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CHAPTER 25: SEXUALITY AND SEXUAL CONCERNS

Overview

Sexuality in Relation to Coexisting Illness

Counseling

Female Sexuality and Women's Health Concerns

    Gynecologic Disorders

    Vaginal Bleeding

    Breast Cancer

    Cervical Cancer

    Uterine or Endometrial Cancer

    Ovarian Cancer

Male Sexuality and Male Genital Disorders

    Impotence

    Prostate Problems


Overview

The normal changes in sexual behavior in older people are not well known, although surveys of sexual activity in older age groups suggest decreases in sexual interest and frequency of sexual intercourse in both men and women. Across all age ranges, women report having less sexual interest and lower rates of intercourse than their male peers. However, these findings must be interpreted cautiously because these surveys cannot distinguish between effects that are due to aging, social customs and values, and gender differences in marital status. There are more elderly widows than widowers, and husbands tend to be several years older than their wives. One study done over a six-year period suggests that men and women have stable patterns of sexual activity: No aging effect was seen.

    Diseases common in older people, such as arthritis, can have an important impact on sexuality. And any medical illness, especially if it engenders anxiety about sex or physical discomfort during sex, can be a barrier to healthy sexual enjoyment. Depression is another common condition that can affect sexual function. Because any sexual problem can be a symptom of a problem within the relationship, the quality of the partnership may also be an issue.

Sexuality in Relation to Coexisting Illness

Various forms of heart disease, including congestive heart failure, recent heart attacks, and angina pectoris, can interfere with sexual function. For example, ordinarily anxiety after a heart attack can cause a decrease in sexual desire and lead to impotence. However, elderly people who can tolerate mild physical exertion, such as walking up two flights of stairs, are capable of sexual intercourse. Even people who have had a recent heart attack can safely engage in routine sexual activity if they can tolerate mild or moderate activity. Clearly, it is important that these fears be alleviated and normal sexual activity encouraged if appropriate.

Arthritis

Sexual activity can also be reduced in people who have arthritis and suffer from pain, limited joint movement, and impaired mobility. (Chapter 17 contains more information on arthritis.) About half of the people who have osteoarthritis of the hip report that there is some interference with sexual activity. In addition to interventions that include adequate management of the underlying arthritis and counseling, specific advice on the selection of positions for sexual intercourse that reduce the stress on the affected joints is available.

Prostate Surgery

Few men who undergo surgical removal of all or part of the prostate, an operation known as transurethral resection of the prostate (TURP), experience difficulties with potency. Therefore, other causes need to be considered if impotence does occur. Before surgery, however, a counselor should discuss with the patient a common complication called retrograde ejaculation into the bladder. This complication, wherein the seminal fluid goes into the bladder rather than out the urethra with orgasm, occurs in as many as 90 percent of men who undergo TURP. Erectile capability and the potential for orgasm, however, are not impaired. Men who must have very extensive prostate surgery for cancer are often concerned that the surgery will result in incontinence or impotence. However, when a nerve-sparing procedure is used, the chance of this happening is usually less than 5 percent.

Breast Cancer

Although men have been known to have breast cancer, by far the greatest incidence is among women. In relation to sexuality, women who have had newly diagnosed breast cancer commonly develop fears of mutilation and anxiety about rejection by their sexual partners. According to one study, only 4 out of 60 women reported having any initial discussion with their physician or nurse about how mastectomy might affect their sexuality, yet more than half of these women expressed the desire for such a discussion. While one-half of these women resumed regular intercourse within one month after their discharge from the hospital, a third had not resumed sexual intercourse six months after hospitalization. In addition to adjusting psychologically to the mastectomy, problems may arise from various treatments and complications that may place physical limitations on sexual activity.

Other Malignancies

Although the emotional responses to cancer cannot be separated from the biomedical conditions that evoke them, terminally ill people may also have sexual needs or sexual problems. Some people may want to push others away, but more typically, people who are affected by malignancy want closeness and reassurance from their sexual partner.

Counseling

Counseling can be a part of any therapeutic plan for older people with sexual concerns. This counseling usually involves evaluating the person's expectations and knowledge of age-related changes in sexual activity. Active communication between the sexual partners is generally encouraged, and, for individuals who do not have an available sexual partner, masturbation is an option. In the nursing home setting, the staff and person's family need to be counseled to address negative feelings about sexual activity between residents. It may be possible for the physician to encourage changes in the nursing home that could facilitate privacy and also promote a better understanding of sexual activity in older people.

FEMALE SEXUALITY AND WOMEN'S HEALTH CONCERNS

The determinants of sexual behavior in older women are complex and interrelated, but we can begin by considering three aspects: motivation and desire, changes in the body's response, and social and cultural influences. The sources of sexual desire have been sought in both biologic and psychologic studies. Biologic research has focused mainly on hormones and transmitter substances between nerves, but the role of these substances remains difficult to determine. Estrogens, because of their beneficial effect on the sense of well-being and other menopausal symptoms, may indirectly have a positive effect on motivation and desire. Psychological investigations have measured sexual thoughts and fantasies as indirect ways to understand motivation and desire. In women who have had their ovaries removed surgically, their sexual fantasies and thoughts are increased by receiving male hormones, but their physical responsiveness and frequency of intercourse are not affected by the surgery.

