Sexual Dysfunction in the Elderly Male

To the Editor: — Morley et al's excellent article1 on the management of sexual dysfunction in the elderly male fails to mention vacuum constriction devices (VCDs). I believe these should be tried along with the other measures outlined prior to recommending a prosthesis. Undoubtedly, penile implantation has undergone considerable improvement over the past decade; however, complications, especially postoperative infections (which may occur in up to 40%)2,3 and adverse psychologial sequelae,4 and the fact that it is irreversible still make it a relatively hazardous procedure. VCDs, which logically may be used either before or following intracavernosal (IC) drugs1 according to the patient's preference, have the advantage of being less invasive, safer, and generally less painful. Also, there is no limit on their frequency of application. However, it is likely that both physician and patient will view them as more unorthodox (ie, less medical) and will be more skeptical. One system tested consists of a transparent acrylic cylinder to one end of which a vacuum pump is attached.5–8 Two substantial rubber bands are doubled over the cylinder at the opposite end, which is open. The cylinder is placed over the penis and pressed against the body with enough force to form an air-tight seal. A vacuum up to 250 mm of mercury may be developed and the penis gradually fills with blood, becoming rigid. This may take several minutes. The rubber bands are then pushed off the end of the cylinder, constricting the base of the penis, and the cylinder is removed. The bands may be left in place for up to thirty minutes, during which an erection is maintained. This is likely to be somewhat larger than normal, because in addition to the erectile tissue, the superficial penile veins become distended. Also, the skin color is more dusky and the penile temperature may drop by up to 1 °C. The bands prevent emission at the end of orgasm, the semen flows away when these are removed. However, the nature of the climax is not otherwise significantly altered. If a decision is made to use the device, subjects are required to practice with it in the physician's office. Once the technique has been mastered, he is provided with VCD and encouraged to use it at home whenever he and his partner wishes. Experience is more limited with the VCD than with IC drugs, but a majority (over 90%) of chronically impotent males (with both organic and psychogenic etiologies) have been able to induce an erection firm enough for intercourse whenever they have wanted.5–8 Actually, as with drugs, it is probable that the VCD would work regardless of the type of impotence, unless the extent of any underlying pathology seriously disorganized the hemodynamics of erection. However, older subjects (especially if they have been impotent for many years) are unlikely to respond as fully as younger persons. Strong erections induced with a VCD (or IC drugs) have not always been synonymous with potency. Of patients clearly able to, up to 20% have not engaged in coitus, presumably for a number of reasons, including a low level of libido (neither IC drugs or VCDs increase sex drive), a poor relationship and/or limited motivation. A further 25% of initially satisfied users are likely to lose interest and abandon either or both the approaches within 1 to 2 years. Possibly the greatest appeal of VCDs (and IC drugs) is their inexpensiveness and the fact that they can be administered and monitored by any interested practitioner without special training. They are not panaceas and will probably have limited overall application. Nevertheless, they may be effective and useful in older patients with either organic or psychosocial impotence (especially those contemplating a penile prosthesis) who fail to benefit from traditional sex therapy and who are motivated for treatment. Further experience with a VCD may generate important information as to how a subject may cope psychologically, both with the restoration of potency, and an artificial aid. Because the VCD is noninvasive and without serious side effects, an individual who had difficulties with this would probably have significantly greater trouble with a surgical implant.