Health Articles

Etiology and Pathogenesis
Impotence increases progressively in frequency with age. About 25% of 65-yr-old men and 50% of 80-yr-old men are impotent. Impotence can be caused by vascular, neurologic, and endocrine disorders and by structural abnormalities of the penis. Drugs also cause impotence in the elderly.
Vascular disorders that can affect sexual function include atherosclerosis and venous leakage. Any occlusion of the arterial supply to the corpora cavernosa—such as from atherosclerosis, a clot (as in Leriche’s syndrome), or vascular surgery (eg, aoitoiliac bypass surgery)—that results in inadequate arterial pressure to the penis can lead to impotence. Venous leakage, in which inadequate compression of the venous drainage of the corpora cavernosa results in excessive venous outflow, occurs in 75% of impotent men with normal neurologic and hormonal function.
Neurologic causes of impotence include trauma, diabetes, multiple sclerosis, and toxins. Trauma to the nerves of the penis can occur from lumbar disk disease and from surgical procedures such as rectal surgery and prostatectomy. Diabetic neuropathy is a particularly common cause of impotence in the elderly. Alcoholism can produce a similar peripheral neuropathy.
Endocrine causes of impotence are relatively rare in the elcierly. However, testicular failure as a result of childhood exposure to mumps, Klinefelter”s syndrome, radiation and chemotherapy, pituitary and adrenal tumors, and other conditions (see TABLE 69-1) can cause extremely low testosterone levels and impotence.
Structural abnormalities of the penis are not common causes of impotence in the elderly. Peyronie’s disease, which is more common in younger men, is characterized by fibrous accumulation in the tunica albuginea, which leads to a deformed erection. Although not technically impotence, the deformed erection may not allow penetration.
Drugs cause an estimated 25% of cases of erectile dysfunction (see TABLE 69-2). Among the most common offenders are some antihypertensives (most notably reserpine, β-blockers, guanethidine, and methyldopa), alcohol, cimetidine, antipsychotics, antidepressants, lithium, sedative-hypnotics, and hormones.
Psychologic causes are less common than organic causes and account for a smaller proportion of impotence cases in the elderly than in younger men. The misperception that prostate surgery will result in impotence may actually cause psychogenic impotence, which may be prevented by thorough explanations both before and after the surgery. Depression can lead to impotence in the elderly, as in younger men, and older men can also experience performance anxiety, especially when having sexual intercourse with a new partner.
Diagnosis
Elderly men today are more likely than past generations to seek help for impotence, and physicians should make them feel comfortable discussing the problem. A comfortable environment can be eslablished by
explaining that impotence is a common problem and by reassuring the patient that treatment is often effective. In private, the patient should be asked if he would like to discuss the matter alone or have his sexual partner present.
History: Before beginning the physical examination, the physician should be relatively certain whether the problem is erectile dysfunction or some other sexual dysfunction. History begins by establishing whether libido is intact and if nocturnal or morning erections occur. A history of changes in secondary sex characteristics or of vascular, pelvic, rectal, or prostate surgery may give clues to the cause. Depression, anxiety, and stress must also be sought, and the physician should learn about changes in sexual partners or problems with relationships. A review of all medication use, including alcohol and over-the-counter and illicit drugs, is essential.
Physical examination: The physical examination is usually less revealing than the history, but it helps detect signs of severe hypogonadism, such as small, soft testes, loss of pubic hair, and gynecomastia.
The bulbocavernous reflex helps establish the normalcy of the peripheral nerves innervating the pelvis. Measuring penile arterial pressure is not generally useful, although measuring pressures in the legs may help establish whether the patient has peripheral arterial disease.
Laboratory evaluation: Laboratory tests generally include obtaining a tree (or total) testosterone level. Other tests for the common diseases that can lead to impotence should be ordered, such as CBC count fasting blood sugar, and thyroid-stimulating hormone (TSH) level. A nocturnal penile tumescence measurement is useful if the occurrence of spontaneous erections cannot be ascertained. The simplest and least expensive test uses a ring of postage stamps placed around the penis at night: if the perforations are broken in the morning, an erection has occurred. More sensitive and reliable measurements can be made at home using a portable computerized unit.
