In 1487, during the Spanish Inquisition, this statement was reportedly uttered by Malleus Malleficarum: "When the member is in no way stirred and can never perform the act of coitus, this is a fridigity of nature, but when it is stirred and yet cannot become erect, it is a sign of witchcraft" (Trethowan, 1963).
Impotence in elderly men has until recently been relegated to the area of witchcraft and has been ignored by most health-care professionals. Indeed, even the public view has remained largely unchanged over the past 500 years. Some physicians, particularly urologists, are interested in the problem, and due to the discovery of some viable solutions, they are bringing the problem to the attention of others. Other health-care professionals and some members of the public are discovering that impotence is an acceptable and even common problem. Solutions have become more available and more widely accepted in the past decade. In view of the fact that by the year 2030, it is estimated that 21.1% of the United States population will be over the age of 65 (Morley, 1986), changing attitudes are necessary. Gerontological nurses must seize the opportunity to make an impact on these changing attitudes and assist those afflicted to find solutions.
The diagnostic criteria of male erectile disorder (impotence) is either one of the following:
1) Persistent or recurrent partial or complete failure in a male to attain or maintain erection until completion of sexual activity. 2) Persistent or recurrent lack of a subjective sense of sexual excitement and pleasure in a male during sexual activity (Leiblum, 1990).
Masters, Johnson, and Kolodny (1988) also define impotence as the inability to have or maintain an erection that is firm enough for coitus. These authors divide the problem into two categories. The first are those men who have never been able to have intercourse. These men are said to have primary erectile dysfunction. Those who have had successful intercourse once, twice, or multiple times are said to have secondary erectile dysfunction. As almost all men have had some difficulty with erections at least once in their lives, these authors classify a client as having a secondary erectile dysfunction if the problem occurs in at least 25% of sexual encounters. This article addresses secondary erectile dysfunction, as no mention of primary dysfunction appears in the literature as a problem in older men.
Masters, Johnson, and Kolodny (1988) point out that sexual dysfunction due to impotence can lead to fears of performing, which can perpetuate the problem. They state that the ability to maintain a firm erection is extremely important to most men and women in this culture.
While there are some men and women who see sex as more than a throbbing, erect penis and do not judge the satisfaction of a sexual encounter on the basis of having intercourse alone, for most people the practical limitations of erectile dysfunction are bothersome (Masters, 1988).
Typically, men react to sexual dysfunction with great dismay, which, coupled with shame and humuliation, can erode many relationships (Cozad, 1988; Masters, 1988).
Impotence in Older Men
The prevalence of impotence increases with age. Whereas 7% of men aged 25 to 54 suffer from this dysfunction, the percentage jumps to 8% of those 55 to 64, 25% of those 65 to 74, 55% of those aged 75 to 84, and 75% of those over the age of 85 years (Morley, 1988). According to Walbroehl (1990), aging changes cause men to experience less sensation in the genital area and a longer refractory period (the interval following ejaculation during which the man cannot sustain another erection and ejaculation regardless of the extent of stimulation). Multiple causes are attributed to impotence in older men, making it a complex problem deserving specialized attention (Morley, 1988).
Morley, one of the major contributors to the scholarly work on impotence in older men, notes that general medical beliefs have not advanced much in 500 years, when lack of an erection was deemed the work of "witchcraft" (1986). Morley believes that most practitioners StUl feel that impotence is psychological, with the fears, phobias, and guilt associated with sexual intercourse as the cause. In 1910, one of Freud's pupils stated that 90% of impotence is psychogenic, and this has remained the prevailing view in medicine (Morley, 1988).
Morley (1986) compares the referral bases of five different sources of patients with impotence. Of note is that family physicians report that 38% of impotence cases are psychogenic in origin, and urologists report 31 % psychogenic in origin; sex therapists, endocrinologists, and medical physicians, on the other hand, report that 12% to 19% have psychogenic causes. Obviously, some confusion still exists as to the cause of impotence, and this can only lead to inconsistencies in evaluative and treatment protocols.
