Manhood: The Rise and Fall of the Penis (14 page)

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just hand-jobs, together,’ replies the patient. ‘I should say I haven’t got a permanent relationship, but when I pick someone up in the pub in the evenings and I come it’s a real turn-off to keep seeing my sperm like that. It’s really embarrassing. Or am I supposed to do it in the dark from now on?’ ‘Blood in sperm’ can definitely spoil someone’s love life, but the problem remains that in the vast majority of cases urological examinations relating to haemospermia reveal no abnormalities.

Inflammation of the prostate

‘As men grow older they believe they still have abundant sexual energy, but they are being fooled by the signals they are receiving because these are being sent to them only by an irritated, worn-out prostate,’ is how the Italian poet, philosopher, essayist and philosopher of science Guido Ceronetti characterized one of the problems of men suffering from inflammation of the prostate. Prostatitis is very common, more so in its chronic than in its acute form. Acute inflammation of the prostate is generally caused by a bacterium that penetrates the prostate from the urinary tract. This can happen easily since the prostate with its many drainage routes is directly linked to the urethra. Prostatitis is not always the result of a urinary tract infection – micro-organisms can also infect the prostate via the blood. Then there are venereal diseases, euphem -

istically called sexually transmitted diseases, which may lead to inflammations. In the past the main culprit was the clap, a gonoccochal infection; nowadays it is mostly chlamydia trachomatis. An added problem is that many women carry this micro-organism without being aware of it and so form a source of infection.

In cases of acute prostatitis the patient is unwell, has a high temperature and, because of swelling, urinating is painful and sometimes completely impossible. Treatment with an antibiotic that penetrates the prostate effectively can prevent the condition from worsening. In the worst-case scenario an abcess develops, which has to be drained by a urologist, usually through the rectum. With a chronic prostate infection things go on simmering: medication brings temporary relief, but after a while the symptoms return. Back pain, pain in the area between the scrotum and the anus (the feeling of sitting on a hot chestnut), a burning feeling when urinating, a frequent urge to urinate: these symptoms can drive sufferers to distraction. Sometimes the symptoms spill over into the patient’s sexual functioning: there is a loss of sexual appetite, ejaculation becomes painful and in the worst case the man becomes impotent. Chronic prostate inflammation is sometimes the result of an inadequately treated acute inflammation. The bacteria hide in out-of-the-way corners and hence do not show up in urine cultures. A cure 66

t h e p ro s tat e a n d s e m i n a l g l a n d s becomes difficult. In some cases stones, or accumulations of calcium, form in the prostate. Very occasionally long-term treatment with an antibiotic brings relief, but mostly it remains an ongoing problem.

Many men with prostatitis change doctors or ask for a second opinion, possibly because advice quite frequently differs widely: one doctor recommends hot baths, another cold ones, one urges less sex, the other . . . etc. That is understandable when one knows that the ailment does not follow a fixed pattern: sometimes the patient feels better after an ejaculation, sometimes even worse. What we do know is that alcohol never helps.

Prostate cancer

Prostate cancer is largely a disease of our age. Two centuries ago it was rare: patients died before the cancer manifested itself. The body is constantly under construction and in decomposition, cells die and are replaced by new ones. This constant renewal allows organs to function normally. If certain cells do not die and change in such a way that they start multiplying abnormally and develop into a malignant tumour, we speak of cancer. But there is huge variation within that diagnosis. These days many men are told that they have prostate cancer, but by no means all of them die of it, or if they do it is only much, much later.

A good example of this is the case history of former French president François Mitterrand (1916–1996). He was first diagnosed with prostate cancer in 1981 at the age of 65 and he died at the age of 79.

Celebrated musician Frank Zappa (1940–1993) was unfortunately diagnosed too late, and died of the disease. The same happened to Prince Claus von Amsberg (1926–2000), husband of Queen Beatrix of the Netherlands, whose ordeal began with his diagnosis in 1998. He had an operation, but this was not radical enough, and subsequent microscopic examination showed that prostate cancer cells were still present, requiring a course of radiotherapy. A side-effect of the radiotherapy was that the draining of urine from the kidneys to the bladder became impeded, and hence one kidney had to be removed. The prince then developed intestinal problems that necessitated a colostomy, and from then on his condition went into a downward spiral, finally resulting in an embolism of the lung and a heart attack. In contrast, the Bond films actor Roger Moore was treated in time.