While several tests are available to assess the penile vascular system, duplex ultrasonography with intracorporeal injections of vasoactive agents is generally the best. A papaverine-phentolamine combination is injected into the corpus cavernosum. Because the drugs are arterial vasodilators, an erection should occur; if erection occurs, such injections could possibly be used therapeutically (see below). Failure to produce an erection indicates venous leakage.
Treatment
Erectile dysfunction can usually be treated successfully, often without surgery. Determining the cause of impotence helps in choosing the initial treatment.
Men whose impotence is the result of psychosocial problems may benefit from psychologic counseling. Even those with primary erectile dysfunction may need psychologic counseling, and it often helps to have the patient’s partner involved. Referral to experts in treating sexual disorders may be helpful when explanations and reassurance are inadequate.
Several drugs may ameliorate impotence, although none is remarkably effective. Yohimbine, an (^-adrenergic blocker taken orally at 5 4 mg tid, appears to help a small proportion of men, especially those with vascular causes. Testosterone replacement therapy benefits only those whose impotence is due to hypogonadism (see above).
Binding and vacuum tumescence devices are often useful for obtaining and maintaining erections, but men who are taking anticoagulants or who have low platelet levels or bleeding disorders should not use these devices. Binding devices, which slow venous outflow at the base of the penis, used alone often help those with mild impotence The devices are made of metal, rubber, or leather with snaps and can be purchased from medical supply houses or pharmacies (see FlG. 69-1)
However, they can also be purchased less expensively at stores selling sexual paraphernalia, where they are known as “cock rings.” The vacuum devices improve on the binder device by increasing arterial engorgement through vacuum assistance (see FIG, 69-2). A plastic cylinder vacuum device is fitted over the unerect penis, and a gentle vacuum is produced by sucking out air with a syringe, pump, or one’s mouth (via tubing). Once an erection occurs, a wide rubber binding band is applied at the base of the penis and the vacuum device is removed. The band retards venous return and helps sustain the erection for up to 30 niin. Binding devices can produce local discomfort and occasional difficulty with ejaculation, especially if too tight, anil vacuum devices can produce petechiae if used excessively. Long-term safety and effectiveness are being evaluated.
Self-injection of vasoactive compounds (intracavernous pharmacotherapy) directly into the corpus cavernosum before sexual activity can help produce an erection (see FIG. 69-3). Self-injection therapy is usually effective when vascular disease is mild to moderate but not when it is severe. Furthermore, self-injection is not acceptable to all patients. A papaverine-phentolamine combination is often used, although the drugs do not have FDA approval. Alprostadil (prostaglandin Ei) is another drug that is used for intracavernous pharmacotherapy. The three agents may be given together, but no advantage of combined therapy over monotherapy has been established. The optimum combination of drugs to maximize effect while minimizing side effects is still being studied.
After injection, the patient should immediately initiate foreplay. He can expect to experience an erection after 5 to 10 min, and under ideal conditions, the erection will last up to 60 min. Problems include priapism, hematomas due to subcutaneous instead of intracavernosal injection, and pain. An injection of dilute epinephrine (20 μg/20 mL saline) or phenylephrine (500 μg/mL saline) usually reverses the priapism.
Permanent penile prostheses or implants may benefit patients with impotence that does not respond to other treatments, especially chronic organic impotence caused by diabetes. A prosthesis produces an erection but cannot correct neurologic deficits that preclude normal sensation. Devices that produce a permanent erection include the Small Carrion semirigid rod prosthesis with a silicone sponge interior and the Flexi-rodII, a hinged modification of the Small Carrion device 1 hat allows the penis to be bent downward more easily when not being used for sexual activity. An inflatable (AMS 700 CX) prosthesis is also available. Contraindications to surgical implants include untreated depression, psychosis, severe personality disorder, and other severe psychiatric problems.
