Health News and Information

For many men, the symptoms of prostatitis appear suddenly and then go away with treatment. For these men, prostatitis is an awful episode to endure and then put behind them; it does not require a lifetime adjustment. But for Alan, a 52-year-old Baltimore attorney with perhaps a “worst-case” scenario of nonbacterial prostatitis, the situation is distinctly different.

His trouble began three years ago. He’d had some minor prostate “episodes” before that, he says, but nothing like this. Then, after seeking treatment for a headache, he was prescribed a migraine medication, in a class of drugs called tricyclic antidepressants. “What it [the drug] did, was slow down my urine flow terrifically.” Within a couple of days, Alan began noticing some new symptoms: “I found I was spending a lot of time going to the bathroom, and I developed some stinging, and a lot of nonspecific symptoms like headaches— just not feeling well. The first time I had sex after that [developing these symptoms], it was painful, and I was sore for a day or two afterward,” with pain in the lower abdomen, scrotum and perineum.

Eventually, Alan was diagnosed as having nonbacterial prostatitis. “The symptoms ebb and flow, but they haven’t disappeared,” he says. These include reduced urine stream; occasional difficulty starting and stopping urination; generalized pain in the perineal region, usually beginning about twelve to fifteen hours after sexual intercourse and lasting two to three days; and “just feeling lousy.” He’s also been awakened by muscle spasms in his perineal region, but he can’t pinpoint an exact location. He tried abstaining from sexual intercourse, but that didn’t help.

At first, Alan had what he describes as “menopausal-type” feelings, accompanied by a lot of anxiety: “When this first came on, because of that fear of losing something very special to me, I think there was a heightened sense of sexual drive or desire, which was of course immediately frustrated by the inability to do anything about the symptoms.” And he thought, “Is this going to be a permanent impairment, will this limit sexual activity and the free expression of physical love in my marriage? Is this going to be the end of a chapter in my life?”

Alan’s suggestions for men with his condition: “First, just try to have a positive oudook on being able to live with this situation. With time, there comes a better ability to adjust and accept what is really a very annoying and irritating condition.”

He was treated early on by an internist, who described Alan’s problem as “prostatosis,” a vague, unhelpful term that means simply “a condition of the prostate.” Another word of advice: “Don’t let anybody tell you it’s all in your head.” Alan even consulted a psychiatrist, who confirmed that prostatitis is “a real, live condition that could not be explained solely by psychological causes.”

“Sometimes the symptoms are worse than others,” Alan says; “I can’t determine what makes them different. There just isn’t any clear-cut pattern. I guess part of this experience has been simply accepting the condition.”

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One advantage of laser prostatectomy is smaller instruments, which should produce fewer strictures, scars resulting from injury to the bladder neck or urethra. And, if the bladder neck is not treated, there should be no retrograde ejaculation and no sexual dysfunction. These techniques cause less bleeding, and unlike the TUR they can be performed on an outpatient basis under local anesthesia. Also, there’s no fluid absorption (so no risk of TUR syndrome).

To date, the biggest problems with these still relatively new techniques have been prolonged urinary obstruction after the operation in some patients, and the need for a catheter (either in the urethra or a suprapubic tube, attached directly to the bladder) for several days after surgery. Also, it takes longer for laser prostatectomy to improve urinary flow than for TUR. So, laser surgery may not be best for an impatient patient. The ideal candidate for laser prostatectomy should have a prostate that weighs less than sixty grams or two ounces; should not have urinary retention; and should have mainly obstructive, not irritative, symptoms.

Another problem is that no tissue samples are available for pathologic study. And if the energy beam creates holes in the prostate, there can be distressing irritative symptoms that persist until the tissue has dissolved and been flushed from the body.

Moreover, lasers may not be as widely available as other forms of treatment because of their cost: Laser fibers are very expensive, and most of them can’t be reused. For each laser procedure, the laser fiber alone costs about $800. (The laser machines themselves cost hospitals about $100,000, but they can be used for other procedures.)

