Manhood: The Rise and Fall of the Penis (23 page)

The most frequent side-effects are tiredness and headache. Hair growth also decreases, and the hair becomes softer. Approximately 5

per cent of testosterone production takes places in the adrenal glands.

In order to shut down production completely, so-called antiandrogens can be given in addition. These include Androcur 50 mg (250–300 mg per day), Anandron 300 mg (150–300 mg per day), Flutamide 250 mg (750 mg per day) and Casodex 50 mg (50 mg per day). One of the most troublesome side-effects of these drugs is painful breast formation. This can be prevented by one-off radiation treatment of a small area around both nipples.

115

m a n h o o d

When the patient starts on a course of an lh-rh analogue an additional dose of an antiandrogen is given in order to prevent a flare-up of the disease due to stimulation of the hypophysis and the resultant rise in testosterone production. After four weeks the gland is saturated with lh-rh analogue and hence the production of testosterone is blocked. Long-term treatment with an lh-rh analogue plus an antiandrogen is called a ‘total’ androgen treatment. This is mostly used in men with metastasized prostate cancer. Hormonal treatment of metastatized prostate cancer is effective in between 70 and 80 per cent of cases.

The average time lapse between the start of the hormonal treatment and the emergence of a hormone-resistant illness, is between a year and a half and two years, meaning that after that time the hormonal treatment no longer has sufficient effect. Although the usefulness of continuing treatment with an lh-rh compound in the case of hormone-resistant prostate cancer has not been incontrovertibly established, the experts believe that when the cancer worsens during treatment with an lh-rh analogue it is better to continue the therapy.

This avoids the eventuality that besides the hormone-resistant prostate cancer cells there is a resurgence in the growth of cancer cells still sensitive to (and hence inhibited by) the hormonal treatment. Although there is no conclusive proof, there are strong indications for the correctness of this assumption, since it was shown by research in the 1990s that the period of patient survival was shorter when the hormone treatment had been terminated, compared with patients with whom the treatment had been continued. This is why even in cases where chemotherapy is given, treatment with an lh-rh is in fact continued.

Even in the case of chemical castration – as the name implies, not much is left of the testicles. Prostate cancer patients in effect become eunuchs.

116

chapter six

Ailments of the Scrotum

As long ago as the nineteenth century it was known that certain medicines could damage the testicles. Félix Roubaud, a famous French physician, described how in treating tuberculosis with iodine vapours he had observed four cases of progressive sexual impotence. He found

‘a marked wasting of the testicles’. Saltpetre was also found to be harmful, the use of bromide compounds affected mainly sexual desire, while camphor inhibited the ‘sensitivity of the sexual system’. Nowadays it is anti-cancer medication in particular that has a bad name in this respect.

Other drugs that can adversely affect the production of sperm cells are salazopyrine (used for inflammation of the intestine), indomethacine (rheumatism), ranitidine and cimetidine (stomach complaints), nitro-furantoine (urinary tract infections), spironolacton (a diuretic), allo -

purinol (gout), cyclosporine (an anti-rejection agent in transplants) and various hormonal preparations. Gossypol is a natural component of cotton seed oil, which in some parts of China is used in the kitchen.

Strikingly, in those regions male fertility was clearly reduced. The Chinese plant
Tryptergium wilfordii
can also cause reduced fertility.

As mentioned in the previous chapter, men with metastatized prostate cancer are mostly given medication to reduce testosterone to what is called ‘castration level’ (surgical castration is scarcely if ever carried out today). Even for elderly men this remains quite an onerous procedure. Partly because of their often advanced age most prostate cancer patients are no longer able to achieve a firm and lasting erection.

The hormonal therapy results in hot flushes, comparable with menopausal symptoms in women. In addition there is the risk of osteoporosis and the accompanying increased danger of fractures.

Erotic fantasies are stimulated by testosterone, and therefore one would expect them to peter out. But that is by no means always the case: the memory has stored many of these fantasies. This phenomenon 117

m a n h o o d

is sometimes called
cinema érotique intérieur.
In such cases erotic caresses by an understanding partner can therefore do wonders. No one should underestimate the fulfilment and satisfaction this can bring, particularly in old men close to death. Knowing one is suffering from incurable prostate cancer and still feeling some life in one’s sexual organs can provide a much-needed boost.

Alcohol has a toxic effect on the functioning of the testicles, and in the case of chronic abuse less testosterone is produced and the liver is less and less capable of breaking down oestrogen (men produce small quan tities of this female hormone). In contrast to men, in women sexual excitement usually increases under the influence of alcohol. Why is that?

In both sexes sexual interest and sexual arousal are related to the testosterone level in the blood. But with women things are more complicated: in their case the production of the male sex hormone (in the adrenal gland, in fat tissue and in the ovaries) varies with the menstrual cycle: the testosterone level is highest in the fertile period around ovulation. Researchers have discovered that a relatively small amount of alcohol (two glasses of beer or wine) is sufficient to cause the testosterone level to rise. The effect is found only around ovulation if no contraceptive pill is used. In the case of women who stop taking the pill the effect is all the greater because with the contraceptive pill the testosterone level remains relatively low throughout the cycle.

Self-examination

A man who wants to know exactly how things are put together down in his scrotum can find out most easily by sitting in a hot bath and feeling himself. Besides being informative, such a voyage of discovery can help in identifying any abnormality at an early date, assuming of course that one has some knowledge of the anatomy of the scrotum.

The surface of a healthy testicle feels smooth, with no irregularities.

