When we use the terms impotence or erection problem in this book, we simply mean that the erection is absent, or that it can’t be maintained firmly enough to have sexual intercourse. We don’t like referring to a man as “impotent” because thaf s attaching a label that can make him feel powerless or ineffectual. Unfortunately, impotence is a word loaded with meanings which have nothing to do with a man’s ability to get and maintain an erection. A dictionary defines impotent as “lacking in power, strength or vigor: helpless.” But the common association of sexual impotence with powerlessness is nonsense. A man can be successful, happy and in charge of many aspects of his life and still have erection problems, just like he can have any other health problems. When it happens, impotence is a problem, but it’s one that usually can be solved. You can take charge of the erection problem in much the same way you deal with other types of health and life problems—by getting informed and getting help. The important thing is to see it as a health problem, not a statement about your worth as a man or a lover.

Doctors use the term primary impotence to mean that a man has never been able to have and maintain an erection thaf s sufficiently firm for intercourse; secondary impotence is the term used for patients who have had healthy, normal erections, but now find themselves with erection problems. You may also hear medical people describing impotence as “erectile dysfunction.” If s important for doctors to have these definitions, but it is equally important for you not to let the words stop you from seeking help. One man avoided going to a sexual dysfunction clinic at a major medical center because he was so turned off by the word “dysfunction.” He felt that showing up at the clinic would be an announcement to the world that he was something less than a man. (Some health professionals recognize this problem and have given their clinics more encouraging names.)

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As soon as people hear the word cancer they become very fearful. Various types of malignancies affect the skin, many of which can be successfully treated if diagnosed early. In most of these skin conditions sunlight plays a major role. If you have spent much of your time in the sun because of your work in the outdoors, or if you were for many years in the habit of sunbathing for hours on end, for many weeks or months of the year, you may be at higher risk for the development of certain skin malignancies.

Most of the different kinds of skin cancers can be well treated if brought to medical attention early. Basal cell carcinoma and squamous cell carcinoma are examples of usually slow-growing skin cancers that can be cured if found early. They most often occur on sun-exposed parts of the body, especially the head, face, and neck areas. Malignant melanomas are less readily curable but if found early may respond very well to treatment.

If you find an area of the skin or a mole that changes its appearance (shape, texture, consistency, or color) very rapidly, bring it to your doctor’s attention. Many skin changes occur quite normally in older persons, and in general you do not have to be worried about all those darkish, slightly raised spots, or little red dots on your skin that have gradually occurred and have been around for many years. It is areas of skin or moles whose appearance changes quickly that should be identified for medical evaluation. You may be sent to a dermatologist (skin specialist), who will treat the problem or take a skin biopsy (remove a small sample of skin for laboratory tests) to make an accurate diagnosis.

Raised or Darkened Areas of Skin As one ages, one’s skin may develop problems that are cosmetically unappealing but not usually dangerous. Most of the dark, raised areas on the skin, called seborrheic keratoses (referred to by one dermatologist as “barnacles of the skin”), are not cancerous and not dangerous, but they may be unwanted. These may exist in many numbers all over the skin and may be removed safely and easily if you so desire. Likewise, actinic keratoses are lightly pigmented, raised, roughened areas on sun-exposed parts of the skin which also can be safely and easily removed at any age, usually by a dermatologist.

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Normally the body loses relatively little iron, except in women who are still menstruating. The amount of iron that is naturally lost through the bowel and skin is quite small. Thus you should need no more iron than a younger person. If you are found to have too little iron in your blood cells, it usually means that there is an unrecognized source of bleeding, often in the bowel.

Occasionally an older person may have an iron-poor diet, containing virtually no meat or protein. This could account for a mild degree of iron-deficiency anemia. This is less likely in Western countries, but it does occur occasionally in elderly people who are poor or who have been vegetarians for many years.

Iron should not be taken as a “tonic.” If an iron-deficiency anemia is discovered, you should undergo a full investigation, especially of your diet and your intestinal tract. Treatment can begin while the anemia is being investigated. However, even though you may feel better after you receive iron therapy or blood transfusions, a proper evaluation of the reason for your anemia should not be postponed.

