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Age Related Changes Impacting Sexuality Part 2
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Age Related Changes
Impacting Sexuality
Continued, Part II
Part 2 of 2
Approximate length of part 2 is 2300 words.
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Again, it is not possible here to examine in detail the treatment
of all
the issues and diseases adversely impacting upon sexuality in the
older
person. However, some obvious conclusions regarding treatment of
sexual
dysfunction in the elderly do arise from even a cursory
consideration of
the above: diabetes mellitus should be treated and controlled,
smoking
and immoderate alcohol consumption should cease; a certain degree
of
physical fitness is required to participate in any physical
activity
including sexual intercourse - and thus the elderly should
exercise. Cardiac
patients should be aggressively, but safely re- habilitated,
obesity
should be controlled, STDs treated, medications may have to be
adjusted
or replaced and surgery (eg. for female genital problems such as
prolapse uteri or
uterine/adnexal tumors etc.) may have to be undertaken. Hormone
deficiencies (male and female) should be corrected. Other medical
conditions such as arthritis may need attention beyond medication
including counselling in special sexual positioning for
intercourse.
Psychiatric problems must also be addressed: Psychological
evaluation for
sexual dysfunction is indicated in many cases in either sex, but
especially
in males, so as to exclude psychiatric causes for impotence such
as
abnormal fear of the vagina, sexual guilt, fear of intimacy or
depression (Berkow & Fletcher).
Often, even if a male has functioned without difficulty in the
recent
past, factors such as divorce and death of a partner can have a
negative
emotional impact on sexual functioning. As time passes, sexual
inactivity in either sex makes the re-establishment of patterns
of intimacy and
sexual functioning increasingly difficult. Psychoses, dementias
and
various degenerations of the central nervous system such as
Alzheimer's
disease will obviously impair sexuality.
The author chooses to discuss in more detail only one exciting
area of
recent advance in the treatment of sexual dysfunction - treatment
for
male impotence:
Attempts have been made to correct impotency using every
imaginable
ingredient from Ginseng root (a Chinese herb) to powdered
rhinoceros
horn. Modern medicine no longer believes in these and such other
nostrums
as "Spanish Fly" which can cause severe renal failure.
Even the Yohimbine
extract, popular some years ago, seems to have little efficacy.
Vasodilating agents such as nitroglycerine applied as a cream
directly
to the penis appear to do little more than cause headache by a
mechanism of
systemic vasodilation.
Primitive pygmies stiffened the male organ with a slender stick
which
they slipped into a pocket of skin tunnelled along the shaft of
the
penis. Perhaps that was the inspiration for the modern penile
implant which
comes in many versions.
The most complicated is the inflatable penile implant. Rosenthal
(p. 232-
242) describes this device as consisting of two silicone-covered
cylindrical balloons implanted in the corpora cavernosa of the
penis and connected to a saline-filled reservoir located behind
the pubic bone and inflated by a small pump placed in the
scrotum. This is
an expensive but very acceptable solution, preferred by most men
and
women. It closely mimics the normal anatomy, becomes rigid,
full-length
and thickens with inflation. When not in use it is unobtrusive.
However,
the mechanical failure rate is higher than most other systems,
though
this has recently been improved.
Other versions described by Rosenthal include a self-contained
inflatable penile uni-rod with a flexible central linkage; and
the popular permanent, semi- rigid implant. These are cheaper and
easier to install and have a decreased failure rate; but do not
thicken the penis as much, may leave the head of the penis
somewhat droopy ("Concord-glans", after
the airplane of that name with its drooping snout) and present
concealment problems.
Another variant not mentioned by Rosenthal employs a
"backbone" of plastic links which can be snapped in and
out of rigidity. But this mechanism can suddenly fail during
intercourse, as can the self-contained uni-rod. Other surgical
procedures for impotence have attempted venous ligation in
instances of venous leakage and microvascular surgery similar to
aorto-coronary bypass grafting on the heart to bypass occluded
penile
arteries. However, the vasculature in the penis is even more
microscopic
than that of the heart and results have been poor to date with
these
procedures.
For a number of decades external penile vacuum devices, such as
manufactured by Osbon, have been popular. They cost a couple
hundred
dollars in cheap version and consist of a plexiglass cylinder
(connected
to a pump), the open end of which is lubricated, placed over the
penis and
pushed against the pubis to create a tight air-seal. The penis
then
engorges as the air is pumped out of the cylinder creating a
partial
vacuum around it. Finally, thick rubber bands are slipped off the
open
end of the device over the penile base and air is allowed into
the
cylinder as the penis is withdrawn. This results in a rigid
erection, though somewhat
"floppy" at the constricted base. It is very
serviceable for the female
and persists to some extent even after orgasm. However the bands
must be
removed within half an hour to prevent penile necrosis and both
the
application and removal of the bands can be uncomfortable for the
wearer.
Also, the penis tends to be abnormally cold during intercourse,
since
there is no through-flow of blood; and at least partial
retrograde ejaculation
is common because of the external obstruction to the urethra.
The latest and most exciting male erection aid is Caverject -
Alpha 1
prostaglandin (PG1) (Pecyna, 1995). For some time urologists,
recognizing that many cases of impotence are associated with poor
penile
dilatation, have use vasoactive chemicals such as phentolamine
and
papaverine, either alone or in combination to promote penile
tumescence.