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Urinary retention—difficulty in emptying the bladder completely, or in urinating at all—also can be triggered by many things, including consuming alcohol; having prostatitis; and taking such medications as antihistamines, antidepressants, tranquilizers, or decongestants. It could even mean prostate cancer, although in most cases, prostate cancer is regrettably “silent,” producing no symptoms until it becomes considerably advanced. Two other symptoms, however—trouble starting urination, and a slow or weak stream— almost always signal obstruction.

The lower urinary tract can also be affected by neurological disorders such as diabetes mellitus; multiple sclerosis; Parkinson’s disease; and spinal stenosis, pressure on the spinal cord that impairs the brain’s ability to communicate with the bladder. These and other diseases can give rise to obstructive and irritative symptoms like those in BPH. (Parkinson’s disease makes it particularly tricky to treat the symptoms of BPH. For more on this, see Chapter 10.) The term “neurogenic bladder” refers to a bladder affected by such conditions.

So, because other conditions can mimic the obstruction produced by BPH, a good medical history is vital even if you have what seems like a classic case. An injury to the urethra (from an episode of gonorrhea many years ago, perhaps, or from having a catheter inserted into the bladder during a surgical procedure, such as a coronary artery bypass) can produce a urethral stricture—a scar that narrows the urethra—that has nothing to do with the prostate, yet produces urinary problems just as BPH does. Blood in the urine, or pain in the bladder or penis could point to a bladder tumor; it could also indicate that a stone has developed in the bladder, prostate, or kidney. And having a history of other urologic problems—recurrent tract infections or prostatitis, for example— could mean one of these old adversaries has returned, in a different guise.

You will also be asked to score your symptoms on a questionnaire (such as the one in table 9.1). Be honest; your answers will help your doctor determine whether your symptoms are mild, moderate or severe, and the impact they’re having on your life.

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DRUGS FOR PAIN

It makes sense to treat each level and kind of pain differently. At the lowest level is mild pain that responds to aspirin, acetaminophen (Tylenol), or ibuprofen (Advil or Motrin). Next come low-powered opiates, drugs such as codeine. As opiates go, these drugs are considered weak. In terms of pain relief, they can’t hold a candle to high-powered opiates such as morphine—the highest rung on the pain ladder. (However, these milder opiates generally are sufficient to ease moderate pain.) The biggest advantage to strong opiates is “their lack of ceiling effect,” as one study puts it. “Increasing the dose always increases the pain relief,” although it can also increase the side effects.

In addition, other drugs not generally classified as painkillers—particularly corticosteroids—have proved helpful in reducing inflammation and bringing relief from some spinal pain. Ask your doctor if one of these drugs might be right for you.

If you are elderly, have other health problems, or are taking other medications, certain painkillers may have a stronger effect in you than in other men. Be sure to discuss these factors, the side effects of various drugs, and the form in which you should take these drugs—a pill, or liquid, rectal suppository, skin patch, or shot—with your doctor. If you need additional information, your pharmacist may also be able to provide you with the package insert sheets for various drugs. These generally are impenetrable, written in tiny print, and confusing—they contain more information than most people want to know. They also tend to list every possible side effect, even the unlikely ones. However, some people find this information helpful.

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External-beam radiation therapy is an excellent treatment option for many men with prostate cancer. First and foremost, it requires no surgery—this is a key advantage for older men, as well as for men with other health problems that might preclude major surgery. Also, it can be used in men with prostate tumors that are too far advanced to be cured by surgery.

There are two standard approaches to radiation treatment for prostate cancer—sending radiation into the tumor from the outside, with external-beam radiation therapy, and implanting radioactive seeds directly into the tumor; this is called interstitial brachytherapy.

Currently, the “gold standard” for radiation is external-beam radiation therapy. Sophisticated refinements have transformed it from the imprecise, mostly palliative treatment it was just decades ago into a powerful treatment that can cure localized cancer—not just relieve the symptoms of advanced disease.