Mitterrand’s experience shows that there is a form of prostate cancer that develops so slowly that it may be twenty years before the growth becomes life threatening. When such a process begins only at a late stage in life, at the age of 65, for example, the patient may experience some discomfort, but very frequently has no symptoms at all. With 67

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such a virtually benign form of prostate cancer one can live for years without any problem or symptom. Some urologists call these types of cancer ‘pussycats’, as opposed to the ‘tigers’, highly malignant and dangerous prostate cancers. Tigers can sometimes, but not always, be recognized by the pathologist by microscopic analysis when the diagnosis is made. The higher the Gleason sum score – named after the scientist who devised the best method of grading prostate cancer – the greater the chance that the cancer is a tiger.

In the spring of 1949 the philosopher Ludwig Wittgenstein felt more tired than usual and was found to be suffering from anaemia. At the end of the summer, on a visit to the United States, he became very ill and had to be admitted to hospital. He was not frightened of a diagnosis of a serious illness, but did dread an unnecessary prolonging of his life, leaving him to await death for years in a state of complete helplessness. What’s more, he was frightened of dying in America and exclaimed to his host and ex-colleague Norman Malcolm: ‘I don’t want to die in America. I am a European. What a fool I was to come.’ At first no sign of a serious disease was found, but back in England he was proved right. He wrote in a letter to Malcolm:

I have prostate cancer. But it sounds much worse than it is, as there is medication which, so they tell me, may alleviate the symptoms of the disease, so that I may live for years yet. The doctor tells me that I may be able to work again, but I can’t imagine that. I wasn’t at all alarmed when I heard that I had cancer, but I was when they told me that they could treat me, because I have no desire to go on living. My wish was not granted. I’m being treated by everybody with the greatest kind-ness and I have a terribly kind doctor, who is no fool.

The man who wrote in his diary in 1930 ‘Very often or almost always I’m frightened to death’, showed not a trace of fear when death approached.

For forty years Anatole Broyard was an editor, literary critic and essayist on the
New York Times
. At the age of 69 he was told that he had prostate cancer. He gives an account of this period in
Intoxicated
by My Illness
, the main message of which is: ‘I would advise every sick person to evolve a style or develop a voice for his or her illness. In my case I make fun of my illness.’ Although the writer states that after hearing about his fatal disease he loses all belief in the irony of the human condition as such, he clings to his ironic perspective, which the diagnosis of cancer does not destroy. On his first visit to the specialist he takes a seat in the waiting room. Full of appreciation he studies the 68

t h e p ro s tat e a n d s e m i n a l g l a n d s tasteful décor and counts himself fortunate that the doctor who designed this room is to be his doctor. The doctor comes in and asks Broyard to follow him to his room. He finds himself in a completely impersonal room with an equally impersonal consultant. He decides to change doctors: ‘I found another urologist. He is brilliant, famous, a star and my response to him was so positive that my cancer immediately went into remission. My only regret is that he does not talk very much – and when he does, he sounds like everyone else.’

Broyard would like his urologist to develop a little more depth and have a bit of a sense of humour, a doctor who would appreciate both the comedy and the tragedy of his illness: ‘I find an irresistible desire to make jokes. When you’re lying in the hospital with a catheter and iv in your arm, you have two choices: self-pity or irony. If the doctor does not get your ironies, who else is there around?’ His friends find it difficult to take this step. You don’t make jokes about a serious illness.

Is irony lost on cancer? In
Case Histories: Essays on Literature and
Medicine
, Arko Oderwald writes that irony is one way of making fun of society’s lies about a disease. ‘Apart from that, in an ironic book about illness, the (self-)irony means that there are still a few laughs, which makes reading it a lot more pleasant than all those auto -

biographical accounts that cannot detach themselves from immediate experience.’

