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Mr D. complained that using a condom often left him soft with no erection and his wife was disappointed. He was married with two children and the doctor felt surprised by the complaint. Later he told how he had recently led a discussion about contraception at his church youth club. It was OK to talk at church, but at home it was difficult. ‘Women don’t understand how men find it difficult to talk.’ He added, ‘Whenever she talks to me about condoms, it turns me off, and I wouldn’t want her to try and put one on me.’ This sounded like a polite complaint and the doctor listened quietly. Mr. D. went on, ‘If I join in the conversation when she goes on about coming off the Pill, she seems to get excited and silly and I don’t like that.’ It was becoming clear that his real worry was that his wife might want another baby. The doctor realized that these two people were not communicating. He observed the house – a few essential jobs done, but in need of partial rebuilding. He knew that Mr. D. was a carpenter who did his own small building jobs on the side. Why was his own home so neglected? The doctor reflected, ‘Sarah has to wait a long time to get what she wants from you.’ Mr. D. laughed uncomfortably and other subjects were talked about. That was a while ago. Sarah is now off the Pill, much happier and they are using condoms. He is on the waiting list for a vasectomy, and as he says, ‘It’s time I did my bit.’

Here was a man who was complaining that condoms made him soft, but discussion with his doctor allowed him to talk more freely with his wife and to identify his real worries that his wife might want more children. However, when they could communicate openly he discovered his fears were groundless and they could use condoms happily again.

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There have been very few side effects to this procedure, the main one being temporary urinary retention in most men. Early studies of HIFU in animals and men have been promising. One highly sophisticated HIFU unit currently being tested (called Sonablate) comes equipped with a rectal probe that uses ultrasound to map out the prostatic urethra.

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Residual Urine Measurement. This determines whether you’re emptying your bladder completely—and if not, how much urine you’re leaving behind. This can be done by an ultrasound examination of the lower abdomen, performed immediately after urination, or by passing a small catheter into the bladder and measuring the amount directly. If it turns out that you do indeed have large amounts of residual urine, watchful waiting (see Chapter 10) may not be a good treatment option for you. These measurements may also be a helpful way to follow the course of your disease and bring to light any change in obstruction.

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Now, for pain that is concentrated in one area—a portion of the spine, for instance—more specific pain treatment is a far better approach. Two good options are “spot” radiation and radioactive strontium-89.

“Spot” Radiation

This is localized external-beam radiation treatment, targeted at one or several painful bone metastases. It won’t prevent new metastases from cropping up in bone, but it generally helps ease pain in the sites it does treat. Spot radiation often results in several months of dramatic relief from pain, and it helps prevent spinal cord compression (see below). In recent studies, 55 percent of patients received complete relief from pain, 33 percent had partial relief, and only 12 percent had little or no response.

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In the past, interstitial brachytherapy has not been as successful in controlling prostate cancer as external-beam radiation therapy. However, the development of advanced guidance ultrasound systems, three-dimensional treatment planning and templates to ensure an even distribution of radiation throughout the prostate may improve this technique’s results.

Recently, cryotherapy—killing prostate cells by freezing them— has become increasingly popular as a less-invasive form of treatment for localized prostate cancer. Although it appears to be well tolerated, and involves only a short hospital stay, it remains to be determined whether it will be as effective as external-beam radiation or radical prostatectomy in curing prostate cancer.

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Another drawback to the perineal approach is that it’s more difficult for surgeons to see—and thus protect—the neurovascular bundles, the thin packets of nerves that sit on either side of the prostate and are essential for erections. Therefore, preserving potency is not as certain. Also, the operation is not ideal for heavyset men, particularly men with what one doctor describes as a “large-barrel abdomen.”

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