with Kaitlyn Barnes
Genitourinary (GU) simply refers to our genital and urinary organs—prostate gland, penis, testicles, urethra, the bladder, and the kidneys. These are grouped together because of their physical proximity in the body and because our reproductive organs and urinary system both use the urethra. The health problems that arise and compel men most frequently to seek medical care will involve disorders of the GU system, which can encompass prostate infections, erectile problems associated with aging and/or illness, and sexual diseases. Reviewed in this chapter are the GU and sexual health issues that become the concerns of middle-aged and older men more than younger men: prostatitis, benign prostatic hyperplasia, kidney stones, erectile problems, and sexually transmitted diseases (STDs) in later life. The two urogenital cancers—prostate cancer and bladder cancer—are addressed in chapter 19.
Physicians and medical researchers actually do not know all that the prostate gland does, but what is known is that the prostate contributes to both sexual and urinary function. So, take note: a healthy prostate is another reason to exercise, avoid obesity, eat your vegetables, keep fat intake low, quit smoking, and drink alcohol only in moderation. Each lifestyle decision directly affects your prostate and, in turn, your sexual health and risk of earlier death.
Contrary to popular belief, the prostate doesn’t just start getting larger as we become older. In fact, it never stops growing after puberty, and it is the eventual enlargement of the prostate that causes most GU problems. It is natural for the prostate gland to enlarge as we age, but if it grows more rapidly than is ordinary, it is likely that you may encounter some type of prostate problem earlier in your lifetime than other men do. Nearly half of men after the age of 60 show evidence of at least one type of prostate trouble. Here’s one common example:
David mentioned that he’s feeling frustrated. Because he has to get up several times each night to urinate, he isn’t sleeping well. Sometimes he can’t go back to sleep, which leaves him groggy, tired, irritable, and unable to concentrate for most of the day. What’s especially driving him nuts is that David also has an urge to urinate while commuting, during his after work walks, and often while sitting in short meetings. He’s stressed. (Reported by Brendan, a nurse practitioner)
To begin, it is important to know where your prostate is and what it does, as well as what distinguishes a healthy prostate from three different prostate problems: prostatitis (an inflammation), benign prostatic hyperplasia (BPH), and prostate cancer. If you are like most men, you probably are not exactly sure where the prostate is located, or what it does. The prostate is a gland found only in men and most other male mammals. About the size of a walnut in a healthy adult man, it was the size of a pea when you were born. It is somewhat firm; 30 percent of it is made up of muscular tissue, and the rest consists of glandular tissue. It is located between the bottom of the bladder and the base of the penis, and it backs onto the front wall of the rectum. The urethra (the tube that empties urine from the bladder through the penis) runs through the center of the prostate. The outer surface of the prostate gland is a layer of muscle called the prostatic capsule.
Figure 15.1. The male reproductive tract. Courtesy of ducu59us/Shutterstock.com.
The prostate is a key part of men’s reproductive system and has several purposes. The glands in the prostate produce nearly three-quarters of the milky white seminal fluid that is ejaculated during an orgasm. The urethra carries the seminal fluid through the penis, and as the prostate gland begins to empty during orgasm, it tightly squeezes the upper part of the urethra to prevent urination during ejaculation. During our climax, the muscular glands of the prostate pulse and propel forward the seminal fluid (and the sperm that was produced in the testicles). Men who have had a vasectomy ejaculate only the seminal fluid that is produced and stored in the prostate and none of the sperm cells made by the testicles. The prostate-specific antigen is the enzyme produced primarily by cells lining the ducts of the prostate gland to help keep the seminal fluid in its liquid form.
Problems with the prostate will not affect your ability to have an erection or ejaculate; however, prostate problems interfere with urination. In short, the prostate makes some of the fluid for semen, keeps urine out of the semen, and enhances pleasurable sensations of arousal and orgasm.
Since the prostate sits right in front of the rectum, the back portion of the prostate can be felt during a digital (or finger) rectal examination by your physician.
No one likes the idea of [a rectal exam], and you certainly don’t go around talking about it. (A man in his seventies)
The [digital exam] might worry some guys, but it didn’t worry me at all. It’s all over quickly, and that’s that. (A man in his sixties)1
The examination takes only a minute and should be entirely painless. If the exam is your first, you can expect that your physician will tell you that he needs to insert a single, gloved finger into your rectum in order to examine your prostate gland. Usually you will lie down and roll to one side, away from the physician, or you may be asked to simply bend over and rest the upper half of your body on the examination bed. The physician will cover a finger with a lubricant and insert his finger an inch into your rectum. Most men report that they feel a little pressure without any pain or physical discomfort. The discomfort you might experience is the odd sensation of having someone touch your anus and knowing that someone is doing this. A few seconds may elapse as the doctor waits for the sphincter muscle to relax, then he touches the rectal wall to determine the size of the prostate gland and moves his finger in a tight circular motion to feel the lobes and groove of the prostate gland. Most physicians continue to talk with you during the exam, and they let you know when they are removing the finger and using a premoistened wipe to remove excess lubricant. The exam is done.
Your physician would expect to have felt a firm and hard rubbery prostate gland. An enlarged, spongy gland may indicate either nonbacterial prostatitis or BPH. By age 50, about 25 percent of men suffer from symptoms of an enlarged prostate, and by age 80 up to one-third experience symptoms severe enough to require treatment.
