of improvements of parameters of sexual functioning during androgen administration to elderly men with low or (low) normal serum testosterone levels (Hajjar et al. 1997), although in the setting of controlled studies, the improvements were generally modest and only significant for some of the assessed variables (Kunelius et al. 2002; Steidle etal. 2003).

Dealing With Erectile Dysfunction

Dealing With Erectile Dysfunction

Whether you call it erectile dysfunction, ED, impotence, or any number of slang terms, erection problems are something many men have to face during the course of their lifetimes.

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