Sexual disorders (SD) in aging males has only caught recent global attention. Contrary to the previous conception of elder males proceeding towards asexuality, recent studies show that most of them maintain sexual wishes and fantasies into old age as well.
Sexuality in aged males has a substantial Quality of Life (QOL) problem. In the dearth of any health-related complications, many elderly men exhibit active sexual interest which is apparent by their involvement in such happenings.
Sexual Disorders in aging males results from biological, lifestyle, psychosocial, and other physical variations. Changes in sexual functioning negatively affect all components of sexual activity, including libido, penile erection, and semen ejaculation. Social isolation, social distancing induced by COVID-19, non-availability of companion or disinterest, emotional and relational strains, all can cause depression, further escalating sexual slowdown. The impacts of androgen deficiency, related lower urinary tract symptoms (LUTS), cardiovascular illnesses and associated risk factors such as diabetes, hypertension, dyslipidemia, smoking, inactive lifestyle, obesity, chronic illnesses, effects of various medicines, and surgeries may further amplify the impairment of sexual functions.
Sexual Disorder and Androgen Deficiency in Aging Males
Androgens are extremely important for the development and growth of male outer genitalia and, hence, a reduction in the endogenous androgens is bound to have a negative effect on the sexual functioning of males. With aging, there is a decrease in the serum levels of testosterone. This is generally linked with increase in sex hormone–binding globulin additionally decreasing the bioavailable testosterone. It is known to all that incidence of male Sexual disorders surges with aging. Therefore, there is a correlation between decrease in serum levels of testosterone and increasing Sexual Disorders. This correlation has been found to be causal in nature rather than a mere coincidence. A general clinical example is Sexual Disorders in men who have been treated with complete androgen deprivation for carcinoma of prostate.
Testosterone impacts erectile functioning by both central and peripheral activities. The central action is connected to enablement of craving and arousal following stimulation through visual, olfactory, auditory, and tactile provocations besides thoughts initiating from the prefrontal area. This is seen as a liberal rise in the threshold for erection with aging. Peripheral action of testosterone is activated on the smooth muscle cells and the endothelial lining of the sinusoids in the corpora cavernosa. Testosterone plays a significant role in the RhoA/Rho kinase pathway and nitric oxide (NO) production through the neuronal NO synthetase (nNOS). As a result of thus, there are complications in initiating and sustaining erections. Apart from this, testosterone has been discovered to be acting as a maintenance fluid for the well-being of corpora cavernosa. There is proof from animal studies signifying apoptosis of cavernosal smooth muscle and deposits of adipocytes in the subtunic region of corpora cavernosa subsequent to androgen scarcity by orchidectomy. This causes suboptimal compression of tunical venules causing venous leakage and ill-maintained weak erections. This has been shown to get cured with the administration of testosterone. This has been established by clinical studies wherein hypogonadal men with erectile dysfunction (ED) have displayed venous leakage documented with pharmaco cavernosography, which got reversed upon administration of testosterone.
The occurrence of hypogonadism in men with Erectile Dysfunction is more than what is generally thought to be. The occurrence of hypogonadism in men with Erectile Dysfunction has been assessed to be 4.8%. although, when free testosterone levels were used, 17.6% of males with Erectile Dysfunction were found to be hypogonadal. Hypogonadism leads to reduced response to sildenafil in men with Erectile Dysfunction. The response percentage of sildenafil increases when hypogonadism is treated appropriately with testosterone replacement. Testosterone replacement alone is enough in treating Erectile Dysfunction in 40% of men with hypogonadism and ED together. Therefore, a hypogonadal condition must be omitted in men with early poor response to sildenafil.
LUTS and Sexual Disorder in Aging Males
Sexual Disorders and LUTS are highly prevalent in aging men. The most common trigger for LUTS is benign prostatic hyperplasia (BPH). A total of 26 per cent men aged 40 to 79 years in Olmsted County were found to have LUTS while the Baltimore Longitudinal Study found the occurrence of BPH/LUTS to be up to 79 percent in the eighth decade. A study indicated that more than 50% of men above the age of 40 years have Erectile Dysfunction and this was powerfully associated to age among few other factors.
It has now been epidemiologically established that these two conditions do not simply co-exist in an alike population of older men but are interrelated with each other. A Survey on the aging males studied the relationship between LUTS and Sexual Dysfunction and found LUTS to be a major hazard factor in both erectile and ejaculatory ailments, independent of other risk factors. Another study on aging Spanish men found LUTS to be the strongest risk factor for Erectile Dysfunction in elderly men.
A lot of theories have been advocated to describe the physiologic reason for relation between LUTS and Sexual Dysfunction. One theory trusts that LUTS is a part of the metabolic syndrome and both LUTS and Erectile Dysfunction are caused by autonomic hyperactivity. Amplified smooth muscle contraction arbitrated by raised Rho kinase activity may be another common pathway for the above two conditions. Finally, pelvic atherosclerosis may also add up for chronic ischemia and resultant LUTS and Erectile Dysfunction.
