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We’ve Never Really Understood the Prostate

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The mistreatment of women on sexual health issues — from mastectomies and hysterectomies to pregnancy and even surgery on sex organs to enhance male pleasure — at the hands of mainly male physicians has been a major theme since the emergence of the modern feminist movement in the 1960s.

But what has been largely overlooked has been the similar sort of mistreatment and manhandling of men and their prostates at the hands of mainly male, but now also female, urologists.

It took Ericka Johnson, PhD, a professor of gender and society at Linköping University, Sweden, using feminist studies critiques, to expose this maltreatment of men in her new book, A Cultural Biography of the Prostate (MIT Press, 2021).

For much of history, as told by Johnson, the prostate has been unknown and unappreciated, an anonymous mass of glands, blood vessels, and muscle tissue. The great anatomic artists didn’t acknowledge the existence of the prostate until the 16th century.

Once medicine got a bead on the prostate about 120 years ago, the aggression began — a virtual war on the gland that exists to liquefy sperm, easing the way for pregnancy.

But reminiscent of the attacks on women by gynecologists and other doctors, early urologists performed orchiectomies with the ill-conceived notion that surgical removal of testicles would help men with the urinary problems from overgrown prostates. It didn’t.

Surgeons at Johns Hopkins developed the destructive mastectomy and then moved on to the just as destructive prostatectomy. Breast cancer and prostate cancer are twin phenomena, though early critics focused on the breasts and ignored prostates.

In a chapter on the PSA blood test, which Johnson says is the “most feared test” for men, she describes the confusion and damage wrought by PSA screening in more contemporary times, starting in the 1990s, which resulted in a few lives saved and many men becoming the victims of impotence, incontinence, penis shrinkage, and loss of libido because they rushed into interventional treatment.

I had undergone PSA screening since my mid-50s, beginning around the year 2000. I had no warning signs of problems. But during summer 2010, my internist became alarmed as my PSA had risen from 3.2 ng/ml to nearly the threshold of trouble, 4.0 ng/ml. He sent me to a community urologic oncologist for an evaluation.

The urologist performed a transrectal biopsy in his office — with my lucky wife present (talk about sharing). The first biopsy was inconclusive. So, I had a follow-up done — no wife present — in December 2010. A single core was found, with a one-millimeter fragment of Gleason 6. The urologists presented this as an existential threat. I know now that many urologists don’t consider Gleason 6 a cancer.

The urologist tried to talk me into an immediate radical prostatectomy. He didn’t support active surveillance. I got a second opinion the next day at the University of Chicago, where they offered active surveillance and I gladly accepted.

I’m not alone in this terrifying experience. Unfortunately, many men were — and remain — frightened by their PSA results and Gleason scores and aren’t given or decline the option of active surveillance.

Since its identification, Johnson notes: “The prostate was associated with masculine physical activities, like horse-riding in the damp and cold, or long hours of office work. The historical material also contained elements of sexual morality, blaming prostate problems on sowing wild oats in one’s youth, or marrying a younger wife in the autumn of one’s life.” Wrong again.

Johnson’s views on the “absent prostate,” are a tour de force. She writes: “The absent prostate, the prostate that has been surgically removed, scraped away from the inside, radiated, electrocuted, microwaved, pharmacologically shrunk, or otherwise destroyed. The missing prostate was the discursive — and very real — source of at least as much torment as a still-present-in-the-body prostate.”

The missing prostate takes on a life of its own and may haunt its previous owners and partners for years to come — or not.

As someone who has avoided aggressive prostate treatment, this chapter was eye-opening: the absent gland still exerts a presence on men who have had surgical or radiation treatment and experienced sexual and urinary side effects.

The missing prostate is still present in these men’s lives and those of their partners. This chapter gave me a deeper understanding of the impact of treatment on friends of mine who were even driven to the brink of suicide by the consequences they and their partners or spouses experienced, including urine leakage in intercourse and retrograde ejaculation.

To most men, the prostate is an invisible organ until they experience seemingly inevitable troubles. It can be benign prostatic hyperplasia, prostate cancer, or prostatitis, which itself is a mystery within a mystery to which Johnson devotes a chapter.

She notes the need for medicine to understand the prostate issues of gay men and transgender women whose prostates are intact and can become cancerous.

In my view, Johnson should have written a chapter on active surveillance, a strategy that could help the majority of the 1.4 million men globally who annually are diagnosed with prostate cancer avoid the potentially nasty side effects of surgery and radiation therapy.

I am biased as a man who has been on AS for many years. Johnson may be biased because of what a huge success AS has been in Sweden: 55% of U.S. candidates with low-risk prostate cancer go on AS versus about 94% in Sweden.

Why the huge gap between the systems? There’s more at play than the differences in the incentives for healthcare systems to provide treatments or perform surgeries.

Other topics I would have liked to have seen covered in the book include an analysis of whether Gleason 6 actually is cancer and a perspective on the ongoing debate over transrectal versus transperineal biopsies. However, Johnson’s minor sins of omission are overshadowed by her insight, prose, and analytical skill.

The late comedian George Burns, who played “God” in the movies, was asked what mistakes he, as God, had made. His answer? First, there was the avocado and its outsized pit. And then, there was the prostate.

Johnson sheds light on the mistakes doctors have historically made with the prostate and the impact this has had on society, and on men with and without these underappreciated glands and their partners.

Johnson will be speaking in a webinar at 12 p.m. Eastern Time on Saturday, February 26 to Active Surveillance Patients International. You can register here.

Howard Wolinsky is a Chicago-based medical freelancer who has written this blog about his cancer journey for MedPage Today since 2016, and has been on active surveillance for very low-risk prostate cancer since 2010. He is the author of the book, Contain and Eliminate: The American Medical Association’s Conspiracy to Destroy Chiropractic.

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