Part 30: Overview of Clinical Treatment (Vascular Lesions, Endocrine Disorders, Neurological Lesions, Drugs and Psychological Factors)
In terms of the causes, erectile dysfunction can be divided into two main categories: organic erectile dysfunction and functional erectile dysfunction (or psychogenic erectile dysfunction). Organic erectile dysfunction is caused by some organic factor and is often manifested as the inability to achieve an erection at any time. Functional erectile dysfunction occurs due to physiological changes in the nervous system, with psychological factors being the primary cause. It often only results in the inability to achieve an erection during sexual intercourse, or in the inability to achieve an erection after penetration.
In the past, it was believed that erectile dysfunction was mostly caused by psychological factors, while organic erectile dysfunction accounted for only 10% to 15%. In recent years, with the continuous deepening of examination and diagnosis, it has been found that many diseases can cause erectile dysfunction, and the proportion of organic erectile dysfunction is constantly increasing.
Especially for middle-aged and elderly men, as their bodies gradually age, various age-related diseases inevitably arise, and many common age-related diseases and their treatments can often impair male sexual function from different angles. Some studies have found that organic lesions account for approximately 50% to 80% of erectile dysfunction patients over the age of 50.
Therefore, the prevention and treatment of age-related diseases are closely related to maintaining the sexual function of middle-aged and elderly men. Only by actively treating these age-related diseases and discontinuing or reducing the use of drugs that impair sexual function can sexual function be fundamentally improved.
Factors affecting sexual function in middle-aged and elderly men can be mainly divided into five categories: vascular lesions, endocrine status, neuropathy, medications, and psychological state.
I. Vascular lesions and decreased sexual function
Penile erection requires changes in the following three blood vessels:
(1) Through corresponding spinal reflexes, especially cortical reflexes, under the influence of the parasympathetic nervous system, the afferent arterial pressure of the penis increases, accompanied by the dilation of the cavernous arteries; (2) Relaxation of the smooth muscle of the cavernous body causes dilation of the blood sinuses, allowing a large amount of blood to enter the cavernous body, at which point the blood volume can increase by 41%, thereby increasing the girth of the penis; (3) Due to the increase in girth of the penis, the relevant veins of the penis close, obstructing the return of blood from the cavernous body, allowing the cavernous body to further fill and the penis to harden. The synergistic effect of the above three aspects ensures a full and effective erection of the penis. Any deficiency in any of these aspects can lead to erectile dysfunction, namely vascular impotence.
Because the incidence of arteriosclerosis increases with age, vascular causes also increase in sexual dysfunction among middle-aged and elderly men. An angiography study confirmed that internal pudendal artery occlusion accounts for a significant proportion of cases in men over 50 years of age.
Other arteriography studies have also confirmed that penile blood vessels may be obstructed in erectile dysfunction patients without peripheral vascular disease. Foreign scholars performed penile arteriography on men over 35 years of age with erectile dysfunction and found that 93% of cases in the younger age group were within the normal range, with 2% suspected of having abnormal venous drainage; while in the older age group, 89% had stenosis or closure of blood vessels in the iliac and cavernous systems.
Therefore, vascular erectile dysfunction may be the most common cause of sexual dysfunction in middle-aged and elderly people.
II. Endocrine status and decreased sexual function
Androgens affect sexual function by influencing sexual behavior, maintaining the physiological activity of reproductive tissues, and producing sperm. Hypogonadism can lead to decreased libido and erectile dysfunction, which can improve with androgen therapy.
Although sexual function declines with age, there is still debate about whether testosterone levels decrease in older adults. Some studies have found decreased plasma testosterone and increased gonadotropins in older adults. Others believe that free testosterone is related to the frequency of sexual pleasure, while luteinizing hormone is indirectly related to loss of libido, decreased sexual pleasure, and difficulty achieving nocturnal erections.
Conversely, some studies have found that while older adults may experience reduced sexual activity, their serum testosterone levels do not necessarily decline with age. Furthermore, many chronic diseases in older adults can lower testosterone levels; tissue insensitivity to androgens may also be a factor contributing to decreased sexual function in older adults.
Other endocrine disorders in the elderly, such as thyroid disease, adrenal gland disease, and diabetes caused by pancreatic endocrine disorders, can also lead to decreased sexual function.
III. Neuropathy and Decreased Sexual Function
The autonomic nervous system primarily controls penile erection in male sexual response, while the trabecular smooth muscle of the corpora cavernosa controls the hemodynamics of erection. Adrenergic nerves regulate smooth muscle tone via α or β receptors, and the sacral parasympathetic nerves control gonadal secretion.
