Below the Belt

It's Time Men Drop Their Locker Room Jokes and Honestly Confront Their Problems in Reproductive Health

by Valerie Chapman

Let's face it guys. It ain't easy being on the Y-chromosome side of the gender gap, especially when it comes to taking care of the family jewels. For one thing, you just don't talk about what goes on "down there" the way women do. It's a well-known fact that most women are shameless when it comes to discussing intimate details of their monthly cycle. Guys would rather eat broken glass than talk to anyone about what goes on in their torpid zone.

And another thing, you've got all those super-virile male stereotypes to live down. You never hear Dirty Harry or Rambo complaining about fertility or prostate problems. Even sensitive, new-age kind of guys find it easier to explain quantum mechanics than to talk with their partners about impotence.

Part of this code of silence surrounding men's sexual health is a cultural inheritance. Unlike women--who early on get detailed instructions from their mothers, other female relatives and lurid soap operas about sexual maturity, physiology and hygiene--men rarely receive counsel from their fathers about the care and maintenance of their singular apparatus. On television, graphic commercials for virtually all types of female hygiene products imply that women have a rich and active--if itchy, moist or leaky--reproductive system. In contrast, in the analogous geographical area, men appear only to have athlete's foot of the crotch, i.e., jock itch. The image of a Ken-doll with crusty underwear comes to mind.

Until fairly recently, even the medical profession has slighted people of the masculine persuasion. For centuries, women have enjoyed an exclusive medical specialty, obstetrics and gynecology. Only in the past few years have scientists, physicians and other health care practitioners devoted their energies to developing the dynamic field of men's reproductive health.

At the University of Washington, medicine has gone below the belt. The UW can boast of innovative research, therapy and clinical practice in the diagnosis and treatment of prostate disease. Work on male fertility and potency have also made the UW a national leader in advancing men's sexual health. Warning Signs and Places for Help

Without an exact equivalent to obstetrics and gynecology, most male research resides in the Department of Urology. Since Urology Chair Paul Lange arrived five years ago, the brisk, fair-haired former Minnesotan has created one of the top centers for research into male genito-urinary concerns.

Under his leadership, the department has attracted more than $10 million in research funds, including a federal award of $3 million for establishing the O'Brien Center of Excellence in Urologic Research. The department also made headlines when it was part of a four-year, $20-million Milken Foundation Award granted to Dr. Leroy Hood, chair of the Department of Molecular Biology, for research into the genetics of prostate cancer.

So what is this troublesome doohickey called the prostate? The prostate is a walnut-sized gland that sits at the base of your bladder and is wrapped snugly around your urethra, the tube that carries urine out of your body. It's primary function is to provide fluid and nourishment for the sperm in your semen. (Here's a tidbit of information to wow your friends at parties: Did you know that your sperm is the only part of your body that uses fructose, instead of glucose, for energy? Fructose provides a faster, necessary sugar rush to aid sperm on their appointed rounds).

Normally, the prostate is a quiet little creature that churns out chemical candy bars for needy flagellae without so much as a peep. However, nearly all men, usually in their 20s and 30s, will experience a painful condition known as prostatitis, an inflammation and/or infection of the prostate gland.

In many cases, prostatitis may be caused by bacteria or other microorganisms, and may be treated with antibiotics or other drugs. In some instances, however, no diagnosable causes can be found and the problem can be difficult and frustrating to relieve. This condition, called chronic prostatitis, may require a combination of medications, warm baths and diet restrictions (say goodbye to coffee, alcohol and spicy foods).

The prostate, for better or worse, is the only part of your reproductive system that continues to grow with age, probably due to the male sex hormone testosterone. Many men as they enter their 50s and 60s develop a condition called benign prostatic hyperplasia, or BPH. As the prostate enlarges, it may encroach on surrounding tissues and begin to pressure the urethra and bladder, causing urinary problems. In severe cases, the prostate may block the urethra, causing urinary retention. There are many treatment options for this condition, ranging from medication to surgery.

Cancer of the prostate, which once struck Sen. Bob Dole and recently took the life of rock music legend Frank Zappa, is the most common cause of cancer in men. It is the second most common cause of cancer deaths in older men. Nearly 40,000 men will die of prostate cancer this year, almost equivalent to the number of women who will die of breast cancer.

Yet, it is one of the most treatable of cancers if caught in its early stages. The cancer can be detected by a digital rectal exam (only five seconds of very mild, mostly mental, discomfort) and a blood test. The physician first determines if the prostate is significantly enlarged. Depending on his or her findings, you may undergo a blood test to determine the level of prostatic specific antigen (PSA). If your PSA level is high, it may indicate the presence of cancer. Based on these two tests, your physician may order a more intensive diagnostic workup that will confirm or dismiss the initial diagnosis.

