Problems in the male partner after childbirth may have a significant influence on the quality of the couple’s sexual relationship. These problems may be caused by many different factors, some of which will not be fully conscious. A study of the doctor/ patient relationship may provide a clue to the problem. Sometimes the couple are unable to express their feelings openly because of anger or fear of hurting each other. For the family planning doctor the problems may be expressed as difficulties with contraception, or the disturbed sexual relationship may make contraceptive decisions difficult. Where problems in the male partner are acknowledged or suspected, an offer to see him or the couple together can be helpful.

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The rhythm method implies a great deal of control but is poorly understood by many men. Several of those spoken to thought the rhythm method meant withdrawal. Once clarified, it was clear that there were many misunderstandings. The days after menstruation were regarded as safer than those before. However, those couples who did use it seemed to share their understandings and were happy. As expected, these were couples with a keen desire for the natural, or strong religious beliefs. They were aware of confusing medical advice on timings, and had their own feelings about what was safe despite the advice. Usually both the man and the woman knew when she ovulated, and this closeness was apparent in discussion. ‘It puts a brake on us’, said one man. ‘If we have been cross with each other, she doesn’t always ovulate, and then we have to wait.’

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Contraception is often considered to be just about stopping babies, but it also says a great deal about having a good sex life without the fear of a pregnancy. Why are doctors so afraid to bring up the topic of sex with their patients when discussing contraception? It is so important to elicit possible problems early on. Is she wanting a good sex life with no babies? Is she wanting to delay her family until the ‘right time’, and also have a good sex life? Is she wanting to enjoy an active sex life with her partner without the obvious responsibilities that a baby will produce, at the present time or maybe forever? Is she having a sex life at all – or is it just that everyone else takes the Pill when they are in a stable relationship, engaged or getting married? The assumption that sexual intercourse has taken place when the woman has been on the Pill for many years is common, but it is not always justified, and appropriate comments or questions to clarify the situation should be mandatory.

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The provision of the best possible care for young people in today’s society, with pressure towards sexuality coming not just from the internal forces towards maturity which have always been present, but also from the peer group and, most strongly, from the media, is not easy for the professional. There is an over-riding need to provide the practical help necesssary to reduce the risks in an atmosphere that is acceptable to the patient, as has been described in this chapter. Considerable skill is needed to allow the patient to feel that her sexuality is allowable and valuable, while at the same time warning her of the health risks.

What, then, of the more general health education that is offered to other patients? The family planning consultation is seen as an ideal opportunity to broach such subjects as smoking and obesity, but the young person may feel such advice to be ‘yet another lecture’. If given unthinkingly, she or he may be antagonized so that they stop coming for the contraceptive help which is so desperately needed. However, if given sensitively and at an appropriate time, the assumption that she or he is now grown up enough to want to look after themselves can enhance self-esteem.

Perhaps the most difficult dilemma for the doctor, as for young people themselves in the age of AIDS, is to reconcile the strong, inevitable and healthy emotional and sexual drives, with the possible risk of serious damage to their health or even death. The equation

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‘I want a health check,’ she commanded, forceful and unsmiling. Doctors and nurses are not used to being ordered about in this way; it is easy for hackles to rise and defences to spring up. The doctor felt attacked and was tempted to retaliate, to point out that this was family planning, not a well woman clinic, for example. Instead, she inwardly observed this difficult atmosphere, and wondered what was behind it. ‘We haven’t seen you for some time,’ she commented. Mrs A. shrugged, but remained silent. ‘Are you still on the Pill?’ ‘No,’ another shrug, then defiantly, ‘We use a sheath.’ The tension level in the room rose. ‘Look, I’ve come for a health check – that’s all!’ The doctor thought to herself, ‘Contraception produces tension, but is not to be discussed.’ She changed tack. ‘Of course we will examine you. Have you been having any problems?’ Immediately, the reply shot back, ‘No.’ Another glare at the watch. The doctor sat back and waited, refusing to be bounced into this checkup, realizing that, so far, she had been doing the work here. Now she let the patient decide how to continue.

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Can finasteride help prevent malignant growth in the prostate? In other words, can it stop prostate cancer from forming? The National Cancer Institute has launched a multimillion-dollar study to find this out. For seven years, this massive project will follow 18,000 men, aged 55 and older, who are otherwise healthy (men with any prostate ailment, benign or otherwise, are not eligible). All of-the men will take daily pills; half of them will get finasteride, the rest will get a placebo. All of the men will have regular physical exams, including a digital rectal exam and PSA test, during the study period. And, at the end of the study, all of the men will have a prostate biopsy. The study is double-blind—neither the men participating in the study nor the physicians treating them will know who’s getting the finasteride until it’s over.

