Archive for December, 2020

Sex and the Middle-Aged Male

December 19, 2020

Andrew Siegel MD  12/19/2020

The Natural Physiology of Male Sexual Function with Aging

Welcome to the club, the > 50-years-old club. If you want to enjoy being a member of the club, you need to know the rules and expectations of club members.

Most human beings experience the peak of their physical abilities in their twenties and thirties. With aging comes a gradual anatomical and functional decline in all body systems, and the male sexual response is no exception. Aging results in changes in all parameters of sexuality, including sex drive, erectile and ejaculatory capacity and refractory period. The topic of today’s entry is the natural and expected changes in male sexual function with aging. A valuable resource for this material is Human Sexual Inadequacy by Masters and Johnson, pioneering at the time of being published 50 years ago and now a classic.

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It is important for the middle-aged male and his partner to understand the natural and expected physiological sexual decline that occurs with the aging process. Knowing what to expect and putting one’s sexual function in its proper context is key to avoiding erectile insecurity and the vicious cycle of anxiety about the loss of masculinity that can doom erectile function.

Recognize that men of any age are not robots with the expectation of a perfect sexual performance on every occasion, as many factors contribute to the male sexual response, including physical health, psycho-emotional state, relationship issues and other intangibles. Aging can further influence these factors. One thing that is clear is that the most powerful sex organ is the brain, which can be thought of as the governor of sexual response, capable of fostering a sensational sexual performance on one extreme, to erectile failure on the other (performance anxiety or stage fright).

PHYSIOLOGICAL CHANGES IN MALE SEXUAL FUNCTION WITH AGING

For the purposes of this discussion, “older” is arbitrarily defined as > 50 years-old. Yours truly is clearly past his prime!

Masters and Johnson recognized four phases of the male sexual response– excitement, plateau, orgasm, resolution–a convenient means of deconstructing and studying it.

EXCITEMENT PHASE

In the excitement phase, penile erection occurs as a result of an arousing sexual situation.  Accompanying erection is thickening of the scrotal skin and elevation of the testicles

It is physiological for the older male to have a somewhat diminished sex drive, although this is highly variable.  The natural decline in testosterone levels with aging contribute to reduced libido. Diminished desire is sometimes on the basis of poorer erectile capacity with loss of interest and desire simply because one’s performance is less than optimal.  Partner issues also weigh heavily into this, with the post-menopausal female partner often less interested and experiencing physical issues causing sexual limitations. 

The older male is slower to erect; the response may take minutes and require a good deal of tactile stimulation whereas previously the response time may have been seconds with no physical manipulation required. There is also a physiological increased laxity of the scrotal skin and less testes elevation with stimulation.

PLATEAU PHASE

In the plateau phase, there is increasing engorgement of the erectile chambers and the head of the penis, increasing size and elevation of the testicles, and a pre-ejaculatory secretion as a result of discharge from the bulbourethral gland. 

The older male often experiences less penile and testes engorgement and a scantier pre-ejaculatory fluid discharge than earlier in life. Rigidity may be reduced, with perhaps a 3/5 or 4/5 rigidity versus 5/5 rigidity of the younger male. However, even with a slower reaction time that requires tactile stimulation and less rigidity, there is often enough firmness for vaginal penetration and the firmness can often morph into increased rigidity once sexual intercourse is initiated. Although the older male is able to obtain this initial rigidity, it is not uncommon for him to experience the premature loss of the erectile rigidity, with less durable erections.

ORGASM PHASE

Orgasm consists of three phases: emission, in which seminal fluid and sperm from the epididymis, vas deferens, seminal vesicles, and prostate is deposited into the urethra; ejaculation, the forcible expulsion of semen from the urethra resulting from contractions of the peri-urethral and pelvic floor muscles combined with relaxation of the external sphincter and urogenital diaphragm; and orgasm, the emotional excitement and climax that accompanies ejaculation, with considerable subjective variation.

The younger male experiences an initial phase of “ejaculatory inevitability” in which the prostate and seminal vesicles contract every 0.8 seconds for 2-4 seconds followed by a secondary “expulsive” phase in which there is forceful spurting of pressurized warm seminal fluid with often a substantial arc of release. Physiologically, in the older male, these two phases commonly merge into one, with a likelihood that the first phase disappears entirely. The ejaculatory process is often shortened, with diminished contractions, force, pressure, volume and a dribbling quality arc.  The pleasure derived from ejaculation also tends to diminish with aging, with the act of ejaculation becoming less dramatic. One of the few sexually redemptive features of aging is better ejaculatory control than when younger, often with disappearance of premature ejaculation issues.

RESOLUTION PHASE

There is loss of erection, the testicles decrease in size and drop down to the bottom position of the scrotum, and the scrotal skin regains its laxity.

In the older male, there is a return to a flaccid state in seconds after ejaculation, whereas in the younger male it may take minutes or longer. The refractory period–the time after ejaculation that it takes to obtain another erection–increases substantially in the older male. It may take hours or perhaps longer for the older male to obtain a second erection, whereas in the younger male it could be minutes.

Bottom Line: There are natural changes in the male sexual response with aging, just as there are in all bodily functions.  However, many men who maintain good health may anticipate satisfying sexual function well into their senior years. The key is knowing what to expect.

Recent NY Times article about a specific diet geared to help erectile function.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX