Chapter 9

As Old as You Feel: The Life Story of the Penis

“Is it not strange that desire should so many years outlive performance?” Shakespeare eloquently and perceptively once noted.[1] It might seem strange to men whose penis power appears to diminish with age, but it is certainly not strange to a urologist. Of all the circumstances that affect the functioning of a penis, the most predictable is the normal, inevitable process of aging.

By far, the most frequent complaint I hear is a variation on the following: “Something’s wrong, Doc. I am not the man I used to be.” What men usually mean when they say that is that they do not have the same level of sexual desire they used to have, it takes longer to get an erection, it takes longer to ejaculate, it takes longer to get aroused again after they make love, and their erections are not as firm, or some of the above or all of the above. These are all predictable changes that occur as men get older. They happen at different times to different men, but they happen to every man who lives long enough.

Problems arise with either of two responses to the aging process: (1) the patient does not realize that such changes are normal, so he concludes that he has a medical or psychological problem; or (2) he does know that these developments are typical and concludes that he is hopelessly over the hill. Either conclusion is erroneous and detrimental to a man’s overall happiness and to his penis health in particular.

A typical example of the first kind of man is a colleague of mine. A radiologist approaching his fiftieth birthday, he had always been a man of superpotency and excellent general fitness. Noticing that he was getting cramps in his legs while running, he saw an internist. The diagnosis was claudication, a condition characterized by cramping of the leg muscles while exercising. This is caused by diminished blood flow. Claudication is usually the result of arteriosclerotic plaque blocking the arteries supplying blood to the legs. The radiologist concluded that if the blood flow in his legs had become impeded, the same might also be true of the blood supply to his penis. This was the explanation for which my colleague had been searching. He had been alarmed for some time by a decline in his penis power. His ego had prevented him from saying anything to me in the past, but now that he was sure it was a medical problem, he opened up. He had his condition evaluated by a vascular surgeon and then came to me for treatment.

After a complete uro-vascular profile, I was able to say without reservation that the blood flow to his penis was nearly as good as it was when he was thirty. I suggested that perhaps a little help from vasoactive pills (e.g., Viagra, Levitra, Cialis) would be the answer. It turned out his penis power was still at a very high level, but his erections were not as firm as they used to be. That was the problem. When he compared the firmness of his erection to what it was five or ten years earlier, he was clearly losing ground. I asked him, “Do you run as far as you did at twenty-five? Can you jump as high? Can you lift as much weight? Can you do as many push-ups? Can you dance until dawn? You do not expect to do those things at your age. You know what happens to our bodies as we age. That is why athletes retire in their thirties. How, then, do you expect your penis to be as firm at age fifty as it was at age twenty?”

The other response to aging is typified by the countless men who resign themselves to a sexless life. They are often worn out, ailing, cynical, and prone to complaining about life in general. Some enter retirement and lose their enthusiasm and joy for living. Many men experience a slight loss of memory or hearing as they age. They begin to interpret changes in their sexuality as a sign of impending death. They put their penises out to pasture without even a gold watch or a ceremony. What a sad waste of penis power!

The key point to remember is this: as you age, you do not lose penis power, and your penis performance does not become inferior. It simply changes. It becomes different. Unless you have a legitimate medical disorder that interferes with your penis functioning, you can be as superpotent at eighty as you were at twenty. It is essential to understand the changes that come about with aging, accept them gracefully, adjust your attitude, and make the most of what you have. It is all relative, and it is all in your head—your big head that is.

Penis Passages

To understand what happens to the penis as men age, we must first examine the ways in which the penis evolves from birth through adulthood.

From birth until puberty, the penis is basically a conduit for urine. The mechanism of erection, however, is present even before birth. All male children, including infants, get erections. They are involuntary and not associated with anything sexual. These childhood erections occur due to nerve stimulation and can be caused by a full bladder or rubbing the penis with a towel after bathing.

Then comes puberty. Peculiar things start happening. The testicles have developed to the point where they produce enough circulating testosterone to alter the size and appearance of certain body parts. At this stage, a boy develops secondary sexual characteristics, including facial, underarm, and pubic hair, a deeper voice, adult-size genitalia, and the ability to ejaculate. Suddenly, the penis is a wonderful novelty! Adolescents cannot play with theirs enough. Simply looking at a sexy picture or a girl’s legs can stimulate the young penis to a full erection. Teens realize they can masturbate and inevitably discover that it can be even nicer with a partner.

Typically, when a boy reaches his late teens, he becomes sexually obsessed. His level of desire, the ease with which he becomes aroused, and his capacity for frequent sex are astounding. Dominated by hormones, physically fit, and not yet burdened by adult responsibilities, the teenage male is a walking erection, capable of getting one at any time with little or no provocation and ejaculating five or six times a day! At no time does the penis rule the brain more than it does in adolescence. I am reminded of the time a professor of mine brought down the house with a cogent observation about young men in college. Princeton was not yet coed when I was an undergraduate, so the auditorium was filled with a few hundred male freshmen in a philosophy survey course. The professor looked over the students and said, “All of you guys out there with such brilliant minds have this piece of meat hanging between your legs. These days, your whole life is fixed on that piece of beef. It’s all you think about, day and night. If there were any way to channel the mental energy focused on your collective dicks into a more productive intellectual plane, I might find a Nobel laureate out there, and surely most of you would go through college Phi Beta Kappa and summa cum laude while saving a hell of a lot of energy in the process!” The room roared with laughter, and the professor reveled in his accurate depiction of the power of the penis on the mind of an adolescent male.

The Early Years

The penis problems that I treat in patients in their late teens and early twenties are typically those associated with hypersensitivity. The young man who is unsure of himself and is worried about whether he is as normal or as virile as his friends might lose his perpetual erection at precisely the wrong moment because of sheer nervousness. More typical is the problem of premature ejaculation. As discussed in chapter 3, the adolescent penis is extremely sensitive, the volume of semen produced is higher than at any other stage of life, and the young man usually has not had enough experience to develop self-control. He might ejaculate before penetration or immediately thereafter. This could be embarrassing enough to make a young man shy away from sex permanently. If only the lad knew how typical this was!

The solution for most young men is simply to have more frequent ejaculations. (In this age of AIDS, I must add a cautionary note: frequent sex should not be regarded as synonymous with indiscriminate sex.) For men in their late teens and early twenties, the refractory period can be as short as a few minutes. If you ejaculated prematurely the first time, the next time you will last longer simply because there is less fluid in your seminal vesicles and less physiological urgency to release it. It requires a higher level of stimulation over a longer period of time to get through the excitatory phase to when the reflex of ejaculation occurs. I’ll explain more about premature ejaculation later.

In spite of these facts, there is a surprisingly large number of men with penis weakness in their early to late twenties. It almost never stems from something physical, even though, medically speaking, the “peak” of sexuality might have been passed at age nineteen or twenty. It seems to have more to do with the stage of life they have now entered. The young men in this group are usually out of school and no longer in a safe and predictable environment where their stature revolves around popularity issues. They are no longer protected by their parents. They are suddenly dealing with the harsher realities of life and making “grown-up” decisions. The “big man on campus” is now the “little man” in the office. The star student now has to pass tests that are not on paper and are not multiple choice. The girls he picked up in classrooms and fraternity houses are now young women with mature needs and demands of their own. The young man may find himself in a real relationship for the first time, along with the complexity and confusion that comes with it. For the first time, he is working long, hard hours. He usually feels exhausted by Friday. Work pressures and strain are impinging upon him. These negative forces are not easily brushed aside.

All of this often leads to a high level of stress. For someone without the skills, seasoning, or maturity to deal with it, the result can be devastating. Most young men have not yet developed the ability to compartmentalize their lives. Such pressures can often cause a young man to question his masculine identity. A serious case of self-doubt can occur and inevitably lead to unwanted penis consequences.

Is It Ageless?

Then come other changes. These changes evolve from the peak period of sexuality until your penis is laid to rest with your other organs at life’s end. Interestingly, these changes will not be seen in the penis itself. Agelessness is one of the most remarkable aspects of the penis, and yet another paradox. The penis undergoes virtually no change in size or appearance as you age. While your other organs degenerate, your skin wrinkles, your waistline expands, your hair gets gray, and your scalp starts to show through, your aging penis continues to look nearly the same as it always did. If you were to compare an unaltered photograph of a twenty-year-old erect penis side by side with an eighty-year old erect penis, you would not be able to tell the difference! The same is more or less true of flaccid penises, although the trained eye of a urologist might discern a subtle difference. In the elderly penis, there is some relaxation of the suspensory ligaments (located just under the pubic bone), which gives the impression that the penis has lengthened. This is more illusory than real; the penis is not really longer, it is just drooping a bit. Conversely, there is no shrinkage of the penis with age, as many men fear. Remember, the length and width of the erect penis are dictated by the size of the corpora cavernosa, the tubular structures that fill with blood in the erect state. That does not change once a man reaches maturity.

