Why did John G., a man who has little faith in doctors, submit himself not only to an operation, but also to one that is regarded with suspicion by many in the medical profession? The reason is that John was desperate. For years he had endured stomach discomfort with heartburn, indigestion and reflux. In his 40s these symptoms seemed to worsen, but, being fit and otherwise healthy, he put up with them. As he approached 50, however, the pain became excruciating.

Sometimes the burning sensation in his food pipe was so extreme it would drive him to consume two rolls of Quick-Eze a day. He would drink a bottle of Mylanta a week and go through a box of bicarbonate of soda a month. When told surgery could help, he was sceptical. Although he had to sleep on a stack of pillows and his nights were repeatedly broken by reflux, pain, coughing and an awful taste in his mouth, he stayed away from doctors.

That was until he had to pull over while driving home along the freeway. Suddenly, along with the usual regurgitated food and acid, blood began coming up. His oesophagus was bleeding. Over the years, the valve between his stomach and oesophagus had lost pressure and allowed a constant wash-up of acid. This had become so acute that the acid had burned the lower end of his oesophagus raw.

The specialist was fairly blunt. John’s ulcerated oesophagus was in a pre-cancerous condition and he had two options. He could take a chance that his condition would not progress or have surgery to fix the faulty valve. Reluctantly, he agreed to the operation, known as a fundoplication, or a hiatus hernia repair. The outcome was astonishing.

’1 am now 1000 times better. The only minor adverse effects are that occasionally I burp and cannot control it. I can quieten it but cannot stop it. I also cannot eat huge meals,’ he says.

These hernias occur when the upper part of the stomach slips through the diaphragm and into the chest cavity. About 30 per cent of people over the age of 60 have one, and they become more common with age, although many remain symptom free.

Most of the people who seek a repair are 50-something males. Men seem to have more severe acid exposure. During the operation, part of the stomach is wrapped around the lower oesophagus to make the valve stronger. Until the seventies this was done through an open chest operation; between 1970 and 1990 it was done through the belly. Both operations took TA hours and required a 2-week stay in hospital. The success rate was variable, and was often no more than 60 per cent.

Complications resulted with patients not being able to swallow after surgery or suffering severe bloating. Consequently the operation acquired a bad name. Although the procedure has changed radically, old prejudices persist. While physicians often believe modern acid-suppressing drugs are infallible and make the operation unnecessary, a lot of general practitioners have not been re-educated about the new techniques.

Today the operation is done with a laparoscope in an hour. Two days later the man goes home, and he’s back at work in a week. Specialist surgeons who do this operation say that afterwards more than 90 per cent of patients are free of symptoms and have no intractable side effects. Less than 2 per cent get some bloating or trapped gas and about 1 per cent report a sensation of food sticking to the valve.

The typical patient who could benefit from such an operation has failed to obtain relief with acid-suppressing drugs and suffers severe heartburn, regurgitation, belching or coughing as reflux spills into the mouth and lungs. In the morning, such men often find their pillow stained brown with the residue of dribbled gastric contents.

*101\105\2*

This is a common question asked by men about to have a vasectomy. They have been assured that following the operation they will continue to produce copious quantities of sperm but are concerned about what happens to them.

There are two possibilities. If a man has an open-ended vasectomy, the sperm fall into his scrotum instead of hurtling out into the world. In the scrotum they are broken down and, like all dead cells, removed by the body’s scavenger system.

If a man has a closed vasectomy, which involves tying off the tube in two places, the sperm are trapped in the testicles, where they are eventually broken down and reabsorbed.

Following a successful vasectomy, men should experience no long-term discomfort. In less than a week, tenderness should be gone and intercourse can be resumed.

In rare cases, however, men can be left with a persistent ache in the testicles. This ache is probably caused by a backup of sperm in the 6 metres of fine tubing that twines behind each testicle. This tubing has fragile walls that can easily be burst by a backlog of trapped sperm.

About 4 per cent of men who have a closed vasectomy develop mild testicular pain. This can be relieved with drugs, with surgery or by rejoining the vas.

If the man has an open-ended vasectomy, he is three times less likely to experience post-operative testicular pain. Cutting the vas higher up also reduces the likelihood of pain.