On a positive note, the past decade has brought about increasing recognition that impotence is a common problem in men over 50 years of age (Morley, 1988). In a study of medical outpatients, clients were eager to discuss and seek evaluation of the problem (Slag, 1983). The researchers identified 401 subjects (of a total sample of 1,180) with impotence through direct inquiry, when previously only six were identified. This gives credence to the fact that the question must be asked. Morley (1988) points out that although physicians are always obliged to check the medical causes of chest pain before assuming psychogenic causes, when an older man complains of impotence, psychogenic causes are usually the first that come to mind. Slowly, some experts are beginning to break this pattern and change the history of this approach to impotence.
Experts recently involved in the study of impotency in elderly men have described three separate profiles of these men. First are those types of impotency that can be attributed to organic causes, second are those that have solely psychogenic causes, and third are combinations of the above (P. Mahmood, personal communication, February 1990; Morley, 1988;).
Penile tumescence (erection) requires a coordinated interaction of the vascular, hormonal, and nervous systems (Morley, 1986). This is probably why impotence can have multiple causes in older men; these systems can slow down simultaneously as normal aging occurs (Morley, 1988). In addition, the psychological effects of the multiple losses of aging (eg, retirement, loss of spouse or friends) can cause depression, which can lead to sexual performance anxiety (Morley, 1987; Wahlbroehl, 1988).
Kravis and Molitch (1990) state that the most common medical causes of impotence are endocrine in nature. These include hypogonadism, thyroid dysfunctions, and diabetes. These authors attribute endocrine disorders with 25% to 35% of all impotence, with two thirds being due to primary sex abnormalities and one third due to complications of diabetes. Other medical causes of impotence are vascular disease, neuropathy related to alcoholism, medication side effects, and zinc deficiencies (Morley, 1987). Slag et al (1983) noted that many clients who became impotent secondary to medications, when questioned, gave their impotence as a reason for noncompliance with medications.
Evaluation for causes of impotence begins with a history and a screening for major psychological problems with the client and, ideally, his spouse (P. Mahmood, February 1990; Morley, 1987). Levels of testosterone and luteinizing hormone should be measured, as well as thyroid and zinc levels (Morley, 1986). A work-up for diabetes, alcohol related neuropathy, and medication side effects is also necessary. Diabetes can cause vascular as well as neural changes, which lead to irreversible impotence (Morrison, 1988).
A differential diagnosis of psychological versus medical causes can be ascertained by tests of nocturnal penile tumescence. Morley (1986) and Slag et al (1983) describe tests of the turgidity of the erection; these range from expensive inpatient tests where the client must stay overnight for three nights to a simple test using stamps, which can be self-administered at home. The preferred test is the use of a Dacomed sheath, which fits over the penis, because it is convenient and reimbursable by most insurance companies. The sheath contains wires of different strengths that will stay intact or break, depending on the strength of the erection. The stamp test is a variation of this. Four holiday seals are wrapped snugly around the penis with the overlapping stamp moistened to seal the ring. A positive test is indicated by a stamp that is broken along the perforations when the patient awakens in the morning.
Vasculogenic causes can be evaluated with Doppler ultrasound of the penis, and the readings compared with brachial systolic pressures. Values below 0.7 of the brachial pressure are indicative of a vasculogenic problem (Morley, 1986; Slag, 1983). Techniques for measuring venous leak or veno-occlusive dysfunction are currently being developed (Payton, 1988) and are not widely used (P. Mahmood, personal communication, February 1990).
At a recent meeting of Impotents Anonymous, the positive outlook of the longstanding members was evident. They continuously reiterated that "help is available." Indeed, the physician who attended the meeting stated that it is rare that anyone who requests help is not at least partially satisfied (P. Mahmood, personal communication, February 1990).
Sex therapy is available for clients and spouses, and is probably most helpful when an interested spouse is involved (P. Mahmood, personal communication, February 1990; Wallace, 1987). Psychosexual counseling involves re-education, redirection, and graded sexual exposure (Wallace, 1987). In an older man to whom sexual prowess was always important, aging changes may be discouraging. Another potentially serious problem, termed geriatric sexuality breakdown syndrome, is described by Walbroehl (1988). This occurs because society views sexual desires as unnatural in the elderly population, and can cause older persons to feel guilty when they experience sexual desires. Therapy is also helpful to augment treatment when medical causes are identified, or when a combination of factors are involved (P. Mahmood, personal communication, February 1990).