    Sexual thoughts, urges, and desires decrease with increasing age, but again, it is not known how much of this can be attributed to aging per se. Regardless of the state of the woman's motivation, however, older men and women both report that the behavior of the male partner often determines the frequency of sexual activity.

    The body's responses to sexual arousal include increased genital blood flow, vaginal expansion, and lubrication of the lining. Because estrogen stimulation is necessary to maintain the lining of the vagina and the tissues around the urethra, it probably also has a role in providing the necessary reactions for the arousal response. Although arousal occurs in healthy women who have very low estrogen levels, the response is slower and less intense. The actual mechanism of arousal is not clearly understood, but it seems to be under the control of very rudimentary parts of the central nervous system.

    In older women, the low estrogen state that follows the menopause can lead to thinning of the external and internal genitalia. Pain with sexual activity is the hallmark of this altered anatomy, but reduced sexual function can also occur even if there is no discomfort. For example, women after the menopause may report that they feel less genital sensation, which may mean that they feel and respond less during the arousal phase of the sexual response cycle. Other changes include reduced secretions of the opening of the vagina, diminished vaginal lubrication, lessened vaginal expansion, and decreased swelling of the blood vessels in the lower vagina. These changes may not be perceived by the older women as discrete events or signs, but they may collectively reinforce her perception that she is less sexually responsive.

    Social and cultural influences on sexual behavior in older women include age-related assumptions about appropriate gender-specific behaviors and acceptable sexual practices. For example, one assumption might be that men should be the initiators of sexual activity. Another belief might be that there is only one correct position for intercourse or that intercourse is the only way of expressing intimacy. These assumptions may persist even in the face of physical or emotional changes that come with age. Clearly, a broader definition of acceptable activities, responses, or expressions should be considered to accommodate the older self and the older body.

Addressing Female Sexual Concerns

Women have not traditionally been comfortable volunteering information about sexual problems, but as the past several decades have brought dramatic shifts of self-perception and general awareness of gender issues, both women and physicians, whether male or female, are perhaps feeling less reticent about discussing sexual problems and what can be done to treat them. This is not to say all reticence is gone, however. In one gynecologic practice, for example, only 3 percent of the women patients came to see a physician specifically because of a sexual complaint, but when all the women patients were questioned directly, 15 percent revealed that they did, in fact, have such concerns. Some women may require a long-term relationship with their doctor before they will disclose any sexual complaints, and some doctors may find it difficult to raise the subject of sexual activity. One way to approach the subject is to raise questions or include comments about sexual function in matter-of-fact discussions of overall health status, raising more specific concerns if necessary.

    Your doctor's recommendations for treatment of various problems will depend upon the cause. A list of possible causes and treatments of sexual dysfunction in older women is shown in Table 40. Sexual counseling and educational strategies may be the most effective approach to resolving a sexual problem. Physicians have sometimes hesitated to offer such counsel because they felt it involved discussing a patient's intimate behavior and would offend their patients. Recent experience, however, suggests that people with problems are eager for advice or recommendations for solutions. For example, one interview conducted in an arthritis clinic found that 40 percent of the women expressed interest in hearing specific sexual advice from their physician. Encourage your doctor to share simple educational directives with you, as these are often all that is needed. For example, experimenting with various positions during intercourse to reduce discomfort, or considering alternative forms of intimacy such as hugging, caressing, and fondling can make a significant difference in sexual enjoyment for the older woman who has arthritic or other movement disorders.

Estrogen Therapy

While the overall relationship between estrogen supplementation and female sexual functioning is complicated and not well understood, some of the beneficial effects are clear. Estrogen reduces genital atrophy and can reduce the discomfort sometimes caused by sexual activity. It is likely that the improved genital tissue due to estrogen supplementation has a beneficial effect on arousal. Regardless of the precise mechanism, a relationship probably does exist between an improvement in the sense of overall well-being and mood and improvements in the desire and motivation of sexual functioning.

    Because of the limits of current information, women and their physicians should have an open discussion about the benefits and risks of estrogen supplementation, wherein both parties are able to express their concerns. Several routes of estrogen administration are available, each with specific advantages and disadvantages.

    For the older woman who is already taking estrogen but has a lowered interest in sex, there is no obvious solution. The question is whether androgens or male hormones could provide a little extra benefit. However, before considering the use of these compounds, there are many other contributing factors that must be reviewed. One should also note that while male hormones do increase sexual fantasies and urges in women, this may not automatically translate into an actual change in the frequency of sexual activity or in an increase in the body's responsiveness.