Prostatitis is an inflammation of the prostate gland and does not increase your risk of prostate cancer. This disease can affect men of any age, yet it begins to become common before we reach age 50 and triggers nearly 2 million physician visits annually.2 Anywhere between 9 and 16 percent of men experience prostatitis; it accounts for one-quarter of all physician visits involving men’s GU system, and perhaps as many as 50 percent of men will suffer from nonbacterial prostatitis / pelvic pain during their lifetime. Symptoms of chronic prostatitis—primarily pelvic pain and urinary burning, urgency, frequency, and hesitation—cause havoc on the quality of men’s lives.3
Prostatitis can involve one of several types of inflammation and has been divided into four clinical categories: acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Only 5–10 percent of prostatitis cases are caused by bacteria. With acute bacterial prostatitis, you experience the symptoms of an infection—fever, chills, nausea, body aches, and feeling lousy. This usually results from a bacterial infection from another area of the body which has invaded the prostate. The infection can also be caused by some of the bacteria within our urine. As the urine is being voided and traveling through the urethra, the bacteria may cross over and affect the adjacent prostate gland. Sometimes, though rare, men experience chronic bacterial prostatitis, because trace amounts of the bacteria “hide” in the prostate and didn’t die with initial antibiotic treatment. Whether acute or chronic, bacterial prostatitis symptoms most often involve problems with ejaculation and urination: burning sensation when urinating (dysuria); difficulty urinating, such as dribbling or hesitant urination; frequent urination, particularly at night; urgent need to urinate; and pain or discomfort in the area between the penis and rectum (perineum), which you particularly notice when you sit. The infection is treated with antibiotics, and on occasion some men with a severe infection may need to be briefly hospitalized to flood the body with antibiotics.
You can also experience prostatitis that doesn’t involve bacterial infection, and this is eight times more common than having an infection. The least understood and most difficult type of prostatitis to treat is called chronic prostatitis (or chronic pelvic pain syndrome), and it accounts for 80–90 percent of prostatitis diagnoses. The prostate is “inflamed” (swollen, irritated, painful), yet the causes are not clearly known. Urologists think that stress, irregular sexual activity, or a history of allergies might be contributing factors. Antibiotics are of no use, because there is no infection. Weirdly, the urine and semen usually contain higher-than-expected counts of the white blood cells that are typically produced to fight an infection, yet no bacteria is found when the urine specimen is examined. The other main type is prostatodynia, in which the pain and other symptoms tend to be localized to the prostate, with no obvious inflammation of the gland and no white blood cells in prostatic secretions.
The symptoms of nonbacterial prostatitis include frequent urination and urinary burning, genital pain, intermittent discomfort/pain in the lower abdomen and back for 3 months or longer, and an occasional discharge through the urethra during a morning bowel movement. For some men the symptoms persist, and for others the symptoms go away and return without warning, with the cycles varying in severity. Like other poorly understood conditions, nonbacterial prostatitis remains irksome. No single type of treatment is the gold standard. Some men use medication to reduce uric acid associated with gout, hot baths to provide symptom relief, anxiety/stress medication, biofeedback and relaxation training, and an added course of antibiotics just in case.
The exasperating symptoms of prostatitis will surely affect your quality of life. Whenever symptoms arise, it is best to immediately consult a physician. Episodes of prostatitis can have serious consequences if left untreated, even if treatment is not very effective. Pain is never a good sign, and it can be treated. Whenever you experience pelvic pain, painful urination or ejaculations, or difficulty urinating, see a doctor.
Of the hundreds of species of mammals, all of which have prostate glands, only men and man’s best friend, dogs, are known to suffer from enlarged prostate.4 Usually simply referred to as prostate enlargement, BPH is part of aging and can be maddening. As indicated by its name, BPH is noncancerous. Perhaps half of men in their fifties and sixties begin to develop BPH. By age 80 it is likely that 90 percent of men will experience BPH, and only a third of these men will have symptoms that warrant treatment.
Figure 15.2. Normal and enlarged prostate. Courtesy of National Cancer Institute.
The prostate gland has two noticeable growth periods: one during early puberty and the other starting after age 40. Scientists are not certain why this second growth period starts and why the prostate enlarges as we age. One theory is that prostate gland cells are programmed to “reawaken” and trigger prostate growth. Other clinicians think that it is related to the gradual reduction in testosterone and the parallel increase in estrogen that occurs as we age. Whatever the actual cause(s), the gradual enlargement of the prostate to the size of a golf ball takes place as men age. As it enlarges, the prostate will often squeeze the urethra like a fist around a hose, making urination more troublesome. While benign, BPH is certainly bothersome.
The symptoms of BPH can vary greatly, but the most common ones involve changes or problems with urination—a need to strain or push to get the urine flowing; a hesitant, interrupted, weak stream while urinating; leaking or dribbling a bit after urinating; and more frequent urination, especially at night. Not welcomed are getting up to go to the bathroom two, three, four times a night; having difficulty urinating; and experiencing incomplete emptying of the bladder because of the difficulty in voiding when BPH squeezes the urethra. The American Urological Association has a symptom index (see p. 293) and raises the quality-of-life question: “How would you feel if you had to live with your urinary condition the way it is now, no better, no worse, for the rest of your life?” Rated on a scale from 0 to 6, would you say you would feel “delighted,” “pleased,” “mostly satisfied,” “mixed feelings,” “mostly not satisfied,” “unhappy,” or “terrible”?
Treatment options. Men who have BPH end up seeking treatment to relieve symptoms. Most physicians are wary of too early treatment when the gland is only mildly enlarged and the symptoms are not awfully troubling.5 They recommend what is sometimes called “watchful waiting” as the first line of treatment. This is because the symptoms of BPH can completely disappear without treatment in a third or more of mild cases.
The Food and Drug Administration (FDA) has approved a handful of medications to relieve common symptoms. Most of the drugs are alpha blockers (technically, alpha-adrenergic blockers), which also are used to treat hypertension. In treating BPH, they relax the smooth muscle around the prostate to reduce the squeezing of the urethra and improve urine flow. The frequently used alpha blockers are doxazosin (Cardura), tamsulosin (Flomax), terazosin (Hytrin), and alfuzosin (Uroxatral). There are the standard precautions—tell your physician and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. There are serious complications when using some other medications, and feelings of drowsiness and dizziness are regularly experienced.
Another class of drugs known as 5-alpha inhibitors is also regularly prescribed. Both finasteride (Proscar™) and dutasteride (Avodart™) treat BPH by blocking the body’s production of a male hormone that causes the prostate to enlarge. Actually, they interfere with the enzyme that converts testosterone into an androgen, called dihydrotestosterone (DHT). Greater amounts of DHT are associated with prostate enlargement and male pattern baldness. These 5-alpha inhibitors appear to prevent further enlargement of the prostate and may actually shrink the prostate in some men. However, both drugs can also cause erectile difficulties and decreased libido and increase your risk of male breast cancer. This trade-off needs to be weighed carefully and discussed with your sexual partner.