Penile revascularization surgery is still largely experimental. Surgery should be reserved for those with localized, identifiable lesions and performed only by highly skilled surgeons. Ligation of venous drainage is sometimes beneficial for those with impotence caused by venous leakage.

Male hypogonadism is not common in the elderly, with surveys suggesting a prevalence of less than 4%. Most cases in elderly men have no ready explanation and are associated with a combination of pituitary and testicular hyporesponsiveness. However, as shown in TABLE 69-1, hypogonadism is also caused by exposure to many drugs and toxins and by a number of illnesses.
Symptoms and Signs
Mild hypogonadism has few or very vague and nonspecific symptoms and no physical findings. Severe and prolonged hypogonadism leads to reduced skeletal muscle mass and the loss of body hair and masculine habitus. Small, soft testes and a loss of scrotal pigmentation and rugae are important clues.
Laboratory Findings
Leydig cell function may be estimated by a morning measurement of bioavailable (free) testosterone; a value < 67 ng/dL signifies hypogonadism. A total testosterone value of < 300 ng/dL is also diagnostic of hypogonadism, but the free fraction is more sensitive because of the increased binding of testosterone to sex hormone-binding globulin in the elderly. The level of luteinizing hormone is normal or low in almost all hypogonadal men. Dynamic testing with gonadotropin-releasing hormone adds little information, because the response is usually proportional to the basal luteinizing hormone level. A normal prolactin level helps exclude a pituitary tumor as the cause of hypogonadism.
Treatment
Hypogonadism is treated with androgen therapy. Long-acting esters of testosterone and 19-nortestosterone (the enanthate and the cyclopen-tylpropionate) are administered IM in a dose of 100 to 200 mg every 1 to 3 wk (usually as 100 mg each week, 200 mg every 2 wk, or 300 mg every 3 wk). Alternatively, oral forms of testosterone derivatives, which have an alkyl group in the 17 position, are usually prescribed as 5 to 50 mg/day of methyltestosterone (10 to 50 mg orally or 5 to 25 mg bucally). The IM formulations are generally preferred because the oral agents may cause hepatotoxicity with reversible elevation of hepatic enzymes, occasional episodes of cholestatic jaundice, and hepatic tumors. Sublingual forms of androgens may be safer than of'il forms.
Testosterone therapy restores muscle strength, bone density, hair pattern, libido, sense of well-being, and mood in severely hypogonadal men. Its effectiveness in the elderly is not usually as clear-cut as in younger men, and a 3-mo trial is recommended to identify benefits before either proposing long-term therapy or terminating treatment because it seems ineffective.
Therapy stimulates erythropoietin secretion, increasing the hematocrit. By enhancing activity of hepatic triglyceride lipase, it also reduces HDL cholesterol levels and increases sensitivity to the anticoagulant action of warfarin derivatives. Some degree of prostate growth and an increase in prostate-specific antigen (PSA) level liay occur, but development or exacerbation of obstructive symptoms is rare. Patients with elevated or borderline values of PSA probably should not be treated with androgens because of persistent, but unpn>Ved, concern that androgens promote the development of prostatic carcinoma. However, for many the benefit may outweigh the risk, so tb^t therapy may still be appropriate after careful consideration.

Spermatogenesis is remarkably sustained throughout life if testicular androgen synthesis is adequate; however, androgen production does decline with age. The impact of this reduced androgen synthesis on health, well-being, and sexual function has not been determined.
As testosterone secretion diminishes, its diurnal variation is also blunted, resulting in a lower 6 to 8 AM peak. Mean gonadotropin levels rise slowly, but large pulses of luteinizing hormone are less frequent, which impairs pulsatile testicular response. Binding of testosterone to sex hormone-binding globulin increases with age, resulting in substantially less unbound, bioavailable testosterone. Also, metabolism of testosterone is slowed. Evidence suggests that androgens play an important role in libido (sexual appetite) and influence the frequency of nocturnal erections; however, erections produced by erotic stimuli can occur despite low levels of androgens.