Patients with low levels of testosterone are sometimes helped by treatment with testosterone injections (Kravis, 1990). Zinc replacement has also been found to be helpful in those with zinc deficiency (often concurrent with hypogonadism) (Morley, 1987). Treatment of diabetes may not reverse impotence, but it is necessary to maximize functioning (Morrison, 1988). Management of medical illnesses (especially hypertension) with medications that do not have impotence as a side effect is sometimes difficult, but a competent physician who is willing to work with the client can usually come up with an appropriate treatment plan (P. Mahmood, personal communication, February 1990; Slag, 1983).
The newest and widely accepted treatment for impotence is the Pharmocological Erection Program (PEP) injection. This is an injection of vasoactive agents that reduce the resistance of arteriolar and cavernosal smooth muscle tissue, leading to increased arterial flow that creates subsequent venous trapping (Williams, 1989). The most common drugs used are papaverine and phentolamine (P. Mahmood, personal communication, February 1990; Pay ton, 1988; Williams, 1989).
The dose is tailored to each patient by trial and error to achieve an erection that lasts the desired time but not greater than 2 hours (P. Mahmood, personal communication, February 1990). This is to avoid priapism, whereby the client is unable to stop the erection, and which could lead to permanent damage of the penis. Priapism should be treated immediately by aspirating 70 mL to 100 mL of blood from the corpora (Morley, 1987) or by using an antidote (P. Mahmood, personal communication, February 1990).
Preliminary research by Sidi (1988) showed a high degree of patient and marital satisfaction and increased well-being in clients. A 50% dropout rate for the program was noted, and reasons given included cost, need for frequent follow-up, and concerns about administering injections. PEP injections have also been used to bolster self-confidence in cases of psychogenic impotence (Morley, 1988). Usually after a few injections, the client no longer needs the medication and can achieve erections on his own (P Mahmood, personal communication, February 1990; Morley, 1988;).
Penile implants were favored by two people at a recent Impotents Anonymous meeting (1990). "Currently, three types are available: the semi-rigid, the adjustable malleable or hinged, and the inflatable" (Morley, 1986). In 1988, Morley reported that penile prosthesis have proven 80% satisfactory in a number of series. Salesmen at an Impotents Anonymous (1990) meeting showed the semi-rigid and the inflatable (with balloon inserted in the testicular area), and stated that these were the most popular options. There is also a variation of the inflatable prosthesis, with the reservoir implanted in the abdomen (Morrison, 1988).
Penile implant surgery is simple, with only very small incisions required in the penis, testicular area, and abdomen (Holmes, 1987; P. Mahmood, personal communication, February 1990). It should be noted that once these devices are implanted, irreversible tissue damage occurs; if the implant must be removed, any erectile function that was left prior to implantation will be lost (P. Mahmood, personal communication, February 1990). The only other serious complication is postoperative infection (Holmes, 1987; P. Mahmood, personal communication, February 1990).
Surgical penile arterial revascularization procedures have been developed in the last 15 years (Pay ton, 1988). In 200 procedures performed at the Boston University Medical Center, Payton (1988) states that 80% of clients reported improvement in erections. This procedure is appropriate only for persons with "failure to fill" and "failure to store" impotence (Payton, 1988).
Support groups are emerging for impotent men. I discovered the existence of a local Impotents Anonymous chapter through an advertisement in a local newspaper. Impotents Anonymous is part of a national organization entitled Impotence Institute of America and has been in existence for 4 years. An introductory flier states that the organization is committed to helping impotent men and their spouses cope with this difficult problem.
During the session I attended, about one third of the 16 men attending claimed to have been helped by injections or prostheses. Several participants asked questions about the use of these treatments. Two wives of patients using injections shared their experiences in learning how to administer and in using the injections. One new participant expressed fears of being swindled by the medical profession for unsuccessful treatments, although he had tried none of them. The session seemed to fulfill its purpose of allaying the fears of those who came and in providing a variety of helpful information. The presence of a nurse and a urologist enhanced the group, but they in no way controlled or dominated the group discussion. The group was facilitated by a married couple who have successfully used the PEP injection twice a week for 4 years. Although all of the clients remained anonymous, I estimated that no one present (except the prostheses salesmen) was under the age of 50 years. Two participants admitted to being over age 70, and many more appeared to be in that age bracket.
