Manhood: The Rise and Fall of the Penis (26 page)

m a n h o o d

years in Bosnia these have been documented extensively, as has castration. The latter humiliating procedure is as old as the hills. In the Middle Ages in particular men were castrated as a punishment for sexual misdemeanours or miscalculations.

In the twelfth century the testicles of Pierre Abélard, the great theologian and philosopher, were cut off after his elopement with his beloved pupil Héloïse. Abélard deeply mourned the loss of his manhood and wrote extensively about it in his memoirs. As for Héloïse, she was sent intact to a convent, and later gained fame as the head of an establishment called Le Paraclet, founded by her former lover. The two of them eventually found the same resting place in the cemetery of Père Lachaise in Paris.

It is said that Rasputin’s sizable testicles and penis are preserved in a specially made velvet box. This crazy Russian monk died an unenvi-able death: he was poisoned, shot, raped, castrated and finally drowned. However, no one seems to know what has happened to the box, any more than we know what has become of Napoleon’s private parts!

In 1934 Professor Johannes Lange published a monograph on
The
Consequences of Castration in Adults – Illustrated with Reference to
War Experiences.
Adolf Hitler is not mentioned in the book, but it is known that he lost a testicle, probably at the Battle of the Somme in 1916. He became what I once heard an up-and-coming urologist describe as a ‘single-stoner’. Hitler’s case is not absolutely certain: it might of course have been an innate abnormality. During the Second World War the Allies made fun of the Führer in the song ‘Hitler Has Only Got One Ball’, which was later recorded by Bette Midler.

Torture involving the genitals is typical of ‘dirty wars’ and, more especially of dictatorships. In
The Feast of the Goat
Mario Vargas Llosa devotes page after page to it. From 1930 to 1961 the Dominican Republic was ruled by a dictatorship of the worst kind. A certain Rafael Castration of

the lover.

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

Leonidas Trujillo Molina ruled like a little Hitler. The writer gives an unvarnished and compelling picture of the absurd manipulations of this despot. After days of torture one of the rebels is slowly finished off: When they castrated him, the end was near. They did not cut off his testicles with a knife but used a pair of scissors, while he was on the Throne. He heard excited snickers and obscene remarks from individuals who were only voices and sharp odours of armpits and cheap tobacco. He did not give them the satisfaction of screaming. They stuffed his testicles into his mouth, and he swallowed them, hoping with all his might that this would hasten his death, something he never dreamed he could desire so much.

Chronic testicular pain

Men who have a tendency towards hypochondria quite often express this by complaining about their testicles. This may relate to a feeling of heaviness, a nagging or a stabbing pain. Complaints about such symptoms can become a source of frustration for everyone involved, the patient, the gp and the urologist. For the patient because he feels he isn’t being taken very seriously, for the gp because he/she does not know what to do and for the urologist because by the time the patient is referred to him/her a great deal of frustration has built up and the uro -

logist knows in advance that no objectively verifiable abnormalities will be found. So we are not talking about the acute pain of a twisted stalk of the testicle or the chronic pain of a swelling in the scrotum; with this pain a physical examination reveals no abnormalities.

Those affected are mostly relatively young, sexually active men, who have intermittent problems. Pain is signalled in one or both tes ticles, sometimes spreading to the groin. It is important to ask certain questions: when does the patient feel pain? Only during the day? Only when sitting for long periods or on the contrary when standing for long periods? Did the problem appear suddenly and continue from then on?

Does the testicle pull towards the groin during an attack of pain? Does the pain sometimes pass when the patient is lying down? Has the patient undergone sterilization? Is there also pain during and/or after ejaculation? How frequent are the patient’s ejaculations?

The physical examination of course comprises the careful feeling of the groin, the seminal cord, testicles and epididymides. The epididymis is normally sensitive to the touch, meaning that pain on contact by no means always points to an inflammation. Examination of the patient in a standing position is an absolute must (if medical students omit this in 133

m a n h o o d

an examination, they fail outright). This can help one diagnose a ruptured varicose vein as the cause of the nagging pain. In this case the person examining feels and sees a ‘can of worms’ next to the left testicle, which disappears when the patient lies flat.