Distinguishing the testicle itself and the epididymis is fairly simple: the epididymis hangs behind the testicle like a runner bean. At the bottom, where its tail begins the epididymis merges with the seminal duct; this can also be easily located and felt.

The chance that in the course of such a self-examination one will find a lump between one’s thumb and forefinger that according to the textbooks shouldn’t be there, is quite high. However, this should not lead to immediate panic, since in the great majority of cases this is fluid.

The best-known forms of this are the
spermatocele
, filled with a grey liquid which under microscopic examination reveals sperm cells, the
hydrocele
, filled with pale yellow-coloured clear liquid, and the
hema-tocele
, filled with blood.

118

a i l m e n t s o f t h e s c ro t u m

Undescended testicles

A ridgeling stallion is one in which both testicles have remained at the back of the abdominal cavity and have not descended into the scrotum.

Such horses are almost always infertile. With mares, however, he behaves just like a normal stallion, since he still produces normal quantities of testosterone. If the animal is sold as a gelding, the new owner may experience problems, as a ridgeling stallion is inevitably less placid than a gelding. In this way undescended testicles can lead to great confusion and dissension.

In Ancient Rome men with two undescended testicles were not allowed to appear in court as witnesses. Roughly speaking, 20 per cent of cases involved two undescended testicles. The Ancient world did have some notion of surgery, but the range of operations was limited.

In fact in those days the choice was between being castrated brutally or with a razor-sharp knife. Moving undescended testicles to their appointed place was impossible. There is little point in treating undescended testicles with medication in the form of hormones and this is scarcely ever done these days. Too often hormones proved ineffective and an operation was subsequently needed anyway.

Over 80 per cent of undescended testicles can be seen or felt in the groin. If they can be neither felt nor seen, doctors speak of crypto -

orchidism, meaning literally ‘hidden testicle’. That usually means that the testicle has got stuck somewhere behind the abdominal cavity.

These make up some 20 per cent of the total. Tissue examination of undescended testicles shows irreversible abnormalities in the sperm-cell producing tissue from six months after birth onwards. It is therefore crucial to relocate the testicle as soon as possible, that is, in the scrotum.

This kind of procedure is called
orchidopexy
, and in it the testicle is inserted and secured in the scrotum. If the seminal cord is short this can be a particularly awkward operation.

Cryptoorchidism is also found in animals. In cats the abnormality is fairly rare (0.7%), but in dogs it occurs regularly (between 0.8% and 11%, depending on the breed). It is most common in small breeds such as poodles, Yorkshire terriers, dachshunds, Chihuahuas, Maltese terriers, toy schnauzers and shelties. Dogs with this abnormality are excluded from breeding. As in humans, if left untreated the sperm quality is anyway exceptionally poor. There are some animals in which crypto orchidism is normal. In almost all marine mammals, with their streamlined shape, the testicles are located in the abdominal cavity, and the same applies to elephants and hippopotami.

In humans, if the testicle cannot be felt, keyhole surgery is first carried out to check whether the testicle has been formed at all. If the 119

m a n h o o d

testicle is located high up behind the abdominal cavity, the distance is too great to bring it down together with its stalk. In that case a clamp is put on the stalk, that is, on the artery and vein, after which the blood supply is taken over by the small artery belonging to the seminal duct.

This is followed six months later by a second procedure in order to transfer the testicle to the scrotum, a procedure which can also be performed by keyhole surgery.

Being born with a testicle lodged behind the abdomen involves an increased risk of testicular cancer, which is not decreased by timely relocation in the scrotum. In addition it quite frequently happens that no connection is found between such a testicle and the epididymis, which of course means that no sperm cells can be expected from the testicle concerned. It is important in all cases to pinpoint the position of both testicles on the ‘testicular map’ immediately after birth. It is highly improbable that a testicle which has first been located in the scrotum will move to a position behind the abdominal cavity. The

‘testicular map’ is important in the diagnosis of a ‘retractile testicle’.

For a short period after birth the previously explained cremaster reflex is not yet present. The reflex goes on increasing until puberty, quite frequently causing boys’ testicles to be pulled into the groin. If there is no ‘testicular map’ and there is doubt whether the diagnosis should be

‘undescended testicle’ or ‘retractile testicle’, it sometimes helps to examine the child while he is lying in a warm bath or squatting.

Multiple testicles

Men with no testicles, one testicle or two are nothing out of the ordinary, but men with three are rare. A story is told of a monk who was unable to keep his vow of chastity because of having three testicles, while an eighteenth-century account describes a man with multiple testicles, a condition known medically as
polyorchidy
, who was capable of sexual intercourse up to his hundred and twenty-fifth year. Others were reputedly capable of ejaculating twenty times in one night.

Ambrosius Paré, one of the giants of medical history, believed that extra testicles were a common phenomenon, and many surgeons shared his view. Undoubtedly these were almost always spermatoceles that were mistaken for additional testicles.

In a medical career of nearly thirty years I have only ever encountered one case of multiple testicles. The boy in question had three – a case of
triorchidy
, which can take various forms. There may be an extra testicle without an epididymis or seminal duct (a), an extra testicle with an epididymis but without a seminal duct (b), an extra testicle with an epididymis attached to the seminal duct of a testicle located below (c), 120

a i l m e n t s o f t h e s c ro t u m

The various

forms of poly-

orchidy.

and an extra testicle with an epididymis and an extra seminal duct.

These are different kinds of tissue faults between the sixth and eighth week in the development of the embryo, the period during which it is decided whether one is going to look like a girl or a boy as regards external sexual characteristics.