Clearly, the easiest form of prostatitis to diagnose is the acute bacterial form (the fever and chills are a big tip-off). But for the other kinds, and for prostatodynia, other tests are needed. Because of the prostate’s location—below the bladder, and just in front of the rectum—it can’t been seen or examined from the outside. So the first step in examining it is usually the digital rectal examination, in which a doctor’s gloved, lubricated finger is inserted into the rectum to feel for lumps or enlargement, or anything else unusual. This examination may be uncomfortable, but it doesn’t hurt and it’s generally brief, lasting less than a minute.

One important test for prostatitis is prostate massage. This is also done during a digital rectal exam, as a doctor vigorously massages or presses on the prostate to express, or force, fluid out of the prostate and into the urethra. This fluid then is collected on a glass slide and examined under a microscope in the doctor’s office. The purpose of the test is to look for such signs of infection or inflammation as abnormally high levels of white blood cells. This can be done while you wait and, like the digital rectal examination, it’s usually more uncomfortable than painful. (One exception: In acute bacterial prostatitis, the rectal examination will have found a remarkably tender prostate that is also swollen, warm and firm. In this case, a doctor should not continue with prostatic massage; it would be too painful, and could lead to the release of bacteria into the bloodstream, causing sepsis. Because a urinary tract infection often accompanies acute bacterial prostatitis, the harmful bacteria can be targeted by a simple urine test.)

*306\201\8*

The treatments in this section all have something in common: Waves. They all channel a form of energy—heat, radio frequency, ultrasound, microwaves, and light—to kill cells. Energy waves are generated, focused, aimed, and fired at the overgrowth of BPH tissue surrounding the urethra. Some waves work like a shotgun, blasting holes in the prostate. Others are as sensitive as a scalpel, delicately nibbling away at BPH tissue until the urethra is free.

As yet, none of these treatments can be classified as standard therapy. They’re trial should include a placebo-treated group of patients for comparison. If it’s a more invasive form of treatment, the results should always be compared to the accepted gold standard—in this case, the TUR. Is there a noticeable improvement in benefits?

Next, make sure that both subjective and objective results were measured. (Remember, encouraged by being involved in a study, a man might feel that his flow rate has improved more than it actually has.) All participants in the study should at least have completed symptom scores and had uroflow measurements taken. Ideally, the study should be stratified according to age, risk factors and severity of obstruction. Endoscopic treatment techniques preferably should be compared only to TUR and, if feasible, these studies too should include a placebo-procedure group.

*267\201\8*

Think of arteries “hardening” as years and years of cholesterol build-up take their toll; eventually, blood has a hard time maintaining its normal pressure and flow as it makes its way through them. BPH doesn’t involve a plaque-like accumulation—the build-up here involves an increase in cells, spongy glands and muscles—but what’s happening to the flow of urine is roughly the same, and that can be linked to the gland’s increased size and weight.

The Estrogen Connection

Another hormone that’s being implicated as a factor in BPH is estrogen. Male hormones, such as testosterone, can be converted to estrogen by an enzyme called aromatase. By itself, estrogen doesn’t make the prostate grow significantly. Researchers have learned, however, that estrogen stimulates the body’s receptors for androgen, or testosterone. Among other things, this enhances the action of DHT in the body; it also stimulates stromal cells, and inhibits cell death. This can lead to BPH.

*229\201\8*

If you’ve been castrated, make sure that all the tissue was taken out. This is easier than it sounds; all you need is a blood test to measure your testosterone level. Similarly, if you’re taking estrogen or an LHRH agonist, make sure you’re getting the recommended dosage and taking your pills regularly— taking a pill at six one morning and at midnight the next night, for example, might mean the level of hormones is fluctuating. Again, a blood test can confirm whether your testosterone level is at the crucial castrate range. In either case, if there’s too much testosterone in the blood, dosage regularity is probably the problem, and it can be fixed.

If your testosterone is in the castrate range and you’re not on flutamide, you could try taking it to see whether this makes your PSA levels fall. Some men are helped by this. If, however, you already are taking flutamide in addition to castration, estrogen or an LHRH agonist, try stopping the flutamide.

In a few men, prostate cancer comes back as a kind of tumor called a small-cell carcinoma. This may be the case if there is a large recurrence of cancer in the pelvis or liver—especially if your PSA level is low. A biopsy should find this out. It’s an important fact to know because small-cell prostate cancers have a make-up similar to other small-cell cancers (of the lung, for example), and they respond to the same kinds of chemotherapy drugs used to treat these other small-cell tumors.