Penile erection is accomplished through engorgement of the corpora cavernosa, two paired vascular bundles. Because each corpus caverno-sum is surrounded by a tough, fibrous sheath (the tunica albugineai. engorgement leads to rigidity. Erection occurs when arterial blood flow into the corpora cavernosa exceeds venous outflow. The pudendal artery supplies blood to the corpora, and blood flow is controlled by relaxation and contraction of arterial smooth muscle. Venous drainage occurs through venules just below the tunica albuginea. These venules are easily compressed as the corpora fill. The penis is innervated by the T11-L2 sympathetic nerves and the S2-4 somatic and parasympathetic nerves.

Many drugs adversely affect sexuality (see TABLES 68—1 and 68-2). Some interfere with the autonomic nervous system, which is involved in the sexual response. Others affect mood and alertness or change the production or action of sex hormones. Assessing the effects of drugs on sexuality is more difficult in women than in men, since potency problems in men are more obvious. However, drugs that affect men may also affect women, and further studies in women are warranted.
A patient who suspects that medications are the cause of sexual problems may be tempted to discontinue the drugs or decrease the doses without informing the physician. The possibility of adverse drug effects on sexual function should be discussed openly with patients, who should be encouraged to report any side effects.
Although the effects of specific drugs on sexuality are outlined in TABLES 68-1 and 68-2, some drugs deserve special mention. Antipsychotics, such as thioridazine and other phenothiazines, may inhibit erection or ejaculation, even though the capacity for erection remains. Tranquilizers can depress the sexual responses of women and men, and some antidepressants can inhibit sexual desire.
Antihypertensive drugs are the most common pharmacologic cause of impaired erection. Cardiac drugs that are often implicated in erectile dysfunction include those with peripheral or central actions of sympatholytic or β-adrenergic blocking activity. Those that have less of an effect on sexual function include calcium channel blockers, angiotensin converting enzyme inhibitors, and peripheral vasodilators. Methyldopa reduces blood flow to the pelvic area, thereby inhibiting erection. When certain antiarrhythmic drugs and β-blockers cannot be avoided and sexual dysfunction results, patients may benefit from encouragement to explore other forms of intimacy and physical pleasure.
The excessive use of alcohol is a common yet seldom considered factor in sexual problems; although it may stimulate desire, alcohol inhibits performance. Up to 80% of men who drink heavily experience such effects as impotence, sterility, and loss of sexual desire. Alcohol with its depressant action can also affect a woman’s sexual desire. Many of the effects of moderate to heavy drinking are reversible if the drinking is stopped in time. Since alcohol tolerance decreases with age, smaller and smaller amounts may produce negative effects. People who choose to drink regularly should avoid drinking for several hours before sexual activity and should limit themselves to 1,5 oz of hard liquor, 6 oz of wine, or 16 oz of beer in any 24-h period.

Rate of recovery and return to sexual activity after surgery varies. Thorough explanation of surgical procedures, together with practical advice and emotional support before and after surgery, can enhance recovery and the return to previous levels of sexual activity (see also Heart Disease under EFFECTS OF MEDICAL PROBLEMS ON SEXUALITY, above).
Hysterectomy
Refraining from sexual activity for 6 to 8 wk after hysterectomy is usually advised to allow the surgical wounds to heal. Feelings of depression after hysterectomy are common and usually last from 2 to 10 days, although some women report them for 6 mo or longer. Hysterectomy without oophorectomy does not usually impair sexual function. However, women who are highly sensitive to cervical and uterine sensations during orgasm are aware of the loss. Although oophorectomy decreases testosterone and other androgen levels fas well as estrogen and progesterone levels), the effects on sexuality have not been well studied.
Mastectomy
The loss of one or both breasts can make a woman feel sexually mutilated, and the psychologic effects may be severe. Sexual desire may be lost because of embarrassment, inability to accept the loss of the breast, or fear of being less attractive to a partner. Periodic depression is common and should be expected during the first year or two after mastectomy.
Rehabilitation programs, such as the American Cancer Society’s Reach to Recovery program, help women and their spouses deal with the physical, psychologic, and cosmetic concerns of breast surgery. Couples should share feelings openly and support each other emotionally.
