When all else fails, and no cause can be found for bloating, heartburn or other abdominal discomforts, one US physician pulls out his tape measure.

He measures the patient’s abdominal girth and then he measures the patient’s trousers. If the latter is smaller than the former, he diagnoses ‘tight pants syndrome’, and his prescription is simple: buy bigger trousers.

Even in our dressed-down era, dangers still lurk in the clothes we wear. We may not have to endure scalp sores or lice from wigs, and today’s women rarely find themselves swooning as a consequence of lacing their corset too tightly, but we do have blue jeans.

These jeans, with their reinforced seams, can be pretty uncompromising. One doctor even coined the phrase ‘jean seam coccygodynia’, meaning a sore tailbone brought on by sturdy jean seams.

Then there are men with ‘stretcher’s scrotum’, caused by vigorous stretching in tight shorts. Those who wear close-fitting pants and carry a wallet in their hip pocket risk ‘credit-card-wallet sciatica’, a painful condition caused by the pressure of a fat wallet on the sciatic nerve. This, fortunately, is completely curable with a Svalletectomy’ and some looser trousers.

About 20 years ago there was a popular notion that tight pants posed a potential danger to male fertility. Men were advised against wearing jockey-style underwear and tight pants as it was feared these would heat their testicles. It was thought boxers and spacious strides would provide breathing space and allow the production of more and better-quality sperm. This advice is no longer given.

But tight clothes can aggravate testicular discomfort and pain. All urologists see a number of young men who complain of pain radiating up from their testicles. Generally no cause can be found but looser clothing may prevent the pain from worsening.

As a rule of thumb, you know you need to go up a size when you climb into your car and your trousers and underpants pull backwards on the car seat and put pressure on your testicles. If you are travelling a short distance it won’t matter but over long stretches this can cause discomfort.

Tight pants can also aggravate groin rashes or jock itch. Jock itch, known as tinea cruris, often infects the groins of men who perspire heavily. This area needs to be kept dry and well ventilated but tight pants keep it warm and moist. The fabric also rubs against the affected skin, making the condition worse.

Synthetic fabrics can aggravate this even further because they tend to keep heat in and don’t allow the area to breathe. Tinea cruris is difficult to eliminate and doctors recommend loose clothes and cotton underwear as part of treatment.

Tinea is caused by a microscopic fungus called a dermatophyte and is said to affect 20 per cent of the population, about 77 per cent of whom are men. Apart from the groin, it occurs in the webbing between the toes. This form, known as tinea pedis, or athlete’s foot, causes scaling, itching and discoloured, crumbly toenails.

Shoes should be chosen for comfort rather than fashion, as it is estimated that ill-fitting shoes cause more than 60 per cent of foot problems. Besides corns, bunions and nail deformities, they can alter the biomechanics of a man’s walk.

Most men’s feet continue to change thoughout their adult life. Shoe size may increase with weight gain or when the man’s pattern of activity changes. Pads on the feet may grow thinner with age. Podiatrists caution men against buying shoes with the idea of wearing them in because often it’s the foot rather than the shoe that has to adjust. How, for example, could a winkle picker ever adjust to a healthy broad Australian male foot!

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Bullies are everywhere. Although bullying is usually thought of as a childhood phenomenon confined to the schoolyard, it extends deep into the workplace. There are as many 50-year-old bullies as there are 5-year-old bullies except that the middle-aged ones are highly skilled and capable of sophisticated manipulation.

Even competent, confident older men get bullied. The one constant in all bullying situations is that victims always know when it has happened. They may have difficulty articulating the experience but they have a strong emotional recognition of what happened.

The kind of bullying that starts with a push and a shove in the primary-school playground becomes more subtle as males age. Adults can be so ingenious that they can send their victims over the edge without anyone else knowing they were pushed.

‘lake the case of a local police officer whose life was in ruins. Despite his letters of commendation, his peers perceived him to be a nerd. He didn’t fit in. He didn’t smoke, he didn’t drink and he went to church.

The early tangible signs of the bullying included putting rotten fruit in his pigeonhole, tampering with his gun and mail, scratching the paint on his car and sabotaging his work.

Daily, his peers set him up so he was then reprimanded for violating protocol. His problem was that he was a good victim’. He didn’t fight back, he was forgiving and he didn’t have a group of friends to protect him. but eventually he could no longer keep it up and overreacted. His peers look him off to the government medical officer and claimed he was paranoid. The medical officer trusted the peers and assumed the man was delusional. He labelled him with a paranoid personality disorder and in so doing deprived him of his career.

Victims always blame themselves for being a victim. Just as a 6-year-old boy hates himself for letting the bully see him cry, so a grown man despises himself for being crushed.

There are three things victims should do. The first is to tell somebody about it, because keeping it quiet can be toxic. The second is to change the usual response to the bullying: if a show of strength is not appropriate, there are many effective techniques for turning the situation around. The third thing is to harden the target: the victim should make it harder for the bully to get to him, just as he might burglar-proof his home to make it harder for it to be broken into.