Why do scientists think a BPH drug can have an effect on prostate cancer? One reason is that finasteride lowers a man’s levels of PSA, an enzyme made by the prostate used as an indicator for prostate cancer. Another assumption is tied to the fact that finasteride works by interrupting a hormonal process (it blocks an enzyme called 5-alpha-reductase, which changes the male hormone testosterone into a substance called DHT—the active form of male hormone within the prostate). Prostate cancer is intrinsically linked to hormonal activity. So maybe, some scientists speculate, by thwarting the prostate’s normal hormonal pattern, prostate cancer can be stopped before it ever has a chance to begin.

However, other scientists doubt that finasteride will have any effect in preventing prostate cancer. First, there’s no evidence that DHT is the hormone responsible for the growth of prostate cancer. In fact, the levels of 5-alpha reductase activity are actually lower in prostate cancer than in normal tissue. Also, there’s no supporting evidence from laboratory experiments to suggest that finasteride will work; in one animal tumor model, in fact, finasteride has no effect at all. And finally, finasteride’s effect in men who already have prostate cancer is marginal at best—which makes it unlikely that it will have any effect in preventing the disease.

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The first option is called “watchful waiting,” and it doesn’t mean “do nothing.” It means “wait and see.” The course of BPH is often hard to predict; your symptoms could improve, get worse, or stay the same. Beyond watchful waiting, broadly speaking, there are two paths—surgical and medical. (See table 10.1, page 257.) The choice depends on the severity of your symptoms. If you have one or more of the conditions mentioned above that require treatment, your best option is surgery. But if your symptoms are moderate—that is, not severe enough to require surgery—a trial of medical therapy makes sense.

Watchful Waiting

This is the most conservative approach to BPH, and for most men with mild symptoms, it’s the best. Remember, just having an enlarged prostate does not mean you need treatment. It’s only when the symptoms of enlargement become bothersome, or if your urinary function is seriously affected, that you should consider treatment. So, many doctors begin with what’s called a “watch-and-wait” approach to the problem. They keep a close eye on your condition, with checkups once or more a year to make sure you’re not developing any complications. Sometimes the symptoms of BPH get better on their own. If they don’t, then you and your doctor will move on to the next step—deciding what treatment’s best for you.

Risks. Like any other treatment option, watchful waiting is also something of a gamble—low-risk, but a gamble all the same. A few men in programs of watchful waiting develop acute urinary retention, the inability to urinate. A few develop urinary tract infections; some see blood in their urine; some go on to develop kidney or bladder damage without any noticeable change in their symptoms (this is called silent prostatism). But such complications from watchful waiting are rare indeed. You can lower the odds even further by limiting your fluid intake before bedtime and by refraining from taking certain over-the-counter medications, such as decongestants, which can make your BPH symptoms worse.

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Hormone therapy works in almost every man; it prolongs life and eases many symptoms of advanced prostate cancer. In some men, its effects last for years. Why doesn’t it cure the disease? Because prostate cancer is “heterogeneous”—it’s a bunch of different cells mixed up together. Some of these cells respond to hormones; some of them don’t. This means that a hormone treatment which targets one kind of cell, the kind that responds to hormones, has absolutely no effect on the hormone-insensitive cells all around it. They keep right on growing, unfazed. Ultimately, if a man lives long enough, these cells eventually overtake the hormone-sensitive cells. And right now, we don’t have any way to stop them.

This fact has two important implications for patients: One, there’s no evidence that starting hormone therapy early in the course of prostate cancer is any more effective in prolonging survival than starting treatment if and when a patient needs it—when a man has bone pain from the cancer, for instance. Again, the cells that ultimately prove fatal are the hormone-insensitive cells—and to these cells, whether hormone therapy comes earlier or later does not matter one bit. Two, there is no good evidence that other forms of hormone manipulation—total androgen ablation, for instance— provide much benefit after hormone therapy has stopped working.