A recent study6 reported that men given a combination of dutasteride and tamsulosin had significantly improved symptoms of BPH compared to men who took either one alone; the combination significantly reduced the occurrence of the acute urinary retention problems. Consequently, the FDA approved Jalyn™ (dutasteride and tamsulosin), a single-capsule drug that combines the two popular BPH medications. This combination yields both sets of side effects: dizziness, drowsiness, sexual problems, and increased male breast size.
Many nonpharmaceutical therapies are also available and helpful. One of several types of microwave treatments and laser therapies is an option when the prostate becomes too large for good quality of life. Transurethral microwave therapy (TUMT) uses microwave heat to burn away excess prostate tissue; it takes about an hour and can be completed as an outpatient. Similarly, photoselective vaporization of the prostate (PVP) is a minimally invasive procedure that uses a special high-energy laser. Both procedures reduce BPH symptoms and preserve sexual function. Treatment usually does not require general anesthesia and is performed in the urologist’s office or an outpatient setting. Your urologist will usually provide medication to reduce discomfort and help you relax during the procedure, and you might have the option to listen to your iPod or read during the procedure. Most men do not require a catheter after either procedure, and those who do typically are catheterized for less than 24 hours.
AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX FOR BENIGN PROSTATIC HYPERPLASIA (BPH)
BPH Treatment for Moderate to Severe Symptoms
1. Watchful Waiting
2. Medical Therapies
Alpha blockers
• Alfuzosin
• Doxazosin
• Tamsulosin
• Terazosin
5-alpha reductase inhibitors
• Dutasteride
• Finasteride
Combination therapy (alpha blocker and 5-alpha reductase inhibitor)
3. Minimally Invasive Therapies
TUMT (transurethral microwave heat therapy)
• TherMatrx™
• CoreTherm™
TUNA (transurethral needle ablation)
HoLAP (holmium laser ablation)
4. Surgical Therapies
TURP, laser, and similar surgeries
• Transurethral electrovaporization
• Transurethral incision of the prostate
• Transurethral holmium laser resection
• Transurethral laser vaporization
• Transurethral laser visual laser ablation
Prostatectomy
Another treatment strategy uses either high or low radiofrequency energy to burn away the excess prostate tissue. This noninvasive treatment applies precision-focused ultrasound waves to heat and destroy the targeted tissue. The procedure (called transurethral needle ablation, or TUNA) also involves inserting a scope into the urethra and then placing two small needles into the prostate. The needles permit electrodes to pinpoint and deliver radiofrequency energy directly to the obstructing prostate tissue.
As gruesome as any of these procedures might initially sound, they represent much more a psychological hurdle than having to deal with actual physical pain. Much like the oddity of your initial rectal exam, men are wary of the procedure until they’ve gone through it.
These less invasive strategies, however, may not fully relieve severe BPH complications. When this occurs, prostate surgery may be the last resort. The transurethral resection of the prostate (TURP) procedure is the most common of prostate surgeries. This surgical procedure involves no external incision. Instead, after general anesthesia, the surgeon reaches the prostate by inserting an instrument (a resectoscope) through the urethra and removes piece by piece the tissue squeezing the urethra. Most doctors and former patients swear by the TURP procedure—the disturbing symptoms of BPH are erased. Even though it takes several months after surgery to no longer pass blood in your urine and again achieve an erection without any difficulty, post-surgery most men are free of the maddening symptoms of their enlarged prostate.
Other surgical procedures (called radical prostatectomy) remove the prostate, are much more invasive, and have troublesome side effects such as incontinence and erectile dysfunction (ED). One study7 reports that fewer than half of the men who had surgery (specifically, bilateral nerve sparing radical prostatectomy) felt that their sex lives had returned to normal within a year.
Although an enlarged prostate will eventually occur for nearly all men, there are some complications you don’t have to accept and can treat. Most men who experience BPH can manage their mild to moderate symptoms with nonsurgical therapies and, often, nonpharmaceutical therapies. There are some herbal treatments. Even making some lifestyle changes can help control the symptoms and prevent your condition from worsening. For example, staying active rather than being a couch potato helps reduce symptoms, and it is commonly advised that you reduce your caffeine and alcohol intake, as well as not drinking anything for 2 hours before heading to bed.
Your kidneys are bean shaped and about the size of a man’s fist. They really do look like kidney beans, just larger. They are located below the rib cage, one on each side of the spinal column. They regulate the body’s fluid volume and electrolytes (which include sodium and calcium) by daily cleaning about 200 quarts of (dirty) blood, separating out roughly 2 quarts of extra water and waste products from the blood. The extra water and waste become urine, which is stored in your bladder until you urinate.
Kidney Stone Symptoms That Warrant Seeing a Physician
• Extreme pain in your back or side that will not go away
• Cramping that causes vomiting
• Blood in your urine
• Burning feeling when you urinate
• Urine that looks cloudy and/or smells bad
A kidney stone is a hard, crystal rock that forms in the kidney and is developed from calcium crystals and other salts that separate from the urine (see figure 15.3). The most common type of stone contains calcium in combination with either oxalate or phosphate. Kidney stones (sometimes called urinary stones) may be as small as a grain of sand or BB or, less often, even as large as a marble or golf ball.
Figure 15.3. A, stones forming and traveling in the kidney. B, size of stones compared with a Euro penny. A, Courtesy of rob3000/Shutterstock.com. B, © Eskimo71/Dreamstime.com.
If you get one stone, you are at risk for another, and men’s risk of kidney stones becomes more an issue as we get older. Kidney stones are common, affecting at least 12 percent of North American men by age 70.8 For reasons that are not yet known, the percentage of people with kidney stones has been rising since 1980, and while the gender ratio is narrowing some, men are at three times greater risk than women.9 Environmental and lifestyle factors play an important role in who is at risk. It is becoming apparent that kidney stones are associated with type 2 diabetes, hypertension, body size, and a diet that’s high in sodium and sugar.10 Some medications also raise men’s risk of kidney stones, particularly some of the diuretics and calcium-containing antacids.