More and more reports are published about nutrition and the appearance of full-blown prostate cancer, or the transformation from a pussycat into a tiger. The use of soya proteins, vitamin E and a low-fat diet supposedly protect one from prostate cancer. Precisely how that works is not yet known. As far as fats are concerned, those deriving from red meat receive a very bad press, while fish oil with its poly -

unsaturated fats is not seen as harmful. The average selenium level in the Western diet is 40 micrograms, which is very little: the World Health Organization recommends between 50 and 200 micrograms a day. Ivan Wolffers, a professor of medicine, makes it clear that he feels little affinity with alternative medicine, but ‘if people are really at rock bottom and for example apply endive leaves to their back with a bandage over them because they think that can restore their strength, I think: if it gives those people some peace of mind, what harm can it do?’

‘Blessed is he who pees well to his dying day. No one now need suffer the agonies people once had to endure: that is a consoling thought’, writes Ceronetti in
The Silence of the Body
. In his view prostate disease remains a huge drama, but at the same time he maintains that the great advance in medical science is not so much the controlling of pandemics, but the reduction in urological agony. He adds that many people live by results. ‘Doctors and patients crawl from 69

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lab result to lab result, as if everything were quantifiable, but once someone has the examination result (of, say, the Prostate-Specific Antigen or psa test) in his hands, he can never regain his innocence, he knows too much.’ How true that is! How little is written about the right not to know . . .

The female prostate

Even in urological handbooks the female prostate is given very little attention. Since 1880 the organ has been known as Skene’s glands.

Skene was a gynaecologist and published on the subject in a medical journal. In fact, the female prostate ought to be named after the short-lived scientist Reinier de Graaf. Shortly before his death he described not only its anatomy but also its physiology. He observed that fluid was produced by women as well as men during sexual arousal and orgasm. In modern medicine it has thus far received little attention, though Professor Milan Zaviacic of the Comenius University in Brati -

slava, a pathologist, has made it his life’s work. In 1999 he published an extensive scientific monograph on the subject.

Like the male prostate, its female counterpart produces a specific antigen (psa), acid phosphatase, glycoproteins and fructose. The Skene glands weigh between 2.6 and 5.2 g and are located at the back of the urethra, that is, between the urethra and the vagina. Their dimensions are: on average 3.3 cm long, 1.9 cm wide and 1 cm high. There are several scores of drainage outlets from the gland tissue to the urethra, many more than in men. Zaviacic’s test subjects were required to wear the same cotton panties for several days. The professor then coloured the part of the panties that had been in varying degrees of contact with the end of the urethra. Through this specific colouring it was proved that acid phosphatase, abundant quantities of which are produced in the male prostate, also flowed from the female urethra.

Various researchers have tried to discover what quantity of fluid women lose on ejaculation. The values vary from 3 to 50 millilitres on each occasion. While by no means all women can feel themselves ejaculating (estimates vary between 6 and 40%) it is probable that a form of ejaculation at orgasm is universal. Of course, researchers can capture the ejaculate for examination. If that is not possible, urine can, for example, be examined before and after an orgasm for certain substances, including psa. The psa content of female ejaculate averages 0.82 nanolitres per millilitre. One may speculate about the significance of the existence of the female prostate, for example for sexology, urology and gynaecology. As regards sexology, it is plausible that the Gräfenberg or G-spot, first described in the 1950s, is in fact the female 70

t h e p ro s tat e a n d s e m i n a l g l a n d s prostate. For the urologist it is important to know that some 10 per cent of urethral cancers involve an adenocarcinoma, that is, prostate cancer. In addition, the female prostate quite frequently becomes inflamed, and in such cases an antibiotic is no help at all. As with men, prostatitis in women is difficult to treat: antibiotics have difficulty in penetrating the prostate.

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chapter four

Testosterone and Sperm

Human testicles and those of male chimpanzees are considerably larger than those of gorillas and orang-utans, two species of ape closely related to man. Gorillas and orang-utans have modest genitalia for their large body size and ejaculate relatively meagre amounts of sperm. These animals do not require abundant quantities of sperm cells for reproduction. The male, with his silvery coat, lords it over ‘his’ females in the gorilla harem, and other males rarely dare take him on. This ‘alpha male’ does allow other males to have sex, but only with immature or pregnant females. His imposing appearance ensures that the fertile adult females remain off limits to his subordinate fellow-apes. Although orang-utans also avoid a ‘sperm competition’, things are slightly different with them. These solitary orange-coloured giants, which roam the forests of Borneo, have a very restrained sex life.