Healthy sex life might need a little nudge as we get older

Thomas Jaffe, a surgeon at the University of Pittsburgh Medical Center (UPMC), has done penile implants to correct erectile dysfunction in otherwise healthy septuagenarians looking to resume normal sex lives.

Sex therapist Connie Lappa helped an 80-year-old man with medication-resistant, diabetes-related ED and his slightly younger wife learn alternative means of giving one another sexual pleasure. The result: He bought her a vibrator, and Ms. Lappa said, "to her surprise she had her first orgasm of her life."

So is there an age limit for having an active sex life?

"If there is, we should all be lucky to live so long," says Neil Resnick, the geriatrician and gerontologist who directs the Institute on Aging at the University of Pittsburgh. "In other words, there is no age at which sexual desire is lost. Sex is affected by ... a lot of things. But provided everything is normal (physiologically and psychologically), then the answer is 'no.' Sex drive and sexual capabilities are both maintained."

Physiologically speaking, women can maintain a comfortable, enjoyable sex life more easily than men.

"Men may lose the ability to get and maintain an erection. Women don't have that physiological limitation," said uro-gynecologist Halina Zyczynski, director of the Women's Center for Bladder and Pelvic Health at Magee-Womens Hospital of UPMC.

Still, there are some problems as women pass through menopause and production of estrogen diminishes. Many, though not all, older women have drier, less pliable vaginal tissue, a problem exacerbated by lower production of lubrication during sex. Both can cause uncomfortable or painful intercourse.

Some also report a lessening of sex drive, but that's a symptom that also can be caused by medications, psychological issues like depression or stress and/or relationship problems. That symptom has multiple solutions.

But there are easy treatments for the lack of lubrication and a tight vagina.

For lubrication, there are quite a few over-the-counter products. Some are water-based; others have bases of petroleum, natural oils or silicone.

"Assuming they don't cause allergic reaction ... they address the problem for the moment in terms of lubrication," Dr. Zyczynski said. "But they don't change the skin and the problem of dryness."

Prescriptions containing estrogen, however, can rejuvenate that skin and restore some of that elasticity. The estrogen comes in various forms, including topical creams, a silicone ring with a 90-day supply of estrogen cream and estrogen vaginal tablets. "They're all variations of treating the same problem, which is (the need for) estrogen," said Dr. Joanne Oleck, director of urogynecology and pelvic reconstructive surgery at Allegheny General Hospital.

Not all men lose the ability to have erections, but in general, they do undergo a series of changes in their sexual organs.

"A lot of testicles grow smaller ... (which) has to do with the ability to make semen," Dr. Resnick said. "It is what it is. They're smaller, softer than in youth, but most don't care how big a testicle is. ...

"The effective level of testosterone goes down, but not sufficiently so that it will eliminate sexual drive or erections.

"Erections are slower in age and less rigid with age, and some of that has to do with the blood supply with erections. It all has to do with the opening up of valves, pipes and plumbing. ... It takes more stimulation to get an erection and it's not as firm, but at no age in absence of disease or drug interaction, no matter how old, he ought to be able to get and maintain an erection and be sufficient if the woman has sufficient lubrication."

The erection will be of less duration and having an encore performance will take longer, he added, "but that's easy to adapt to."

But Dr. Zyczynski and Ms. Lappa say it may not be easy for the man's partner to adapt to.

"Ninety percent of the time when couples stop sex it's because of the man, not the woman," Dr. Zyczynski said. "Sex becomes embarrassing or frustrating for them, so they're not having the immediate, spontaneous erections, need more stimulation to get an erection, and their erection is not as reliable as they have been, so men will tend to avoid sex."

Ms. Lappa also said vaginal discomfort during sex frequently is caused by ED. "When the partner's erections are not firm or not directed, patients have talked about (forceful penetration) ... which makes the whole situation worse. And many times, fixing the ED addresses the vaginal discomfort. ...

"An inability to achieve orgasm or ejaculation ... prolongs intercourse well beyond the comfort zone for women, and that's (also) something that's fixed with the men rather than the women."

