Stents are tubes, implanted and left in place to hold open a space that otherwise would collapse or be compressed—in this case, in the urethra where it’s choked by the prostate. The tubes are not visible and can be implanted quickly, in outpatient surgery that lasts about fifteen minutes. They are a good option for older men who are too ill to be eligible for other procedures. They’re also a major addition to the meager range of alternatives formerly available to these men. Until recently, this consisted mainly of bladder catheters, left in place indefinitely, whose presence in the body over time leads to urinary tract infection, sepsis, bladder stones, and even kidney damage.
With the stents, there’s no need for a urinary catheter, and the procedure can be performed under local anesthesia. There’s hardly any bleeding during or after the operation, minimal recovery time, and sexual function is not impaired.
The stents come in several models. The newest ones are made of nickel-titanium alloys, which are flexible and have an intrinsic memory—they expand when heated, and become flaccid and increasingly malleable when cooled. They’re easy to install and, when positioned correctly, will expand when irrigated with warm water. If it becomes necessary to remove them, these stents can be irrigated with cold water, which cause them to contract and become malleable again. They’re designed to be incorporated into the body, to meld with the epithelial tissue lining the urethra—a feat that takes the body about three to six months to accomplish, as the tissue knits a thin blanket of cells to cover the tube. Why is this coverage necessary? It’s like greasing a pan before cooking so nothing will stick to it—except the “grease” here is the body’s own cells. (During this time, bicycle riding and other activities that put pressure on the perineum should be avoided.)
One drawback of the stents is that no prostate tissue is removed and sent to a pathologist for examination. Also, the possibility exists that, over time, the epithelial tissue lining the urethra could do such a good job of covering the tube that it might overgrow the stent, and surgery to correct this may be needed. Stents aren’t a good option for men with BPH in the middle lobe; the site of enlargement interferes with the coverage of epithelial cells.
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Do you have BPH? There are some telltale symptoms. These include: A weak urinary stream, hesitancy in starting to urinate, and difficulty maintaining and stopping the stream (this can include a small amount of “dribbling” afterward). Also, many men with BPH have to urinate ffequentiy, especially at night, and often with a strong sense of urgency. If not treated, these symptoms can lead to some serious problems, including urinary retention—when the bladder stays completely or partly full—and even kidney damage.
Men who have any of these symptoms should see a doctor to determine exactiy what the problem is. It’s important to know if you have BPH. It’s equally important to make sure you don’t have a more serious condition such as prostate cancer, urinary tract infection, bladder cancer, bladder stones, a neurogenic bladder (a bladder affected by a neurological disease), or a urethral stricture (scar tissue that blocks the urethra); all of these can mimic BPH.
The doctor’s evaluation will include a detailed medical history, a physical, including a digital rectal exam; a urinalysis (examination of urine for bleeding and infection); and blood tests to check the level of PSA (an enzyme produced by the prostate) and to evaluate kidney function. Depending on your symptoms, you also may need other tests including a measurement of urinary flow rate (uroflowmetry), a check for residual urine in the bladder, an evaluation of the upper urinary tract with ultrasound or X-rays, cystoscopy (a “periscope” view of the urethra and bladder), and, for some men, bladder pressure tests to rule out neurological conditions.
After the diagnosis of BPH has been confirmed, the next step is to decide, with your doctor, what to do about it.
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When cancer invades bones, they become brittle. Brittle bones break. Therefore, men with metastatic prostate cancer are prone to broken bones (called pathologic fractures). Most susceptible are bones that bear much of the body’s weight, in the hip and thigh. Sometimes, doctors can take steps to protect bones at risk—putting pins in the hip bone to strengthen it, for example. Such steps are a good idea when a bone has a large chunk of cancer (greater than three centimeters in diameter) that takes up at least half of the bone’s outer shell.
Other Complications
Urinary Tract Obstruction
If you’re having any of these symptoms—weak urine flow; hesitancy in starting urination; a need to push or strain to get urine to flow; intermittent urine stream (starts and stops several times); difficulty in stopping urination; “dribbling” after urination; a sense of not being able to empty the bladder completely; or not being able to urinate at all—it’s probable that the cancer has become extensive enough to block your urinary tract. Several procedures are available to ease these symptoms, including a TUR procedure or the placement of stents.
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Doctors have long known that hormones play a major role in the life of the prostate. In 1786, an English surgeon named John Hunter became the first to demonstrate in animals that a radical operation, castration, caused the sex accessory tissues, including the prostate, to shrink.
But it wasn’t until the 1930s that anyone discovered why this happened. At the University of Chicago, a trio of investigators discovered that removing the testes shut down production of testosterone. And, when shots of testosterone were injected back into castrated animals, these tissues were restored to normal size and function. This Nobel Prize-winning research included another valuable finding—that castration also could shrink prostate cancer.
