Mrs A. took the progestogen-only Pill while she was breast feeding her second child but was advised to change to the combined Pill when she began to wean him. She now had a girl and a boy and felt her family was complete. She was already working part-time. Before her first pregnancy she had taken the combined Pill and again between the children, but now it did not seem to suit her. She had been back to the doctor several times with minor complaints and tried different brands. This time she asked to be fitted with a cap. The doctor noticed that Mrs A. seemed very anxious and asked a lot of questions during cap fitting. She wondered whether Mrs A. was worried about choosing a less effective method, having said she wanted no more children, or whether perhaps she really did want more children and was hoping ‘to make a mistake’, but she kept these thoughts to herself and listened.
‘Can the cap do any damage? How long does it take the Pill to get out of your system? Should I have another cervical smear?’ Instead of offering reassurance, the doctor said, ‘You seem to be rather worried about yourself.’ ‘It’s only since my son was born. It’s all so silly really, but I feel I’ve got to keep myself healthy for them. I suppose it all goes back to when my little brother was born. My mother was a long time in hospital with him. I don’t really know what was wrong, but I know she nearly died. I was only four but I still remember it.’
Did Mrs A. think that what had happened to her own mother might happen to her, or was it the frightened child of four within her that the doctor was reassuring?
The doctor shared these thoughts with the patient, thoughts which had been provoked by the patient’s remarks and were therefore more relevant than her previous ideas about reliability, and after a moment or two Mrs A. said, ‘I think I’ll try just one more Pill. There’s no reason at all why I shouldn’t. I was perfectly happy on it before and I really don’t want to risk getting pregnant again.’ Two months later, having shared her anxieties with the doctor, Mrs A. had settled happily on the Pill and all was well.
In this case the experience of the birth of her son reawakened memories and feelings in Mrs A. from her early childhood. In some women the feelings may come from the deepest levels of the unconscious, and may be so traumatic that serious psychological upset can occur. However, in many women such as Mrs A. the memory can easily be dealt with once it is put it into words, and the doctor who can assist in that process has a great deal to offer.
*180/197/1*
The cap lies in the vagina. It is a temporarily accommodated guest without eyes or ears. Provided it does its job, it is tolerated, and guests are fine to have around if you feel well. If you are not feeling so well, they are not so fine.
Most doctors are familiar with the issues that a cap brings to the fore for a woman, but the feelings it arouses in the man are less well studied. Men have been heard to use combative phrases to decribe it. T don’t fancy catching my weapon on that’, and ‘What if I knock it into the wrong position?’ For them it is not an unnoticed companion in their private place.
Mr E. is now separated from his wife. Things had been strained for some time. She had asked him to go back to condoms ‘because of the mess’. Later she announced, ‘You can leave them off if you want now.’ Mr E. said he could cope with the cap, but could not understand how hurt he felt when she told him she had been using it for several weeks before she told him. ‘I had hoped it meant we were getting closer’, he said, ‘but that thing [the cap] was worse because I couldn’t see it.’
*143/197/1*
At the next visit Miss R. had stopped taking the Pill and then started it again, and had many complaints about feeling weak and tired, and having vague aches and pains. Again, she was not examined. During the next year she saw many different members of the clinic staff with complaints about sore breasts, fear of infection, pain in her leg (which could have been a deep vein thrombosis), and continuing anxieties about her parents finding out she was on the Pill, and about her marriage prospects. Finally, one day Dr A. noticed that the boyfriend was always in the waiting room, and was able to lead the patient to a discussion of the question of choice, and the patient’s right to say yes or no to sex. This led to further questions about virginity, and the state of her hymen, although again no genital examination.
Following this important consultation her visits to the clinic became less frequent, and later she was able to admit that she was not ready for sex when she started and that she should not have done it. However, there was no discussion of the feelings that led her to start.
*70/197/1*
Mrs H.’s unpredictable behaviour resulted from her conflict between the wish for a stable life and motherhood and the desire for a good time. She had no model of a stable mother hence her distress and anger when her first social worker left. Hurt and rejected by her mother, she nevertheless envied her apparent freedom and gaiety. She loved her father but also despised him for being unable to control her mother. These feelings were later transferred to her husband. Without inner control she looked to others for control, but then found difficulty in accepting it. Her very inadequacy as a mother made her get pregnant in the hope that she could prove she was different from her mother. However, each time she found the demands of babies and small children too great.
In this case a measure of understanding about the unconscious forces underlying Mrs H.’s actions, and close co-operation between the doctor and social worker, allowed a consistent approach, and prevented the conflict about control being acted out between those who were trying to help.
Sustained support from the same workers over a considerable time is needed for such women until they can take the responsibility for contraception themselves. It is essential for the woman to be supported in her choice of method so that she can learn about her own limitations in using it. Eventually she may come to accept that outside control – in the form of sterilization – is the answer, but this can be done only when the woman herself wants it and should never be imposed.
*32/197/1*
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.
*279\201\8*
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.
*240\201\8*
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.
*201\201\8*
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.
*163\201\8*
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.
*126\201\8*
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.
*129\164\2*