Normally, urine contains chemicals that prevent or inhibit calcium crystals from forming. These chemical inhibitors do not seem to work for everyone, causing some men to form the stones. Kidney stones may not produce symptoms until they begin to move down the tubes (ureters) through which urine empties into the bladder. When the crystals remain tiny (e.g., grains of sand), they will travel through the entire urinary tract and pass out of the body in the urine without being noticed. Bigger kidney stones, the size of a BB or so, also can be passed while urinating but not without discomfort. These “larger” stones may impede or block the flow of urine out of the kidneys. This causes swelling of the kidney and pain. The pain is usually severe.
Men who have never passed a kidney stone may not realize the severity of the symptoms. Some men report an abrupt piercing, cramping pain in the lower back or side near a kidney or groin. As a rule the pain increases and decreases in severity, somewhat like the rhythm of ocean waves. Compared to the discomfort of an enlarged prostate when voiding, a kidney stone is significantly more painful. As the (smaller) kidney stones work their way down into the bladder and through the urethra, they will normally cause some blood in the urine—the stones are most often jagged or knotty (resembling coral more than marbles), though some are smooth.
Quite obviously, stones as large as a marble will not pass through the urethra. This type of stone usually stays in the kidney, and if it becomes troublesome, your urologist will take steps to get rid of it. No longer is invasive surgery the first line of treatment. Urologists now use a range of more effective treatment alternatives. For example, when the stones are marble sized, extracorporeal shock-wave lithotripsy (ESWL) can be used to send shock waves directly to the kidney stone from outside your body. Lying on a table, a medical technician uses ultrasound or low-energy X-ray images to identify the exact location of the stone(s), followed by ultrasonic waves (or shock waves) to break up stones into tiny pieces. These pieces leave the body in the urine. Multiple ESWL treatments may be required, especially for multiple stones.
Larger and/or harder stones will necessitate more invasive intervention. The preferred method is percutaneous nephrostolithotomy, or “tunnel surgery.” Percutaneous means that the procedure is done through the skin. The procedure involves a small skin puncture in your back and passing a tubular medical instrument (called a nephroscope) directly into the kidney. The scope creates the tunnel to the stone, which can be fragmented using ultrasonic waves, a laser, or electrohydraulic pressure (much like used in mining). The procedure necessitates general anesthesia and, often, a plastic tube (nephrostomy) temporarily left in the kidney and exiting from the back to assist in drainage of the urine for a few days.
The best prevention is to drink (more) water. Drinking lots of water helps to flush away the substances that form stones in the kidneys. Ironically, the good news is that regularly having a beer can help prevent kidney stones because beer provides an increase in magnesium intake, which helps prevent the calcium crystals from being formed in your kidneys; it is the stouts, porters, or other beers with lots of hops that are best.11 Do not misinterpret this research, however. Beer is also a source of empty calories associated with men’s belly fat (beer belly), and being overweight creates a greater risk for kidney stones and heart disease than the benefit of a beer is to preventing stones. If you are overweight, drink water.
In a society that is focused on and arguably obsessed with maintaining healthy lifestyles and now “healthy aging,” it comes as no surprise that sexual health is also at the forefront of our attention. The cultural maxim suggests that so long as the man sexually performs, his manhood is unquestioned. But should he fail to get and sustain an erection, his sexual health is not in question; his masculinity is. For most men, our sexual well-being is equated with the expectation that sexual function should be reliable. As a 58-year-old man reported, “I suppose in the most simplistic terms, I associate getting an erection with being a man.” Sexual performance proves masculinity, and impotence signals “failed” masculinity.
It is very likely that when men are partnered, healthy, and sexually active, sexual intercourse remains a routine dimension of a relationship. Researchers who study aging report that the salience of sexual activity slowly diminishes in its importance to relational intimacy as we age; however, “diminish” does not mean “end.” Sexual desire and activity continue to play a vital part in most men’s sense of self throughout their later years, whether gay or heterosexual.12 Being partnered and remaining bodily unchallenged, men regard their sexuality as a dimension of a relationship, something managed by their own and their partners’ sexual interest. Their sexuality is a taken-for-granted asset, like a heartbeat, until confronted by its failure.
Physiological aging and a decline in sexual function are not inevitably linked, even though much of the advertising for ED medication suggests as much. When, or if, sexual performance becomes a problem, the man first experiencing sexual difficulties may be turning 90, not 55. And, unlike his father’s generation, he has options. Since the introduction of the oral drug sildenafil citrate (Viagra™) in March 1998, drug advertising airing during the evening news and baseball games has encouraged men to remain “forever functional.”13 At first, the advertisements targeted older men and presented ED drugs as a magic bullet to solve a man’s impotence; however, the advertising now emphasizes a couple’s sexual interests. Lifestyle sexual health medications such as Tadalafi and Cialis can be taken daily and remain active in the man’s body for 24–36 hours.14
Men’s Birth Control: Vasectomy
Vasectomy is a safe and virtually foolproof birth control method. Men who have sought vasectomies are mostly white, married, and in their midthirties, and roughly a half million men seek a vasectomy every year in the United States. The surgical procedure takes about 30 minutes and involves blocking or cutting the tube (vas deferens) so that the man’s ejaculate no longer contains sperm. “No scalpel” vasectomies are most common.
For more than a decade, the AARP Magazine has commissioned studies to better understand middle-aged and older men’s (and women’s) sexual lives and sexual attitudes. By all accounts, men’s self-reported frequency of sex and the quality of their sexual relationship(s) have improved over the past 30 years. Indeed, though it’s a pleasure that’s falsely assumed to dwindle with aging, sex continues to play a very important part in many older men’s and their partners’ lives. Researchers regularly find that more middle-aged and older couples are having sex (and enjoyable, satisfying sex) than was found in earlier generations.15
Among men who maintain sexual interest—and most men do16—only one man in four is obliged to reformulate the meanings of sexual intimacy to bring it in line with his ED, which emerged as a result of an age-related health problem (such as diabetes) or a reaction to certain prescription drugs. Among older men who remain sexually active—and most men are17—their sexual activity may eventually shift to emphasize kissing, hugging, and sexual touching. The evolution of sexual activity from strictly coital sex to include other forms of sexual intimacy seems key to what sustains men’s sexual satisfaction. As we get older, our sex becomes more interactive. There is more time allowed for foreplay and talking and laughing. Older lovers are more pleasure oriented, and we enjoy the process of warming up much more than when we were younger. We don’t limit sex play to the genitals (see chapter 20).