On a national level, the founders of the Impotence Institute of America have published two "messages" in the Journal of Urologie Nursing (MacKenzie & MacKenzie, 1989; Mackenzie, 1989). These messages encourage health-care professionals to be aware of the problem as being treatable, and to encourage patients who seek it to get help. The role of nursing in setting up and encouraging support groups is emphasized.
IMPLICATIONS FOR GERONTOLOGICAL NURSES
Exploration of information and resources should be the responsibility of any gerontological nurse who has male clients. Little is available in nursing literature as yet. Using a wellness perspective, the topic can be addressed as one that is common to this age group, but that can be helped by a variety of approaches. It is imperative that nurses advocate for their clients in advising a thorough assessment and careful planning in the use of prosthetic devices. Gerontological nurses should serve as resource persons, offering support and guidance with this timely but touchy subject.
In a recent wellness group for 12 men over the age of 65, a 1-hour session was devoted to the topic of impotence. The session was run by a female nurse who was knowledgeable of the topic. The men accepted the presence of the woman and they discussed the topic openly. In fact, they had asked that the topic be addressed several weeks prior to the formation of the wellness group. An overview of assessment and options for impotence was presented. The men were able to ventilate their feelings about the frustrations they experience and the general attitude of society. Some expressed an interest in having their wives attend future sessions.
In addition to providing information and offering support, gerontological nurses have an ideal opportunity to study the affect of such sessions on the participants. This could provide needed information in a field that previously has given data on medical interventions but little other insight.
As the elderly of this nation become a more active voice, and as elderly clients are asserting themselves to discover solutions to their problems, gerontological nurses can play a vital role in the newly acknowledged problem of impotence in older men.
- Cozad, J. Impotence: Psychosocial aspects, evaluation methods and treatments. Urologie Nursing 1988; 9(2):10-12.
- Holmes, P. New treatments for impotence. Nursing Times 1987; 83(34):42-44.
- Impotents Anonymous. Monthly OceanMonmouth County Chapter Meeting, Paul Kimbal Medical Center, February 1990.
- Kravis, D., Molitch, M. Endocrine causes of impotence. Medical Aspects of Human Sexuality 1990; 24:62-67.
- Leiblum, S.R., Rosen, R-C. Sexual inquiry and the management of sexual concerns. Sexuality in the 1990s: Issues, controversies, new directions. Robert Wood Johnson Medical School, Piscataway, New Jersey. Unpublished handbook.
- Mackenzie, BA., Mackenzie, E.V. Message from the impotence institute of America. Journal of Urological Nursing 1989; 8(1): 559-561.
- Mackenzie, E.V. I.A. and I-ANON: Points to ponder. Journal of Urological Nursing 1989; 7(4): 516-517.
- Masters, W.H., Johnson, V.E., Kolodny, R.C. Human sexuality, 3rd ed. Boston: Scott Fbrresman & Co, 1988; 501.
- Morley, JE. Impotence. Am J Med 1986; 80:897905.
- Morley, J.E., Korenmen, S.G., Mooradian, A.D., Kaiser, EE. UCLA geriatric grand rounds: Sexual dysfunction in the elderly male. J Am Geriatr Soc 1987; 35:1014-1022.
- Morley, J.E. Impotence in older men. Hasp Pract 1988; 23:139-142,145-146,152-153,157158.
- Morrison, H. Diabetic impotence. Nursing Times. 1988; 84(32):35-37.
- Payton, XR. Impotence: A non-prosthetic approach. Urologie Nursing 1988; 9(l):10-20.
- Sidi, A.A. Vasoconstrictive intracavernous pharmacotherapy. In RJ. Krane, ed. The urologie clinics of North America. 1988; 15:95-101.
- Slag, M.F., Morley, J.E., Elson, M.K., Trence, D.L., Nelson, CJ., Nelson, A.E., et al. Impotence in medical clinic outpatients. JAMA 1983; 249:1736-1740.
- Trethowan, W.H. The demonopathology of impotence. Br J Psychiatry 1963; 109:341-347.
- Wahlbroehl, CS. Effects of medical problems on sexuality in the elderly. Medical Aspects of Human Sexuality 1988; 22:56-66.
- Wallace, J. Impotence. Nursing Times 1987; 83(49):42-43.
- Williams, L. Pharmacological erection programs: A treatment option for erectile dysfunction. Rehabilitation Nursing 1989; 14:264168.