All serious disease impacts sexual function adversely, and this is especially true in the elderly. In contemporary culture, sexual function is considered to be the province of the young. This cultural attitude denies the geriatric patient the right to sexual self-expression. When illness or infirmity interferes, the spouse may not be able to cope with a partner’s disease and the change in sexual behavior caused by the condition. After surgery, there may be a direct relationship between the development of sexual problems and lack of discussion about sexuality prior to discharge from the hospital. Finally, fear of death during intercourse may lead a couple to sleep apart. A lack of communication about sexual concerns is common between physician and patient when both are concerned about the primary disease. In Western culture, both patient and physician are generally inhibited from speaking about sexual function.
Despite great patient desire for an effective oral therapy for erectile dysfunction, few effective agents exist. Yohimbine is an alpha-2 blocker specifically available for the treatment of erectile dysfunction. Unfortunately, it has had only modest success (compared to placebo) in several recent clinical studies. The response rate seems higher in patients with psychogenic impotence (31% complete and 31% partial) than organic impotence (18% complete and 27% partial) . Despite these relatively poor results, yohimbine is often prescribed for patients seeking treatment for impotence because of its relatively mild side effects (anxiety, nervousness, slight increase of blood pressure) and ease of administration.
In contrast with past misconceptions that 90 percent of erectile dysfunction was due to psychiatric or psychologic disorders, current belief is that 50 percent of impotent patients have an underlying organic disorder.
The percentage is certainly higher in the older male population. If a probable diagnosis of psychogenic erectile dysfunction is made after appropriate history, physical examination, and diagnostic evaluation, an attempt at psycho-sexual therapy is indicated.
However, most patients will suffer from a combination of physical and functional problems. In the geriatric population, reactive depression secondary to illness, loss autonomy, or loss of a lifelong partner may all contribute to functional erectile dysfunction.
There are few controlled studies establishing the effectiveness of behavioral therapy for these patients, who are often resistant to referral. 25 percent of patients referred to psychiatry never contacted the clinic, and of those who did, 83 percent refused therapy or terminated therapy early.
Efforts should be made to encourage patient participation in therapy as part of the general rehabilitative effort.