The penis comprises three long cylindrical chambers (see figure 15.4). The single, smaller chamber on the bottom (called corpus spongisum) encircles the urethra, which is the tube for urine and ejaculate. The two large chambers on top (called corpora cavernosa) comprise most of the erectile tissue. Erectile tissue is structured like a sponge, containing irregularly sized spaces. When you are aroused, the arteries running through the corpora cavernosa open up and the expandable erectile tissues in all three chambers fill with blood. This produces the erection. The erection begins when a man becomes sexually aroused from a touch, a thought, something seen, or even something heard. Nerves from the brain send messages to the penis, which allows blood to enter but not exit. The penis will grow in size and stiffen. It does not become erect by itself. Erection requires sensory or mental stimulation, or both—interaction between the brain and the body. Hormone messengers sent from the brain to the local nerves in the penis cause the smooth muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces—much like a dry sponge expanding as it soaks up liquid. Once the muscles in the penis contract and begin to stop the inflow of blood, they open outflow channels and the erection is reversed.
Figure 15.4. Anatomy of the penis. From A. P. S. Kirkham, R. O. Illing, S. Minhas, et al. (2008). MR imaging of nonmalignant penile lesions. Radiographics, 28, 837-853, figure 1.
Expert opinion in sexual medicine indicates that having erections—with or without sex—helps preserve our sexual function. The clinical evidence suggests that men age 55–75 who have long periods without sexual arousal more likely have erectile difficulties. In addition, should you stop engaging in sexual activity, including masturbation, you’ve added to the risk of not being able to get or sustain an erection. Sexual arousal causes oxygenated blood to flow into the penis, and when this occurs, the health of the smooth muscles, nerve fibers, and blood vessels responsible for erectile function is maintained. A European study of nearly 1,000 older Finnish men found that the men who had infrequent sexual intercourse (less than once a week) doubled the risk of developing erectile difficulties.18
Is the message that we need to “use it or lose it”? Maybe not. Most men have several spontaneous erections each night while sleeping. Just by having erections at night, even in the absence of sexual activity, we have built-in neurobiological protection against any erosion of our erectile capabilities.
It is the smooth muscle of the penis, a type of muscle that can only relax and contract around the blood vessels, that lets blood flow into the three chambers to cause the penis to become erect. The pharmaceutical revolution that occurred in the late 1990s targeted those smooth muscles. Viagra, Levitra, and Cialis are PDE-5 inhibitors designed to block phosphodisterase type 5 (PDE-5), the enzyme that breaks down the erection-producing chemical in our bodies. The ED drugs relax smooth muscle cells and widen blood vessels to enable the penis to fill with blood, enhance the hardness and duration of an erection, and increase the ability to achieve a new erection shortly after ejaculation.
Occasional erection problems happen to most men. If you can’t maintain an erection long enough to have successful intercourse in over half of your attempts, you are experiencing ED. This varies in severity: it can be a total inability to achieve an erection, an inconsistent ability to do so, or an inability to maintain an erection for satisfactory sexual relations. ED severity has been assessed by the five-item International Index of Erectile Function, IIEF-5, which is also referred to as the Sexual Health Inventory for Men.19 Summing the responses to the five items provides you an IIEF score, and, based on the sum, ED severity is classified into the following five categories: severe ED (5–7), moderate (8–11), mild to moderate (12–16), mild (17–21), and no ED (22–25). Very few men have ED severe enough that they have no erectile response at all. But many men, especially as we get older and our heart health has been compromised, may experience some problems with erections.
It is estimated that nearly one-quarter to one-half of men will report some erectile difficulties,20 and roughly 5 percent of 40-year-old men versus 25–30 percent of 60-year-old men experience moderate to severe erectile problems.21 The pervasiveness of the condition is a result of the greater number of older men in the nation’s population. Erectile problems are associated with higher rates of chronic health problems—diabetes, obesity, hypertension, heart disease—and the medications and treatments used to manage these chronic conditions.22 Many drugs, both prescription and nonprescription, also interfere with the erectile response, particularly medication for lowering cholesterol or blood pressure. If you are taking regular medication for any health issues, do check your drugs for their side effects.
Common Causes of Erectile Dysfunction
• Coronary artery disease
• Diabetes
• Hypertension
• Kidney disease
• Medications (e.g., antidepressants, antiarrhythmics, antihypertensives)
• Smoking
• Heavy alcohol use
• Prostate surgery
• Trauma to spine or pelvis
• Anxiety
The onset of ED usually occurs slowly as a result of our health, but ED can be an unexpected side effect of surgery, trauma, or a new medication. By whatever way ED emerges, being unable to either have or sustain an erection causes distress, challenging men’s self-esteem and, at times, their sexual relationship(s). Commenting on how his self-esteem was rocked, one man disclosed,
Oh it was knocking [me] terrible. … I work with other men and I think it [my ED] knocked my confidence in certain ways. Not outwardly. Outwardly, it always seemed that I was one of the lads and that I was okay … but inside … I didn’t feel that I was matching up to them. I just felt I wasn’t as good as them basically.23
As a result of direct marketing to consumers, researchers find that more middle-aged and older men now feel an unrelenting pressure to be as sexually fit as they were when younger.24 Is it surprising that Pfizer sold approximately 1 billion pills in the first decade after Viagra™ was introduced?25
The first line of defense that will protect your sexual health and erectile functioning isn’t taking ED drugs; rather, it is to take steps to improve your overall health, especially your heart health. If you smoke, this means quit smoking. The incidence of ED is nearly twice as great in men who are smokers compared to nonsmokers.26 Study after study shows that cigarette smoking has an awfully negative effect on a man’s ability to have or sustain an erection.27 In one study, for example, men who smoke more than 20 cigarettes a day had a 60 percent higher risk of ED, compared to men who never smoked.28 To improve your erectile health also means taking up a healthy low-fat, low-sodium, and low-cholesterol diet; cutting back on the alcohol; and getting more exercise. Exercise alone improves blood flow, gets the (bad) cholesterol out of your blood, and improves libido and mood. Cutting back on the alcohol decreases the risk that you will experience a limp penis.
INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF-5)
When health problems or one of your medications interfere and lifestyle changes are not enough to overcome your erectile difficulties, there are effective ED medications. Viagra, Levitra, and Cialis have revolutionized the treatment of erectile troubles and virtually replaced the complicated and painful options that existed before the mid-1990s. But these ED drugs are not miracle cures. The medications work via a very complicated series of biochemical reactions to help create an erection. The drugs do not produce desire, nor do they affect your libido. You have to be sexually aroused for the drugs to have any effect. When you are “turned on,” the medication kicks in.
You also need a partner who accepts or supports your use of the erection-assisting medication; otherwise, the sexual experience will not result in a pleasant experience for either you or your partner.29 When you and your partner are in sync about you using an ED drug, the research suggests that there are significant improvements in the quality of sexual relations, men’s self-esteem and hardness confidence, and partners’ reports of sexual satisfaction (see also chapter 20).30
Side effects, when reported, can include temporary vision changes (in the case of Viagra), back pain and muscle aches (in the case of Levitra), indigestion, headache, flushing of the skin, and a stuffy or runny nose. It is rare, but a few men have reported hearing and vision loss and an erection that will not go away.
Sex researchers caution that it can be difficult for heterosexual men’s wives to fully understand what effects ED has on men. To bridge this gap, you should talk to your partner about your feelings, your erectile difficulties, and your sexual preferences going forward. Without the conversation, it is understandable that your sexual partner might use sexual myths to guide him or her and falsely presume that your erectile difficulties equal impotence, or he or she might mistakenly believe that avoiding sex altogether is helpful. Hence, have an in-depth conversation with your partner about your sexual health and your and your partner’s sexual intimacy preferences.
Most sexually transmitted infections (STIs) and STDs are passed from one person to the next through contact with an infected sexual partner’s bodily fluids such as semen, pre-ejaculate (the few drops of semen that are released before ejaculation), vaginal secretions, and blood. Yet some types of STIs (e.g., human papillomavirus, or HPV) and STDs (e.g., herpes, cytomegalovirus, syphilis) can be transmitted simply through intimate contact, including kissing and touching. STDs are caused by viruses, bacteria, or parasites that survive in moist, warm surroundings such as your mouth, urethra, anus, and a woman’s vagina. Take note: there are more than 25 different infections or diseases that may be spread from one person to another when the contact is vaginal intercourse, oral sex, anal sex, or (sometimes) even kissing. The surest way to avoid transmission of STDs is to be in a long-term mutually monogamous relationship with a partner who is known to be uninfected.
STDs are more widespread among middle-aged and older adults than you might first think, and your risk of getting an STD does not decrease just because you are getting older. In fact, the risk of getting an STD has more than doubled in the past 10–15 years for men age 50 and older.31 Experts attribute this marked rise of infection rates among boomer-age and older men to sociological trends, such as higher midlife divorce rates and the straightforwardness of online dating services to meet new sexual partners, as well as to a greater open-mindedness among Americans about having sex (or a sexual relationship) outside a marriage or monogamous partnership. Expert opinion also acknowledges that the principal reason for the escalation of STDs is a lack of sexual knowledge and failure to engage in safer sex.32
What increases a mature man’s risk? The risk boils down to one basic lesson: you’re at risk of contracting an STI if you take on a new sexual partner, and you are at great risk if you do not practice “safer sex.” It isn’t unusual for boomer-age and older men to have a new partner or multiple partners. Many divorced and widowed men begin dating again, and they are very likely to become involved with multiple new partners. Perhaps as a consequence of the “newness” of dating again and the availability of multiple partners, research shows that this group of men engages in sex more often than same-age married men. The use of ED drugs by some of these men also seems to further add to their risk of an STD, by making sex possible and by engaging in higher-risk sexual behavior, whether by the number or type of sexual encounters or not using a condom.33 The lesson is that dating again fuels the risk of picking up an STD and passing it to a partner, often without knowing it.34
In addition, more middle-aged and older married men are having sex outside marriage compared to prior generations. A 2009 AARP study found that one-fifth of the men (age 45 and older) acknowledged already having had a sexual relationship outside their primary relationship. And a report from the Centers for Disease Control and Prevention (CDC) estimated that 6 percent of married men had sexual contact with more than one opposite-sex partner during the past year.35 Because these estimates are based on what men report and there has been a stigma against having sex outside marriage, the AARP’s and CDC’s estimates are surely conservative. The likelihood of a married man becoming involved in what is sometimes still called an “extramarital” relation is highest during the early years of marriage, decreases to a low point until about the time of the eighteenth wedding anniversary, and thereafter increases continuously.36 Knowing this, is it surprising that 40 percent of middle-aged men and one-third of older men say they did not feel it is “always wrong” to have sex with someone other than a partner, particularly when their partner either has dementia or is physically ill and cannot have sex?37
Experts say that we are more likely to find a new sexual partner when we are involved in a “sexless marriage”—one in which a couple make love no more than 10 times a year, whether the cause is someone’s physical health or loss of interest. Among men age 50–65, roughly 20 percent of their marriages fall into this category.38 In the same study, 85–90 percent of the men felt that a satisfying sexual relationship was important to their quality of life. The takeaway message here is that men who value the importance of sex are apt to pursue a new sexual liaison.39
The risk of an STI among middle-aged and older men is markedly increased because they are less likely to use condoms. One study reveals that roughly 90 percent of men over age 50 did not use a condom when they had sex with a date or casual acquaintance, and 70 percent didn’t even do so when they had sex with someone they just met.40 In another study, just 12 percent of the sexually active men age 50 and older who were unmarried and actively dating reported regularly using a condom.41 Perhaps after years of being with one partner, men build up a false confidence that they’re not at risk of an STD. This is, of course, magical thinking and puts you at great risk.