What does change with age is how the penis behaves. The first thing older men notice is that it takes longer to get an erection. This might start happening to men during their twenties. It might happen so gradually that it is not even noticed until they approach middle age. Much depends on the kinds of relationships they have and the frequency of their sexual activity. At some point, men discover that it takes more stimulation to get them hard. Once your testosterone levels diminish with age, fantasies are no longer enough; the mere sight of a sexy body might not do it, nor even heated foreplay. It might require a little more direct stimulation from your partner. As I previously noted, many older men can only get an erection from the vacuum effect of oral sex and the psychological aspects associated with that sexual act.

As you age, you might also notice that your erections are not always as rigid as a steel rod like they were during your teenage years. Sometimes they are only half-hard or semirigid until added stimulation hopefully brings them to full strength. This, too, is normal, but men often greet this phenomenon with panic, recalling the days when they seemed to spend half of their time concealing their erections.

The same is true of the refractory period. It is a well-documented urologic fact that the amount of time it takes to recover after an ejaculation increases in proportion to a man’s age and the volume of the ejaculate decreases. When a man reaches his fifties and sixties, the refractory period might be as long as twenty-four hours, even with direct stimulation. At age eighty, it might be one week. Men also notice that the ejaculation itself feels less and less explosive as they age; the semen leaks out rather than being forcefully expelled. Orgasms might also feel less intense. All of this is a normal part of the aging process. You should anticipate these changes and greet them without bitterness or alarm.

The good news is that with age comes increased experience, wisdom, and seasoning, which should be a huge boon to your sex life. There is an old story that illustrates this fact with a bit of humor. Two bulls, an old bull and a really young bull, are roaming the plains of Wyoming. They come upon a ridge overlooking a valley filled with thirty grazing cows, and the young bull jumps up and down with excitement, shouting, “Let’s run down this hill as fast as we can and screw us a few cows!” The old bull, surveying the situation, turns ever so calmly to his young companion and says, “Son, how about we mosey on down there real slow and screw them all!”

The point of this story is that as you age, your body may not be as flexible as it once was, your sex drive may diminish, and your erections may not be as firm, but your wisdom and sexual insight can be used to your advantage. Do not panic if it takes a little longer to get erect. On the contrary, you and your partner can enjoy the extra foreplay required to get you ready. Do not feel let down if you cannot go at it a second or third time without a long rest—this does not signify a decline in your manhood. Focus your attention instead on getting the absolute most out of the intercourse you can handle. Do not be let down if your ejaculations are not as volcanic as they once were—you can still enjoy the pleasure of orgasm well into old age.

Sex does not get less enjoyable with age or become in any way inferior. It just becomes different. Sex can be better than ever if you have the right attitude. Not only do you naturally acquire greater ejaculatory control, but if you have been paying attention over the years, you should also have learned a great deal about women in general, and your partner in particular. You should have learned tricks for arousing and satisfying the person with whom you share your bed, and vice versa.

One thing you may have to do as you age, especially when you reach your sixties and seventies, is adjust your style of lovemaking. Your penis might look as young as ever, but the rest of you has aged. You might have more control over when you ejaculate, but your arms might not be strong enough to support you for as long as they used to do. The muscles in your back and legs might tire quickly, and your joints and ligaments might not be as flexible. This may mean you have to rest or change positions more often. You might have to try different positions entirely.

The fact that physical fitness is an important aspect of maintaining sexual strength should encourage you to maintain a healthy lifestyle. You should make it a priority now to improve your overall health and fitness with a healthy diet and a vigorous exercise regimen, before the effects of aging begin to ravage your body. If you keep a positive attitude, you will find all of this a challenge, not a burden.

Another change occurs with age, and this one should be viewed as a bonus: it takes longer to reach orgasm. As the old joke from the old guy goes, “It takes all night to do what I used to do all night long.” But this is not a problem, especially if you found it difficult to control your ejaculations in the past. Young men who were quick on the trigger find their sex lives far more satisfying when they reach the age when delaying orgasm is no longer a chore but a natural process. If your partner is a woman, she may even get more pleasure because it is usually easier to bring a woman to orgasm with prolonged intercourse than with quick encounters. The more satisfied your partner is, the more aroused you will be.