"There are two types of prostate cancer," explains Lange. "A slow-growing type of cancer that appears in most elderly men, and a highly virulent, rapidly metastasizing malignancy that may appear in men of any age. Presently, we are unable to determine which type of cancer a person might have, and therefore, how to provide the best, least intrusive treatment.

"You see, many more men die with prostate cancer, than from it. If you were an 80-year-old and I could determine that you had the slow-growing cancer, I probably would take a 'watchful waiting' attitude, with the idea that you are more likely to die of other causes than prostate cancer, and that aggressive treatment may be more debilitating than the disease itself.

"However," Lange continues, "If you were a 40-year-old father of three and I determined that you had the virulent type of cancer, I would provide the most aggressive type of treatment possible.

"Our research at this point is focused on developing diagnostic tests that will be sensitive enough to distinguish between the two kinds of malignancies.

"This is where Dr. Hood's work comes in," Lange adds. "We are working with him to discover the genetic codes for these two different types of cancer and to develop diagnostic tests to screen for them."

Working with Lange is Dr. Robert Vessella, a colleague of Lange's from Minnesota, who has been studying the chemistry of PSA for more than 10 years. He hopes to refine the current tests to make them not only more predictive, but increasingly sensitive to lower levels for earlier detection.

"After treatment for prostate cancer, we monitor the levels of PSA in the blood at regular intervals," explains Vessella. "Immediately after surgery or radiation or chemotherapy, the PSA levels will be zero. However, over time, if we didn't get all of the cancer, the PSA levels will begin to rise. But our current tests can't detect PSA until it reaches a certain level in the blood, which means that the cancer has been proliferating over a period of time.

"As with any cancer, the earlier we can detect it, the more likely we are able to stop it."

In light of the fact that most men will have problems with their prostate at some point in their lives, Lange lobbied for and established the Prostate Center at UW Medical Center, one of the first in the Northwest. Just opened in 1995, the center specializes in the evaluation and treatment of prostate diseases and in education about treatment options.

The second major focus in Lange's department is male fertility. "Much of the work in fertility has been done on women," says Charles Muller, director of the Reproductive Fertility-Andrology Laboratory. "For one thing, it's a simpler model in a way--you're only dealing with one egg a month. Secondly, most treatment for male infertility begins and ends with endocrine therapy. Unfortunately, less than one percent of men have endocrine problems that affect fertility. So we're looking at the sperm themselves, to see why they aren't capable of fertilizing an egg."

Men produce bazillions of the determined, tail-wriggling little gollywogs every day, and each is programmed to perform complicated and precise steps to ensure maturity, mobility and viability in their quest for mortality. In addition, sperm has to work like a son-of-a-gun to pass through a biological obstacle course to get within nodding distance of an egg.

"Most places that purport to test for male fertility just look at semen under a microscope to see if: 1) the sperm are alive and moving; and 2) if there are enough of them in the sample to successfully fertilize an egg," says Muller. "But sperm doesn't work that way in real life. The sperm leave the semen and have to propel themselves through the cervical mucosa, which requires a different type of motion than in semen."

Computer imaging of sperm molecules, courtesy of Dr. Muller's laboratory.

Muller uses a computer program to plot the speed and direction of how sperm move when they are taken out of semen. According to Muller, the sperm must be capable of changing motion as necessary to accomplish fertilization.

As if this wasn't enough, the beleaguered sperm must then undergo another essential transmogrification. It has to shed the sperm cap before it can enter the zona pellucida of the egg (sort of like doffing your hat when you meet a lady). Muller notes that failure to lose the sperm cap is a common and treatable male fertility problem.

The lack of an energy-producing molecule, called cyclic-AMP, in the sperm can also cause male infertility. The sperm just aren't as frisky as they need to be. This problem, called immotility, can be treated by adding cyclic-AMP to a semen sample and then performing in vitro or in utero fertilization.

Another cause of male infertility is a condition called "leukocyta spermia," in which there are too many white blood cells in the semen. This condition may be the fault of that pesky prostate, which if inflamed or infected, can release white blood cells into the semen. The white blood cells produce chemicals that impair or even destroy the sperm. Most men can regain fertility after treatment with antibiotics.

As devastating as infertility is, the thought of impotence strikes black terror into most men's hearts. Forget the locker room jokes and sniggers. Our sense of self as a sexual human being, male or female, is essential to our self-esteem and dignity. According to Urology Professor Richard E. Berger, director of the UW Reproductive and Sexual Medicine Clinic and clinical director of the UW Male Fertility Laboratory, a satisfying sexual life is within every man's reach.