Sometimes the cause of an iron-deficiency anemia can be mysterious, frustrating both the physician and the patient. One 91-year-old woman was referred to me because she had suffered from anemia for more than ten years. The anemia would come and go, sometimes alleviated by iron pills and sometimes not. She had had many X-rays of her gastrointestinal tract as well as a gastroscopy and colonoscopy, but no cause of anemia was found. When her stools were checked, they revealed microscopic amounts of blood. Sometimes she noticed small amounts of red blood in the toilet bowl, but this happened infrequently.

At 91, her anemia had become so bad that she required periodic blood transfusions because iron therapy alone no longer kept her blood count high enough to avoid constant fatigue. After the other X-rays were unrevealing, I recommended an angiogram of her intestines to determine whether a source of bleeding had been overlooked. When I asked the radiologist to do this X-ray, which does have some risk, he protested, “She’s ninety-one years old. Why don’t we just treat her with blood transfusions?” I persisted in my request for the X-ray and told him that she wanted to attend the wedding of a great-granddaughter in a few weeks. The angiogram indeed revealed that she was bleeding from a small blood vessel in her large bowel. Within a few days she had bowel surgery and was found to have a benign abnormality of blood vessels that made them leak frequently, causing her to be anemic. The surgery went remarkably well; she left the hospital in ten days, and was able to attend the wedding. At 93, she continued to be well, without anemia, more than two years after her surgery.

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Once a diagnosis is made, treatment is usually successful. Excess thyroid hormone can be corrected with medications, and improvement occurs quickly and lasts as long as the drugs are taken. Medications such as propylthiouracil block the manufacture of thyroid hormone. Beta-blockers, also used to treat angina pectoris and high blood pressure, effectively blunt the effects of excess thyroid hormone on the heart. These drugs, however, do not correct the underlying cause of the excess thyroid hormone production, but they do correct the symptoms while other treatment is being planned.

The underlying cause of hyperthyroidism is treated frequently with radioactive iodine, taken by mouth. Thyroid-blocking medications may be necessary for a while after the radioactive iodine is given. Eventually, the radioactive treatment has a permanent effect, and the other medications are discontinued.

The medications and the radioactive therapy have few serious side effects. In very rare cases some thyroid-blocking drugs can cause problems with the bone marrow. The most common problem that can occur after treatment with radioactive iodine is that the thyroid gland may become underactive. This is frequently unavoidable, but correction with thyroid hormone replacement is easy. Your physician will check for this side effect periodically.

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Although often thought of as a type of rheumatism, polymyalgia rheumatica affects the blood vessels rather than the joints. The symptoms, however, are usually aches and pains in the muscles and joints, especially around the shoulders and hips. Sometimes back pain may become severe and result in weakness, which makes it impossible to get out of a chair. The other symptoms include weight loss, poor appetite, headache, a sudden loss of vision, and depression. An erythrocyte sedimentation rate (ESR) test and a biopsy of a blood vessel in the scalp may be necessary to diagnose this condition.

This diagnosis should be considered whenever an unusual type of rheumatism occurs. Treatment with cortisone by mouth is usually effective. Medication may have to be continued for eighteen to twenty-four months, but the dosage can be gradually decreased to avoid side effects.

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Glaucoma is the result of an increase in pressure within the eye. As the pressure builds, the retina is slowly damaged and eventually destroyed. You may have chronic glaucoma without any symptoms until your vision becomes severely damaged. You may notice a distortion of vision and halos around lights or find that your vision has become poor. During an attack of acute glaucoma, there may be sudden eye pain, redness, and a rapid deterioration of vision. In most people, however, the disease is not painful, but it can progress slowly and insidiously, leading to impaired vision or blindness.

You should have your eyes checked at least once a year. The eye pressure should be measured to determine whether it is elevated. This can be done by a family doctor who has experience in the technique or by an ophthalmologist. It may not be sufficient to have your vision tested by an optometrist, and in some areas, optometrists are not trained or allowed to measure eye pressure. Glaucoma might not be diagnosed when your vision is being checked for glasses by an optometrist. Ask whether he has measured your eye pressure when you visit.

Some medications used to treat depression, heart disease, or bowel disorders can increase the risk of glaucoma. Some eye drops can also make glaucoma worse. If you suffer from glaucoma, ask your physician about the effects of new drugs on this condition. And make sure that any physician you see knows that you have glaucoma.