If hormones lose their effect on the tumor, there are several other options for treatment of the disease and specific symptoms, including new chemotherapy drugs, “spot” radiation to painful sites of metastases (chunks of cancer that have broken off from the main tumor and established themselves in new locations, such as the bone), a radioactive substance called strontium-89, which is specially tailored to treat bone pain, and a whole host of powerful pain medications, their is no reason for any man with prostate cancer to live in excruciating pain. Aggressive pain management is not only beneficial—it’s been shown that men who aren’t in terrible pain live longer—it’s your right as a patient. Help is available; take it.

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Surgical removal of a man’s testicles (also called an orchiectomy) is the easiest and least expensive way to control testosterone. As surgical procedures go, it’s simple. The operation can be performed under spinal anesthesia or, if the patient is not strong enough to tolerate this, even a local anesthetic. This is what happens: A surgeon makes a small incision in the scrotum, and brings out each testicle individually through this opening. Then the surgeon cuts the vas deferens and blood vessels that supply each testicle, and the testicles are removed. Some surgeons perform what’s called “subcapsular orchiectomy.” In this operation, the surgeon opens the lining to the testicles and empties the contents of each testicle. The lining is closed again, and this empty shell is placed back inside the scrotum—so nothing looks different; in other words, no one can tell from outward appearance that there’s nothing inside the scrotum. The basic differences here are cosmetic—and therefore psychological—and for some men, this makes the thought of castration easier to accept. However, some surgeons don’t like to perform this operation because they worry that some testosterone-producing cells may be left behind.

After surgery, patients usually can go home from the hospital the same day—or, at the very latest, the next day. The only major complication to worry about with surgical castration is bleeding. However, this shouldn’t be a problem if the surgeon makes a point of checking that all bleeding is stopped before the scrotum is closed, and that a compression dressing is left in place to control the smaller, harder-to-see blood vessels.

Castration works fast; it reduces the body’s amount of testosterone by 95 percent almost immediately, and permanently. Boom—within about three hours after surgery, testosterone levels begin to plummet to a level called the “castrate range.” This is considered the gold standard, an important point of comparison in monitoring hormone therapy—as certain drugs are judged by their ability to reduce testosterone to this range.

Some doctors used to believe that several months after castration, the body began producing more testosterone at other sites—and that this was the reason prostate cancer continued to grow This is not true. There is no delayed increase in testosterone and anyway, that’s not why prostate tumors keep growing—they continue to spread because of the cancer cells that are not affected by hormone therapy.

What happens to the prostate tumor after castration? It begins to shrink, and men with symptoms of obstruction or pain caused by the cancer begin to feel better right away.

Castration’s advantages are that it’s effective almost immediately and that its results are permanent—there’s no need to take daily medication. And, because it is a “one-shot” treatment, it’s relatively inexpensive.

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For the first few days or even the first couple of weeks of external-beam radiation therapy, you may feel nothing out of the ordinary; it takes a while for the cumulative doses of radiation to build up and have an effect. But by the third to fifth week, many men react with symptoms that can range from mild to severe; in most cases, these generally go away within days to weeks after the course of treatment is over. Sometimes, men develop these symptoms six months or more after treatment.

Most common complications are bowel problems (diarrhea, rectal itching or burning, urgency to have a bowel movement, painful cramps) and urinary trouble (feelings of urgency, painful or difficult urination, stress incontinence, and the need to urinate frequently, especially at night). For as many as 85 percent of men, these symptoms become acute enough to require medication.

In one analysis of 1,020 men treated in two large studies, about 7 percent of men needed to go to the hospital for treatment of more severe urinary problems. These included blood in the urine, bladder inflammation, and urethral stricture or bladder neck contracture—both caused when scar tissue develops and impedes urine’s progress out of the body. Urethral strictures accounted for more than half of these problems, and they seemed to develop mostly in men who had undergone a TUR procedure for BPH. Fewer than one percent of the men needed surgery to fix these problems. (A bladder neck contracture can be re-opened in outpatient surgery by a urologist, using a cystoscope, who makes a few tiny cuts to relax the tight scar tissue. Most urethral strictures respond well to dilation—stretching the urethra, in one or two sessions. Stubborn strictures may also be treated with tiny incisions, like those done to ease bladder neck contractures.)

Just a little over 3 percent of the men in this study experienced chronic

intestinal problems, including rectal inflammation, diarrhea, rectal bleeding, an intestinal ulcer or development of an anal stricture (tight scar tissue that can interfere with bowel movement); fewer than one percent experienced bowel obstruction or perforation. And complications that proved fatal were extremely rare—0.2 percent.

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