Neurogenic erectile dysfunction is caused by abnormal neurological factors that impair the ability to produce or maintain penile erection. These factors are related to abnormal penile sensation, abnormal penile vasomotor control, and abnormal regulation of the activity of the lumbosacral erection reflex center and the brain.
Neurological diseases are one of the causes of decreased sexual function in middle-aged and elderly men. These include spinal cord injuries and diseases, peripheral nerve dysfunction, intracranial diseases, and other related factors, all of which can cause erectile or ejaculatory disorders.
IV. Drugs and Decreased Sexual Function
Middle-aged and elderly men are prone to overuse of medications, and the side effects of these drugs often interfere with the sexual function of older men. Reports indicate that drug-induced erectile dysfunction accounts for approximately 10% to 25% of cases among older men.
Any drug that alters the body's hormonal environment, somatic nerve and autonomic nerve conduction, or hemodynamics of the reproductive organs may cause decreased libido and affect penile erection or ejaculation. Its mechanisms of action are: (1) sedation or inhibition of the central nervous system; (2) antagonism of cholinergic or adrenergic nerves; (3) increase in prolactin levels in the blood; and (4) direct antagonism of androgens, especially at higher doses and longer durations of use.
The main drugs that cause male sexual dysfunction are antihypertensive drugs and antipsychotics. Other drugs such as sedatives, antidepressants, antihistamines, anticholinergics, hormones, alcohol, digoxin, cimetidine, nicotine, and noscapine are also commonly used by middle-aged and elderly people. Long-term use can cause erectile dysfunction.
V. Psychological state and decreased sexual function
Among middle-aged and elderly men with decreased sexual function, 35% to 95% have psychological factors. Purely psychogenic erectile dysfunction is not common in middle-aged and elderly men, but it often coexists with organic erectile dysfunction.
Psychogenic erectile dysfunction usually develops more quickly and is accompanied by decreased libido, often triggered by stressful life events or significant psychological trauma. In contrast, patients with organic erectile dysfunction often experience a worsening of their sexual dysfunction due to psychological factors such as anxiety, depression, or misunderstandings about the disease, making recovery more difficult.
As can be seen from the above discussion, in most cases, decreased sexual function in middle-aged and elderly men is not an independent disease, but a symptom of many geriatric diseases. It is a manifestation of the aging process of the body in middle-aged and elderly men, and its treatment should adopt a combination of holistic and local methods to achieve satisfactory results.
However, current TCM clinical practice often treats impotence in isolation, emphasizing syndrome differentiation over disease differentiation, resulting in poor treatment outcomes. Through years of clinical experience, the author has found that combining the treatment of decreased sexual function with the treatment of underlying geriatric diseases (i.e., combining aphrodisiac and anti-aging), and combining syndrome differentiation for treatment with differentiation of the underlying geriatric disease (i.e., combining syndrome differentiation with disease differentiation), can often significantly improve treatment effectiveness.
In light of this, this article selects 14 common geriatric diseases that can cause sexual dysfunction in middle-aged and elderly people. For each geriatric disease, we first briefly introduce the basic knowledge of its diagnosis and treatment and the pathological mechanism that causes sexual dysfunction, and then focus on the traditional Chinese medicine treatment of various basic syndrome types.
Several prescriptions are introduced for each syndrome type for clinical selection and application. These prescriptions have the following characteristics: (1) They have the dual effects of aphrodisiac and anti-aging, that is, they can enhance sexual function and treat primary geriatric diseases, which complement each other; (2) The drugs are carefully selected, and each prescription consists of no more than 6 drugs. They are easy to use, but the dosage is large, and the effect is strong; (3) If necessary, 2 to 3 prescriptions can be combined according to the characteristics of the condition and the efficacy of the prescription to improve the treatment effect; (4) Most of the drugs used in each prescription have modern pharmacological or clinical research basis and have strong drug targeting; (5) If the medication is accurate, the use of Western medicine can be appropriately reduced or stopped under the guidance of a physician to reduce or eliminate the damage of Western medicine to sexual function.
Most of the prescriptions listed in this article are accompanied by descriptions of relevant pharmacological studies of the Chinese herbs in the footnotes. However, to avoid repetition, a particular pharmacological effect of a certain Chinese herb is generally only described once in a prescription where that herb is the main ingredient and primarily exerts that effect. If the herb appears in other prescriptions, that pharmacological effect will not be described again.
In other words, each prescription only introduces the pharmacological effects of one or two Chinese herbs. Other pharmacological studies have already been discussed in other prescriptions and will not be repeated. Readers should consult the preceding and following sections to gain a comprehensive understanding of the pharmacological effects of the herbs in each prescription.