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The percentage of homosexual offenders vs. adults who had ejaculated during sleep is moderate in comparison to other groups. However, in early life they rank high in accumulative incidence: by age twelve they are third with a fifth of their members having had nocturnal emissions; by age fourteen they are second with 41 per cent; and by age sixteen they are third again with 57 per cent. Thereafter the figures become moderate. The median homosexual offender vs. adults had his first nocturnal emission at die age of 15.2 years, the youngest age on record, but this is not unexpected since these offenders reached puberty earlier than did others.

In age-specific incidence the unmarried homosexual offenders vs. adults display a relatively large percentage (51 per cent) in their early teens (thanks to their “head start” mentioned above), but their percentages thereafter are in no way unusual until age twenty-six after which they have the second smallest or smallest percentages of any groups. The age-specific incidence figures of the married fluctuate rather wildly. These men rank first from sixteen to twenty with a figure of 64 per cent, then rank intermediate to low until age-period 31-35 when they are second with 50 per cent, and then drop back to an intermediate position thereafter.

Before marriage the average (median) homosexual offender vs. adults who had nocturnal emissions had them about 5 to 6 times a year; these are somewhat high frequencies for sex offenders but low compared to the control group.

Aside from their teens and early twenties when the unmarried homosexual offenders vs. adults derived a moderate proportion of their total sexual outlet from nocturnal emissions, they display the smallest or next-to-smallest proportions from then on, never exceeding 3 per cent after age twenty-five and usually being 1 or 2 per cent. It is not that their emissions were rare; it is simply that they were far outweighed by the much more frequent masturbatory and homosexual activity.

The married homosexual offenders vs. adults present a similar picture, moderate (and even high at age-period 16-20) proportions of total outlet that were derived from nocturnal emissions earlier in fife, and small proportions later. In age-periods 31-35 and 36-40 they share with the homosexual offenders vs. children the smallest proportions (1 per cent) of any group.

Of all groups, the homosexual offenders vs. adults had fewest (63 per cent) individuals with heterosexual dreams and the most (82 per cent) with homosexual dreams. In dreams of contact with animals, they have 5 per cent, the same as the homosexual offenders vs. children. This is of especial interest, since they are third in the percentage who had overt sexual experiences with nonhuman animals.

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The incest offenders vs. adults share with the incest offenders vs. minors the distinction of being the least homosexual of the various comparative groups. Only 12 per cent, the smallest proportion recorded, had any homosexual contacts either in or out of prison, and none solely within prison. Only one man reported any sexual arousal from thinking of or seeing members of the same sex, and this was not a strong arousal. Only this one individual had more than incidental homosexual activity, which we define as having had 21 or more homosexual contacts or more than five male partners. Note that in prepubertal life the future incest offenders vs. adults had little homosexual play.

In keeping with this record the accumulative incidence figures are low. The largest percentage (14 per cent) is seen by age fourteen, but as more individuals reached puberty at older ages the figure drops to 9 per cent by age sixteen and builds up to 12 per cent by age eighteen, which is as far as our calculation can be carried. In age-specific incidence one finds that only between puberty and fifteen did any offenders have homosexual activity, and then only few (8 per cent). Among the married males homosexual behavior was confined to the years from twenty-six to thirty-five when 5 per cent were involved. The proportion of total sexual outlet derived from homosexual behavior is minimal, never exceeding 1 per cent; in no other group was homosexuality quantitatively less important.

Like the incest offenders vs. minors, the incest offenders vs. adults strongly disapproved of male homosexuality, ranking third in this respect, with three quarters reporting disapproval as against 6 per cent who approved.

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The next commonest variety of aggressor, constituting perhaps 10 to 15 per cent of the aggressors vs. adults, might be termed the explosive variety. These are men whose prior lives offer no surface indications of what is to come. Sometimes they are average, law-abiding citizens, sometimes they are criminals, but their aggression appears suddenly and, at the time, inexplicably. As one would expect in situations where individuals snap under hidden emotional stresses, there are often psychotic elements in their behavior. The stereotype of this variety of aggressor is the mild, straight-A high school student who suddenly rapes and kills. For total unexpectedness, one of our cases is equally dramatic. A small, physically delicate, devoutly religious eighteen-year-old had been reared by his mother, who seems to have dominated him. While heterosexually oriented, he never developed sociosexually with girls of his own age; instead, on rare occasions he engaged female children in what would be called childhood sex play had he been preadolescent rather than fifteen or older. He was never able to achieve coitus, but usually ejaculated when the children struggled or when his penis touched their genital area. This behavior resulted in his being sent to a juvenile institution for about a year. On his return home and only a few days after his eighteenth birthday, during his mother’s absence he asked a neighbor woman to come into the kitchen and light the oven for him. When she entered he struck her on the head with a hammer, hoping to knock her unconscious so that he could have coitus. She was not rendered unconscious by the blow and succeeded in escaping.