Prostatectomy
Potency is rarely affected by the most common form of prostatectomy, transurethral resection of the prostate, although retrograde ejaculation is common. Healing usually takes up to 6 wk, after which sexual activity can be resumed. Men often assume incorrectly that sexual impairment is inevitable because of the physical proximity of the prostate to the penis. Factual information from physicians can alleviate fears. About 10% of men lose some ability to achieve an erection, although most men return to their presurgery level of sexual functioning. Most impotence after transurethral resection of the prostate is psychologic: about 3% to 5% of men develop nonpsychologic impotence. Suprapubic or retropubic prostate surgery may result in impotence.
Orchiectomy
The psychologic impact of this procedure can be devastating. Emotional preparation before and counseling after surgery are essential. Physiologic impotence does occur, but some men are able to have normal erections. When testosterone can be given soon after orchiectomy, potency may be retained. However, replacement testosterone therapy is usually contraindicated because in the elderly, orchiectomy is usually performed to treat prostate cancer.
Colostomy and Ileostomy
Patients who are sexually active before surgery usually can continue to be so afterward, although the adjustment can be complex. Couples should be given medical guidance and offered psychologic counseling. Some 250 ostomy support groups throughout the USA provide information and help.
Rectal Cancer Surgery
In men, removal of the rectum and anus with a permanent colostomy may result in total impotence. The proximity of male genital organs to the lower rectum leaves essential nerve fibers vulnerable to damage. In women who undergo this procedure, capacity for sexual arousal and orgasm is usually retained, since essential nerves are further from the surgical site.

A number of common medical problems can affect sexual functioning. Because sexual activity is often important to a person’s well-being, physicians should include a thoughtful discussion of sexuality when treating the medical problem.
Heart Disease
People with angina or heart failure and those who have undergone coronary artery bypass surgery or have had a myocardial infarction may avoid sex because of an assumed risk to life, but studies indicate that cardiac death during or after sexual activity is rare. Under most circumstances, patients with heart disease have few reasons to abstain from sex and many reasons to continue (eg, an opportunity for mild exercise and release of physical and emotional tension).
After myocardial infarction, an 8- to 14-wk waiting period is generally recommended before resuming sexual intercourse. The period of abstinence depends more on the patient’s interest, general fitness, and conditioning. Depression and anxiety are common up to 1 yr after myocardial infarction, and avoiding sexual activity may exacerbate depression. Antidepressant drugs may further reduce sexual libido and capacity. A physician’s support and encouragement can greatly help patients overcome their fears.
When heart failure is managed effectively, the physical exercise and emotional release associated with sexual activity may contribute to a patient’s improvement. After an episode of pulmonary edema, a 2- to 3-wk recovery period is usually advised before resuming sex.
Physical symptoms, side effects of medical treatment, orfear of sudden death from physical exertion causes many patients to become sexually dysfunctional even before they become candidates for coronary artery bypass surgery. Patients who have had surgery should be reassured about the safety of” sexual activity within reasonable limits to prevent straining the surgical repair. The sternum usually requires 3 mo to heal completely. Self-stimulation or mutual masturbation may be a less strenuous alternative to intercourse and usually can be started earlier in the recovery period.
Prolonged sexual problems can occur after surgery if the patient is not closely monitored. Exercise programs to improve cardiac function (eg, increasingly strenuous walking) can reassure patients who are afraid to resume sexual activity. Even though surgery may eliminate the need for medication, some patients become psychologically dependent on nitroglycerin before sexual activity because of previous chest pain upon exertion. Patients with arrhythmias may need the reassurance of successfully performing a treadmill test to overcome anxiety about engaging in sexual activity.
Hypertension
Men and women with mild to moderate hypertension need not restrict sexual activity. In men with untreated hypertension, the incidence of impotence is about 15%; the effects of hypertension on female sexuality are not as well studied. Selection of antihypertensive drugs should focus on those that do not impair sexual response (see EFFECTS OF DRUGS ON SEXUALITY, below).