In difficult economic times or during restructuring in a workplace, bullying always comes into play. Managers often start trying to make life hard for some men to encourage them to make a decision to leave. Managers will give these subordinates work they don’t like, threaten a transfer, give them the cold shoulder or perhaps isolate them.

Whenever there is a big influx of new people into a workplace, bullying is sure to occur. When new recruits enter the police force, it is rather like boys entering the first year of high school. Bullying sorts out who will be top dog. Some workplaces, like the military, encourage bullying, not only up and down the hierarchy, but across ranks too.

Bullying should not be confused with healthy competition. During competition people squash others along the way as a means to an end. In the long term, victims are more likely to suffer loss of self-esteem and depression and have more difficulty in maintaining intimate relationships because they cannot trust others.

One effective defence against bullying is to make friends – the sort who can provide a buffer against the bullying.

*89\105\2*

Every now and then, medicine throws up a cure that is so quick and so simple that patients find it difficult to accept. This has happened with one of the most common forms of vertigo. Men who have spent years enduring this frustrating condition can have it vanquished in a 10-minute consultation in which no drugs, machinery or invasive procedures are used. All it takes is a painless manipulation of the head.

Some men are dumbfounded when they hear of the method. They think it’s a crackpot idea.

Vertigo is an illusion of movement. Although stationary, a sufferer feels either that he is moving or that objects about him are moving. This sensation is quite distinct from mere dizziness, unsteadiness or giddiness. About 5 per cent of men and women visiting general practitioners complain of vertigo, describing an unpleasant feeling of imbalance and spinning, often accompanied by nausea and vomiting.

Its origins can be difficult to determine because more than 80 disorders are reported to have vertigo as a possible symptom. Vertigo takes different forms, with the most common being known as benign paroxysmal positional vertigo, or BPPV. This form is triggered by a change in the position of the head. It can happen when a man rolls over in bed, when he turns around in the car to reverse or when he puts his head back to reach a high shelf.

As he does this, he is overcome with a brief but intense sensation of whirling and disorientation. This can recur throughout the day and cause considerable distress. In some men it may go on for years. In others it may resolve itself spontaneously in weeks.

It usually occurs on one side only, and each bout lasts no more than 30 seconds. Men who suffer vertigo over a prolonged period sometimes develop stiffness as a defence against movement.

BPPV is more prevalent in older people and usually happens for no apparent reason. It results from degeneration in the inner ear and can also follow trauma or an infection.

Fortunately, about 95 per cent of those with BPPV can be cured quickly.

But it wasn’t always so.

It has been known for some time that BPPV arises because of a problem in one of the three semicircular canals of the inner ear. Back in the early eighties, there was a great reluctance to do invasive surgery on the inner ear. The rule was that the inner ear should never be violated for fear of causing deafness.

However, after experimenting on animals and discovering it was possible to drill into and plug the problematic semicircular canal without affecting hearing, doctors tried it on two men who were already deaf and were willing to have the operation. They were both cured.

The first man was in his mid-60s and had suffered so much from his vertigo that he was prepared to risk hearing loss and have the operation. He had lived with BPPV for almost 3 years and found it intolerable.

The procedure was a success and his hearing was preserved. Since then, this operation has been used around the world, with excellent results. But the original doctors hardly use it anymore! Rather, they use a simple head manipulation because it is quicker, cheaper, less invasive and, usually, just as effective.

There used to be a popular theory that a deposit in the canal caused BPPV. Later there was a theory that it was caused by small particles in the fluid in the canal. These canals are lined with fine hairs, and it was believed the particles stimulated the hairs, causing a tremendous sensation of movement when the person was quite still.

One surgeon opened up one of these canals and actually extracted the particles, providing proof for the particle theory. He showed that if you could get the particles out of the canal, you could cure the BPPV.

All one needed to do was to move them. By manoeuvring the head, it is possible to mechanically steer the particles out of the semicircular canals and into another part of the inner ear where they will do no harm. This requires some skill and knowledge about the anatomy of the inner ear.

The 5 per cent of people who don’t respond to this manoeuvre could be candidates for the surgery or one of the other methods for treating BPPV, such as drugs and habituation exercises that attempt to train the brain to cope with vertigo on a daily basis.

*66\105\2*

Like all cancers, prostate cancer can change a man’s image of himself. Not only can it trigger depression and force him to confront his mortality, but the most well-adjusted man may also find that the emotional stress of living with such a cancer interferes with sexual desire and performance. In some cases, his natural concern with its intimate location will render him psychologically impotent.

Even men who can cope with the emotional burden of prostate cancer have to cope with the physical treatment, which can also affect sexuality. Many men see it as an assault on their genitals, their hormones and their sense of masculinity. Depending on the type selected, it can limit erectile function, eliminate ejaculation or reduce libido.