How Is Glaucoma Treated? The most important part of treatment for glaucoma is early diagnosis. When high eye pressure is found before there is severe damage to vision, most people can be treated successfully with eyedrops or medications that decrease the pressure. If the eyedrops are not completely effective, surgery including new laser techniques may be recommended. During an attack of acute glaucoma, you will first receive intensive medical treatment to decrease the pressure. This may be followed by surgery to allow the excess fluid to drain from the eye. In most instances glaucoma can be treated and controlled if the diagnosis is made early. It would be tragic to lose your vision from a condition that can be so effectively treated, so have your vision and eye pressure tested at least once a year.

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Can Strokes Be Prevented? The main factors responsible for strokes include high blood pressure and atherosclerosis. We do not know how to prevent atherosclerosis, although some evidence suggests that changes in the diet, with a decrease in the amount of animal fat, may play a role as does smoking cessation. However, no one can say that if you stop eating animal fats altogether or stop smoking you will not suffer from strokes. This may be partially true for younger people, but it has not yet been proven.

The reduction of high blood pressure, however, has definitely been shown to reduce the likelihood of a stroke. Anticoagulants have been found to lessen the likelihood of strokes in certain people. Unfortunately, some of these medications may have serious side effects and are used only in certain situations. If you have shown evidence of a transient stroke, your physician may use anticoagulants to try to prevent another stroke. Anticoagulation therapy must be carefully supervised to avoid the risks of bleeding.

Recent evidence indicates that medications such as aspirin and other drugs that affect platelets can decrease the stickiness of the blood and prevent strokes in certain individuals. Some physicians therefore prescribe small doses of aspirin, dipyridamole, and sulfinpyrazone for potential stroke victims. Aspirin appears to be the most effective of these agents. It will take more time and research before it is known for certain whether these platelet-inhibiting drugs are effective. Their risk, however, is less than with anticoagulants.

Under certain circumstances surgery may prevent a stroke. If you have a partial blockage of one of the main arteries going to the brain, this can sometimes be corrected. This treatment is very controversial. An angiogram of these blood vessels is necessary in order to make the diagnosis.

How Are Strokes Treated? If part of the brain is permanently damaged by a stroke, that part will no longer function. However, the rest of the brain continues to operate. At the time of a stroke, one may be at risk of developing pneumonia, so hospitalization is usually required. If the stroke is mild, this may not be necessary. A stroke victim is sometimes placed in a special neurological Intensive Care Unit to prevent complications.

The rest of the treatment is directed to prevent further brain damage and to teach the remaining healthy brain some of the tasks that were previously done by the damaged part. Therefore, although no treatment can reverse the damage, a great deal can often be done to improve the outcome.

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The intestinal tract is prone to various kinds of tumors, many of which are malignant. Some tumors grow and spread slowly and cause a bowel blockage. Others may be hidden until they spread to other parts of the body, which often makes successful treatment difficult. In general, the symptoms include poor appetite, weight loss, bleeding from the bowel, nausea, vomiting, and a change in bowel habits. Often the symptoms are vague, and it may take a long time to discover the tumor. All the factors involved in the causes of gastrointestinal cancer are undetermined. Some families appear to have a tendency to develop tumors of the bowel, some of which eventually become malignant. People who have had ulcerative colitis (an inflammation of the colon and rectum) for many years appear to be more prone to large-bowel cancer than others.

Many claims have been made about dietary influences on intestinal malignancy. Some researchers believe that the small amount of roughage in Western diets is a major factor in the increased incidence of these tumors. Some claim that the large amounts of animal fats and of nitrosamines used in processed meats (bacon, salami, bologna, and so on) is responsible. And many reports attest to the belief that large doses of vitamin C or vitamin E decrease the likelihood of this cancer.

None of these assertions has been proven. A number of ongoing studies are trying to determine the relationships between diet, vitamins, and intestinal malignancy, but it will take some years before the results are available. In the meanwhile, it would probably be prudent to increase the amount of fiber in your diet and decrease the amount of dietary animal fat and of processed meats, which, in addition to nitrosamines, contain large amounts of salt. However, there is not enough conclusive evidence to merit the use of large doses of vitamin C or vitamin E.