Therapy for LUTS also leads to enhancement in sexual function. Surgical therapy with transurethral resection of the prostate lead to lower pain during ejaculation and enhanced erectile function in a study of 340 males.
These theoretical, epidemiologic, and trial data proposes a relationship between LUTS and Sexual Disorders which helps further study and may be open to a common combination therapy.
Drugs-Disease-Surgery and Sexual Disorder in Aging Men
Sex is a significant component of a healthy emotional and physical relationship, and its significance does not deteriorate with increasing age. While two-thirds of aging men exhibit interest in continuing sexual activity, their ability to do so depends upon their health standing and the availability of a companion. Although aging and functional deterioration may impact sexual function, the urologist should rule out disease or side effects of medicines and surgery in all such patients coming with Sexual Dysfunction.
Sexual function may be negatively impacted by common conditions such as diabetes, obesity, dyslipidaemia cardiovascular disease, arthritis, alcohol abuse, and depression. Administration of cardiovascular risk factors may decrease sexual dysfunction by refining endothelial function. Obesity may lead to endothelial dysfunction and hypogonadism by uplifting the levels of pro-inflammatory cytokines. Lifestyle variations to cut weight have been shown to have a positive impact on sexual function by dropping the levels of C reactive protein and IL-6. ED is pretty common in diabetic males, present in about 75% of diabetic males over 60 years. Likewise, high total and low-density lipoprotein cholesterol and hypertension are among other factors which when effectively controlled can possibly reverse the related decline in sexual function.
Aging men are more expected to be on one or more chronic medication for related comorbidity. Furthermore, with aging there is also a reduction in renal and hepatic clearance of drugs. This causes a higher likelihood of sexual adverse reactions in this age group, which can be cured with meticulous enquiry and smart substitution. Medications responsible for Sexual Disorders include selective serotonin reuptake inhibitors, alpha and beta-blockers, tricyclic antidepressants antipsychotics, diuretics and antihyperlipidemic drugs.
Surgery is also a possible cause of Sexual Disorders in aging men. Transurethral resection of the prostate habitually leads to rearward ejaculation, which can be quite worrying for the patient except if he has been warned beforehand. Other pelvic surgeries such as radical cystectomy, radical prostatectomy, and abdominoperineal resection also have a negative impact on both erectile and ejaculatory functions. Therapy of such patients involves a stepladder method starting with sildenafil and going up to the usage of a penile prosthesis.
In conclusion, the evaluation and treatment of Sexual Disorders in aging men needs a multifactorial tactic. Simple measures such as rationalization of medications, control of risk factors, and rehabilitation after surgery can lead to significant enhancement in their sexual functioning.
Cardiac Risk and Sexual Disorders in Aging Men
Sexual disorders and cardiovascular diseases share mutual risk factors and are often related to each other as both are caused by endothelial dysfunction. Men at low cardiac risk comprise lower than 3 cardiac risk factors, controlled hypertension, congestive heart failure-grade-1, stable angina, post-myocardial infarction (MI > 6 weeks), mild valvular disease. These can be treated for Erectile Disorders and can be sexually active without additional unpleasant cardiac event. Men at higher risk include unstable angina, CHF (gr.3-4), MI (<2 weeks), uncontrolled hypertension, moderate to severe valvular disease, recent stroke, and arrhythmias. These men need to have their main disease controlled and should be steadied before treating Erectile Dysfunction and planning to recommence sexual activity. Men at intermediate risk comprise more than 2 risk factors, MI ( >2, <6 weeks), moderate angina, CHF (GR-2), and stroke. These are candidates for restratification as either low or high risk and treated accordingly.10
The close relationship between Erectile Dysfunction and cardiovascular disease (CVD) is an indication to estimate sexual pasts of all males who present for cardiac evaluation. Early detection of Erectile Dysfunction may allow for early diagnosis and supervision of cardiovascular disease.
Erectile Dysfunction is an early marker of cardiovascular disease as they share common risk factors and pathophysiology connected to endothelial dysfuncton. Any male who shows no cardiac symptoms but presents with Erectile Dysfunction should be tested for dyslipidemia, diabetes, cardiovascular diseases and hypertension. All patients with risk factors but asymptomatic for cardiac disease should go through stress test for risk stratification. Lifestyle variations like dropping weight and amplified physical activity may prove beneficial in Erectile Dysfunction cases. The recognition of Erectile Dysfunction as an early marker for Cardiovascular diseases has led to the certainty that any man with Erectile Dysfunction should be considered a cardiac patient until proved otherwise. These patients should be encouraged for lifestyle changes.
Aging-induced sexual disorders in men are very similar to female menopause, except age-related testosterone reduction is gradual and not related with the as dramatic onset of symptoms. We often refer to symptomatic men as having “andropause.” Like menopause, andropause is not a disease. It is a part of the natural human aging process. Our society needs to be progressive about these disorders so that men can also open up about their sexual disorders and lead a healthy and happy life.