Vasectomy is not just for young men. Older men with wives of childbearing age line up for the operation too. Between 5 and 10 per cent of men who have had a vasectomy seek a reversal at some later stage. A successful reversal cannot be guaranteed, and during the routine pre-operative counselling, men are told their operation may well be permanent.

To cover this contingency, some take out ‘fertility insurance’ and have their own sperm frozen and stored. Human sperm have been successfully stored for 18 years, and it is known that 50 per cent of women who receive thawed sperm become pregnant within 6 months. But fertility insurance is fairly uncommon, and only vasectomy patients request it.

There is a simple technique that can be used as an alternative to surgery for men who ask to have vasectomies reversed. It involves a single injection into the testicular area under local anaesthetic to remove sperm. In vitro, single sperm are then introduced into the partner’s egg.

There is much concern about the side effects of vasectomy. Short-term effects of bleeding, infection, bruising, swelling and discomfort usually resolve in between 4 and 7 days. After the operation, about one in 400 develop a haematoma (large clot) or abscess and need to be hospitalised.

Men should be alerted to the possibility of the long-term side effects of testicular pain and to the controversy about prostate cancer, although there is no substantial, sound evidence to support or not support a statistical link between vasectomy and this cancer. Scares about heart disease and testicular cancer linked to vasectomy are now considered largely baseless.

When vasectomy is voluntary, there is virtually no adverse psychological reaction. In places such as India, where there is coercion, the ‘regret’ factor is high.

Genuine sexual dysfunction after vasectomy is rare because the operation does not affect testosterone production or libido. Some men are, however, uncomfortable at the idea of shooting blanks.

*77\105\2*

The human nose has a secret life that rivals any other area of the body. In the mirror it looks pretty unremarkable, especially as it becomes a bit lumpy and droopy with age.

But inside it is full of tissue similar to that found in a man’s most personal parts and has what can popularly be described as the equivalent of a ‘G spot’. This spot has evolutionary biologists in a frenzy of excitement. They say it may be the clearing house for subliminal impressions that lead to instant dislikes and irresistible attractions.

As noses go, the human one is underrated. Compared to that of animals, humans’ olfactory capacity is said to be extremely rudimentary. While many animals depend on their noses for survival, humans dismiss theirs as blunt instruments.

The human nose is full of rich erectile tissue. During the day, this tissue goes through natural cycles in which it congests and decongests, turning on and off nasal erections.

Most people are not aware of these cycles, which last up to

6 hours and alternate between nostrils. As one side goes up, the other goes down. People are, however, aware of a feeling of fullness in the nose if they challenge gravity and hang upside down. Smoking, drinking, breathing in ammonia vapour or low levels of oxygen can produce the same effect, as can pregnancy or thyroid hormones, exercise and massage. After sex some people are left with engorged noses that drip.

With advancing age, many men’s noses drip even if they are celibate. This ‘old man’s drop’ results from excessively watery nasal mucous and has been known to be successfully treated with testosterone.

Just as age eventually affects other erectile tissue, so it affects the nose. Each human nostril has three sets of turbinates, which are bony cavities containing blood-filled erectile tissue. These are the airconditioners of the body and adjust inflowing air to suit the individual system, by warming, cooling or humidifying it. Whatever the temperature and water content of the air breathed in, by the time it reaches the lungs, the turbinates have ensured that it is at body temperature and matches body humidity.

With age, the blood supply to the turbinates diminishes, the mucosa around them dry out a little and they work less efficiently. This can cause crusting in the nose and lead to ropy post-nasal discharge.

Age also causes the cartilage hood at the end of the nose to droop. As this happens the tip of the nose sags and the nostrils narrow. This causes some people difficulties, particularly when they are recumbent at night and sleep is interrupted.

Finally, age also gets to the 12 million smell receptor cells that are housed right up in the bridge of the nose. When you want to take in a full aroma, you sniff deeply to get the smell-laden air right up to the bridge. If the nasal passages are obstructed, less air gets there. If the receptors are old, they are less able to appreciate the full bouquet.

It is not known what effect years have on the mysterious ‘G spot’, which, although new to us, was first identified in humans almost two centuries ago by a Danish anatomist called Jacobson.

His spot, now known as the Organ of Jacobson, can be seen by the naked eye and consists of a pair of tiny pale pits, one on either side of the nasal septum, 1.5 cm above the nostril, just above the floor of the nose.