In addition, most boomer-age and older men who used condoms 30 years ago didn’t enjoy the experience, and many aren’t aware of the new generation of thin condoms that do not take away from erotic sensations. Condoms are now sold in various colors, tastes, shapes, and packaging to match personal preferences. All condoms must comply with FDA requirements—they must be constructed to be protective. Correct and consistent use of condoms will sharply reduce the risk of getting an STD.
Whatever the cause—midlife divorce, widowers dating again, a sexual liaison outside marriage, online dating, high-risk sex, or simple ignorance—imagine the following: You have just been to the doctor and received the devastating news that you have an STD. Do not be hesitant to find out what this means for your health and your future sexual activity. Can you control the symptoms, and are the effects of men’s STDs more serious than just embarrassing?
Chlamydia is the most commonly reported bacterial-based STI men encounter and is spread through vaginal or anal intercourse. Chlamydia can be diagnosed using a sample of urine. The most common site of the infection is inside the urethra (the tube through which men urinate and pass sperm). During unprotected sex, the bacteria are transferred through genital fluids from one partner to the other. Symptoms include watery discharge from the penis or anus, burning pain during urination, and painful intercourse; a symptom may show up within 1–3 weeks after having sex, yet one-quarter of men with chlamydia remain symptomless and unknowingly affect their partners’ sexual health. Because it is bacterial, it can be treated with antibiotics; if untreated, it can lead to pneumonia, serious urinary tract infection, and even eye infections.
There really are new, super thin, and not-so-tight condoms on the market these days. The thinner condoms balloon slightly over the penis, with a layer of lubricant, and then there’s an outer thin skin that makes sure that sperm can’t leak out. Men tell me they feel great and are very sexy and effective.
Source: Schwartz, P. (2010, May). Not your grandma’s condoms. AARP.
HPV and genital warts are closely related. There are more than 40 different types of HPV, and most have no symptoms among men. As of this writing, there is no test to find HPV in men. Though most men who get any type of HPV are asymptomatic and never develop noticeable health problems, passing on this virus to a female partner can lead to serious and irreversible damage, such as causing her cervical cancer. HPV is transferred through genital contact, usually during vaginal and anal sex. It may also be passed on during oral sex. Practicing safer sex (using a condom) protects the health of all of your partners, present and future, as well as yourself.
Some types of HPV infect men’s genital areas, including the skin on and around the penis or anus; other types can infect the mouth and throat. The more common HPV infections cause genital warts; some forms of HPV can cause penile, anal, or head and neck cancer. The types of HPV that cause genital warts are not the same as the types that can cause cancer. Genital warts are small, flat or raised, cauliflower shaped, and found on the penis, testicles, or anus. They can show up in just a few weeks but up to even 8 months after having sex with someone infected with HPV. The warts don’t go away on their own, and left untreated, they can be painful, eventually growing to block the opening of the urethra. Because HPV cannot be cured, topical medication (involving trichloracetic acid) or laser surgery can remove the warts, yet the warts may recur since the virus stays in your body.
Hepatitis B (HBV) is a viral infection involving the liver; there is no cure for men already infected. You may have already contracted hepatitis B and do not know it, because most men who are infected are asymptomatic. This virus is spread during vaginal, oral, or anal sex, and it’s “incubation” period lasts 6 weeks to 8 months. If you are having sex with an infected partner, your risk is greatest when exposed to blood and a bit less when exposed to other body fluids (e.g., semen, vaginal secretions). Men having sex with men are at greater risk than men exclusively having sex with women. The onset of symptoms causes flu-like feelings that don’t go away, nagging tiredness, discolored or dark urine, and liver damage and consequently becoming jaundiced (or yellowing of the skin). Even though there is a possibility that this infection may clear up on its own, some men suffer through chronic infections for many years.
Gonorrhea (“the clap”) remains a common STD. This, too, is bacterial and treatable with antibiotics. Gonorrhea is spread through contact with the vagina, anus, penis, or mouth; to reiterate, you can become infected without intercourse or ejaculation occurring, since transferring the bacteria from the infected person to you occurs simply by direct contact. The bacteria usually grow in your urinary track, but they can also be found in your anus, mouth, and throat. Roughly 10 percent of men with gonorrhea have no symptoms at all. Most men, however, begin to have symptoms within 2–5 days after infection, while some symptoms can take as long as 15–30 days to appear. The typical symptoms include a pus-like discharge from the penis, a burning or painful sensation when urinating caused by urethritis, or a rectal infection that includes discharge, soreness, and anal itching caused by proctitis. Many men will also experience epididymitis, a painful condition where bacteria has spread from the urethra into the ducts attached to the testicles. Untreated, gonorrhea is dangerous—it can cause heart problems, kidney problems, arthritis, and disorders of the central nervous system. Once diagnosed, the disease is easily treatable with an antibiotic, either in pill form or by injection; if it’s an injection, a single dose is usually all that is required. Oral antibiotics require a longer course of treatment. Common antibiotics are ofloxacin, cefixime, and ceftriaxone.
The herpes simplex virus has two variations: type 1 (or HSV-1) isn’t common and most likely affects the lips and mouth in the form of cold sores; the more common strain (HSV-2) emerges in the genital and anal area. HSV-2 is one of the most common STDs and will show up 2–7 days after having sex, though the symptoms can emerge as late as 30 days after having sex. A small proportion of men can have no symptoms, but most do. Common symptoms include small, painful blisters on the penis or mouth that will burst, leaving small, equally painful sores; itching or tingling sensations in the genital or anal area; and flu-like symptoms that involve swollen glands or fever. The blisters last 1–3 weeks and will go away untreated, but you still have herpes. Herpes cannot be cured. Once the first outbreak of blisters subsides, the herpes virus goes dormant and hides in the nerve fibers near the infection site. Symptoms may come back later, particularly during times of stress, in less severe and shorter episodes.
HIV/AIDS is a viral-based STD that is the most serious and potentially deadly of all STDs. The number of men age 50 and older living with the human immunodeficiency virus (HIV) has been increasing in recent years; this age cohort accounts for 15 percent of new HIV diagnoses and roughly 25 percent of all HIV/AIDS cases.42 The increase has multiple causes; for example, many boomer-age and older men are having unprotected sex with new partners,43 and the antiretroviral therapy (HAART) has made it possible for many HIV-infected men and women to live longer, even though their HIV can never be cured and can continue to be spread through unsafe sex.