The researchers were able to achieve the same effect chemically; they found they could shut down testosterone with doses of female hormones called estrogens. Estrogens blocked a signal, transmitted in the brain by the pituitary gland, called luteinizing hormone (LH), which stimulates testosterone. The oral estrogen, called DES (diethylstilbestrol), is what’s known as a chemical castrator; it causes impotence.
For now, hormonal therapy means one of two main choices: Surgical castration, a “one-shot effect”; or chemical castration, a lifetime of medication.
Impotence is likely with almost every kind of hormone therapy; 90 percent of men on hormone therapy lose sexual drive and the ability to have an erection. In the future, however, new hormone treatments (discussed later in this chapter) may prove effective without causing impotence.
For a time, hormone therapy does control prostate cancer. But what some doctors used to believe—that prostate tumors are nourished only by hormones, that hormone starvation will stop the cancer from spreading—is, unfortunately, not the whole story. Ultimately, hormone therapy will not stop the disease’s progression.
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Radical prostatectomy is certainly not a new cure for prostate cancer; it’s been around since 1904. There are two versions of this operation—the perineal approach, and the retropubic approach. The radical retropubic prostatectomy used to be notorious among surgeons for the extreme bleeding that went along with it, and both of these procedures used to have two devastating side effects— impotence and incontinence.
That picture has changed. The last fifteen years have seen dramatic improvements to the retropubic approach, based on new understanding of the prostate’s anatomy. The development of new techniques has lessened the awful blood loss, and the operation has become far safer for patients. And, with what surgeons call “a bloodless field,” it’s now possible for them actually to see what they’re doing—a major improvement! In the process, critical structures can be looked for and saved that previously were unrecognized and damaged as surgeons blindly felt their way. More precise techniques have reduced the likelihood of troublesome urinary incontinence to about 2 percent (and even those 2 percent aren’t incontinent all the time). New anatomical discoveries also have made it possible for surgeons to preserve potency in the majority of men.
And perhaps most exciting, better understanding of the anatomical terrain means surgeons can now remove more tissue along with the prostate than anyone ever thought possible—which improves the operation’s chances of cutting out all the cancer.
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Masters and Johnson found that simple advice on and attention to technique, such as in the list below, provided the answer for one in eight of their so-called ‘infertile’ patients.
Excessive exercise and jogging have been associated with subfertility and so should be moderated.
Y-fronts-To function effectively the testes need to be cooler than the rest of the body so it is sensible not to wear Y-fronts which prevent the testes moving downwards when hot.
Miscarriage-Even if fertilisation and implantation are achieved the foetus may still be lost. In fact up to three-quarters of all conceptions are lost, usually without the woman even knowing she had conceived.
Loss of the foetus later on is a more obvious miscarriage and has a much more profound effect on a woman and her partner. Ironically, even though Nature seems to reject so many foetuses we humans too add to the number by electing to terminate unwanted pregnancies. The active process by which we do this is called abortion.
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Some men suffer from a delay in reaching orgasm and cannot ejaculate with their penis in a vagina. Some can be masturbated or fellated to orgasm by the woman if they withdraw, whereas others cannot be brought to orgasm by a woman at all, by any means, and may not be able to ejaculate if a woman is even in the same room. Some men who are successfully treated for premature ejaculation then suffer from retarded orgasm and vice versa. The majority of the partners of such men are distressed by it. Some women conclude that they have over-stretched their vagina during masturbation or childbirth and that this is the explanation.
However, the problem sometimes presents itself directly in the form of complaints that the vagina is too large or too wet or that the penis, or some portion of it, has lost its sensation. Some men in this group are discovered to compress their penises tightly during masturbation. They have simply mis-trained themselves and now cannot respond without tight penile pressure. Others complain of intense penile pain, which they naturally want to avoid, at orgasm. In all such cases intercourse or pleasure is being avoided in order to reduce anxiety.
Diabetes and various drugs can be the cause in men who complain of a lack of sensation, but more often their ultimate unconscious need is to deny that they are having intercourse. It is only by doing this that they can function at all. Some, who unconsciously equate genital fluids with excretion, want to avoid soiling the woman and others unconsciously equate the woman with their mother. Their response is not to stop sex with her but not to ejaculate inside her. Others who, it is easily imagined, were rebuked and punished by women — sometimes even by older sisters — for genital activity in childhood, are simply afraid to lose control and reach orgasm in the presence of a woman.
Relatively inexperienced men who have this problem say that at some point during intercourse the whole business loses its excitement and that distracting thoughts enter their minds. The explanation is that as their level of pleasure and therefore, to them, sinfulness, rises, so does their anxiety, so reducing the pleasure. Some maintain their erection and others simply lose it. Although most, but not all, men enjoy intercourse more if the woman also moves her pelvis, this activity or what she says can be the distraction which intrudes into the man’s mind. It increases his self-awareness and thereby his anxiety about what he is doing.