For some men, the problem might be that it takes too long to ejaculate in general, and not just as they age. This is usually associated with a reduced level of sensitivity in the penis or a habitual mindset that views prolonged sex as the only way to achieve orgasm, or both. Because some partners who are otherwise willing may find prolonged sex irritating, painful, or unpleasant, I recommend prolonging foreplay, trying new positions, and otherwise addressing whatever issues may be causing the problem. Some men believe they have to perform a sexual marathon to please their partners. This belief can be problematic, especially in situations where men assume that what they want for themselves is compatible with their partners’ needs. Regardless of the scenario, it is crucial for men to make the appropriate adjustments to accommodate their partners’ comfort level. Communication, awareness, and consideration are the best triad to navigate the intricate workings of a sexual relationship, especially as you age.

When the Going Gets Tough: Male Menopause and TRT

Getting old is not for wimps. It is an undeniable fact that as we age, we can no longer run as fast, jump as high, or dance all night long the way we used to do. Similar to what happens to women during menopause, for men over forty, testosterone levels start to fall at an average of about 1 percent per year. As indestructible teenagers, it was testosterone that helped build our muscles and develop strong bones. As young men, record-setting levels of testosterone made us heroes on the gridiron on a sunny, Saturday afternoon, boosted our energy levels to allow “all-nighters” with ease, and propelled our foolish actions with the false belief that our youthful bodies could scale an unattainable mountaintop or perhaps even leap from a helicopter without a parachute and land on our toes with the grace of a ballet dancer.

As urologists learn more about the role of testosterone in the physical and mental development of young men in their prime, we are also studying the role of testosterone in the aging body. With this in mind, testosterone replacement therapy (TRT) has been promoted in the print media and television, and especially over the Internet as the solution to the male equivalent of female menopause (in men, it is known as andropause). TRT brings with it the promise that it will improve a man’s libido, increase muscle mass, eliminate cognitive deficiencies, elevate mood, and bolster bone density.

Progressive testosterone (androgen) deficiency in aging men has led to a syndrome known as hypogonadism, which can manifest in osteoporosis (loss of bone density), decreased libido, erectile dysfunction, and mood changes (i.e., the “grumpy old man syndrome”). In addition, hypogonadism causes muscles to become flabby and decrease in size, leaving men with the dreaded middle-age paunch. Hypogonadism has become widely recognized over the past ten years. As a result, physicians have increased the number of testosterone replacement prescriptions at an enormous rate. Pharmaceutical statistics indicate a 500 percent increase in the use of testosterone products in the elderly and middle-aged population, promoting the hopes of turning potbellies into lean six-packs, fragile bones into pillars of strength, and grumpy old men into enthusiastic Lotharios.

Who Needs Testosterone Replacement?

In order for a physician to determine if a patient needs testosterone replacement therapy (TRT), blood levels of testosterone must be assessed. Some important numbers should be kept in mind when measuring serum testosterone: the accepted low limit for normal adult men is a testosterone level of at least 200ng/dl (nanograms per deciliter). If a man’s serum testosterone is below 200ng/dl, TRT is recommended. If a man’s serum testosterone level falls between 200 and 400ng/dl, the risk-to-benefit ratio of TRT and its attendant hazards, which I will discuss below, must be considered. This range of testosterone level is considered a grey zone for TRT. Therefore, all of the potential risks of TRT must be discussed between the patient and his doctor. For serum testosterone levels of greater than 400ng/dl, not only is there no benefit to TRT, but there is also considerable risk involved. Men who are experiencing some of the symptoms of andropause should consult a physician, have their serum testosterone checked, and determine how best to proceed with treatment, if any.

Good News, but at a Price

No discussion of TRT would be complete unless we weighed the risks against the benefits. First, the long-term effects of TRT are not well defined. The main areas of concern for me are cardiovascular and prostate problems, both of which are commonly associated in men with diminished testosterone levels. Cardiologists have noted that the increased incidence of coronary artery disease in men, compared with women, may be testosterone-dependent. It has been found that men receiving long-term TRT have significant changes in their lipid profiles. These changes directly affect cardiovascular health. Unfortunately, TRT lowers the beneficial cholesterol (high density lipids, or HDL) widely recognized for its role in protecting against coronary artery disease. This is bad. The good news is that TRT also lowers the bad cholesterol (low density lipids, or LDL) responsible for blocking coronary arteries. It is encouraging that these effects on the lipid profile may be minimal when TRT maintains a serum testosterone level below 400ng/dl. However, the cardiac risks increase dramatically when TRT is taken to abusive or supra-physiological levels above 500ng/dl.