When the patient is in a lying position the doctor can provoke the cremaster reflex by stroking the inside of the thigh or the lower abdomen. If the testicle pulls towards the groin and this is accompanied by the typical pain, the patient has an exaggerated cremaster reflex: because the muscle fibres are relatively too strong, the testicle is pulled into the groin. Information on this condition is vital; in extreme cases it may be decided to sever the muscle fibres in an operation.

Pain after a hernia operation can also occur and is caused by damage, which may or may not be temporary, to the tiny nerves that run along the inguinal canal to the scrotum. Generally speaking, patients often tell us that they only have a problem when sitting and when asked often turn out to have a sedentary occupation. Examples are taxi drivers, lorry drivers, sales reps, etc. In that case it is good to pay attention to clothing. Tight jeans are fatal to men with testicular pain – jeans are stiff and constrict the testicles.

Often testicular pain is related to sexual activities, since the patient sometimes has more pain during ejaculation or afterwards. It can sometimes go on for days. It is not always clear whether this is connected with the degree of arousal, too much or too little sex. Think of Zorba the Greek, who one fine day, after a month of abstinence on an island where he has been doing some building work for an Englishman, says: ‘I’m downing tools, I’m off back to the mainland – my groin is killing me.’

Often testicular pain is accompanied by pain in the area between the anus and the scrotum. This is usually wrongly diagnosed as chronic inflammation of the prostate when it is actually chronic pelvic pain caused by insufficient relaxation of the pelvic floor muscles. Treatment by a physiotherapist in such cases is often much more effective than long-term treatment with antibiotics.

Unfortunately there are by no means always ready-made solutions.

Careful gathering of the facts is important, which in practice means taking the time to go through the symptoms and not giving the impression that one is not taking the case seriously. Chronic testicular pain is hard to treat. If the pain really derives from the scrotum and is not referred pain, severing the nerve pathways on a level with the external inguinal ring or a little higher will interrupt the conduction of pain sensation. If a trial blockage high in the seminal cord with a local anaesthetic results in a reduction in pain for the period for which the medication is presumed to work (for example, lidocaine one to two hours, marcaine three to seven hours), there are grounds for severing 134

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

the nerves (denervation). A ‘positive’ blockage of the nerves in the seminal cord therefore also confirms that the pain actually derives from the scrotum. In addition the blockage has prognostic value for the success of the surgical denervation.

Epididyectomy
, or the complete removal of the epididymis,
hemicastration
, removal of the testicle
with
epididymis – and
vaso -vasostomy
(a restorative operation after sterilization) are also among procedures used to relieve patients’ pain. Hemicastration is the most often recommended and most effective procedure. Quite tangentially, it should be mentioned that in the past hemicastration was used to determine the sex of the child to be fathered. If one wanted a boy the man’s left testicle should be tied off. Left was associated with weak and right with strong.

The Hottentots used the same method.

In hemicastration an approach through the groin is preferable because it produces better results than via the skin of the scrotum (leaving 76% of patients in comparison with 55% permanently pain-free).

This difference may perhaps be explained by the high tying off of the seminal cord resulting in the complete severing of the genital branch of the nerve. Sometimes there are good reasons for completely ruling out surgical treatment; in such cases the patient is referred to the pain clinic for psychological treatment and/or medication.

Testicular cancer

. . . is rare: in the United States, between 8,400 diagnoses of testicular cancer are made each year. Over his lifetime, a man’s risk of testicular cancer is roughly 1 in 250 (four tenths of one per cent, or 0.4 per cent).

It is most common among males aged fifteen–40 years, particularly those in their mid-twenties. Testicular cancer has one of the highest cure rates of all cancers: in excess of 90 per cent; essentially 100 per cent if it has not metastasized. Even for the relatively few cases in which malignant cancer has spread widely, chemotherapy offers a cure rate of at least 85 per cent today.

