Manhood
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Epididyectomy, or the complete removal of the epididymis, hemicastration, removal of the testicle with epididymis – and vaso -vasostomy (a restorative operation after sterilization) are also among procedures used to relieve patients’ pain. Hemicastration is the most often recommended and most effective procedure. Quite tangentially, it should be mentioned that in the past hemicastration was used to determine the sex of the child to be fathered. If one wanted a boy the man’s left testicle should be tied off. Left was associated with weak and right with strong.
The Hottentots used the same method.
In hemicastration an approach through the groin is preferable because it produces better results than via the skin of the scrotum (leaving 76% of patients in comparison with 55% permanently pain-free).
This difference may perhaps be explained by the high tying off of the seminal cord resulting in the complete severing of the genital branch of the nerve. Sometimes there are good reasons for completely ruling out surgical treatment; in such cases the patient is referred to the pain clinic for psychological treatment and/or medication.
Testicular cancer
. . . is rare: in the United States, between 8,400 diagnoses of testicular cancer are made each year. Over his lifetime, a man’s risk of testicular cancer is roughly 1 in 250 (four tenths of one per cent, or 0.4 per cent).
It is most common among males aged fifteen–40 years, particularly those in their mid-twenties. Testicular cancer has one of the highest cure rates of all cancers: in excess of 90 per cent; essentially 100 per cent if it has not metastasized. Even for the relatively few cases in which malignant cancer has spread widely, chemotherapy offers a cure rate of at least 85 per cent today.
Testicular cancer has several distinct features when compared with other cancers. Firstly, it has an unusual age-distribution, occurring most commonly in young and middle-aged men. Secondly, its incidence is rising, particularly in white Caucasian populations throughout the world, for reasons as yet unknown. And thirdly, testicular cancer is curable in the majority of cases. The number of deaths from testicular cancer in the usa is around 380 annually.
It is essential to discover the growth in good time. Very often testicular cancer causes few symptoms, at most a feeling of heaviness.
Occasionally there is sudden pain because of a haemorrhage in the 135
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growth. One diagnostic trap is swellings that persist after a trauma or an inflammation of the epididymis.
In almost half of cases there is metastasis at the moment when a diagnosis is made. Possible symptoms are back pain, a swelling in the abdomen and breathlessness. Fortunately the prognosis is very favour -
able, even where there is metastasis. In most cases the metastases simply melt away with chemotherapy or radiotherapy. The choice between the supplementary treatments depends on the kind of cancer involved.
Pathologists distinguish between seminome and non-seminome. In the first case the prospects are slightly more favourable than in the second.
The success stories of therapeutic chemotherapy in testicular cancer with metastases (for instance, Lance Armstrong) originate from cisplatinum. In 1966 the American biophysicist Barnett Rosenberg was playing around with a colony of intestinal bacteria, which he exposed to various levels of current between two platinum electrodes. The closer the bacteria came to the electrodes, the less able they were to divide.
That was caused, thought Rosenberg, not by the electric current but by a substance on the platinum electrodes. That cell-inhibiting substance proved to be cisplatinum. When he went on to test the effectiveness of the substance on rats with cancer his intuition was confirmed. Further research showed that cisplatinum had an extra -
ordinarily favourable effect on women with ovarian cancer and men with testicular cancer. When cisplatinum was first used on patients in the early 1970s it did, however, turn out to have a series of serious side-effects, including kidney damage, hearing loss and unbearable nausea.
Nowadays those side-effects are successfully kept in check, for example by a combination of drugs, though long-term research indicates that premature heart problems may occur.
Besides cisplatinum, etoposide and bleomycine are used in the treatment of patients with testicular cancer. The number of courses is determined after a risk classification. During treatment so-called tumour-marker substances are identified in the blood, and in this way the success of the treatments can be assessed. In any case the side-effects of the chemotherapy remain severe: nausea, hair loss, reduction in bone marrow, anaemia, haemorrhages, pins and needles in feet and fingers, and lung damage.
Lance Armstrong
In 1992 Texan Lance Armstrong took the leap into the ranks of professional racing cyclists. A year later he became world champion road racing cyclist in Oslo. With stage victories in the Tour de France, etc.
he emerged in no time as one of the best racing cyclists of his genera-136
a i l m e n t s o f t h e s c ro t u m tion. In the autumn of 1996 this success story came to an abrupt end: Armstrong had testicular cancer with metastases. This was a bombshell – certainly in the world of cosseted racing cyclists, and his team lost a charismatic figure.
As Armstrong put it: ‘My first reflex was: there goes my career.
Later, when the seriousness of the disease sank in, I realized I’d be lucky if I was able to live a more or less normal life again. The doctors gave me a 50% of survival. The diagnosis was worrying to say the least: testicular cancer with metastases in the abdomen, lungs and brain.’