Another effect of TRT is increased production of red blood cells. This increase causes a hypercoagulation state of the blood, causing a thickening that may increase the potential for a stroke or heart attack. This is especially true in smokers, who already have an increased circulating red blood cell volume. Therefore, I do not recommend TRT that raises serum testosterone above 400ng/dl. Having a healthy heart and healthy arteries should not be compromised by the desire to get a slender waistline or bodybuilder muscles.

If you start TRT, do not exceed the recommended dosage in an attempt to radically change your physical appearance. To the aging man who longs for that youthful body that is beginning to disappear, my advice is to modify your diet, maintain a healthy exercise routine, and accept the realities of aging—a reality that sometimes brings with it a little paunch.

The second most important issue surrounding the risks of TRT is understanding its impact on prostate disease. It is well known that TRT does not induce the development of prostate cancer. What it can do, however, is cause rapid and potentially catastrophic growth of an unrecognized prostate cancer. There is no evidence that TRT can create prostate cancers. However, if there is even a tiny focus of cancerous cells in an otherwise benign prostate, TRT can encourage these cells to grow explosively. This can potentially become life-threatening. In my clinical experience, the incidence of prostate cancer in patients who have been on TRT for at least six months is no more than the rate of prostate cancer among men not taking testosterone. The take-home message here is if a man is receiving TRT, his doctor should be meticulously monitoring his prostate health with a periodic digital rectal examination (DRE), cancer screening blood tests (i.e., the PSA test), and prostatic ultrasonography.

With the overwhelming media blitz promoting treatment for male andropause, my patients are asking if TRT is safe and if I recommend it. In my judgment, it is safe to use TRT, and it is clearly beneficial in symptomatic men with a serum testosterone level of less than 200ng/dl. In men whose serum testosterone is greater than 400ng/dl, it is unacceptable. Ultimately, testosterone replacement therapy remains a calculated risk for men over forty, and unfortunately for some men, youthful fantasies must take a back seat to the realities of medical science.

If TRT is suitable for you as a patient, then there are some choices to be made. Unfortunately, all oral preparations of testosterone have been abandoned in the United States because of severe liver toxicity. An acceptable alternative for TRT is intramuscular injection. This has considerable appeal because it is relatively inexpensive. The downside is that dosing is intermittent, which means that the highest levels of serum testosterone are achieved shortly after the injection. Toward the end of the cycle, which usually lasts two to three weeks, the blood level of serum testosterone has diminished to pretreatment levels. Therefore, the effect of the circulating testosterone is variable with high peaks and deep valleys. There are implantable testosterone pellets that are also available. These have the advantage of producing a more stable level of serum testosterone. This treatment modality is expensive and cumbersome, and complications can include unanticipated pellet extrusion, which is uncomfortable.

Over the past several years, an exciting new treatment modality for TRT known as transdermal application has been developed. Transdermal preparations allow the testosterone to be applied directly to the skin with a patch or a gel. This allows absorption to occur through the skin and into the bloodstream, resulting in a normal, steady, and effective level of circulating serum testosterone over a twenty-four-hour period. The transdermal patches are less desirable than the gel. The patches often cause skin irritation, known as contact dermatitis. Transdermal gel, either Testim 1 percent or Androgel, is applied on a non-hair-bearing surface. Testosterone gels are relatively expensive when compared to the cost per month for injectable testosterone. If you need testosterone replacement therapy, your best choice is to find a treatment modality that suits both your physical and financial needs. The results of TRT for symptomatic men are quite remarkable and will improve many of the physical effects associated with the toughest part of life—getting old.

Young at Heart, Young in Person

I cannot reiterate this point enough: attitude is the key to penis longevity. My superpotent patients tell me that sex gives them as much joy at seventy as it did at twenty. Some say it is even better! From my clinical experience, I have concluded that equal pleasure can be obtained from occasional, prolonged intercourse with one orgasm as with frequent, rapid intercourse with multiple orgasms.