According to Lyall Watson’s book Jacobson s Organ, these organs have been disregarded as anatomical ghosts without function. Watson claims that not only are they superchargers, making us more sensitive to odours, but they also open up a channel quite separate from our main olfactory system, feeding an older, more primal area of the brain that monitors molecules that have a profound effect on our awareness and emotional states.

Watson says the most interesting thing is that these organs are not receptive to ordinary odours. They respond instead to substances that have large molecules but often no detectable smell. Rather than communicating with the olfactory part of the brain they go to the section that coordinates mating and other basic emotions.

Conservative physiologists and neurologists are not convinced. They want concrete evidence, preferably from humans willing to have dyes injected into their systems so their brains can be scanned to see where the tracers end up.

Whatever the truth, most humans will continue to follow their noses, whether it makes sense or not.

*54\105\2*

Cancer of the penis is virtually unheard of in men who have been circumcised in childhood. In uncircumcised men, it is thought that irritation under the foreskin, as a result of poor hygiene, infection or an inability to retract the foreskin, can ultimately lead to malignant cell changes.

Some premalignant conditions cause easily detected colour changes on the penis. If there are bright red- or orange-coloured velvety plaques on the glans, the man has a condition called erythroplasia of Queyrat. These plaques are usually painless, moist and slightly elevated, and have sharply defined edges. They appear singly or in groups and require prompt attention, because they can progress to frank cancer.

Another premalignant condition, called leukoplakia, manifests itself as a white, boggy area of thickened skin on the glans. It looks like a splotch of grey-white paint, is usually painless and can be removed with surgery or laser treatment.

Fortunately, cancer of the urethra is very rare in Australia. Kaposi’s sarcoma, a cancer that shows up in red-blue patches, is also rare in healthy Australian men but is commonly found on the genitals of those infected with HIV.

Frank squamous cell carcinoma of the penis is a rare cancer that starts as a lump on or right near the glans. The lump is painless and firm. Eventually it spreads like a cauliflower and becomes ulcerated. The earlier it is treated, the better the outcome. Treatment options include radiotherapy, chemotherapy and surgery.

If the cancer becomes invasive, a partial or total amputation of the penis may be necessary.

One well-known urologist says that on more than one occasion he has seen ‘a man of means, immaculately groomed, accompanied by a loving wife, pull back his uncircumcised foreskin and reveal an advanced cancer with its foul dead tissue. Imagine a rotting cauliflower: that is what it is like – and the groin is filled with enormous matted nodes.’ He has always been astounded that it could have been ignored until it had reached such an advanced degree.

*29\105\2*

The male sexual impulse dies hard. It can survive ageing, disease and trauma, and can live on through major catastrophes such as a heart attack or stroke.

When men emerge from the shock of a heart attack, one of the first questions they ask is, ‘When can I resume sex?’ The usual answer is, ‘When you can walk a kilometre at a comfortable pace or climb two flights of stairs without undue breathlessness.’

On average, this can be achieved within 3 weeks of a heart attack. Although most men are keen to experience intercourse again, they are insecure about whether they can manage it and fearful that it might kill them.

But regular sexual activity is usually no more physically demanding or harmful than other activities involving the same level of exercise and emotion. It should be regarded as safe, provided other activities are safe too. As during all physical activity, blood pressure and heart rate rise during sex, and any associated shortness of breath or anginal pain should be reported to the doctor.

Rather than experiment with new forms of intercourse after a heart attack, men should resume activities they are accustomed too. Most return to their normal activities with their normal partners, but there is no reason why sex with a new partner should be regarded as more dangerous, unless it involves a greater degree of effort.

But while a drink may help, too much alcohol and food may hinder the activity.

A heart attack is often followed by depression, loss and anxiety, which can make significant dents in a previously healthy libido. But these conditions are usually temporary and may be prevented or alleviated by attending a rehabilitation group or by discussing the situation with a doctor, preferably with the partner present.

In some cases the problems are not psychological. Beta-blockers, tranquillisers, sedatives and antidepressants may reduce libido. Being dependent on medication makes some men feel out of control, and this too can reduce sexual interest.

These days it is common for men recovering from a heart attack to attend rehabilitation groups where sexual difficulties are discussed openly. From this they learn that others have similar problems and that many have overcome them. Most recover normal sexual function provided they have support and understanding and attend to any associated problems.

*5\105\2*