Can regular intercourse preserve sexual function in the aging male?

The relationship between erectile dysfunction (ED) and increasing age, with a reported prevalence of 40% at 40 years of age, compared with 70% or more by 70 years of age, is well documented through several well-designed epidemiological studies; for severe ED, rates triple from 5 to 15% for men aged 40 years compared with those aged 70 years [1–2]. Studies consistently demonstrate a steep age-related increase; the primary consideration is accumulation of risk factors for ED, not chronological age itself [2]. Although historical estimates for the prevalence of ED may vary from one report to another, this is explained by the methodology design of the different surveys and the influence of contemporary validated metrics, such as the International Index of Erectile Function (IIEF; introduced in 1998) and minor changes in the definition of ED [2].

Koskimaki et al. recently reported data from the Tampere Aging Male Urologic Study and concluded that regular intercourse protects against the development of ED among men aged 55 to 75 years [3]. Given the potential wide-ranging impact on general health and quality of life, the authors emphasize that healthcare providers should support patients’ sexual activity.

Impact of erectile dysfunction on the aging male

Although more than 70% of men over 65 years are sexually active, 40% are dissatisfied with their sex life [4,5]. In one large, multinational survey, less than 25% of men and women felt that ‘older people no longer want sex’, and over 60% of men and women supported the idea of using medical treatments to aid in sexual enjoyment [6]. Increasing longevity of women and men, recognition of sexual health as an integral part of general health, and the development of a variety of treatments aimed at improvement of sexual function have contributed to a change in the attitude of aging men, their partners and the medical community [7].

Sexual health is determined by interactions between biological, psychological and sociocultural factors of the individual partners and their sexual and intimate interaction in the relationship with their partner(s). ED may increase personal vulnerability, performance anxiety and distress, thus effecting interpersonal relationships on several levels, including avoidance of intimacy but also diminished day-to-day quality of life, including increased worry and lowered self-esteem [7–10]. Men and women who rate their health as being poor are less likely to be sexually active and more likely to report sexual problems; however, the proportion of men or women with sexual dysfunction accessing sexual healthcare expertise remains low, as only 38% of men and 22% of women in a recent study by Tressel Lindau et al. reported having discussed sex with a physician since the 50 years of age [11].

Risk factors for erectile dysfunction

A wide variety of common medical conditions and medications may lead to deterioration in sexual function, and ED may be the first symptom of a variety of systemic conditions including early (presymptomatic) cardiovascular disease (CVD) [12]. The fact that new-onset ED is a harbinger of cardiovascular clinical events (hazard ratio 1.25; 95% CI: 1.02–1.53; p = 0.04) in some men should prompt the clinician to perform a thorough investigation for CVD risk factors if ED is identified; current limitations of screening for ED as part of general patient evaluation limits intervention for all patients in this at-risk population [12].

While relational, psychologic and organic issues are important contributors to ED across age groups, organic issues tend to play a more pronounced role as men age [13,14]. Common risk factors between generalized penile arterial insufficiency and CVD include hypertension, hyperlipidemia, cigarette smoking, diabetes mellitus and central obesity/sedentary lifestyle; ED may also be the first manifestation of many disease states, including metabolic syndrome, spinal-cord compression, pituitary tumors and pelvic malignancies [15]. Men with angina, myocardial infarction or heart failure may also have ED from anxiety or depression. Many commonly used medications, including antihypertensives and antidepressants, cause or exacerbate ED and these results are reported elsewhere [2,11,14].

Aging is associated with changes in hormone levels, including decreased testosterone and increased sex hormone-binding globulin. Although testosterone levels do not correspond to severity of ED, in patients with reduced libido lower levels of testosterone are observed [15]. Even though erections in response to visual sexual stimulation are preserved in men with hypogonadism, and normal androgen levels are not absolutely essential for erectile function, evaluation and correction of hormonal abnormalities, especially with phosphodiesterase type 5-inhibitor nonresponders, is warranted since a high rate of satisfactory response (treatment salvage) is noted [2].

Finally, social drugs including cigarettes and excess use of alcohol also affect erectile function. Cigarette smoking may actively induce vasoconstriction, penile venous leak ED owing to its contractile effect on the cavernous smooth muscle, or accelerate atherosclerotic changes in penile microvaculature [15]. Lifestyle modification remains a key treatment option or adjunct for most men with ED.

Tampere Aging Male Urologic Study

In a study sample of 989 men aged 55–75 years (mean 59.2 years) followed for 5 years, and after adjusting for comorbidity and other major risk factors, men reporting an intercourse frequency less than once per week at baseline demonstrated twice the incidence of ED versus men reporting an intercourse frequency once per week or more (79 vs 33 per 1000; incidence rate ratio 2.2; 95% CI: 1.3–3.8) [3]. Controlled variables included cardiovascular disease, diabetes, hypertension, body mass index, depression and smoking.

Could it be that regular sexual activity functions in a similar fashion as physical function, in this case, preserving the ability to attain and maintain erections? Erectile function is dependent on intact physiologic response to stimulation, including vascular and penile smooth muscle components; of course, this is a simplified overview by necessity but underscores the importance of maintaining ‘penile health’. Just as regular exercise regimens are key to maintaining cardiovascular health, general fitness and enhanced quality of life, ‘signals’ in peer-reviewed literature support a similar paradigm for erectile function including preservation of vascular function, maintained cavernosal reactivity, and prevention of cavernous fibrosis [3]. Montorsi et al. recently reported a study of men with ED following bilateral nerve-sparing radical prostatectomy for which placebo-group patients (double-blind design) attempted intercourse on a weekly basis throughout recovery [16]. In comparison to historical results and patients treated with a phosphodiesterase type 5 inhibitor, this group demonstrated a higher rate of erectile function recovery than expected, part of which has been attributed to the active penile physiotherapy that attempts at intercourse provide. The oft-quoted proverb ‘use it or lose it’ seems justified, but not only from a purely anatomic or physiologic standpoint; continued intimacy and nurturing of the interpersonal relationship, as provided by a healthy sexual component, also protects against the psychosocial decline in interest and sexuality that may occur with time [6–8].

Conclusion

Normal aging does not necessarily mean healthy aging [17]. Koskimaki and colleagues have provided a valuable contribution to the literature concerning aging and male sexual function, and support the notion that healthcare providers bear a responsibility to evaluate the quality of sexual function in the aging male as part of comprehensive patient care. Regular sexual activity seems to preserve potency in a similar fashion to physical exercise maintaining functional capacity [3]. Not only does increased coital frequency decrease the incidence of ED, but it may also benefit the mutually interested patient and partner psychologically, and improves quality of life in many instances.