Many men give up their sex lives as soon as they start identifying themselves as “old,” especially once they retire. The idea that retirement equals nirvana is an unfortunate myth perpetrated in our modern culture. I have observed in my practice that retirement can lead to inertia, boredom, and stagnation. Many of my older patients, even those who are wealthy, choose not to retire. They may cut back their hours and delegate a lot of responsibility to others, but they remain active, both in work and in play. These individuals tend to be my healthiest, most superpotent patients. They live longer, and the quality of their lives seems better than those who stop challenging themselves and throw in the towel for retirement. Do not voluntarily retire your penis unless you are forced to by circumstances beyond your control, such as a serious illness.

Until recently, our society’s image of aging usually excluded sex. It had been considered unseemly for older people to talk about it, much less do it. I know elderly people who have to sneak around to have sex just as they did when they were teenagers because they know it will be frowned upon by their peers and especially by their own children. Other older people stop having sex altogether because they buy into the notion that they are supposed to give up sex. They suppress their sexuality because it somehow seems inappropriate to express it.

It is my hope that the generation I now see entering their senior years challenges all of that. They deserve active, healthy sex lives as long as they remain physically fit. It will not harm them unless they try to do things their muscles and joints are too weak to manage or they overextend themselves to the point of exhaustion. Do not expect to do at fifty what you could do at forty, or do at sixty what you could do at fifty, and so on. Adjust your sexual activities as your body changes, just as you adjust other activities. Look upon the adjustment as both a new challenge and a new opportunity. As you age, learn to use your mind and imagination to make up in creativity what you may lack in physical strength.

As long as you are able to breathe, move your extremities, maintain relative control over your bodily functions, remain alert enough to identify the date and day of the week, and sustain a positive mental outlook, you can continue to exercise your penis power indefinitely. You can help stay superpotent as you age by maintaining good overall health habits: exercising regularly; minimizing your consumption of fat and cholesterol; controlling your weight; refraining from smoking, excessive drinking, and drugs; watching your blood pressure; and seeing your physician regularly. If you stay physically fit and mentally alert, you can remain sexually active as long as you have the urge.

Most importantly, do not think old! Your body may produce less testosterone; your blood vessels may become partially obstructed and diminish blood flow to the penis; and your muscles and joints may begin to deteriorate. But if your mind is still strong, your penis can be strong, too. The key is not to lament what you have lost. Be grateful for what you still have, and make the most of it. Age is not a deterrent to a superpotent man. Rather, it is a challenge and an opportunity. Think of yourself as a singer whose voice is not as powerful as it once was, but who more than makes up for it with phrasing, feeling, and subtlety. Think of yourself as an athlete or dancer whose legs are no longer as strong as oaks but who performs with added grace shaped by the wisdom that comes with experience. If you keep your enthusiasm, you can compensate for, or even delay, the effects of aging.

If you have penis power, you are young no matter what your age may be. The strenuous use of your penis will sharpen your mind, exalt your soul, and keep you feeling vigorous. In short, you do not stop having sex because you get old, you get old because you stop having sex!

In many ways, your later years should be the golden years for your sexuality. You do not have to get up and go to the office in the morning, you do not have to worry as much about kids and bills, you have less daily stress and fewer pressures, you have more privacy, you have more time, and you can afford the luxury of patience. This is an opportunity for a superpotent man to make the most of his penis power.

Andropause versus Menopause

It is also important to acknowledge that as long-term couples age, significant changes occur in both partners. As women experience menopause, their sexuality goes through extreme changes. For the most part, postmenopausal women have a decreased sex drive and are not as interested in sex as they may have been in the past. This is due largely to the marked decrease in estrogen (which is analogous to testosterone) that accompanies menopause, as well as the psychological effects of an aging body (i.e., loss of hair, changes in physical appearance, and often extreme emotional fluctuations). Many women become depressed during menopause. A caring partner must go the extra mile to be sensitive to these changes. Compassion and patience must abound, both inside and outside of the bedroom.

In many aging couples, the lack of vaginal lubrication can become a major obstacle for sex. When estrogen levels start to fall, it becomes increasingly difficult for the vagina to lubricate itself. Topical estrogen or the use of oils can help in maintaining vaginal lubrication. A variety of lubricants can be used effectively and safely. Postmenopausal women have a far greater disinterest in sex than men experiencing andropause. For this reason, the superpotent man must adjust his expectations and learn how to work around the effects of aging on his partner’s body. Talking candidly to your partner about these changes is the best way to find a solution for maintaining a healthy sex life. Above all, do not turn your back on your lifelong partner for a younger, more responsive lover. Beware of the “hard dick syndrome”: a young, sexy lover might make you feel like a stud, but you may realize very quickly that sacrificing the friendship, intimacy, and bond of a long-term relationship might not be worth the quick fix of a young lover.