The causes for erectile dysfunction are many and diverse, said Dr. Thomas Jaffe, director of Magee-Womens Hospital of UPMC urology department and an assistant professor of urology at the University of Pittsburgh School of Medicine:

"Diabetes, high blood pressure, low testosterone, cardiovascular disease, antidepressants -- they diminish penile sensation, which makes it difficult to have enough sensation to ejaculate -- certain blood pressure medications. Beta blockers are the worst. A lot of glaucoma treatments are beta blockers, and you can almost set the date and time of ED to when he started eye drops or a beta blocker blood pressure pill." Prostate cancer surgery, low testosterone levels and other hormones also can cause impotence.

But, Dr. Jaffe added, "I think (the psychological aspect) is equally important as the decades go on.

"It's more important in a 30- or 40-year-old who had one bad (ED) episode who thinks every erection will not succeed, but someone in his 60s or 70s who might be depressed over the death of a spouse, cancer, who knows what, that is a huge component in not having an erection. So they have one failure and they worry it'll happen again, and so it does and it's one vicious cycle you get into."

Fortunately, there are nearly as many treatments available for ED as there are causes. They range in simplicity from the three ED pills advertised so heavily on television -- Cialis, Levitra and Viagra -- (and Dr. Jaffe makes his patients try all three in all available dosages because they differ slightly from one another) to the most aggressive treatment, surgical insertion of one of three penile implant systems: the semirigid, or bendable rods; the two-piece inflatable; and the three-piece inflatable.

In between those two extremes of the treatment continuum are the vacuum erection device; a urethral suppository called MUSE; and penile injections. Like the pills, these three treatments can be abandoned if the patient does not like or respond to them, but if he goes for the most aggressive treatment, the implant, there's no turning back.

"You can take it out, but once it comes out, you'll never get an erection again," Dr. Jaffe said.

"You have to be pretty motivated to go to that point." Many patients will not, and Dr. Jaffe said, "it's pretty clear when people come in, what line they won't cross, how far someone is willing to go."

Nevertheless, he said, "I have months where I'll do six (implants)."

But for those who have reached a medical treatment line they won't cross, or for those whose sexual problems are rooted in psychological or relationship issues, sex therapy may be the final solution. Doctors interviewed for this story have recommended such counseling to patients.

And the reverse also is true.

"When I do my history, I ask a lot of medical questions," said Ms. Lappa, who has offices in Carnegie and Shadyside. "They do affect each other. I try to take a holistic view. Medications, illnesses, being depressed or anxious can affect sexuality. I might send you back to a doctor or for other types of examinations, a physical exam or bloodwork and then move on to the psychoeducation part of it. ...

"Research over time has shown doctors don't ask those (sex-related) questions, and if you don't ask, you're not going to get as many people to bring it up. About one-third are willing to bring it up without the doctor asking."

Therapist Sandra Davis, who sees patients up to the age of about 60 in the Shadyside-Oakland area, said she deals with physiological issues, like advising women on over-the-counter lubricants because she too has found a surprising number of women clients are "too shy to talk to their doctor and gynecologist."

"There's a big education component to this," Ms. Lappa said. "Many don't know what's normal. They worry about some of the (physical) changes."

But, she added, "seniors nowadays are pretty open to all sorts of sex stimulation, much more than people realize. There was a survey in 2007 in the New England Journal of Medicine that found 58 percent of those surveyed between the age of 57 and 64 had oral sex, and 31 percent of those 75 to 85 had oral sex. I don't know what happened to the people in between, but it reflects what I see in the seniors who come in to see me. ...

"I had the sweetest little couple, both in their 70s, with erectile problems," Ms. Lappa continued. "They were going to a doctor, but they wanted to talk about techniques, ask questions. They had only met three weeks before but they were already engaged in sex. They figured they didn't have much time and should make the most of it."

Dr. Zyczynski has had similar experiences with sexually active seniors when discussing surgical options to correct a prolapse, a condition in which a pelvic organ drops into the vagina.

"We can offer a procedure that sometimes results in shortening or narrowing the vagina, but we wouldn't pick that option in someone who wants to maintain the ability to be sexually active," she said.

"As a courtesy I ask everybody," she said. "I've had one 86-year-old woman say, 'Honey, I'm old, but I'm not dead. Of course I'm sexually active.' "