The big question all men want answered is whether impotence is an inevitable consequence of treatment. The answer is no, but it must be remembered that 30 per cent of men with prostate cancer are impotent before any treatment commences. These men will remain impotent.

In the case of the others, different treatments have different outcomes. After treatment some men lose their potency immediately, some lose it gradually and some regain it gradually.

The four main treatment options are surgery, radiotherapy, hormone therapy and watchful waiting (being vigilant but having no active treatment).

The prostate lies in the body surrounded by nerves and blood vessels. Cutting it out without damaging these nerves and vessels is difficult, and it is the extent to which these structures are damaged that determines the degree of potency after the operation.

Surgeons have to balance their enthusiasm for protecting nerves against the certainty of getting rid of the cancer. They don’t want to protect the nerves and leave some cancer behind. Sparing nerves is only possible in some cases.

Nerve-Sparing Radical Prostatectomy After a nerve-sparing radical prostatectomy (removing the prostate with as little nerve damage as possible), 40 to 70 per cent of men are still potent.

Each man’s potential potency depends on his age, the number of nerves spared and his erectile function before the operation. After surgery, erections take between 3 and 18 months to return and are not as strong as they were before. They are said to be 60 to 80 per cent as good, but this assessment is very subjective.

Radiation Therapy Radiation therapy slowly damages blood vessels, and after 5 months of this treatment men may begin to notice an effect on their potency. About 50 per cent of men who have had radiation therapy will be impotent five years later. Ejaculation and orgasm are also affected; the overall result depends on how sexually healthy the man was before the radiation began.

Hormone Therapy Hormone therapy is usually reserved for men with advanced prostate cancer and is essentially a form of chemical castration. It leads to loss of desire, impotence in 80 per cent of patients, decreased ejaculation and less intense orgasm.

Watchful Waiting Men who opt for watchful wailing have to live with the knowledge that they have this cancer and are not actively treating it. This influences (heir self image and may affect their sexuality in the long term.

On a positive note, neither prostate cancer nor its treatment affects the skin of the penis, and sensations there remain unchanged. Furthermore, orgasm is a mental event and can occur without ejaculation. It is a myth that intercourse is the only really grownup form of sex. Much gratification is possible without penetration and with ‘outercourse’. This includes any form of sexual activity that is commonly thought of as foreplay.

Sex therapists say that although foreplay satisfies many women, men often don’t regard it as real sex and their ‘outer-course’ repetoire is limited. Like babies, adults have ‘skin hunger’ and need to be held and touched. There are numerous ways of feeding this hunger. Holding hands, lying together or massaging each other is a good start.

Men missing the closeness of intercourse could regain it using a technique described as ‘soft sex’. This requires the woman to sit astride the man and use her pelvic floor muscles to achieve partial penetration. This can give pleasure to both partners but the woman does need to have a strong pelvic floor.

Following treatment for prostate cancer, many men lose their desire for sex and don’t feel like initiating it. However, they may regain their interest if they realise how many aspects of sex they can still enjoy.

*41\105\2*

About 5 years ago, the managing director of a Sydney manufacturing company noted with alarm that he was having difficulty maintaining an erection. It would rise without any trouble but almost immediately would begin to subside.

At 54, he couldn’t understand why this was happening. ‘My wife was very encouraging, but no matter what she did – and she put in a lot of effort – it just didn’t last. It was an abject embarrassment.

‘Somehow, over the past 3 months, I had developed a curve, down and to the left, in the shaft of my penis,’ the man explained. T never had it before and the specialist said it was Peyronie’s. He said the only long-term solution was a penile implant.

‘We discussed it. My wife is 14 years younger than me and enjoys sex as much as I do, so we decided to go ahead,’ he continued. ‘About 6 weeks later I put it into operation and it worked right away. In a way it works better than before because now I have more control and can last a good 30 minutes.

In my right testicle I have a small flat box which is the pump. It causes me no discomfort and I’m not aware of it in my daily life. It pumps liquid into two tubes which run down either side of my penis to the head. The liquid is stored in a reservoir which is buried in the right side of my abdomen and I don’t feel it either.

The man described how it works. ‘.Some nights we shower together and then massage each other and caress and kiss and love and during this I can bring up a natural erection and perhaps have oral sex. Then she will gently move my hand down, which tells me to pump it up to a full erection. I push a little button on the pump and it takes maybe 30 seconds to work. I think she probably gets more pleasure now than she did before. Afterwards, I release a valve as she folds me down.

‘Although the Peyronie’s came out of (he blue, I have diabetes too, so I’m a double candidate for an implant. The idea of fussing with vacuums or injections didn’t appeal to me. I’ve been comfortable with the implant for 5 years now and have no regrets.’

There are several types of implants available in Australia but the most popular is the three-part system discussed above. The main risks are infection at the time of surgery and long-term mechanical breakdown. Over a 10-year period, about one in three will break down and need to be repaired with further surgery.

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