Erectile dysfunction (ED) is one of the most common chronic diseases in men, and its prevalence increases with age. ED is also the most common sexual dysfunction diagnosed in older men. ED is defined as the inability of a man to achieve and maintain an erection sufficient for satisfying intercourse. ED is a relatively new problem, since before the 20th century, men rarely experienced reproductive age. In addition, older men often suffer from several chronic diseases, leading to polypharmacy, and many drugs can impair sexual function. ED can be caused by arterial, neurogenic, hormonal, cavernous, iatrogenic and psychogenic causes. Today, it is believed that the leading cause of ED is vascular pathology, primarily atherosclerosis.
The aim of this article is to analyze the main aspects of ED, in particular the epidemiology, pathophysiology and treatment approaches elderly men with heart problems.
In a large US study, the percentage of sexually active men decreased from 83.7% in the 57-64 age group to 38.5% in the 75-85 age group. An age-related increase in the prevalence and severity of ED has been demonstrated in all epidemiological studies. For example, in the Massachusetts Male Aging Study (MMAS), there was a tripling of the odds of complete ED from 5% in men in their 40s to 15% in men in their 70s. In the European Male Aging Study (EMAS), conducted in 8 countries and involving men aged 40-79 years, the prevalence of ED increased with age and peaked in the age group of 70 years and older. Over the age of 60, the prevalence of ED increases regardless of comorbidities such as coronary heart disease, diabetes mellitus, and hypertension.
ED and heart disease
ED, as a rule, develops 2-5 years before the manifestation of cardiovascular events, which is associated with a common pathogenetic mechanism (endothelial dysfunction). In congestive heart failure (HF), common in the elderly, symptom control may improve erectile function; if this approach does not work, PDE-5 inhibitors are used as 1st line therapy. In addition to reducing ED, these drugs may indirectly alleviate depressive symptoms and improve quality of life in patients with New York Heart Association (NYHA) class II and III heart failure. It should be borne in mind that patients with NYHA class IV heart failure are contraindicated in sexual activity. In patients with CAD, the prevalence of ED is 42-75%. PDE-5 inhibitors in this category of patients are safe and highly effective.
Consulting a doctor
Open discussion of the problem with the patient and his partner is the first step towards setting realistic treatment goals. The patient and his partner need to be explained the anatomy and physiology of sexual function, as well as the right to receive information about the pathophysiology of ED; provide complete information about non-pharmacological and pharmacological treatments for ED; explain that current oral medications do not “cure” ED but generally significantly improve erectile function in patients without significant comorbidities or conditions such as diabetes or radical prostatectomy. When choosing a treatment method, the priority remains with the patient and his partner, the doctor should, if possible, not take an authoritarian position. In some cases, it is advisable to discuss alternative forms of intimacy that do not involve penetration. Patients with psychogenic and organic psychogenic ED may require specialized psychosexual therapy to reduce anxiety and eliminate unrealistic expectations from medical or surgical treatment.
Obesity, sedentary lifestyle and smoking are strongly associated with ED. Therefore, at any age, treatment for ED should begin with lifestyle modification – weight loss, increased physical activity and smoking cessation. In particular, a meta-analysis of 24 studies showed that weight loss is associated with an increase in bound and free testosterone levels. The combination of a low-calorie diet and bariatric surgery results in a statistically significant (p2 weeks) is not a contraindication to treatment with PDE-5 inhibitors, however, when prescribing nitrates, it is necessary to maintain a period of > 24 hours after taking a short-acting PDE-5 inhibitor (sildenafil, vardenafil) and > 48 hours after taking tadalafil. It should be emphasized that in patients with heart diseases, and the vast majority of such patients are in the older age group, it is preferable to use short-acting PDE-5 inhibitors, such as sildenafil.
The simultaneous use of PDE-5 inhibitors and α-blockers can provoke orthostatic hypotension, so caution should be exercised. The same applies to labetalol and carvedilol, which have α- and β-blocking activity.
When sildenafil was given to healthy young volunteers (at doses of 100, 150 and 200 mg – i.e., higher than recommended), the maximum reduction in systolic blood pressure measured in the standing position averaged -10/-7 mm Hg. Art. 3 hours after ingestion.
None of the PDE-5 inhibitors has been associated with dangerous prolongation of the QTc interval, although the instructions for vardenafil indicate a potential risk. Also, vardenafil is not recommended for patients taking class 1A antiarrhythmic drugs (quinidine, procainamide) and class 3 (amiodarone, sotalol).
Other drugs and treatments
A number of herbal preparations and dietary supplements, such as yohimbine, icariin, and ginseng, have been used in the treatment of ED, despite the lack of conclusive data on efficacy.
Yohimbine is a peripheral and central α2 blocker derived from the bark of the evergreen plant Pausinystalia johimbe; It is also a weak inhibitor of monoamine oxidase. In elderly patients, the drug is not recommended due to the high risk of side effects – hypertension, tachycardia, insomnia, hallucinations and fainting.
Icariin is a flavonol glycoside derived from Horny Goat Weed (a plant in the barberry family) that has been used for centuries in China to improve sexual performance. Icariin has an inhibitory effect on PDE-4 and PDE-5, increasing the production of bioactive NO and mimicking the effect of testosterone. There are no reliable data on the effectiveness, as well as for ginseng, which is considered an aphrodisiac.
Manually operated vacuum constrictor devices create a negative pressure around the penis, which causes stasis in the sinusoidal spaces and an erection; to maintain the latter, a rubber cuff is placed on the base of the penis. The efficiency of the method reaches 90%; it is used in men who do not respond to pharmacotherapy and are unwilling or unable to receive surgical treatment. It should be remembered that the duration of the cuff should not exceed 30 minutes to prevent skin necrosis. In patients with hemorrhagic disorders and in patients receiving anticoagulants, the method should be used with caution.
Intracavernous or intraurethral administration of vasoactive agents is the recommended second-line therapy in men with ED who do not respond to PDE-5 inhibitors. This is a relatively safe, effective (up to 80%) and fast method. As vasoactive substances, prostaglandin E1 (alprostadil, PGE1), papaverine and phentolamine are used. PGE1 and papaverine increase the intracellular concentration of the second messenger cyclic guanosine monophosphate and cyclic adenosine monophosphate, which causes relaxation of cavernous smooth muscles; phentolamine is an α-blocker. Alprostadil is also available for urethral administration in the form of a suppository (MUSE).
Finally, the reserve method is surgical treatment (prosthesis of the penis). Of the three types of prostheses in older patients, a three-piece inflatable prosthesis is preferred; it consists of two implantable rods, a connected pump placed in the scrotum, and a reservoir that is implanted in the preperitoneal space of the lower abdomen. Satisfaction with this treatment method reaches 90-98%.
The ability to achieve and maintain an erection is often equated with masculinity and has a significant impact on a man’s self-esteem.
In the geriatric population, ED is widespread due to an increase in the incidence of heart disease, comorbidities and age-related pathological changes in the erectile tissue.
The multifactorial nature of ED requires a multidisciplinary approach to prevention and therapy. Before starting treatment, the medications the patient is taking should be reviewed and, if possible, medications that can cause ED should be discontinued or replaced.
Treatment for ED with heart problems should begin with lifestyle modifications such as weight loss, increased physical activity, and smoking cessation. PDE-5 inhibitors, such as sildenafil, are the first line of therapy, which are highly effective and safe in men with ED and heart problems.