In addition to gradual slowing, older men may notice less preejaculatory fluid and less forcefulness at ejaculation. In general, testosterone levels decline only gradually, and some very old men still have levels identical to those in younger men. However, chronic illness or alcoholism reduces testosterone levels markedly. Men do not undergo a physiologic climacteric, and they remain fertile until the end of life.
A common concern of men of all ages including older men is their ability to maintain sexual potency and performance. Impotence is distressing and is usually (although inaccurately) attributed to aging (see IMPOTENCE in Ch. 69). However, impotence may occur from time to time at any age for a variety of reasons (eg, stress, fatigue, tension, guilt, depression, illness, excessive drinking, and anxiety over performance). A comprehensive evaluation is needed to separate psychologic from organic causes. Recent studies suggest that organic causes are a major factor in >= 80% of persistent male sexual dysfunction, and psychologic factors alone probably account for only 10% of cases of erectile dysfunction. However, psychologic and organic factors are often intermixed; anxiety over an organic cause of impotence often aggravates the problem.
The diagnostic process begins with a history and physical examination. Depression, anxiety, and stress must also be evaluated. Sleep studies that measure nocturnal penile tumescence help distinguish psychogenic from organic impotence. Such studies can be conducted at home with a portable monitoring unit or in sleep clinics.
Impotence can be treated successfully in most cases, often without surgery. In the case of psychogenic impotence, sexual capacity may return spontaneously; reassurance reduces anxiety and speeds recovery, but psychotherapy or professional sex therapy may be required. Involving the partner in the diagnosis and treatment program is important. Much of the expense of professional sex therapy (including that for couples) may be covered by Medicare or private health insurance, but the cost may be a problem for many older people. Medicare now pays 50% of the allowable charges for psychotherapy whether performed by a physician, psychologist, or social worker. Increasingly, insurance companies are paying for diagnosis and treatment of sexual dysfunction.
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