For far too long, the literature on sexuality and men with disabilities has focused on the ability to get an erection and to father a child. While erections and fertility are important issues, men’s sexual health encompasses much more. Testicular and prostate health, hormonal function, age related changes, psychological status, and lifestyle choices all contribute to sexual health.
Doctors tend to shortchange these aspects of sexual health for men with disabilities. It may be that in the limited time allotted for office visits, the appointment is focused on specific disability related concerns. Another contributing factor may be that the longevity of disabled men is so much less that some physicians do not do a complete battery of tests because they believe the results will not effect the patient’s long term survival. Whatever the case, men with disabilities need to be armed with the same information as all other men so that they can advocate for their own sexual health.
Cancer and Other Causes
General statistics show that U.S. men have a 50 percent lifetime risk of developing cancer, according to the American Cancer Society. There were an estimated 180,400 new cases of prostate cancer in the United States during 2000 with an estimated 31,900 deaths—the second leading cause of cancer death in men. The incidence of testicular cancer was 4.6 per 100,000.
Men with disabilities may stand a greater chance of dying from cancers because medical aspects of our disabilities may mask early warning signs of various sexual health-related problems, making detection difficult. For example, some of the signs and symptoms of prostate cancer are weak or interrupted urine flow; inability to urinate, or difficulty starting or stopping urine flow; the need to urinate frequently, especially at night; bloody urine; pain or burning on urination; continual pain in lower back, pelvis, or upper thighs. According to the American Cancer Society, most of these symptoms are nonspecific and may be similar to those caused by benign conditions such as infection or prostate enlargement, often called BPH (benign prostatic hyperplasia). BPH is treatable. In the same light, many of these signs and symptoms are standard operating procedure for those of us with bladders affected by a neurological condition, so we may not consider screening for cancer or BPH.
The Aging Male
The risk of getting prostate cancer or other conditions such as diabetes, hypertension, heart disease, and depression increases with age. Due to factors outside their control such as inability to exercise and difficulty affording and/or preparing a healthy diet, a disproportionate number of disabled men are obese. Obesity increases the risk of acquiring a chronic debilitating condition. Any of these conditions can impair sexual desire and enjoyment.
Expected changes with aging may be hard to tease out from more serious underlying conditions. For example, changes in sexual function, like erectile dysfunction, are associated with normal aging. However they may also be an early symptom of an underlying disease state resulting in neurologic or vascular changes. At other times they may be the side effect of medication, fatigue, stress, distress or fear.
Robert W. Birch, Ph.D., in his latest book, Sex and the Aging Male. Understanding and Coping with Change, details the “inevitable costs of aging.” These changes begin earlier than we think, usually between 40 and 55 for nondisabled men. In my own case, I’ve noticed some of the changes listed below over the past few years, and I just turned 40. According to Birch, the most common changes are: Sexual drive and urgency decrease; spontaneous erections cease to occur; erections take longer to achieve, and direct and continual stimulation often becomes necessary; angle of erection diminishes and erections are not as firm; a longer period of stimulation is needed to ejaculate and volume and velocity of ejaculate decreases; there may be a diminished experience of orgasm with a longer time needed to recover after ejaculation. While this may sound discouraging, older men report greater satisfaction in lovemaking than younger ones in comparative studies.
The term “male menopause” has been used to describe a condition that encompasses the expected changes described above along with other physical and psychological changes. Whereas in female menopause a woman’s ovaries stop producing estrogen and menstruation ceases, male menopause is associated with a slow but steady decrease in serum testosterone levels beginning in the mid-40s. According to Richard Milstein, M.D., and Julian Slowinski, Ph.D., authors of The Sexual Male. Problems and Solutions, “70-year-old males may be expected to have approximately 50 percent of the testosterone concentrations found in men half their age.” These are just rough estimates and, once again, the timing of these changes may vary from man to man.
One of the few studies comparing sexual health of disabled and nondisabled men found evidence of depressed serum testosterone levels in men with SCI as compared to non-SCI controls. The study, by researchers at Mount Sinai School of Medicine in New York and the Bronx VA Medical Center, showed that the difference was especially notable in men with SCI over 40 who were 6 years or more post injury. Perhaps men in wheelchairs who sit on their testicles all day, often without sensation, may cause injury and decreased testosterone. This clearly needs more research.
Some argue that androgen (primarily testosterone) deficiency in the aging male (ADAM) is a more fitting term then male menopause. Others argue that male menopause is more encompassing than ADAM. Whether you call it ADAM, male menopause, or the climacteric, many men do report a common experience beginning around mid-life.
Beverly Whipple, an internationally renowned sex researcher, reports that physically, a man may notice a gradual decease in muscle mass and strength, an increase in fatigue, and there may be a slight loss of bone mass. Note again that all of these conditions may be accelerated among people with disabilities.
Whipple identifies common psychological symptoms as lethargy, depression, irritability, mood swings and loss of a sense of well-being. These symptoms may contribute both to the phenomenon of mid-life crisis experienced by many men and indirectly exacerbate changes in erectile function, resulting in psychological based erectile dysfunction.
None of the above problems directly affect fertility. In addition to traumatic causes of infertility like spinal cord injury that impairs ejaculation and sperm quality, there are, according to Dr. Michael Werner of wernermd.com, many common physical and lifestyle causes of male infertility. Physical factors include: large varicoceles, which are dilated veins in the scrotum much like varicose veins; very thick seminal fluid; missing or blocked sperm-carrying ducts from procedures like hernia repair or infection; developing antibodies to our own sperm resulting from testicular infection, testicular surgery, or trauma like SCI; testicular failure; various drugs that can impair sperm production or cause ejaculatory dysfunction; hormonal abnormalities; and infections of the reproductive tract, including prostatitis, epididymitis, and orchitis, viral infections, bacterial infections, and STDs.