Various fears can cause the same problem, although they may only be vehicles for yet deeper fears. These include a fear of making the woman pregnant, a fear of VD or AIDS and fears about other men with whom the woman has had intercourse. Thinking about other men makes him jealous or makes him worry that her previous lovers were better endowed sexually than he or were better lovers.
Treating the underlying cause, together with re-education, a decrease in anxiety, a reduced emphasis on orgasm, and an increase in penile pleasures and eroticism, all with the involvement of the woman, with the aim of increasing the efficiency with which the man responds to her manual or oral stimulation, forms the first stage of treatment. Once the woman can reliably bring the man to orgasm she, without saying anything, can on occasions, when he is near orgasm, quickly get on top of him and thrust rapidly so as to make him ejaculate in her vagina. Usually his perceptions change and his anxiety falls.
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This is extremely pleasant for both partners and many women who cannot have an orgasm in any other way often do so with their partner caressing their clitoris with his tongue. There is absolutely nothing revolting or dirty about kissing a woman’s genitals. Either lie between her open legs with your head coming from below or crouch over her with your penis on her upper chest or face and kiss her vulva like this. It helps to have a pillow under her bottom to raise the whole area slightly and to prevent you from breaking your neck! Lick the whole of the vulval area with your lips and tongue and dip your tongue into the vagina and stroke it upwards towards her clitoris. Caress the clitoris with your tongue as if you were using a finger and keep doing what she likes until she climaxes. Most women who have orgasms in other ways, and many who otherwise would not have had one, have extremely good orgasms from such oral caresses. There are lots of other positions (such as sitting on a chair or kneeling on all fours) in which you can kiss your partner’s vulva, so experiment and find what you both most enjoy.
In spite of this a word of caution is necessary since oral sex is a common area of conflict. Some women regard their vulvas as smelly, germ-ridden and revolting, and do not like their man to use his mouth there. Even if they do go ahead, a sign that this is so is that they dislike him kissing them on the mouth afterwards. Some men have a similar view. Some women feel the same about sucking the penis, especially if she suspects the man of wanting to ejaculate in her mouth.
Oral sex with a casual partner about whom there is uncertainty is potentially dangerous because, contrary to earlier opinions, it is now thought AIDS can be transmitted this way. There is an increased chance of AIDS being transmitted in this way from an HIV-positive man if the woman has recently cleaned her teeth because there will be tiny abrasions on the gums through which the virus can enter her bloodstream.
Apart from this the only danger in cunnilingus arises from blowing air into the vagina. Several women have died as a result due to the air reaching the bloodstream.
Cunnilingus: Not all men enjoy doing this to a woman and not all women enjoy having it done, yet it is an increasingly popular type of foreplay. Some women can have an orgasm with a man only in this way.
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A woman’s sex organs are rather more of a mystery than a man’s because many of the important parts lie inside the body and so cannot be seen, and even those that are outside are not easy to look at. As a result some women have some very strange notions about their sex organs. In addition to these problems a woman’s vagina lies only a matter of centimetres away from her anus (back passage) and so may become mixed up in her mind with dirt and stools. Also, of course, girls in our society are brought up to be more ashamed of their genitals and this is another reason why many claim never to have looked at their vulvas even though they very much wanted to. A woman who has irrational fears and suspicions about how she is made will not function well sexually and her partner will not be allowed or encouraged to enjoy her body as he should.
Breasts and sex-During the earliest phase of sexual arousal the first visible sign that anything is happening is that the nipples become erect. This comes about as the tiny smooth muscles in them contract. One nipple often erects before the other and erection can occur without physical stimulation. Stimulation either by the woman herself or by her partner usually hastens erection but is not essential. The nipples increase in length and diameter as the woman becomes more excited and blood collects in and around them. This mechanism is rather like that which causes the penis to become erect. As the woman becomes more aroused the whole breast swells and she may have a measles-like rash on them and over her chest and neck.
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This lasts from about the age of fifty until the death of one of the partners. It is usually a phase of togetherness and increasing satisfaction. The couple have no fear of pregnancy and their sex lives often improve. Unfortunately, some older couples still feel that sex is for the young and so do not enjoy sex nearly as much or as often as they could. Thankfully things are changing in the right direction as far as this is concerned. It is worth taking care not to lose the habit of intercourse if one partner has to go into hospital or is ill for a long period. It is also interesting to see that evidence suggests that an active sex life is linked to a long life. People of this age often have grandchildren who bring pleasure with few responsibilities (a rare combination in life) and no longer have to worry about being competitive at work. The man will have got as far as he is going to and is either settled in his career or is running up to or already in retirement.
In the good man-woman relationship this attachment grows, particularly at times of stress when the couple think about each other, want to be with each other, communicate distress to each other, and are comforted by one another. The bond that forms between long-married couples can be formidable. They tend to think along the same lines and seem to be ‘one body’ as described in the Bible.
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