The cyclist underwent two operations, in which, among other things, his right testicle and a brain tumour were removed. This was followed by three months of chemotherapy and intensive medical care in Indianapolis:
For the first year not a day went by without my thinking about it, but since then the fear has begun to abate. I’m no longer just a cancer patient – I’ve become a racing cyclist again. I’ve got my ambition back. The will to win is back, although it’s not as all-consuming as it used to be. I get over it quicker when it doesn’t work out. Winning is no longer the most important thing in my life. I just enjoy each day as it comes. I kept cycling, even during that tough first year, purely for pleasure. When the doctors gave me the go-ahead, I decided to become a professional cyclist again. Eighteen months later I started my first race. Why? Because I love racing, because it’s my job. But I also did it for everyone with cancer. Everyone thinks that after an illness like that you can never be the same again. I wanted to prove the opposite by winning races again. I’m gradually getting back to my old level. In fact, I’ve got even stronger.
Armstrong writes the way he cycles: straight down the line, always fighting openly and energetically. He’s not the kind of man who hides.
Even just after he had heard the bad news he did not avoid contact with the media. He fought the battle in the open. The Texan’s openness won the respect of friends and enemies alike, in his team and elsewhere.
And at a stroke testicular cancer became a topic in sports reporting and Armstrong became a representative of cancer patients.
His informal ambassadorship soon became official. In December 1996 he set up the Lance Armstrong Foundation, with the aim of fighting all forms of urological cancer by increasing awareness, education and research. Money is collected in the first place through all kinds of cycling events, the largest of which takes place each year at the end of May in his home town of Austin and is christened Ride for the Roses.
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Bilateral cancer
Men who have once had testicular cancer are more at risk than ‘normal’ men of developing cancer in the remaining testicle. Synchronous bilateral cancer occurs in 0.7 per cent and 1.5 per cent develop cancer in the remaining testicle within a year. Only a small number of men are involved, but even so, imagine if it happens to you! Testicular prostheses and testosterone gel, though, make it possible to lead a normal life.
Generall
y speaking, as has been said, excellent treatment results are achieved with testicular cancer, certainly if one compares them with treatments of other types of cancer. Still the patients and all those involved are confronted with a totally different world. Information, mentoring and support are provided by patient support groups.
Testicular prosthetics
Testicular prostheses have been available since 1940. Before 1973 they were made of the metal vitallium, but since then gel-filled implants have been used worldwide. Prostheses are used, for example when:
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an undescended testicle has been removed
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a testicle has been removed because of a tumour
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a testicle has been removed because of a torsio testis that has been discovered too late
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where a testicle has been missing from birth
Why use a prosthesis? Many men feel incomplete without a testicle.
Young men often use one because they do not yet have a sexual relationship, or are frightened of someone seeing, for instance, in the shower after sports or in the sauna or on the beach.
Testicular prostheses come in various sizes, and inserting one is a simple procedure: an incision is made just above the scrotum through which the prosthesis is introduced and if necessary attached. The operation takes about twenty minutes, so that the patient can return home the same day. Research has shown that complications occur only in exceptional cases, and these take the form of: leakage, mostly after a trauma, a haemorrhage, infection, wound dehiscence or an allergic reaction. In order to prevent infection the patient is given antibiotics before and after the operation. In most cases a prosthesis can be claimed on insurance.
In 1999 the radiographer Luca Incrocci from Rotterdam carried out a research project among men with a testicular prosthesis. He examined thirty men aged between eighteen and 75 who had a pros thesis 138
a i l m e n t s o f t h e s c ro t u m implanted. The average age of the research sample was 30. With five of these men there were complications. A few results from this research: 20 per cent still had problems with sexual contacts, 20 per cent still had sexual problems, but almost 70 per cent experienced an improvement in body image after insertion of the prosthesis. The latter fact is significant, since that is what a prosthesis implantation is ultimately about! The other problems can in the great majority of cases be solved not through an operation but by consulting a sexologist.
Modern testicular transplantation
As mentioned in a previous chapter, at the beginning of the twentieth century testicular transplants were widely used with the aim of combating the ageing process. At the time there was absolutely no knowledge of the factors determining the ageing process and loss of potency.
Attention turned to the testicles: testicular tissue, either human or animal in origin, was transplanted, mostly in sections, into the scrotum.
Remarkable results were reported for a broad spectrum of ailments, though the research results were rather coloured by personal motives.
The ensuing polemics damaged the development of endocrinology, the science of hormones. That was even more the case with the commercial exploitation of this irrational treatment. In 1935 testosterone was isolated, so that testicular transplants fell temporarily out of fashion.
Due to new technical capabilities in the surgical field new interest was awakened in testicular transplants in the 1960s. Experiments focused on rats and dogs and eventually led to the transplantation of an individual’s own material, in particular with baby boys who had extreme forms of undescended testicles. Transplantation from one human being to another was initially carried out only in the then virtually inaccessible Soviet Union; virtually nothing reached the outside world.