Stroke
Sexual activity has not been shown to cause stroke or to increase neurologic deficit after stroke. Unless a stroke causes severe brain damage, sexual desire is usually unimpaired. However, sexual performance is more likely to be affected. Some men experience impotence; others do not. The unaffected side of the body should be emphasized in lovemaking. The partner of a woman who has suffered a stroke may become impotent if he fears injuring her, in which case reassurance may be needed. The use of headboards and bedboards can greatly assist positioning necessary for sexual activity.
Diabetes Mellitus
Sexual problems are common in men with diabetes. Impotence occurs two to five times more often in diabetic men than in the general population, even though sexual desire is unaffected. Good control of the diabetes may reestablish potency; however, if the diabetes is already well controlled, the impotence is likely to be irreversible. Concurrent endocrine problems (eg, a thyroid condition) may reduce potency.
Arthritis
The physical disabilities associated with osteoarthritis and rheumatoid arthritis may interfere with sexual desire or performance, but drugs commonly used to treat arthritis do not. A program of exercise, rest, and warm baths is especially useful in reducing arthritic discomfort and in facilitating sexual performance. Experimenting with new sexual positions that do not aggravate joint pain is often helpful; the side-by-side position may be preferred by both partners, especially when the patient has many tender areas and pain trigger points. Since osteoarthritis tends to be less severe in the morning and rheumatoid arthritis less severe in the afternoon and evening, sexual activity can be planned for times of the day when pain and stiffness are diminished. Some patients find that regular sexual activity relieves the pain of rheumatoid arthritis for 4 to 8 h; such relief may be due to hormone production, release of endorphins, or the physical activity involved.
Chronic Prostatitis
Chronic prostatitis is associated with unusually frequent sexual intercourse as well as with abstinence, excessive preliminary sexual arousal, or &n incomplete orgasm. The pain of chronic or recurrent prostatitis may diminish sexual desire. Mild prostatitis may cause some perineal pain after ejaculation.
Therapy for chronic or recurrent prostatitis includes antibiotics, warm sitz baths, and periodic gentle prostatic massage. Kegel’s exercises, which involve contracting the pelvic floor muscles, may also help.
Cystitis and Urethritis
Some women experience recurrent episodes of cystitis and urethritis after intercourse. Although these problems are usually due to the introduction of bacteria into the urethra during thrusting, the cause may be unclear. A urologic or gynecologic evaluation is indicated to determine the cause, as is a discussion of therapeutic and preventive options.
Peyronie’s Disease
Intercourse is painful for about 50% of men with Peyronie’s disease. When the penis is angled too sharply, penetration may become impossible. However”, tumescence is preserved in about 90% of cases, even though there may be some pain. Psychotherapy can help the patient adjust to the Structural and functional changes in the penis. Medical or surgical intervention is not usually effective, but symptoms sometimes disappear spontaneously after several years.
Chronic Renal Disease
Men with chronic renal failure may have reduced levels of serum testosterone, although the reason is unknown, and they are often impotent. Such patients may be treatable when the problem is intensified by concomitant emotional reactions such as anxiety or depression: treatment of the associated, underlying anxiety or depression and couples counseling can be helpful. Kidney transplantation often restores sexual capacity in impotent dialysis patients.
Parkinson’s Disease
Parkinsonism is commonly associated with depression, which may lead to impotence in men and lack of sexual desire in both men and women. Advanced organic involvement may also result in impotence. Sex drive and performance improve in some men treated with levo-dopa, probably because of greater mobility and an increased sense of well-being. There is little evidence that levodopa acts as an aphrodisiac, and it should not be prescribed as such.
Chronic Emphysema and Bronchitis
Shortness of breath brought on by chronic emphysema and bronchitis hinders physical activity, including sex. Solutions include resting at intervals, finding the least taxing ways to have sexual contact, ami using oxygen during sexual activity.

Sexual change in old age is a process of gradual slowing; more time is needed to become sexually aroused and to reach sexual climax. This should not be considered an impairment, since it may permit a better response synchronization between the sexes, compared to that in earlier years when men responded more quickly than women. Men and women often converge in other ways as they grow older: women typically become more assertive and men become more nurturant.
