Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 130

The most common sexual problems among men are difficulty in achieving or maintaining an erection, lack of interest in sex, climaxing too quickly, anxiety about performance, and inability to climax.⁵

Erectile dysfunction (ED) is defined as the inability to attain or maintain a penile erection sufficient for sexual performance on at least two‐thirds of occasions. Physiologically, older males take an amount of increased time to develop erection and experience less full erections with a decreased pre‐ejaculatory secretion. During orgasm, there is a decline in expulsive force and urethral contractions. Following ejaculation, there is a rapid tumescence with rapid testicular descent. The refractory period is markedly prolonged compared to younger men.²⁴

An international study demonstrated the prevalence of ED in men aged 70–75 to be 37%.²⁵ Risk factors include heart disease, hypertension, hyperlipidaemia, tobacco use, obesity, and diabetes. Other contributors to ED include medication side effects (antihypertensives, antidepressants, and antipsychotics), neurological disorders, and benign prostatic hypertrophy.²⁶ Physicians can screen for ED using a validated questionnaire such as the Erection Hardness Score, Sexual Health Inventory for Men, and International Index of Erectile Function. Testosterone evaluation may be considered and is discussed in more detail later in the chapter.

First‐line treatments for erectile dysfunction are phosphodiesterase‐5 (PDE‐5) inhibitors such as sildenafil, tadalafil, vardenafil, and avanafil, which increase erection hardness and duration. The major side effects of PDE‐5 inhibitors are headache, flushing, dyspepsia, rhinitis, visual disturbances, hypotension, and death. People on nitrates should avoid using PDE‐5 inhibitors and nitrates within 24 hours of each other due to the risk of severe hypotension, and men who are on PDE‐5 inhibitors for pulmonary hypertension should avoid using multiple medications in the same class. PDE‐5 inhibitors will not improve erections in men with disrupted penile vasculature. When choosing a PDE‐5 inhibitor for a patient, the timing of medication is important to consider, with avanafil having the shortest onset of action as well as shortest effectiveness time (15–30 minutes and 6 hours, respectively), and tadalafil having the slowest onset of action but longest effectiveness time (60–120 minutes and 36 hours, respectively).²⁶ Men may have to trial several different PDE‐5 inhibitors to identify which meets their needs.

For men who cannot or choose not to use PDE‐5 inhibitors, other options are available. Prostaglandin E1, which can be injected or inserted as a pellet through a catheter in the meatus, can be considered, with good efficacy, ease of use, tolerance, and improved sex performance reported among users.^27,28 Vacuum tumescence devices and penile prostheses have been shown to be effective and satisfactory for men and their partners. These may be especially effective for men whose ED is due to previous prostate surgery.²⁶ Men receiving treatment for ED by any method should be counselled to seek emergency management for priapism (an erection lasting more than four to six hours) if this occurs, due to the risk of permanent corporal fibrosis.

To treat other male sexual disorders, including lack of interest in sex, climaxing too quickly, and anxiety about performance, the physician should evaluate for contributing factors, such as comorbid anxiety and depression. Sleep deprivation and psychological stress may also contribute to these disorders and should be addressed. Certain medications (such as SSRIs and antipsychotics) can diminish libido, and the risks versus benefits of continuing these medications should be considered.²⁹ Patients may benefit from marital counselling to address relationship problems and/or sex‐positive counselling with a trained therapist to address issues at an individual level.