Table 40. Possible Causes and Treatments of Sexual Dysfunction in Elderly Women

FACTORS AFFECTING DIMINISHED SEXUAL FUNCTION

POSSIBLE CAUSES*

THERAPEUTIC STRATEGIES

Decreased motivation

Partner's decreased motivation/capability

Psychosocial evaluation

Genital dysfunction with secondary loss of interest

Medical evaluation

Perceived socially appropriate behavior for age and gender

Education and counseling

Primary alteration in sexual drive

Estrogen/androgen

Relationship dysfunction

Psychosocial evaluation

Depression

Counseling/antidepressants

Genital changes

Vaginal atrophy

Oral or vaginal estrogen Lubricants

Atrophy of the urethra (may contribute to incontinence during sexual activity)

Oral or vaginal estrogen

Changes in body response

Decreased arousal phase

Estrogen (to restore tissue integrity)

Decreased hormonal mediators

Estrogen

Behavioral limitations

Established patterns of male initiation

Education and counseling

Limited sexual script (range of acceptable sexual behaviors)

Explicit advice on sexual practices, with specific attention to limitations that may be operative

*More than one of these may be present.

†More than one modality may be required.

Gynecologic Disorders

A woman's reproduction system is affected by alterations in the pelvic structures and changes due to the menopause (see Figure 44). Other physical problems, such as arthritis of the hips, can make it uncomfortable for the woman to lie in the normal examination position.

    As women age, visual inspection of the external genitalia skin may reveal common changes: Usually, the pubic hair is quite thin; the vaginal opening may be smaller and the lining may be pale and thinned; or the vaginal vault may be shortened or narrowed. These changes may be due as much to vaginal disuse as to tissue atrophy caused by loss of estrogen. Women who have maintained sexual activities do not show these changes to the same extent as women who have not been sexually active for a long time. These changes can make obtaining a Pap smear or an endometrial sample very difficult.

    Pap smears should be obtained at least every three years until the age of 65. After that, there is little evidence for continuing them. However, older women who have not had regular Pap smears should have at least two tests, one year apart, before screening is stopped. Women who have had hysterectomies generally do not need further Pap smears.

Disorders of the External Genitalia

Disorders of the skin and labia increase in frequency with advancing age and can be caused by a number of conditions, including many benign skin growths and some malignancies. Approximately 3 to 5 percent of women with skin disorders have invasive cancer, and approximately 4 to 8 percent have premalignant conditions. Because of this, if you notice any changes in the area of the external genitalia, you should request a careful inspection by your physician who should biopsy any suspicious areas. Any enlargement of the Bartholin glands (located on either side of the vaginal opening) is considered to be caused by a malignancy until proven otherwise with negative biopsies.

    It is important that any abnormalities in the external genitalia be evaluated because they frequently occur with other medical problems (usually metabolic disorders) and because the symptoms can often be uncomfortable and disabling. Moreover, most conditions generally improve dramatically with appropriate treatment.

    Changes of the labia and skin may have pigmentation or may be white, depending upon local factors such as scratching and hygiene. As part of the evaluation, the physician may apply a small amount of a 1 or 2 percent acetic acid (purified vinegar) and then carefully inspect the area with a special magnifying glass or other instrument. This method offers the best chance for discovering abnormalities. The acetic acid causes suspicious areas to turn white. Biopsies are easily performed by using local anesthesia to numb the area and then removing a very small amount of tissue for testing.

    Benign infections of the external genitalia, such as contact dermatitis, allergic reactions, and fungal, yeast, or bacterial infections, can occur in women at any age. Because the skin in this area perspires more than skin elsewhere, increased moisture and irritation contribute to these conditions. Older women will have the same symptoms as those experienced by younger women: redness, itching, swelling, or pain. A physician will likely prescribe a course of genital hygiene and possibly some medication.

    Although cancer involving the external genitalia is rare, its incidence increases with age and peaks in people in their seventies. In the past, radical surgery with regional removal of lymph nodes was the treatment of choice for all invasive cancers involving the external genitalia. More recent studies have suggested that more conservative approaches may avoid the considerable changes in body image, sexual dysfunction, and prolonged recovery time associated with such radical surgery. Again, it must be stressed that biopsy must be done of every suspicious area of the external genitalia so that minimally invasive cancers can be treated early and with minimal surgical procedures to avoid or reduce disability.

    For some people with recurring or advanced cancer, combined radiation therapy and chemotherapy may be effective. This combination is also used for principal treatment in people who are medically unable to withstand surgery.

    Of all the gynecologic cancers that occur in women older than age 75, vaginal cancers constitute the smallest percentage (only 7 percent). Because the majority of women with cancer of the vagina have bleeding, any vaginal bleeding must be checked by an experienced physician. (See page 417 for more on vaginal bleeding.)

Treatment of the External Genitalia. An effective treatment for many skin and labial disorders is good hygiene and keeping the area clean and free from excessive moisture. Sometimes skin conditions are treated with corticosteroids, which unfortunately can cause atrophy of the skin if they are overused.

Disorders of the Vagina

Thinning, paleness, and loss of elasticity are some of the common changes seen in the vaginal lining of postmenopausal women. These changes significantly increase the overall chance of infection and irritation. Although the incidence of vaginal irritation is greater in younger women, the frequency of this problem may increase in older women because of changes that occur after menopause. The types of bacteria and fungi that cause vaginitis, however, are quite similar in younger and older women. The evaluation and management of the condition is essentially the same in both age groups.