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How Is Urinary Incontinence Diagnosed? Measurements of your kidney function and tests to reveal an infection are usually done. A kidney X-ray (intravenous pyelogram) or echogram may be necessary to show the presence of kidney damage or blockage of the bladder.

If the cause of incontinence is not immediately clear, a cystometrogram is often used to measure the amount of urine that your bladder can hold and whether the nerves controlling it are functioning well. During the examination, increasing quantities of sterile fluids are put into your bladder and the pressure developed within it is measured. The test, which is completely safe and has little discomfort, determines whether your bladder is contracting (emptying) normally.

How Is Urinary Incontinence Treated? A urinary catheter (plastic tube) allows urine to drain from the bladder into a plastic bag. This treatment may be useful in temporarily relieving a blocked bladder, but it is not the best treatment for urinary incontinence because it can cause infection. Catheters should be reserved for those who cannot otherwise be treated and in whom the risk of urinary infection is outweighed by the need to be kept completely dry. For instance, after major surgery or trauma, or when a bedridden person has pressure sores, urinary incontinence may contaminate wounds or macerate the skin.

If a urinary infection is found, it may be playing a role in urinary incontinence. The infection should be treated with antibiotics or with drugs that decrease the frequency and urge to urinate. Some people becomes incontinent as part of a depressive illness, and treatment with antidepressant medications can show a remarkable improvement. The use of diuretics and sedatives should be evaluated and, whenever possible, decreased or discontinued. Various medications have been developed which may be useful for incontinence associated with frequent urges to urinate suddenly.

Incontinence in men can be controlled by a clamp that closes the penis. This is rather uncomfortable, and one must be mentally alert for it to be applied properly. In most instances it should be avoided. A condomlike sheath that covers the penis and is connected to a bag by plastic tubing is sometimes useful, especially at night. However, this often causes irritation of the penis.

For those people who are partially or completely bedridden, incontinence pads have been specially designed to absorb urine but leave the body relatively dry. For those who are more mobile, there are special undergarments or pads that absorb urine but prevent the skin from becoming wet. Specially designed pads for adults are available; these are similar to disposable diapers and can be worn inside underpants. They can be very useful in the occasionally incontinent person who is mobile at home or in an institution.

Some improvement can follow changes in habits. Women’s symptoms may improve if they lean forward when passing urine. This helps empty the bladder more efficiently. Although the standing position is normal for men, some can pass urine more easily sitting down.

You should try to pass urine frequently. A commode by the bed or a urinal used every few hours may help avoid wetting the bed or undergarments. Whenever possible, you should remain mobile and stay out of bed. If you have severe constipation, you may develop urinary incontinence until your bowel is cleared. The rectum should be examined to be sure that a full bowel is not pressing on your bladder.

Sometimes incontinence results from a neurological disease, particularly brain tumors and in an unusual type of hydrocephalus, occasionally found in the elderly. A neurologist can make these diagnoses. Surgical treatment of the brain disorder in these unusual situations may also improve the incontinence.

For individuals in institutions because of severe debilitation, urinary incontinence is often a serious problem. Frequent visits to the bathroom or to a bedside commode can sometimes be effective in decreasing the problem.

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You have probably heard and read about the recently recognized disease called AIDS (acquired immune-deficiency syndrome). At first AIDS was thought to be an unusual and rare disease limited primarily to homosexual (“gay”) men. It is now clear that the disease is in fact an epidemic that attacks two groups of people. The first group includes “high-risk” individuals, mainly homosexuals and intravenous drug users. In the second group are “low-risk” individuals who had received blood or blood-product transfusions before tests were available to screen blood for the virus, children who were born to a person with AIDS, or people who had a heterosexual relationship with an infected person.

The virus causing AIDS has now been identified. The AIDS virus or HIV (human immunodeficiency virus) attacks the immune system of the body and destroys a person’s ability to fight off other infections. People afflicted with the AIDS virus become ill with persistent and recurring infections, often of unusual type, and eventually succumb to the disease and its complications.

Although at this time there is no cure for AIDS, some medications can treat and prevent some of the infections that AIDS victims often contract. These drugs have improved the ability of patients to survive these otherwise potentially lethal infections. Scientists are testing a number of drugs to treat AIDS-afflicted individuals and are working to develop a vaccine to protect against contracting AIDS.

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