Testicular cancer has several distinct features when compared with other cancers. Firstly, it has an unusual age-distribution, occurring most commonly in young and middle-aged men. Secondly, its incidence is rising, particularly in white Caucasian populations throughout the world, for reasons as yet unknown. And thirdly, testicular cancer is curable in the majority of cases. The number of deaths from testicular cancer in the usa is around 380 annually.

It is essential to discover the growth in good time. Very often testicular cancer causes few symptoms, at most a feeling of heaviness.

Occasionally there is sudden pain because of a haemorrhage in the 135

m a n h o o d

growth. One diagnostic trap is swellings that persist after a trauma or an inflammation of the epididymis.

In almost half of cases there is metastasis at the moment when a diagnosis is made. Possible symptoms are back pain, a swelling in the abdomen and breathlessness. Fortunately the prognosis is very favour -

able, even where there is metastasis. In most cases the metastases simply melt away with chemotherapy or radiotherapy. The choice between the supplementary treatments depends on the kind of cancer involved.

Pathologists distinguish between
seminome
and
non-seminome
. In the first case the prospects are slightly more favourable than in the second.

The success stories of therapeutic chemotherapy in testicular cancer with metastases (for instance, Lance Armstrong) originate from cisplatinum. In 1966 the American biophysicist Barnett Rosenberg was playing around with a colony of intestinal bacteria, which he exposed to various levels of current between two platinum electrodes. The closer the bacteria came to the electrodes, the less able they were to divide.

That was caused, thought Rosenberg, not by the electric current but by a substance on the platinum electrodes. That cell-inhibiting substance proved to be cisplatinum. When he went on to test the effectiveness of the substance on rats with cancer his intuition was confirmed. Further research showed that cisplatinum had an extra -

ordinarily favourable effect on women with ovarian cancer and men with testicular cancer. When cisplatinum was first used on patients in the early 1970s it did, however, turn out to have a series of serious side-effects, including kidney damage, hearing loss and unbearable nausea.

Nowadays those side-effects are successfully kept in check, for example by a combination of drugs, though long-term research indicates that premature heart problems may occur.

Besides cisplatinum, etoposide and bleomycine are used in the treatment of patients with testicular cancer. The number of courses is determined after a risk classification. During treatment so-called tumour-marker substances are identified in the blood, and in this way the success of the treatments can be assessed. In any case the side-effects of the chemotherapy remain severe: nausea, hair loss, reduction in bone marrow, anaemia, haemorrhages, pins and needles in feet and fingers, and lung damage.

Lance Armstrong

In 1992 Texan Lance Armstrong took the leap into the ranks of professional racing cyclists. A year later he became world champion road racing cyclist in Oslo. With stage victories in the Tour de France, etc.

he emerged in no time as one of the best racing cyclists of his genera-136

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

tion. In the autumn of 1996 this success story came to an abrupt end: Armstrong had testicular cancer with metastases. This was a bombshell – certainly in the world of cosseted racing cyclists, and his team lost a charismatic figure.

As Armstrong put it: ‘My first reflex was: there goes my career.

Later, when the seriousness of the disease sank in, I realized I’d be lucky if I was able to live a more or less normal life again. The doctors gave me a 50% of survival. The diagnosis was worrying to say the least: testicular cancer with metastases in the abdomen, lungs and brain.’

The cyclist underwent two operations, in which, among other things, his right testicle and a brain tumour were removed. This was followed by three months of chemotherapy and intensive medical care in Indianapolis:

For the first year not a day went by without my thinking about it, but since then the fear has begun to abate. I’m no longer just a cancer patient – I’ve become a racing cyclist again. I’ve got my ambition back. The will to win is back, although it’s not as all-consuming as it used to be. I get over it quicker when it doesn’t work out. Winning is no longer the most important thing in my life. I just enjoy each day as it comes. I kept cycling, even during that tough first year, purely for pleasure. When the doctors gave me the go-ahead, I decided to become a professional cyclist again. Eighteen months later I started my first race. Why? Because I love racing, because it’s my job. But I also did it for everyone with cancer. Everyone thinks that after an illness like that you can never be the same again. I wanted to prove the opposite by winning races again. I’m gradually getting back to my old level. In fact, I’ve got even stronger.