While the above case is unusual in that the subject was so sociosexually underdeveloped, in the following case the man’s sexual history was normal. He was a hard-working, semiskilled laborer described by the prison psychologist as having “many fine traits, . . . deep respect for authority, family pride, sense of personal responsibility, a knowledge of right and wrong and a willingness to abide by the same, . . . etc.” His dossier contained numerous and various letters attesting to his good character and respectability. The only negative note was his wife’s statement that he tended to worry excessively and became emotionally upset easily. This statement is biased by the fact that the behavior of the wife and her relatives directly led to the sex offense. This conservative and respectable man had made the error of marrying a girl from a very low socioeconomic stratum who brought with her to marriage not only an unborn child, but a number of shiftless, drunken, parasitic relatives. The resultant bitter arguments essentially destroyed the marriage, and the man decided to make the best of a bad situation by having extramarital coitus with some of his promiscuous female in-laws. He chose his mother-in-law, having interpreted her behavior toward him as provocative; the psychologists say that this choice also was unconsciously motivated by a desire for revenge against his wife and all her relatives. In any case, coitus occurred and the woman was at least partly forced.

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The aggressors vs. children are more likely than other sex offenders to be the youngest child in the family, their proportion considerably exceeding what one would expect. The average aggressor vs. children was reared with five siblings—a number exceeded by only four other types of offenders. The siblings were chiefly sisters: the aggressors vs. children were one of the four groups where the sex ratio favored sisters, who more often than not were older than the aggressor vs. children.

The members of this group got along with their fathers at ages fourteen to seventeen about as well as did most sex offenders. Their adjustment to their mothers, on the other hand, was unequivocally bad: they had the second worst maternal relationship of any group. Nevertheless, enough of them did get along well with their mothers so that when we asked, “With which parent did you get along better?” we found that the number who favored their mothers was essentially the same as the number who got along equally well with both parents. This tendency for the percentage preferring the mother to equal (in the aggressors vs. children) or surpass (as in the aggressors vs. minors and adults) the percentage professing impartiality is a poor omen, shared not only by all aggressors but also by the homosexual offenders, the exhibitionists, and the incest offenders vs. children.

The aggressors vs. children are also characterized by having come from broken homes: 64 per cent, the highest figure for any group and double that for the control group. Relative to other groups, there was a tendency for the breakup to have occurred rather early, when the average (median) boy was about six years old. Also he spent the fewest years in a home in which there was both a husband and wife, regardless of whether or not cither was his own parent. Partly in eon-sequence of this, the aggressors vs. children rank first in the number of years that they lived in a household in which all the adults were women.

While from the record of broken homes it is obvious that the original parents of the aggressor vs. children did not get along well with one another, the subsequent parent and stepparent combination was also deficient in this respect: while slightly over half got along well, one third got along poorly, ranking in the lower half of the scale of inter-parental adjustment when the subject was in his middle teens.

In summary, the early life of these aggressors presents a rather dismal picture: a large number of broken homes followed by protracted residence with the mother (or surrogate mother) with whom the subject got along very badly.

With the home an unhappy place, the future aggressor vs. children, it seems, turned his interests and emotions toward other children. He occupies first place among those who had many boy and girl companions at age ten to eleven, and last place among those lacking girl companions. Whereas almost one third of the control and prison groups had no girl playmates at this age, only about 12 per cent of the future aggressors vs. children were “girl-less,” and some 32 per cent (third rank) reported having had numerous female companions. The aggressor vs. children certainly suffered from no defects in his ability to get along successfully with his peers, even though his relations with his parents left much to be desired. This social success may correlate with the large number who not only had sisters but many sisters. In this connection it is noteworthy that almost 22 per cent of this group (nearly two times as great a proportion as of the next group) first saw postpubescent female genitalia by seeing a sister’s.