If all of these options for hormone therapy have been tried, and the cancer is not a small-cell carcinoma, the next step may be to try and control the cancer and its symptoms with other kinds of drugs—chemotherapy. However, this option is recommended only for men who are strong enough to withstand chemotherapy’s side effects. The other option is to treat specific symptoms as the cancer progresses.

*190\201\8*

Little more than a decade ago, the idea here—zeroing in on the prostate more accurately and completely, but leaving surrounding tissue little the worse for wear—would have seemed like a nice daydream to most radiation oncologists. But over the last several years, great technological strides have made 3-D conformal therapy seem, suddenly, not only achievable but highly promising.

This therapy developed because scientists looked at what was not happening with radiation treatment: Conventional approaches, studies found, weren’t precise enough. For one thing, they weren’t accurately estimating the volume of their target; and because of this, they often didn’t supply enough radiation to kill the whole tumor. What was happening in some men, researchers have learned, was like what happens when a speaker with an inadequate microphone tries to make himself understood to an audience of a hundred thousand people in a vast amphitheater—some, maybe even most of the crowd can hear him, but that still leaves hundreds or even thousands who aren’t getting his message. In traditional radiation treatment for prostate cancer, this inadequate coverage meant that many men who suffered local relapses of prostate cancer did so because they were underdosed.

*152\201\8*

For 44 per cent it was their first sex offense, for about one quarter it was their second, for 17 per cent their third, for 9 per cent their fourth, and 4 per cent had five or more sex-offense convictions before being convicted of a homosexual offense vs. a minor.

As a group only a moderate proportion had prior histories of mental or emotional illness (5 per cent), relatively few were drunk at the time of offense, and none were under the influence of narcotics.

A number large both relatively and absolutely (87 per cent) of the offenses were clearly premeditated and very few were wholly opportunistic (3 per cent). In only three instances were there copartners involved.

The average minor, the object of the offense, was 14.1 years old. Slightly over half of the offenders regarded the boys as friends (third rank) and 13 per cent (again third rank) regarded them as acquaintances. In one third of the cases the two were strangers, a moderate proportion, and in only two cases were they related.

In about one offense in ten there was no physical contact—the relationship ended before contact occurred. In the cases where contact took place a relatively very large proportion, somewhat over half, involved fellation; about one fifth consisted of masturbation; 11 to 12 per cent involved anal coitus; and 8 per cent consisted only of nongenital contact. In comparison to the other homosexual groups these offenders vs. minors have the largest proportion of anal coitus, an incidence of fellation equal to that of the homosexual offenders vs. adults, and moderate amounts of genital and nongenital petting.

The minor objects of these homosexual offenses showed a somewhat higher degree of participation than did the younger objects of the homosexual offenders vs. children. Among the 83 cases where we have both the official and the offender’s version, 83 per cent agreed that the minor boy was either encouraging or passive and 6 per cent agreed that he resisted. In another 6 per cent the official record reports resistance while the offender claimed otherwise.

In only eight instances was force employed, and it appears to have been mild to moderate, never severe. Three cases of threat appear, but two of these were in conjunction with the force cases just mentioned. By and large, it is quite clear that force and threat are infrequent and quite atypical of homosexual offenses against minor males.

As usual in homosexual acts involving minors and children, the probability that the activity will attract legal attention is almost wholly dependent upon the minor or child. In only a small minority of cases were the circumstances such that arrest was probable for intrinsic reasons. The object of the offense reported it directly in nearly 15 per cent of the cases (the other homosexual-offender groups having fewer such complaints), while friends and relatives of the boy accounted for 43 per cent of the arrests. All in all, over half of the convictions stemmed directly from voluntary or involuntary reporting by the minor boy. A comparatively high percentage (12 per cent) of arrests came from witnesses who were neither friends nor relatives of the boy. A full quarter resulted from police investigations, most of which originally had nothing to do with the offense.

Full admissions of guilt were made in from three quarters (to the officials) to four fifths (to us) of the cases. These proportions are quite similar to those of the homosexual offenders vs. adults. From 11 to 16 per cent stoutly denied the behavior, a handful gave qualified admissions, and only 1 per cent claimed they were unable to confirm or deny their guilt because of amnesia induced by alcohol or emotion.

In final pleas, 77 per cent pleaded guilty, 18 per cent not guilty, and nearly 5 per cent made no plea. All homosexual offenders are remarkably uniform in this matter, the percentages of those pleading guilty being 78, 77, and 78 per cent (homosexual offenders vs. children, minors, and adults, respectively), and the not guilty being 18, 18, and 17 per cent.