Co-author of Biopotency: Your Guide to Sexual Fulfillment (with Deborah Berger, Avon Books, 1987), Berger comments frankly about the physical, medical and emotional causes of impotence and the various therapies available for treating it.

The first step is finding a sympathetic, knowledgeable health care provider who will help you discover possible physical causes of impotence. Beware of anyone who tells you "What do you expect? You're getting old." In rare cases, impotence may be the only symptom of a serious disease, such as diabetes or diabetes or multiple sclerosis.

The treatments for impotence are as varied as the causes and effects of the condition itself. Obviously, bad habits such as drinking or smoking too much and indulging in most illegal drugs will put a limp in your love life. Additionally, high stress levels can reduce sexual desire and impair functions. Certain over-the-counter and even prescription medications may cause impotency as a side effect.

Occasional inability to achieve erections is entirely normal, says Berger, and shouldn't be a cause for panic. In cases where impotency is the result of medication or surgery (usually for treatment of prostate problems), men have a variety of medical and surgical options, from erection-inducing injections to surgical implants.

Another fairly common, but relatively unheard of ailment is Peyronie's disease, which affects, on the average, one in 100 men.

"Peyronie's disease, which may be the result of an auto-immune reaction, causes scarring and bending of the penis, and ultimately impotence," says Berger. "It is totally devastating to its victims--but all the more so because men are reluctant to seek help for this condition. It can happen to men in their 20s as well as men in their 70s, although most cases occur in men who are in their 40s. It starts as a hard bump in or on the penis. It's not malignant and in many cases, surgery can help correct the problem."

Impotence is age-related, says Berger, but most men can and should enjoy satisfying sexual relations throughout their life. However, he advises, you should be aware that your body's reactions will change over the course of the years. Most men out of their 20s will start experiencing changes in sexual reaction time; most often, they report far greater satisfaction and enjoyment for themselves and their partner.

Because there is such a distorted body of myth about "normal" male sexuality, many men are afraid that natural changes, such as requiring more time to achieve an erection, herald the bleak onset of impotent old age. They begin to worry unduly about their waning abilities. Unfortunately, one of the most common factors in impotence is emotional and mental stress.

Perhaps the most critical component to a man's sexual health is his attitude toward maintaining good health and an open attitude toward his own unique sexuality. Because of the traditional reluctance most men have about seeing doctors in general and communicating about sexual or reproductive difficulties in particular, men have excluded themselves from the reassurance that a health care worker can give.

At the UWMC Prostate Center, Physician's Assistant Ray Krystyniak says men need to know that it's OK to pay attention to their health. He hopes that the center and other male-oriented services will provide an atmosphere of acceptance and privacy, where men will begin to feel comfortable talking about the physical and emotional side of their sexual health.

"Unfortunately, men are conditioned not to complain, and will ignore symptoms of prostatitis until it is disturbing their lifestyle in a major way," he says. "Men have to learn how to care for themselves and how to ask for help. We want to create a place where men of all ages can take charge of their health." *

Valerie Chapman is a writer for Health Sciences and Medical Affairs News and Community Relations.

It's in the Male: Warning Signs and Places for Help

The symptoms of prostatitis, BPH and prostate cancer are similar. If you are experiencing any of the symptoms listed below, please schedule an examination with your physician.

* Low back pain
* Pain deep in the rectum and scrotum
* Pain in the pelvic area
* Feeling unwell
* Joint or muscle aches, fever (primarily symptoms of prostatitis)
* Pushing or straining to urinate
* Urgent need to urinate
* Frequent urination, especially at night
* Sensation of incomplete bladder emptying
* Burning sensation while urinating
* Weak urinary stream
* Intermittent urinary stream

For more information on male health matters, contact the following resources and support groups:

UWMC Prostate Center: (206) 548-8705
Prostate Health Council: (800) 242-2383
American Cancer Society : (800) ACS-2345
Cancer Information Service: (800) 4-CANCER
Help for Incontinent People: (800) BLADDER
Impotence Institute of America: (800) 669-1603
Make Today Count (counseling/emotional support): (800) 432-2273
Matthews Foundation for Prostate Cancer Research: (800) 234-6284
Patient Advocates for Advanced Cancer Treatment: (616) 453 1477
Us Too Support Groups: (800) 82-USTOO

The UWMC Prostate Center hosts support groups for men who have prostate cancer and prostatitis. Please call the number listed above for more information.

For those who prefer the anonymous intimacy of computer interactions, you may wish to subscribe to the following USENET newsgroups on the Internet:
alt. support.prostate.prostatitis

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