Lifestyle factors include cigarette smoking (causes a 23 percent decrease in sperm density and 13 percent decrease in motility), use of marijuana, cocaine, anabolic steroids, excessive alcohol, lubricants such as KY Jelly and Surgilube, and even excessive exercise.
Prevention and Early Detection
As Whipple points out, “Many men are dealing with their bad habits catching up with them. Smoking, lack of exercise and a diet of fatty foods may bring on sexual problems.” Luckily, there are things we can do to prevent or lessen effects of these problems. Whipple offers the following suggestions: good diet, regular exercise, plenty of sleep, and meaningful activity. Of course smoking cessation and weight loss add years to good health.
While exercise remains elusive to many of us with disabilities, Whipple says it is one of the most potent anti-aging medications known to mankind. Thirty minutes of aerobic exercise six days a week can cut your mortality rate in half compared with sedentary counterparts. Other measures that are more accessible include a diet low in fat and high in calcium; staying active, engaged, and useful; vigorous daily mental stimulation; spiritual fulfillment; and nurturing love through establishing loving connections.
If prevention doesn’t work, early detection is the next best strategy. The American Cancer Association recommends that men 50 and older should talk with their health care professional about having a digital rectal exam of the prostate gland and a prostate-specific antigen blood test every year. As Dr. Richard Spark, author of Sexual Health for Men. The Complete Guide, points out, men cannot do self-examinations of their own prostate glands. Men who are at high risk for prostate cancer—black men or men who have a history of prostate cancer in close family members—should consider beginning these tests at an earlier age. I would suggest this too for those of us whose symptoms would be masked as described above. Monthly testicular self-exams are important also. If you cannot do this on your own, whoever bathes you can be trained to help.
While we are focusing primarily on sexual health, colo-rectal screening is also essential, both for the direct and indirect effects colo-rectal cancers can have. Furthermore, if a man has had anal sex, then he is at risk for HPV induced rectal cancer.
If you are sensing a decease in muscle mass and strength, an increase in fatigue, lethargy, depression, irritability, mood swings and loss of a sense of well-being or are experiencing problems with sperm production, ask your doctor to order a hormone profile. Dr. Slowinski reminds us that most routine blood tests do not measure hormone levels. You have to ask. Thyroid and testosterone tests can detect any hormone deficiency and/or provide a baseline for comparing changes over time. Dr. Werner adds that a hormonal profile will help rule out serious medical conditions, give more information on the sperm-producing ability of the testes, and may reveal situations where hormonal treatment is indicated.
Most sexual health concerns have treatments. If the treatments don’t cure, they may help alleviate symptoms. Like all treatments, there are trade-offs between benefits and side effects.
Hormone imbalance: For low testosterone or androgen deficiency, injections of human growth hormones may help; perhaps off-label use of Clomid or testosterone replacement via injection, patch, or gel may do the trick.
Erections: If erectile dysfunction is a concern, there are the pre-Viagra standards and oral medications. Non-pill options include the stuffing technique, vacuum and constriction devices, injections (e.g., Papavarine or the FDA approved medication prostaglandin E in the form of J&J;’s Caverject) into the shaft of the penis, and urethral suppositories of prostaglandin E. For oral solutions, new therapies on the horizon seek to improve on Viagra. Bayer AG has successfully completed Phase II trials of Vardenafil, which is reported to act faster than sildenafil (Viagra) with fewer side-effects; Eli Lilly and Co. is moving along with its version of a PDE5 inhibitor drug called Cialis that is reported to stay in the system up to 24 hours, thus increasing opportunity for spontaneity.
Infertility: Treatments for infertility are also improving—if you have the financial resources. Conception requires uniting one sperm with one ovum, and how they get together doesn’t really affect the outcome. There are various techniques for sperm retrieval and insemination when there is difficulty ejaculating or compromised sperm quality.
According to Werner, infertility resulting from varicoceles may be corrected by minor outpatient surgery. If the seminal fluid is very thick, semen can be processed to separate moving sperm from surrounding debris, dead sperm and seminal fluid. If ducts are blocked, they may be repaired or unblocked. If this is not possible, sperm may be harvested.
Because sperm are obtained in lower numbers, they must be used in conjunction with advanced reproductive techniques to attempt a pregnancy. Most of the time, the first level of intervention includes intrauterine insemination. If the couple is planning in vitro fertilization, the presence of anti-sperm antibodies is usually an indication to inject the sperm directly into the egg (“Intracytoplasmic Sperm Injection” or ICSI), instead of conventional in vitro methods.
When there are difficulties with erections and ejaculation, either vibrostimulation, electrostimulation or sperm asperation can be used with a combination of intrauterine insemination or ICSI. Hormonal abnormalities may be corrected with hormone replacement therapy as described above. If infection is a factor, when the condition is treated, a man will often see a significant improvement in his semen analysis.
Libido: What about decreasing sexual desire? Dr. Birch says that just because sexual desire isn’t there or isn’t as strong as it used to be, it doesn’t automatically follow that sexual arousal disappears. Birch notes that arousal can be jump-started if the person with the sluggish libido is willing, physically and mentally comfortable, physically and mentally relaxed, and touch begins as nonsexual caress before focusing on the penis. When conditions are right and the touch is effective, arousal can occur and a pleasurable experience will follow.
As in all matters of sexual health, having a disability does not exclude us from being aware of issues and concerns and taking necessary steps to maintain optimum functioning.