Symptoms of Atrophic Vaginitis. Vaginal irritation caused by atrophy frequently produces symptoms of itching, burning, milky or creamy discharge, and discomfort when urinating or with sexual intercourse. Bleeding may also be an early symptom. Changes to the external genitalia become apparent only months or years after the first vaginal changes appear. The smaller labia shrink, and the vaginal opening may become narrow and rigid so that intercourse becomes impossible.

Treatment of Atrophic Vaginitis. While estrogens will usually resolve the symptoms of vaginal atrophy, several precautions must be exercised. Locally applied estrogen creams in the usual doses of 1 to 4 grams per day are readily absorbed through the vaginal lining with resulting effects all over the body. Lower doses of topical estrogens such as 0.5 gram every third day will provide significant relief from symptoms and produce fewer effects overall. However, even at these lower doses, many clinicians still recommend that other hormones such as progestins be used occasionally to protect the lining of the uterus against the effects of estrogen stimulation. Increased use of the vagina can also significantly improve atrophy.

Sagging Pelvic Structures

The pelvic structures are supported by a combination of muscles and ligaments. Injury during childbirth, complications of obesity, atrophy after the menopause, or strenuous activity may damage or weaken the supporting structures and cause the uterus to sag out of place. Some sagging, called prolapse (from the Latin, meaning "before the fall"), is classified according to its severity.

Prolapse of the Uterus

Prolapse of the uterus is termed "first-degree" if the cervix (the opening of the uterus) appears at the vaginal opening, "second-degree" if the cervix and half of the uterus protrude, and "third-degree" if the vaginal walls are turned completely inside out and the entire uterus is exposed.

Symptoms of Prolapse of the Uterus. Women with this condition may notice a sense of pelvic heaviness, a vaginal mass, back pain, urinary incontinence, or bleeding of the exposed organs.

Treatment of Prolapse of the Uterus. When the degree of relaxation is mild, intensive exercises may be beneficial to increase the muscle tone and support the base of the pelvis. Estrogens may also be helpful. However, surgery is usually necessary in instances of complete (third-degree) prolapse. The usual procedure is a hysterectomy. Other surgical repairs may be necessary if the bladder and rectum have also prolapsed.

    Use of a vaginal pessary, a device inserted into the vagina that helps to support the uterus, may be an effective treatment for women who are unable or unwilling to have surgery. There are pessaries in the shape of a rectangle, a ring, or a doughnut. Insertion and removal of a pessary are easier if it is inflatable.

Bladder and Rectal Prolapse

The sagging, or prolapse, of the bladder against the opening of the vagina is called a cystocele. This can accompany or even precede uterine prolapse. The symptoms involve a sense of vaginal fullness or a palpable mass protruding from the top of the vagina. This condition may also cause recurrent urinary tract infections, due to incomplete bladder emptying, or urinary incontinence. Ulcerations in the vaginal lining can occur as the tissues dry out; these ulcers may indicate that surgical repair is necessary to treat the cystocele.

    A rectocele is a bulging of the rectum up through the vaginal opening. A large rectocele may result in incomplete passage of bowel movements. With large rectoceles, surgery is the recommended treatment.

Vaginal Bleeding

About 20 percent of women who experience vaginal bleeding that occurs after the menopause have malignancies. The likelihood that malignancy will be the cause of bleeding increases with age; therefore, any episodes of bleeding after the menopause should be fully evaluated. Conditions that can cause this bleeding are shown in Table 41.

    Generally, an evaluation of the condition involves a thorough examination to check for visual evidence of the conditions listed in Table 41. Endometrial biopsy, Pap smear, and possibly additional studies are needed unless an obvious source of bleeding is discovered. Any abnormal-appearing areas are usually biopsied. Sometimes a progesterone challenge test is performed if the results of biopsies are unremarkable or no other cause for the bleeding has been found. In this test, the hormone progesterone is given for about two weeks. If bleeding occurs when this medication is stopped, this indicates an abnormality involving the lining of the uterus. Further medical evaluation is then required.

Table 41. Causes of Postmenopausal Vaginal Bleeding

  VULVAR AND VAGINAL

Ulceration
Malignancy

  CERVICAL
Irritation/infection
Malignant tumor
Polyp

  UTERINE
Abnormal cell growth in endometrium
Swelling of glands in endometrium; polyps in endometrium
Tumor in endometrium
Other malignant tumor (sarcoma, etc.)

  URINARY TRACT
Urethra (with irritation)
Bladder (infection, malignant tumor, polyp, stone)
Ureter (stone or malignant tumor)
Kidney (stone or malignant tumor)

  OTHER
Tubal or ovarian malignant tumor
Bleeding tendency
Hormonal cause (estrogen replacement, adrenal or ovarian tumor)

Opening in vaginal wall to bowel

Breast Cancer

Breast cancer is the most common malignancy in American women, and its incidence increases with age. The survival time is shorter in women whose cancer is diagnosed after age 75 compared with younger postmenopausal women. This difference in survival is due in part to socioeconomic and cultural factors, such as limited access to health care and the unwillingness of some physicians to submit older patients to aggressive testing and intensive therapy.