In the 1970s a publication appeared on a successful testicular transplant in a pair of monozygotic twins, one of whom had no testicles and the other two. Inspired by this, two Chinese research teams began a test transplant in human beings. Despite the limitations due to the suppression of rejection in the recipient, remarkably good results were achieved, and a report appeared on the first two children fathered with a transplanted testicle. In the view of the researchers testicular transplantation could be of crucial importance for, for instance, anorchid men (literally without testicles), a condition affecting one in 20,000
men. Anorchidy is not life-threatening but if untreated it leads to a loss of libido, psychological problems, premature ageing symptoms and accelerated loss of bone mass. A select group of men with fertility problems might also benefit from testicular transplantation. It could 139
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be used for couples who choose the possibility of having a child independently over new techniques of reproduction and for whom the disadvantages are outweighed by the above-mentioned advantages. Of course female-to-male transsexuals would be eligible for testicle transplantation, though as yet no transplantations from one man to another have yet been carried out. Quite apart from the ethical aspects, it is the side-effects of the medication required after surgery which are the main obstacle to the procedure.
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chapter seven
Ailments of the Penis
You can always rely on a friend, so they say, and hence many healthy young men never stop to think that an erection isn’t a natural occurrence for everyone. In medical jargon we refer to erectile dysfunction –
ed for short: in fact, the word ‘impotence’ is no longer used. Typical erection problems occur when the penis does not become (sufficiently) erect, or when an erection does not last long enough for satisfying sex.
Descriptions like ‘not hard enough’, ‘not long enough’ and ‘satisfying’
are of course highly subjective.
Many men have occasionally have found that their erection is not always equally strong, or sometimes even fails to materialize. ‘Problems’
requiring treatment arise only when symptoms persist for a longer period. ed can adversely affect one’s experience of sex, can damage one’s sense of self-worth and put pressure on a relationship. Many men experience not achieving an erection as a sign of inadequacy. As a result an erection problem can play into the hands of one’s fear of failure, creating a vicious circle. Sometimes there is also embarrassment about seeking help, since it is estimated that only 15 per cent of men with ed consult a doctor. There are conflicting reports from researchers about the frequency with which erection problems occur. At any rate they are much more widespread than most people think.
It is clear that as one gets older the chance of ed increases. One’s sexual appetite may flag somewhat with age, arousal is no longer so intense, the blood vessels are no longer so supple, other physical ailments appear and older men often take medication that adversely affects their erection.
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Psychological or physical?
Not only patients but doctors too consider it important to decide whether the erection problem is caused by psychological or physical factors. Why is that? In the case of a patient with a duodenal ulcer not much attention is usually given to underlying psychosocial problems.
A prescription for medication to inhibit or neutralize stomach acid is soon written out, and constitutes what is known as symptomatic treatment. In the case of ed, however, the patient does not get off so lightly: the experts must, as far as they can, determine whether the problem is psychological or physical in origin. That is probably why many men are ashamed to reveal their erection problems. Research by gps showed that over 85 per cent of men with an erection problem needed help, but only 10–15 per cent had actually sought help. Once he has gone to his gp the man with ed who does not react, or does not react positively to an erection pill prefers to be referred to a urologist rather than to a sexologist. The former works with various types of apparatus, syringes and needles, or may decide on an operation. For many men that is obviously less threatening than having to talk to a sexologist about all k
inds of details of their failed love life. Men have a relatively strong tendency to rationalize. Research into gps’ treatment methods showed that a consultation in which the erection problem is first broached lasts on average thirteen minutes, and in only 10 per cent of cases is the partner present.
The patient can, in the best-case scenario, expect the following questions: is the problem in getting an erection or in maintaining it? If an erection can be achieved, the blood supply is probably adequate.
How long does the erection last? Does the erection disappear before or during coitus, and how long has the problem been going on? Is it affected by the position of the body? (In terms of coital position men are vulnerable in the missionary position: the moment they start making coital movements relatively more blood is channelled away towards their legs, which can be at the expense of the blood supply to the penis – certainly if there is hardening of the arteries. In a nutshell:
‘It’s a choice between sex and legs.’ Other questions probing the cause of the erectile dysfunction include: are there any apparently unrelated physical ailments? What about the use of medication, alcohol, tobacco and drugs? Urologists also often use a questionnaire.
What is the situation among non-Western men? Is ed more common among them? Do they deal with the problem differently?
According to gps, Muslim men often broach sexual problems via a physical complaint. An erection problem may be presented as pain in the penis, knee or abdomen. The complaint is probably expressed in a 142
a i l m e n t s o f t h e p e n i s veiled way because discussing psychosocial and sexual problems with an outsider is taboo in Islamic culture, while ‘being ill’ is accepted.
Turks and Moroccans also generally expect to be prescribed drugs.
Injections are more highly valued than tablets, powders or supposi -
tories. With Turkish men potency and fertility are crucial for their sense of self-worth, vitality and pride. Consequently erection problems can be seen as a loss of vitality or even as the approach of death.