*196\161\2*

A disinclination toward sexual dreams is manifest in an examination of dream content. Sixteen per cent, the fourth largest percentage, of the incest offenders vs. adults reported their nocturnal emissions were not accompanied by dreams. All who had ever dreamed reported ordinary heterosexual dreams and only 6 per cent, the second smallest percentage, reported homosexual dreams. None had sadomasochistic dreams or dreams of animal contact, and only one had bizarre dreams. The lack of sadomasochistic dreams accords with the lack of any conscious sexual response to sadomasochistic stories and pictures. All in all, dreams played a quite minor role in the lives of the incest offenders vs. adults, which is somewhat surprising; in such an inhibited and restrained group one might have expected a compensatory increase in dreams and nocturnal emissions. Indeed, the unmarried males have essentially the lowest age-specific incidence figures of any group up until age twenty-five, when so many had married that our calculation ceases. The age-specific incidence among the married males was moderate to somewhat low in all age-periods where we have a substantial number of cases.

While we have little data on the frequency of premarital nocturnal emissions of the incest offenders vs. adults, no compensatory trend can be seen in the average (mean) frequency. True, the average (median) incest offender vs. adults is in second place in the rank-order of frequency at ages sixteen to twenty, but it is hard to view this as compensatory since the highest frequency of nocturnal emission in this age-period is displayed by the average control-group individual whose sexual outlet exceeds that of the incest offender vs. adults. Moreover, since the median frequency was but 3 to 4 orgasms per year more than the frequencies of other groups, talk of compensatory increase is almost ludicrous.

Paralleling these frequencies, a relatively large proportion of the total outlet of these offenders was from nocturnal emissions during their premarital years up to age twenty; thereafter the proportions are moderate. Among the married the proportions are large until age thirty-five (because of low frequencies of marital coitus), and thereafter become small with increasing age, when, as is usual, nocturnal emissions are rarer.

*154\161\2*

In accumulative incidence, they remain in intermediate positions from ages fourteen to twenty-six. The average (median) aggressor vs. adults had his first homosexual contact when he was nearly fifteen and one half.

In age-specific incidence, the proportion of single aggressors vs. adults who had homosexual activity outside prison is moderate (28-30 per cent) up to age twenty-five. In age-period 26-30 they drop to a low-intermediate level in the rank-order with 14 per cent, and then fall to the bottom of the rank-order with 10 per cent in age-period 31-35. The married men display low-intermediate to high-intermediate percentages up to age thirty and thereafter, like the single men, drop to the bottom of the rank-order in age-period 31—35. (with 0 per cent). In postmarital life the figures vary from low to intermediate.

The aggressors vs. adults are undistinguished in terms of frequency of homosexual contacts (3.4 per year), proportion of total outlet, and number of partners.

When one calculates the frequencies for all unmarried males with homosexual activity during the various five-year age-periods from puberty on, one finds the aggressors vs. adults displaying markedly low frequencies. They had next to the lowest average (mean) frequency before age twenty, and a moderate frequency at twenty-one to twenty-five: the average (median) aggressor vs. adults uniformly ranked next to the lowest in frequencies (about 3 to 5 times a year) from puberty on to age twenty-five, which is as far as our data can be carried for unmarried males.

This group is more tolerant of male homosexuality than most groups (aside from the homosexual offenders, they are the third most tolerant) with 47 per cent disapproving, 12 per cent approving, and with the second largest number (41 per cent) expressing neutrality.

*112\161\2*

Although few had animal contacts, those few had them with an unexpectedly high frequency: for the median individual between puberty and age fifteen it amounted to once every two or three weeks, which represents the highest median frequency. The mean frequency is the same, but earns the offenders vs. adults only an intermediate status in rank-order. The proportion of total sexual outlet derived from this activity was always moderate and also less than that of the control group. The term “moderate” is, of course, used relatively: the actual figures are tiny, being under 1 per cent.

Contact with animals was confined chiefly to early postpubertal life; there were too few after age fifteen to permit meaningful calculation of frequencies.

The animal-contact history of the heterosexual offender vs. adults is puzzling in that, despite the fact that their background is, relatively, strongly rural, the incidence is low; moreover, despite the low incidence the frequencies among those with the experience are high. As far as masturbatory fantasy and dreams of animal contact are concerned, the offenders vs. adults rank intermediate to low.

*70\161\2*

The frequencies of reaching orgasm in petting are not unusual, the offenders vs. children being intermediate in the rank-orders. They generally rank fifth in accumulative incidence of petting to orgasm, nearly two fifths having ultimately had this experience. About one fifth to one fourth reached orgasm through petting in a given five-year period-somewhat large proportions that earn them second to fourth place in rank-order at various ages. All in all, however, they appear to be average to slightly below average in heterosexual petting activity.

*27\161\2*