    Breast cancer screening by means of monthly self-examination, an annual examination, and mammography every one to two years is recommended for women over age 50. Although there is no reliable information on whether there should be an age limit to screening, it's also recommended that screening be discontinued at age 75. On average, breast cancer takes about ten years to grow to about the size of a large pea (1 centimeter, about 1/2 inch, in diameter). In older women, breast cancers are generally slower growing and less aggressive than they are in younger women.

    The outlook for women with breast cancer depends upon a number of factors including the stage or extent of the disease, the presence of hormone receptors for estrogen and other female hormones on the cancerous cells, the degree of cellular maturity (immature cells are more aggressive), the pace of the tumor's growth, and the extent of expression of a special gene called HER-2. The risk of recurrence of cancer in women who have surgical removal of breast tumors (partial or complete mastectomies) is predicted by the presence of cancer cells in the regional lymph nodes, usually under the arm. Even in women with no signs of cancer cells in these lymph nodes, the likelihood of recurrence increases if there is a lack of hormone receptors, if there are very immature cancer cells, or if there is a high degree of rapid cell growth. Approximately two-thirds of cancers in postmenopausal women contain hormone receptors, a finding that generally signifies a more favorable course.

Evaluation of Breast Cancer

In addition to the physical examination, the initial assessment of the severity and extent of breast cancer usually includes blood tests and a chest X ray to look for involvement of other organs such as the bones, liver, or lungs. If these procedures show no specific symptoms or abnormal test results, the value of more extensive investigations remains controversial.

Treatment of Breast Cancer

Surgery is the primary treatment for breast cancer. When the diameter of the primary tumor is 5 centimeters (about 2 inches) or less, removal of the tumor (lumpectomy) and the lymph glands under the arm, in combination with radiation treatment of the breast, is as effective as removal of the whole breast (mastectomy). A critical factor in deciding whether to perform a simple lumpectomy or a mastectomy is determining whether the breast tissue will allow an adequate surgical repair of the breast. An alternative to surgery for either women who have a short life expectancy due to other reasons or who have very small primary tumors may be treatment with a medication like tamoxifen.

    Tamoxifen is also used to delay the recurrence of breast cancer and prolong survival for many older women. While the optimal duration of this treatment has not been established, a minimum of two years' treatment is necessary. Some experts have recommended lifelong treatment. The value of chemotherapy that is more extensive than tamoxifen in postmenopausal women with breast cancer is controversial. Many experts recommend that all women with breast cancer over the age of 65 have hormonal manipulation as first-line treatment, regardless of their hormone receptor status, and that chemotherapy be reserved for women in whom hormonal treatment has failed. Hormonal manipulation as single therapy is ineffective for women with such life-threatening conditions as extensive spread of cancer to the lungs or the liver. In these situations the addition of aggressive chemotherapy is an option to induce a rapid resolution of the tumor.

    Tamoxifen is currently the most common form of hormone treatment. Although medications of the progesterone type are as effective, they are more toxic and therefore best reserved for patients in whom treatment with tamoxifen has failed. Commonly used chemotherapy regimens consist of a combination of medications including cyclophosphamide, methotrexate, and 5-fluorouracil.

Cervical Cancer

The overall incidence of cervical cancer that invades the surrounding tissues has decreased by approximately 80 percent, but it is increasing in older women. It is now clear that many subpopulations of elderly women, particularly those with limited access to continuing health care, were not adequately screened for this disease throughout their lives. Older women who have had normal Pap smears do not benefit from further testing. However, nearly half of women over age 65 have never had a Pap test at all and three-quarters have not had regular testing. Further screening of this group is important with two smears taken at least one year apart. If these smears are normal then no further screening is necessary.

    The primary therapy for limited cervical cancer is surgical removal of the tumor and some of the surrounding tissue. At present, the management of advanced disease with chemotherapy is experimental.

Uterine or Endometrial Cancer

The most common gynecologic cancer in older women, endometrial cancer, involves the uterine lining. Predisposing factors include obesity, never having children, a family history of multiple cancers, diseases of the ovary, and the prolonged use of postmenopausal estrogens without the use of progesterone. For most elderly women, vaginal bleeding is the most common initial symptom, and this often allows uterine cancer to be discovered early. Because screening asymptomatic women has not been shown to decrease mortality of endometrial cancer, routine endometrial biopsies are not recommended unless a woman takes estrogens with progesterone. Surgery is the only curative treatment, but approximately 30 percent of women with widespread disease will respond to various hormonal medications, such as progesterone therapy and to tamoxifen.

Ovarian Cancer

Although it is much less prevalent than cervical cancer or endometrial cancer, cancer of the ovary is the most common cause of death from a gynecologic cancer, and its incidence increases with age. Ovarian cancer does not usually produce symptoms until it has widely spread to other organs. This diagnosis, usually late in the course of the illness, accounts for its high death rate.