Sex is not only safe for older couples, it is also good for them. It maintains overall physical strength, cardiovascular health, and most of all, it keeps them invigorated. Your penis is there to serve you from puberty to old age. Do not give up on your penis, and it will not give up on you.

Penis Posterity

One good reason to be optimistic about the longevity of your penis power is that medical science is capable of helping you, even if aging has reduced the capacity of your body. We know the single most common cause of erectile dysfunction with aging is arteriosclerosis, the abnormal thickening and hardening of the arterial walls. This can restrict the blood flow to the penis and keep it from getting firm enough to penetrate. If a patient with arteriosclerosis is motivated, there are the many treatments we have discussed that can help him, which include prosthetic implants, vacuum erection devices (VEDs), self-injectable vasoactive drugs such as papaverine and prostaglandin-E, and the oral agents (Viagra, Cialis, Levitra). Certain drugs used for lowering cholesterol can also be helpful.

With respect to the use of prosthetic devices and injectable medications, I want to again make an important distinction between the type of patients for whom I do and do not recommend such treatments. A typically acceptable candidate is the man who is suffering from the “leisure world syndrome.” He is often a widower in his late sixties or seventies. He starts to meet older women in a social context, and he begins to date. To his surprise, these women expect a level of sexual activity that he did not anticipate. He is not necessarily able to handle the challenge. This type of patient was usually not very sexually active in the latter years of his marriage. This was perhaps due to his wife’s illness, his own reduced capacity due to impaired blood flow, or perhaps it was simply due to the diminished desire that accompanies long marriages. Now, for the first time in years, when he is called upon to perform, he wants to satisfy his new companion, but he is nervous or embarrassed. He feels like he is less of a man.

If such a patient is in otherwise good physical condition, I aggressively offer solutions and encourage him to take advantage of them. This kind of patient is a legitimate candidate for a prosthetic implant or vasoactive injections, but generally only if he has not responded well to the oral medications (i.e., Viagra, Cialis, Levitra).

On the other end of the spectrum is an aging man who has been married for many years to the same woman. The couple has had a fulfilling life together and remain very much in love, even though their sex life has diminished, perhaps to the point of total inactivity. When they do attempt to have sex, the man finds he is incapable of getting an erection. In a burst of forgotten youth, he decides he wants his old sex life back again and comes to me for help. If I feel he is seeking treatment in the vain hope that it will restore his youthful vigor and virility, I do not encourage implants or vasoactive injections. If the marriage has already adjusted to the absence of sex, these aggressive treatments are not advised. I have found that, once the novelty wears off, this type of patient usually discontinues using the devices. Many a wife has told me that her husband used the prosthesis or self-injection a few times and then stopped. Each case has to be evaluated on an individual basis, preferably with the partner involved in the decision. Treatment has done much good for some marriages of fifty years and longer.

Sex in the New Millennium

I would like to close this chapter on aging with a prediction. Based on my clinical experience and my understanding of current research, I am convinced that the future bodes well for the sex lives of people now entering their senior years and even better for those now middle-aged. I base this prediction on the burgeoning cultural view that the elderly can be active and fulfilled, even when it comes to sex. This is in addition to the amazing progress that has been made in extending the capacities of other bodily functions. The upper limits of what the body can do have been continuously broadened. In sports, what were once considered insurmountable barriers, such as the four-minute mile and the seven-foot high jump, are all now accomplished routinely. The peak years of athletes have been dramatically extended through unique conditioning procedures, nutritional advances, and medical science. There is no reason why the years of active sexuality cannot be similarly extended. There is no reason why penis power cannot continue to grow in aging men.

In this new century, people will be sexually active into their nineties! For one thing, lifespan will continue to increase. Impressive medical advancements, healthier lifestyles, and new discoveries in the field of genetics will continue. This research holds the promise to prolong life through drugs and genetic engineering. I predict that the quality of life in old age will improve geometrically. The elderly are far more vital and far more dynamic than ever before. In addition, society’s attitude toward sex and the elderly is becoming more permissive. It will no doubt become far more acceptable to be sexually active into old age, a trend that will probably accelerate as the generation that came of age during the sexual revolution approaches seniority. For men who are young now, the golden years will truly provide the opportunity for the enjoyable, leisurely exercise of penis power, as long as they are willing to use it.