Their successful social life did not lead to an unusual amount of prepubertal sex play—the aggressors vs. children are average in this respect. This is a bit surprising for yet another reason: they had more time in which to have had sex play than did other groups, because 28 per cent of them did not reach puberty until they were fifteen or older. However, they were strikingly oriented toward the heterosexual: the percentage who had exclusively heterosexual play (32 per cent) almost equals the sum of those with homosexual play and both hetero- and homosexual play. This definite preference for the heterosexual is typical of all the heterosexual aggressors who rank second, third, and fourth in the list of those whose prepubertal play was exclusively heterosexual.

There seems nothing significant about the number of years that sex play continued, but an examination of the techniques used reveals an interesting fact. The heterosexual aggressors tend more than the other groups to have had coitus before puberty—between 69 and 73 per cent of those with heterosexual play had coitus. Only one group, the offenders vs. adults, exceeds the three heterosexual aggressor groups in this respect. The future aggressors vs. children also include the largest percentage who had mouth-genital contact prior to puberty, essentially double the percentage of the sex offenders as a whole and quadruple that of the control group. In brief, the aggressors vs. children who did have prepubertal sex play were not interested in childish exhibitions and manipulations; they engaged in techniques more characteristic of adults.

Half of the group, a relatively large number, had engaged in prepubertal self-masturbation. Only three groups exceed them.

Unfortunately for our analyses, too few aggressors vs. children had prepubertal sexual contact with adults to permit reasonably valid conclusions. Nevertheless, there is a suggestion that they may rate high in this respect and that a large proportion of the contact led to coitus. It is worth noting that 33 per cent (the second highest figure among the comparative groups) had seen adult female genitalia by age eleven.

While this group of sex offenders had the second highest percentage of individuals who had good health in childhood, they also had a relatively high percentage who had poor health; combined, this results in their having had only slightly better than average health.

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In defining the term “animal contact” we wished to discount the experimental masturbation of animals by human beings which is ordinarily a juvenile activity arousing little or no erotic response in the human. In brief, the term here is limited to deliberate specifically sexual contact with an animal, engaged in with the intention of gaining sexual gratification. Therefore we regarded as “animal contact” any oral, anal, or vaginal penetration occurring between a human and some other vertebrate.

Some 16 per cent of the offenders vs. children had had animal contact; this was, as usual, almost wholly in their early postpubertal life. Sixteen per cent is, in comparison with other groups, an intermediate proportion; consequently, it is rather surprising to find that in terms of both mean and median frequency (among those having animal contacts) the offenders vs. children usually rank second. Since the activity chiefly occurred early in postpubertal life, frequencies can be calculated only for the first two age-periods; puberty-15 and 16-20. The average (median) offender vs. children had between 4 and 5 animal contacts a year up to age fifteen and between 8 and 9 from age sixteen to twenty. The mean frequency was about once in two weeks in both age-periods, which is second only to that of the control group.

The age-specific incidence of animal contacts among the unmarried offenders vs. children begins with 10 per cent between puberty and age fifteen, and following the rule that animal contacts become less frequent with age, falls to 6 per cent in age-period 16-20 and to 4 per cent throughout the next two age-periods. Relative to other groups, these offenders occupy intermediate positions in the rank-orders until the last age-period, 26-30, when their 4 per cent figure earns them second rank.

In the proportion of the total outlet constituted by animal contact, the unmarried offenders rank third from puberty to fifteen and sixteen to twenty, the percentages being 2.0 and 1.2 respectively.

Note that the offenders vs. children were in second rank (though with only 8 per cent) of those who had fantasies of animal contact during masturbation. This predilection was not seen in the content of their sex dreams, however.

As a group the offenders vs. children did not have an especially rural background, so this cannot be used as an explanation for the unexpectedly high frequency of animal contact.

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