    The outlook of advanced ovarian cancer has been improved by the use of various combination chemotherapies. For advanced ovarian cancer, the optimum treatment consists of maximal surgical removal of the tumor followed by special courses of chemotherapy. The response rate obtained by this therapeutic strategy is better than 60 percent. The median survival period for this condition exceeds two years.

MALE SEXUALITY AND MALE GENITAL DISORDERS

Sexuality constitutes an integral part of the quality of life for older men. Older men usually notice, however, a distinct difference between their current level of sexual interest and that experienced during early adulthood. Not only is there less interest in the frequency of sexual contact but also the focus of sexual interaction may change from primarily physical to increasingly emotional. Nevertheless, even men who are over the age of 85 still have sexual interest, and intercourse remains the preferred form of physical sexual contact.

Impotence

Impotence, the most common sexual complaint in men, is the inability to maintain an adequate penile erection for successful sexual intercourse. Although information on erections and aging is incomplete, it appears that erection rigidity peaks in the late teens and then gradually declines throughout adult life. In the absence of disease, the older man's erections remain adequate for intercourse, but they require a greater amount of direct stimulation to be maintained. Some men may perceive this requirement for additional stimulation as a sign of impending failure, which it is not. When disorders involving the pelvic blood vessels and nerves are superimposed on these age-related changes in erections, inadequate rigidity for intercourse often results (see Figure 45).

    The male hormone, testosterone, is responsible for maintaining genital tissues as well as inducing sexual interest. While it appears to play a role in facilitating fantasy-induced erections, the role of testosterone in maintaining erections produced by local stimulation appears to be minimal.

How Erections Are Produced

The neurologic stimulation for erection can either be caused by fantasy or local stimulation. Specific parts of the brain and nervous system mediate these various responses. Direct genital stimulation produces impulses that travel to the lower part of the spinal cord and then return to the penis, traveling each way through specific nerves. Substances are released that cause relaxation of the blood vessels. An erection occurs through a dilation of the blood vessels that increases inflow to the penis. As this blood flow increases, the venous outflow is also restricted. The increasing blood flow with relatively reduced outflow results in increasing pressure within the penis and produces rigidity. Orgasmic release of chemical messengers allows for the outflow of blood, and the tissue of the penis deflates.

Evaluation of Impotence

Generally, when an older man who complains of impotence consults with his physician, the physician will need to determine whether an evaluation is needed. Most older men report a gradual increase in the amount of stimulation required to achieve an erection, and that both the rigidity and duration of erections decline with aging. If the physician concludes that an assessment is warranted, it generally includes a detailed medical interview and evaluation focusing on information that is shown in Table 42. Monitoring for erections that occur during sleep may help differentiate medical from psychological causes of impotence, although the validity of these observations in older men is not clear, and the results of any tests should be interpreted with extreme caution.

Table 42. Information to Be Obtained During an Evaluation for Impotence

  DEFINITION OF THE PROBLEM
Is the dysfunction really erectile failure?
Or is the dysfunction related to decreased sexual interest, orgasmic ability, mobility?

  PRIOR FUNCTIONING
Compare quality of best prior erections to that of current erections.

  ONSET
Acute onset suggests psychogenic cause or adverse drug reaction.
Chronic onset suggests an underlying disease.

  PROGRESSION
Intermittent progression suggests psychogenic cause.
Progressive progression suggests an underlying disease.
Establish duration of erectile dysfunction.

  ERECTIONS UPON AWAKENING
Rigid erections suggest psychogenic cause.
Nonrigid or absent erections suggest an underlying disease.

  ASSOCIATED MEDICAL/SOCIAL DISORDERS
Prescription or social drugs (e.g., cigarettes, alcohol).
Diabetes mellitus, neurologic disease, vascular disease, pelvic or abdominal surgery.

  Breast enlargement
suggests endocrine disorder.

  Poor circulation in the legs
suggest vascular disease.

  Penile size
--enlarged abdomen and small penis may hinder the effectiveness of a suction device.

  Neurologic disease in the pelvis or legs
suggests penile neuropathy.

  Testicular atrophy
suggests hypogonadism, alcoholism.

    The blood vessel supply to the penis can be assessed using ultrasound. Generally, the penile blood pressure is compared to the blood pressure in the arm. Blood tests are sometimes obtained to check for diabetes mellitus or low testosterone levels in the blood. Sometimes a very high level of the hormone prolactin can cause impotence even with normal testosterone levels. Because of this, physicians sometimes order a prolactin blood test if testosterone treatment is not effective. In most cases, the high prolactin level is due to the effect of medications or to kidney failure. A pituitary tumor can cause this condition.

Treatment of Impotence

As with most conditions, impotence is most likely to be successfully treated when therapy is based on the cause of the disorder. For example, the man whose impotence is related to drugs is unlikely to respond to sex therapy.