Special Concerns of Men
In addition to gradual slowing, older men may notice less preejacu-latory fluid and less forcefulness at ejaculation. In general, testosterone levels decline only gradually, and some very ofd men still have levels identical to those in younger men. However, chronic illness or alcoholism reduces testosterone levels markedly. Men do not undergo a physiologic climacteric, and they remain fertile until the end of life.
A common concern of men of all ages including older men is their ability to maintain sexual potency and performance. Impotence is distressing and is usually (although inaccurately) attributed to aging (see IMPOTENCE in Ch, 69). However, impotence may occur from time to time at any age for a variety of reasons (eg, stress, fatigue, tension, guilt, depression, illness, excessive drinking, and anxiety over performance). A comprehensive evaluation is needed to separate psychologic from organic causes. Recent studies suggest that organic causes are a major factor in > 80% of persistent male sexual dysfunction, and psychologic factors alone probably account for only 10% of cases of erectile dysfunction. However, psychologic and organic factors are often intermixed: anxiety over an organic cause of impotence often aggravates the problem.
The diagnostic process begins with a history and physical examination. Depression, anxiety, and stress must also be evaluated. Sleep studies that measure nocturnal penile tumescence help distinguish psychogenic from organic impotence. Such studies can be conducted al home with a portable monitoring unit or in sleep clinics.
Impotence can be treated successfully in most cases, often without surgery. In the case of psychogenic impotence, sexual capacity may return spontaneously; reassurance reduces anxiety and speeds recovery, but psychotherapy or professional sex therapy may be required. Involving the partner in the diagnosis and treatment program is important. Much of the expense of professional sex therapy (including that for couples) may be covered by Medicare or private health insurance, -but the cost may be a problem for many older people. Medicare now pays 50% of the allowable charges for psychotherapy whether performed by a physician, psychologist, or social worker. Increasingly, insurance companies are paying for diagnosis and treatment of scxua! dysfunction.
Special Concerns of Women
Older women usually can continue their earlier patterns of sexual functioning until the end of life or until serious illness intervenes. Women tend to be less concerned about sexual performance than men but are more worried about loss of youthful appearance. Some women enjoy sex more without the possibility of pregnancy. The frequency of intercourse for heterosexual women is often related more to the age. health, and sexual function of their partners for the availability of a partner) than to their own sexual capacity or interest.
For women, most sexual changes are associated with menopause, when estrogen production slows. The effects of menopause on sexuality may include vaginal dryness leading to irritation or pain, a change in vaginal shape (shortening and narrowing), less acidic vaginal secretions with greater possibility of vaginal infections, cystitis due to thinning of vaginal walls with less protection for bladder and urethra, reduction in clitorai size, stress incontinence, and increase in facial hair.
Estrogen replacement therapy has long been used for menopausal symptoms and is effective in treating all of these changes as well as in controlling hot flushes; the specific therapy is discussed in Ch. 83. However, given the risks associated with estrogen replacement therapy, many women are skeptical about its benefits and often experience “estrogen anxiety,” a fairly new psychologic issue of midlife sexuality. Other measures, such as using water-based vaginal lubricants (eg, K-Y Jelly), can help prevent or control vaginal dryness and irritation during intercourse.

Sexuality is associated more with intimacy than just with the act of sexual intercourse. Sexuality in old age is often described in terms that include the opportunity to express passion, affection, admiration, and loyalty; the affirmation that one’s body is functioning well; the maintenance of a strong sense of identity; a means of self-assertion; a protection from anxiety; a renewal of a sense of romance; a general affirmation of life, especially the expression of joy; and a continuing opportunity to search for new growth and experience.
However, not all older persons have such positive attitudes. Even physically and mentally healthy persons may internalize the negative image of the typical older person as a desexualized invalid. Another social prejudice is one that falsely characterizes an elderly person who seeks sexual satisfaction as either a “dirty old man” or a “lecherous old woman.” The inability to come to terms with aging may lead some people to envy the young and to feel hostility and bitterness toward them, to show prejudice against other older people and refuse to associate with them, to reject an aging partner, and to make frantic attempts to appear young.