HIV is primarily transmitted during vaginal, anal, or oral sex. One-third of all new cases of HIV/AIDS occur among men exposed through high-risk heterosexual relations; half of the new cases occur among men who have sex with men. The rates of HIV are 12 times greater among black men than white men, and five times higher among Hispanic men than white men.44 HIV symptoms develop slowly, usually showing up over the course of several months, but maybe not until several years have passed after contact with the virus. Men and women living with HIV may not know that they have it, since they could remain asymptomatic and undiagnosed for several years; it is this group that is most likely to unknowingly spread the virus when engaging in unsafe sex.
It is difficult to first notice that you have HIV; the most common symptoms are weight loss and tiredness, flu-like symptoms that just don’t go away, diarrhea, and, sometimes, white spots in the mouth. Because of the stigma of HIV/AIDS, middle-aged and older men may be reluctant to see a physician or seek HIV testing. If you have been recently dating, regular HIV testing is recommended. When you see your physician for a regular checkup, it’s likely that he or she will underestimate your sexual activity or else not discuss it at all and, in turn, not offer HIV testing or discuss prevention. Take charge and talk to your physician. While treatment for this infection can significantly prolong an infected man’s life, for far too many men (and women) this infection eventually progresses to AIDS and, in the end, death.
Syphilis (“the pox”) is another bacterial infection that is usually transmitted through vaginal, oral, and anal intercourse, as well as kissing. It’s very contagious when the infected person has sores, yet not as contagious when the infection is temporarily inactive. It is very easy to cure in its early stages. A single injection of penicillin will cure a person who has had syphilis for less than a year. For someone who has had it for longer than a year, additional doses of an antibiotic are necessary. Not many cases of syphilis occur among people aged 50 and older, and two-thirds of recent cases of syphilis were among men who have sex with men. The CDC recommends that men who have sex with men be tested for syphilis annually.45
When syphilis is undiagnosed and untreated, the infection can go through three phases, and its symptoms can be difficult to recognize. During the first phase, the symptoms include painless sores (or ulcers) on the mouth, lips, genitals, or anus; they show up sometime between 3 and 12 weeks after exposure and last roughly a month. These sores (called chancres) not only spread syphilis but also make it easier to transmit and acquire the HIV infection sexually. The sores fade away after a month, but you still have syphilis. Left untreated, the infection progresses to the second phase, and new symptoms appear, ranging from body rashes, even on the soles of the feet and palms of the hands, to flu-like feelings such as fever, fatigue, weight loss, muscle aches, and swollen glands in the groin. These symptoms may also come and go for 2 years. Finally, should the infection continue to be untreated, it becomes a tertiary infection that eventually damages the brain and heart. This occurred too often for men several generations back. Whatever damage was caused by the infection before it is treated cannot be undone. This STD can be diagnosed through a blood test and/or examination of the fluid that oozes from the sores.
Aside from sexual intimacy in a trustworthy monogamous relationship, there’s only one foolproof way to avoid an STI or STD—to abstain from sex. But this isn’t a realistic option for men who enjoy sexual intimacy. The best alternative is to practice “safer sex” (not safe sex). Safer sex means taking precautions during sexual activity to protect yourself from getting an STD and to help prevent STDs from being spread to your partner. It recognizes that the risk of STD transmission isn’t assured, because there is no way of knowing with certainty that a new sexual partner is not already infected. Practicing safer sex doesn’t mean eliminating sex from your life, nor does it mean eliminating erotic feelings. What it does mean is being smart and staying healthy. It requires prior planning and good communication between partners. It means showing love and respect for your partner(s) and for yourself. Safer sex means enjoying sex to the fullest without acquiring or transmitting sexually related infections.
One of the best methods to lower the per-act risk of STD transmission is for men to use condoms when engaging in vaginal, anal, or oral intercourse. Condom use isolates body fluids and thus helps us avoid contact with vaginal fluids, semen, or blood, should your partner be infected and absolutely unaware of being infected. Incorrect condom use, not just the bad decision to not use a condom, may also lead to STD transmission, since transmission can occur with a single act of intercourse with an infected partner (see insert on correct condom use).
All in all, condoms and communication make sex much safer. Typically, condoms are meant to fit any average-sized penis (approximately 4–7 inches). Early studies on heterosexual transmission of an STD established that male-to-female transmission to the vagina was significantly more likely than female-to-male transmission from the vagina, and the early evidence also showed that being the receptive partner in unprotected penileanal intercourse is associated with a high risk of an STI.46 These patterns urge us to recognize that protecting the health of our partner (and ourself) is best accomplished by discussing and using safer sex practices and being honest about our sexual history. Step up, be responsible, and have fun experiencing the sexual intimacy you want and deserve.
How to Use a Condom Correctly
• Use a new condom for every act of vaginal, anal, and oral sex throughout the entire sex act (from start to finish).
• Before any genital contact, put the condom on the tip of your erect penis with the rolled side out.
• Do not unroll the condom before placing it on the penis.
• If the condom does not have a reservoir tip, pinch the tip enough to leave a half-inch space for semen to collect.
• Holding the tip, unroll the condom all the way to the base of the erect penis.
• Make sure to always eliminate any air in the tip to help keep the condom from breaking.
• If you feel the condom break, stop immediately, withdraw from your partner, and put on a new condom.
• After ejaculation and before the penis gets soft, grip the rim of the condom and carefully withdraw from your partner.
• Remove the condom by gently pulling the condom off your penis, making sure that semen doesn’t spill out.
• Wrap the condom in a tissue and throw it in the trash where others won’t handle it.
• Ensure that adequate lubrication is used during vaginal and anal sex, which might require water-based lubricants. Oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) should not be used because they can weaken latex, causing breakage.
Source: Department of Health and Human Services (2010). Male latex condoms and sexually transmitted diseases: Condom fact sheet in brief. Atlanta: Centers for Disease Control and Prevention.