    The advantages and disadvantages of various treatments for impotence are shown in Table 43. Of these therapies, the least invasive is the penile orthotic device, which is also referred to as a vacuum device. There are two types. The first is a hollow cylinder in which the flaccid penis is placed. The cylinder is then attached to a pump that generates a negative pressure, thus pulling blood into the penis and surrounding tissues. An erectlike state is created and can be maintained by placing a constricting band around the base of the penis before removing the cylinder. This constricting band should not be left in place for more than 30 minutes because of decreased blood flow to the penis. This approach has few adverse effects, but it does require good hand coordination and men with very severe blood vessel disease may not be able to achieve adequate rigidity. The treatment is best suited for men with nervous system problems or problems in the veins. On the positive side, the device is effective, noninvasive, and reversible. It is certainly a procedure men with impotence should consider.

    The second type of vacuum device is condom-shaped and maintains rigidity during intercourse. It is connected to a small tube with which air is sucked out, thus creating a slight vacuum that helps draw the penis into the condom. The condom itself is relatively rigid so that the combined rigidity of the condom and the penis is usually adequate for penetration. This device can be helpful in impotence caused by virtually any problem, but it may be especially useful for men with penile curvature. However, its use is associated with decreased sensitivity, and the lack of aesthetic appeal makes it an undesirable therapy except for couples who are very supportive in their relationship.

Table 43. Treatment Options for Elderly Men with Impotence

TREATMENT

ADVANTAGES

DISADVANTAGES

Testosterone

Inexpensive Noninvasive

Rarely effective

Sex therapy

Noninvasive

Expensive
Time-consuming

Vacuum erection
devices

Noninvasive

Cumbersome
Not effective in presence of
severe vascular disease

Rigid condom
devices

Noninvasive
Effective regardless of cause

Decreases sensitivity
Lacks aesthetic appeal

Papaverine or
phentolamine

Erection looks normal

Cavernosal fibrosis (uncommon)
Requires injection

Prostaglandin E1

Erection looks normal

Burning sensation
Requires injection

Malleable prosthesis

No mechanical parts that might
malfunction

Permanent erection

Inflatable prosthesis

Erection looks normal

Often requires reoperation

Arterial bypass

Definitive therapy

Very invasive
High failure rate

Venous ligation

Definitive therapy

Very invasive
High failure rate

    Self-injection of the penis is the treatment receiving the most attention today. It involves the direct injection of vasoactive substances, blood vessel activators, which chemically bypass the usual nervous system pathways to produce an erection. Because this process mimics that of a normal erection, injection-induced erections are natural in appearance and function. The substances injected usually include papaverine, phentolamine, and prostaglandin E1. These are all effective agents for penile self-injection, but the person's response depends upon the cause of the impotence. For men with impotence caused by nervous system disease, there may be a hyperresponsiveness to these injections, while a person with very severe blood vessel disease or fibrosis may not be able to develop a completely firm erection. The self-injection technique represents a major advance to treating impotence but is associated with some short-term complications, such as prolonged erections, which need to be reversed if they last more than four hours. There are simple ways to do this under a physician's supervision. Studies have shown that prostaglandin E1 causes a slight burning sensation in the penis for some men. There are also indications that papaverine and phentolamine can occasionally cause penile scar tissue.

    Penile prostheses or implants are safe and effective but they should be reserved for individuals who have experienced failure with other treatments. The prostheses that are currently available include rigid, flexible, and multiple-component inflatable devices. The rigid devices have solid cylinders that are surgically implanted within the penis. Their major disadvantage is that they make the penis permanently firm. While the flexible prosthesis is similar, it can be bent for improved concealability. Both rigid and flexible prostheses can be inserted under local anesthesia. The inflatable prostheses have fluid-filled cylinders that are inserted within the penis and backed up by a pump placed near the scrotum and a reservoir placed in the abdomen. These control the movement of fluid. The pump controls the erection and requires manual skill to operate it, and mechanical problems frequently occur. The overall reliability of these devices is unknown.

    The type of prosthesis chosen depends upon the preferences of the person and his partner. Satisfaction after prosthesis implantation has been good in short-term studies, but well-designed longterm follow-up studies that measure satisfaction have not been completed. A few accounts suggest that the inflatable devices produce greater satisfaction than the other devices. Taken together, the surgical complications of these implants are relatively few, and their success rate is high enough that the implant option is reasonable for older men.

    While improving the blood supply of the penis through surgery to the arteries and veins has the potential for correcting the underlying causes of impotence, attempts to do this have met with only limited success. Such procedures have a very disappointing success rate of much less than 50 percent.

Prostate Problems

Prostate Enlargement

Benign prostatic hypertrophy (or BPH) is the gradual enlargement of the prostate gland. It is rarely identified in men under age 40, and its occurrence increases progressively with advancing age so that it is present in about 90 percent of 80-year-old men. A 50-year-old man has about a 20 to 25 percent chance of requiring surgery to reduce the size of the prostate gland. Development of BPH is believed to be caused by male hormones.