Feelings of guilt and shame may surface. Brought up during an era of Victorian-like prudery, some older persons are probably misinformed about issues of sexuality and feel guilty about their desires. They may refuse to discuss the issue of sexuality or to accept help when problems are obvious. Reassurance and information from a physician may help these persons achieve a more positive self-image.
Boredom, fear, fatigue, grief, and problems with a mate affect the sexual behavior of all persons. However, the elderly are also more likely to experience depression and illness or incapacitation of a partner. While some people look forward to the freedom of retirement, others react to it with feelings of low self-esteem and self-worth.
With advancing age, women outnumber men, and women living alone are more likely to be poor and to have complex physical and psychosocial problems. Over 50% of older women are widows, 7% have never married, and 2% are divorced. Thus, about 60% of older women are without a spouse, in contrast to about 20% of older men. Partners are in short supply, especially for women. When opportunities do arise, older persons often feel unfamiliar with the practices of dating and courtship. They may not have undertaken such activities for decades.
Physicians should be aware of their older patients’ needs and should be especially sensitive about the reluctance of those who have lost their companions to reenter the world of dating.
Negative societal attitudes about masturbation and homosexuality also can interfere with sexual expression. Some men require sexually arousing photographs and videos to assist fantasy as well as physical manipulation by their partners to achieve an erection. Both men and women without partners, heterosexual or homosexual, may seek out pornography or prostitutes. An estimated 10% of the population including the elderly is homosexual, and while long-term relationships are common, many elderly homosexual persons have not publicly revealed their sexual preference. Their relationships and physical problems are not much different from those of heterosexuals and require the same thoughtful approach and treatment.

A comprehensive national survey of sexuality has never been done for any age group. Therefore, the nature and frequency of sexual activity among the elderly, including its association with marital or health status or any other variable, is unknown. Available data consist of the important but now historic and limited Kinsey studies (1948 to 1949), the physiologic investigations of Masters and Johnson, and the findings of both the Duke Longitudinal Studies and the Baltimore Longitudinal Study on Aging. Questionnaire surveys of self-reported sexual activity have been conducted by mail (eg, by Consumers Union). The most important conclusion is that contrary to prevailing beliefs, sexual desire and satisfaction are important to many elderly persons. A number of factors (eg, low intrinsic drive dating back to youth, physical disability, poor marital relationship, or the death of a spouse or companion) may be responsible for an older person’s being disinterested in sex or having an inhibited sexual drive.
A sexual history, with emphasis on current sexual function, should be part of the general medical evaluation of an older person. Physicians should handle sexual issues with dignity and skill. The discomfort physicians may feel in discussing the subject is often the result of negative stereotypes, personal anxieties, objections to the expression of sexuality by the elderly, or simply ignorance.

Benign neoplasms of (he mesentery and peritoneum are twice as common as malignant neoplasms; however, they are still rare.
BENIGN NEOPLASMS
The most common benign neoplasms are fibromas and lipomas. Most often found incidentally during routine examination, these tumors frequently grow large before causing symptoms. The most common symptoms are vague abdominal pain and bloating caused by compression or traction of adjacent structures. Intestinal obstruction may occur.
Diagnosis is usually made by x-rays that reveal extrinsic compression of the large or small bowel. Surgical excision is curative.
MALIGNANT NEOPLASMS
Malignant neoplasms of the mesentery and peritoneum, which are rare, usually include mesothelioma, fibrosarcoma, or leiomyosarcoma. Symptoms and signs include vague abdominal pain and bloating caused by traction or compression of adjacent structures and intestinal obstruction. Weight loss, anorexia, and weakness can also occur. Mesothelioma is associated with asbestos exposure.
Diagnosis is made by x-rays, including an upper GI series, barium enema, and CT scan, lhal reveal extrinsic compression or signs of invasion of the small or large bowel and other local structures. Surgery is the only effective treatment for cure or palliation. However, chemotherapy and radiation therapy may improve results for mesothelioma.