These chemicals are given as injections deep into the corpora and
can be
quite painful. They are variably effective, complicated by
priapism and
associated with long term side effects such as fibrosis of the
penis and
Peyronie's disease.
More recently, PG1, first available as Alprostadil liquid for use
in
maintaining pediatric patent ductus arteriosus, now marketed as
the
erection aid "Caverject", has become available as an
alternative. This
is somewhat more expensive than the older agents at about
$18.00/treatment compared to about $1.00 - $13.50 for papaverine,
phentolamine and various combinations. But it appears to be much
more
effective, and safer, at producing durable erections in most
males with
erectile dysfunction, whether from organic or psychogenic causes.
Caverject is supplied as a refrigerated powder in a convenient
pocket-
sized plastic pack which contains saline diluent in a pre-filled
syringe
with a 30 gage needle. It is mixed as needed and injected deeply
into
the superior-lateral penile shaft about a third of the distance
from the
base, following cleansing of the injection site with an alcohol
pad. The
shaft of the penis is then tightly compressed over the injection
site to
prevent hematoma and the penis is occluded between two fingers at
that
level for about five minutes so that the chemical is not lost
into the general
circulation. Within no more than five more minutes a rock-hard
erection
which some middle-aged men have described as the best experienced
in 30
years is achieved. It can last up to three to four hours and is
significantly retained after orgasm. Many men are able to have
multiple
episodes of intercourse at the same sexual encounter with greatly
decreased refractory periods. Erections in the four to six hour
range are
discouraged and an erection lasting six hours requires medical
attention.
Never-the-less, though package inserts recommend dosages
sufficient for
maintenance of half-hour erections, most dosage regimens appear
to result
in significantly longer episodes.
Complications include some penile pain at the injection site,
penile ache
after lengthy erection and hematoma. Priapism is rare. Injection
sides
are alternated. Three doses represent maximal weekly usage. A
further
refinement, expected shortly will involve intra-urethral dosing
of PG2
as a cream, with greatly reduced side-effects of pain,
possibility of
fibrosis and priapism; and allegedly equivalent functionality. It
thus appears
that this therapy has revolutionized the treatment of male
erectile
dysfunction and will largely obviate the need for other
treatments of impotence.
It is obvious that sexuality involves much more than sexual
intercourse,
and that intercourse itself encompasses far more than the
penetration of
a vaginal canal by a firm penis. Even mutual orgasm is unaffected
by
impotence and total sexual satisfaction is quite independent of
penetration. Indeed, the author stressed at the commencement of
this
paper that sexuality is the overall expression of
"gender-flavored"
personality rather, even, than "sex" in the popularly
understood meaning
of the term.
In fact, one of the problems that all humans face is attempting
to
measureup to an unrealistic fantasy model of sexuality
(Zilbergeld, 1992, p.
37). If the penis cannot measure up (and it never has been
able to measure up) to societal myths, then the discrepancy can
be even more
cruel with age.
The adolescent penis is as close as it comes to the myth of steel
and
explosive multi-orgasm. Even at age 35 there are signs of
mellowing with
decreased frequency of masturbation and wet dreams and less
hardness in
general. Going into mid-life, somewhere in between 40 and 50, the
penis
is softer at its best, often requires direct physical stimulation
to
achieve hardness and hangrequency of orgasm and less erection.
But with
some care and a sympathetic partner (and with a little medical
assistance as
required) the senior penis can still provide pleasure for both
partners,
even though differently from decades before. Often all that is
required
is an appreciation that things are not broken, just different.
(Zilbergeld,
p. 108-110).
Never-the-less, in full recognition of the potential harm and
long-standing cultural inadequacies of a penis-centered approach
to
sexuality, the author has specifically focussed on the treatment
of
erectile impotence for a brief instant, rather than any of the
other myriad of dysfunctions at the heart of disordered sexuality
in the aging. This is because penile
potency is an almost universal symbol of adequate human
sexuality; and because
the concept of male erection is so central to adult human sexual
mythology and reality: At a cerebral level sophisticated humans
recognize
that sex is more than mere penetration and that sexuality is more
than sex. Many do
adjust to the realities of a flaccid penis. But at some deeper,
primal
level, a lot of imagined and actual sexual malaise can fade into
inconsequentiality in the presence of a proudly erect male member
offered
by a loving partner. A woman does not necessarily need such a
penis -
love is nothing for her if not romance over mechanics - but such
a penis by
validating her mate in his own eyes - reassures both of them, not
only of
his virility, but also of her desirability. And, by making him
happy, as
much as anything else, it frees them to reach beyond anxiety and
miscommunication, to a shared experience of love which will
likely spill
over into their larger lives.
If an older woman's, usually minor, sexual maladjustments are
corrected
with a little estrogen and some lubrication, she and her senior
mate
(who is usually more severely sexually afflicted) can once again
enter the
magic land of youth - or at least frolic on the fringes - if the
male can
bring an erect organ to the proceedings. The satisfaction
generated for both
partners can re-affirm love and a sense of self-worth and
re-establish in
both partners a sense of joyous participation in the totality of
human
experience and adult functionality; which is no less than the
expression
of sexuality in its fullest sense.
Care-givers have a significant responsibility to assist clients
in
verbalizing, recognizing and diagnosing these conditions of
disordered
sexuality associated with aging, so that we may seek to correct
them
within the framework of a coherent therapeutic strategy.
The End
By Lucy THORNTON
November 13, 1996
14:19 +0000
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