Symptoms of Prostate Enlargement. BPH usually begins to produce symptoms in men at about age 50. Because urine flows from the bladder through the prostate gland, prostate enlargement often begins to block the passage of urine. The common symptoms of BPH are caused by either obstruction or irritation. The most common obstructive symptoms are difficulty beginning to urinate, straining, decreased force and caliber of the urinary stream, dribbling after voiding, a sensation that the bladder has not emptied completely, and not fully emptying the bladder after urinating. A man with irritative symptoms might complain of frequent urinating, urinating at night, pain on urinating, and a sense of the urgent need to urinate. Men who complain of irritative symptoms may have a disease other than BPH, such as a urinary tract infection, bladder cancer, or the effects of neurological diseases on the bladder.

Evaluation of Prostate Enlargement. A rectal examination to feel the prostate gland does not reliably identify BPH or the possible obstruction caused by it. Therefore, if any of the symptoms listed above are present, the physician may recommend other studies, such as ultrasound (an examination of the bladder and prostate using sound waves), to obtain a clearer picture of the prostate size.

Treatment of Prostate Enlargement. Surgical removal of the obstructing tissue around the urethra is the usual treatment for BPH. It may be recommended if there is a change in kidney function, complete obstruction of the kidneys, recurrent urinary tract infections, or significant retention of urine in the bladder. In the absence of these indications, it is difficult to know whether surgery will help. Certainly, the severity of symptoms and the expected gains in the quality of life after surgery are important considerations. At times, urinary incontinence associated with a constant feeling that one needs to urinate suggests that surgery would very likely correct the problem. There are situations, however, in which the removal of obstructions may actually worsen incontinence.

    If surgical therapy is selected, the size of the prostate gland determines the type of surgical approach. For relatively small prostate glands, a simple incision (or cut) along the prostate can be performed. This incision made through the urethra is usually a shorter operation with less frequent postoperative bladder neck scarring compared with the actual removal of prostate tissue (transurethral resection). However, since the incisional approach does not remove any prostate tissue, it is more likely to miss early stages of prostate cancer. For prostate glands of moderate size, the standard procedure is to core out the center of the prostate in a transurethral resection. For a very large prostate gland, surgery using an abdominal incision or an incision between the scrotum and rectum may be performed. Sexual potency is generally preserved after prostate surgery, but a common complication is retrograde ejaculation, where the seminal fluid prompted by orgasm is propelled into the bladder rather than out of the urethra. Despite the backward movement of seminal fluid, the pleasure of sexual activity is not affected.

    A procedure involving balloon dilation of the prostate is not recommended since obstruction frequently recurs, and bleeding and incontinence frequently result.

    For men who do not undergo surgery, medical therapy may be helpful but not curative. For example, certain medicines may decrease the muscle tone of the prostate and may benefit up to 20 percent of men, even though medication does not reduce the size of the obstructing prostate. In addition, drugs that block the action of male hormones have also improved urinary function in some men. These medications are very expensive, and therapy must continue indefinitely for the benefits to be retained.

Prostate Infection

Infection of the prostate (prostatitis) can occur as either a sudden or a smoldering infection. Although sudden prostatitis does occasionally occur in older men, smoldering infection called chronic bacterial prostatitis (CBP) is more common. More important, CBP may contribute to concurrent urinary tract infection. While older men with CBP may have no symptoms at all, common complaints include mid- to low-back pain, urinary urgency, frequency, need to void at night, and discomfort between the scrotum and rectum. The condition requires careful evaluation by a physician. The treatment for CBP is generally antibiotics taken orally, for at least four weeks.

Prostate Cancer

Prostate cancer is the most common cancer among men over the age of 65, and its management is related to the extent of the disease. Prostate cancer has an extremely variable growth rate and many men live a long time without any treatment. A lab test called PSA, or prostate specific antigen, is often used to follow the progression of the disease, and it is sometimes used as a screening test.

    There is a lot of controversy about the treatment for prostate cancer; therefore, an older man may get varying opinions from different physicians. If a man is found to have a small amount of prostate cancer that has not spread outside the gland, then surgery to remove the prostate is often recommended. If the cancer is restricted to the prostate, there is a good chance that surgery (prostatectomy) will be curative. In this situation, some physicians may recommend radiation therapy rather than surgery, which is also acceptable. Each approach has its benefits and drawbacks, but both seem to be effective in early prostate cancer. Radiation therapy is more likely to cause problems with the intestines or bladder whereas surgery (prostatectomy) is more likely to cause impotence and urinary incontinence. The likelihood of impotence following surgery has markedly decreased with a special procedure that spares the nerves that produce an erection.

    If the cancer cells have spread outside the prostate, there are several treatment options to try to inhibit the growth of the tumor. Hormonal therapy is often used in an attempt to deprive the tumor of male hormones, which are necessary for its growth. This can be achieved with castration, drug therapy, or combination therapies. Radiation therapy or surgery is sometimes used to decrease the amount of the tumor, and can relieve urinary obstruction or local pain. Widespread prostate cancer is not currently a curable disease, but there are many scientists investigating the use of chemotherapy. Bone pain is a major complication of extensive prostate cancer, and it is usually responsive to hormonal therapy, radiation treatments, corticosteroids, or pain medications.




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