The interview was prickly. The doctor, although recognizing that the patient’s request to be seen alone might be symptomatic of some underlying anxiety, found herself not only having to contain her own annoyance, but having to accept a rebuff to all her gentle probings. ‘I’ve only come for a check-up, that’s all,’ said Mrs B. ‘Of course I’m feeling tired, who wouldn’t when the baby wakes several times in the night? The delivery wasn’t what I expected.’ ‘You expected something different?’ asked the docotr. ‘Why shouldn’t I? I went to all the antenatal classes, didn’t I? And I want you to fit me with a coil,’ she said, as if putting an end to further discussion. She brandished a leaflet. ‘I’ve read all about it, at least I don’t have to think about it.’ Think about what, thought the doctor. A pause. ‘What did you use before?’ The Pill, but it never really agreed with me, then the cap; that was fine but I couldn’t possibly use it now.’ A spasm of pain crossed her face but she was already moving towards the couch. Breasts and abdomen were examined, then the perineum – a beautifuly healed episiotomy scar, but Mrs B.’s hands were across her eyes. The doctor said, ‘Tell me what you think it is like down there.’ ‘It’s horrible, horrible. I wanted everything to be natural but the baby got stuck. They kept saying that I should have had an epidural but I didn’t want it and I didn’t want to be cut. Stitching me up was even worse; there were all these people in the room. I don’t think I’ll have a coil fitted today, I’ll come back later.’ ‘When I put my fingers inside you, can you tell me what it feels like?’ Subtly the doctor was putting Mrs B. back in charge of herself. ‘Then you can decide what method of contraception it’s going to be. You might like to go back to the cap after all.’ With the doctor’s help Mrs B. was able to recognize with astonishment how normal her vagina felt, and even managed to insert a new cap.’Actually,’ said Mrs Â. ‘I think I would like a coil. It’s possible to be a bit more spontaneous isn’t it?’ She gave a shy secretive smile. She was even beginning to think about sex.’And as long as you do it I don’t really mind if your trainees watch.’ Having shown her feelings with the doctor, Mrs B. was able to take a positive decision about herself and was back in control again.

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Men do not like buying them. They talk of the embarrassment of feeling that shop assistants believe condoms are for a mistress rather than a regular partner. They do not trust mail order companies not to divulge details to other sales agencies. Bulk buys are perceived as being generic and possibly substandard. A more popular method than over-the-counter sales is by using a credit card to buy from an advertisement in a woman’s magazine. Selling here is seen as conferring some special degree of approval – and can be left more easily for the partner to do. At the other extreme, one young man told me, ‘It is best to make a joke of it. Go up to a young assistant in a chemist with a packet and ask her what this sort are like.’ Not necessarily a joke for the shop assistant. If this man, with his general lack of embarrassment, finds buying a problem, then it must deter some men altogether.

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Blood clots in the legs can occur in as many as 12 percent of men after radical prostatectomy, and pulmonary embolisms, or blood clots in the lungs, occur in an estimated 2 percent to 5 percent of these men. (In one Johns Hopkins study of 1,300 radical prostatectomy patients, fewer than 2 percent had a blood clot, and two men died of a blood clot.)

Clearly, the best way to deal with this problem is to prevent it from ever happening. Some doctors do this by administering blood-thinning medications such as mini-dose heparin before surgery. Some doctors also give their patients compression devices—various forms of heavy-duty support hose—for the legs. One of these looks like a pair of “long Johns,” and is designed to force all blood into the deep veins, and keep the flow powerful and continuous. (Sluggish blood flow leads to clot formation.) Other hose have special compression chambers that control blood flow, and are designed to “milk” blood up the leg.

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The most common complication during surgery is excess bleeding, usually a result of a blood vessel being injured during the operation. That’s why it is absolutely critical that your surgeon has mastered the techniques for ensuring a “bloodless field” (see “An Anatomical Approach to Surgery,” and “Are You in Good Hands? What to Look for in a Surgeon,” in this chapter).

Less common complications include injuring the rectum or ureters; such injuries can be repaired during surgery, and extra surgical precautions can be taken to avoid permanent damage.

Other complications include blood clots and bladder neck contracture.

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In a Johns Hopkins analysis of 503 potent men, 34 to 72 years old, 68 percent remained potent after radical prostatectomy. Age and the stage of cancer as well as surgical technique—the surgeon’s skill, and whether or not one or both neurovascular bundles were removed during the operation—all can affect potency. The breakdown, by age: Potency was preserved in 91 percent of men younger than 50, in 75 percent of men aged 50 to 60, in 58 percent of men aged 60 to 70, and 25 percent of men over 70.

In men younger than 50, the potency rate is similar (about 90 percent) in men who kept both neurovascular bundles intact, and in men who had one nerve bundle removed. This suggests that all that’s needed for men to achieve erection is one of these nerve bundles, and that nature has provided a spare.

In men older than 50, however, the sexual potency rate was higher in men who had both neurovascular bundles preserved than in men who lost one bundle. When the relative likelihood of impotence after surgery is adjusted for age, the risk is twice as high if the cancer has penetrated the prostate wall; if it has invaded the seminal vesicles; or if one neurovascular bundle has been removed.

To sum up: The men most likely to remain potent are younger, with disease confined to the prostate. These also are the men who will benefit most from surgery.

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The artificial sphincter is an elaborate device, but there are several simpler solutions that involve the injection of material (collagen) into the urethra or bladder neck. It’s possible that with further refinements, these techniques will be sufficient for managing incontinence in almost all men who develop it.

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woman know they are secure together; that they can cope with the bad times as well as the good; that they want a baby for the baby’s sake only and not to please themselves, to keep up with the Jones’s, improve their own self-esteem and so on; and until they can provide for it without undue sacrifice on their part.

Producing another human being who may well live for eighty or more years is becoming an increasingly awesome undertaking. Most couples are having fewer babies and having them later. This is surely responsible. An increasing proportion of couples (up to 10 per cent) are choosing to have no children at all for various reasons and others are unable to do so because they are infertile.

The ideal way to space a family is not known. Nature’s way, which depends on long-term, unrestricted breastfeeding, ensures that babies are born at intervals of about two and a half to three years. This is not acceptable to most Western couples who do not want a baby every three years throughout their reproductive life, but can be useful between their first and last babies.

If children are born too closely together the mother may be over-taxed, but longer intervals can increase rivalry between the children. Spreading them out with very long intervals means the family is committed to child rearing for years on end, but this suits some women who feel most fulfilled when caring for babies. Longer intervals also reduce the severity of the economic effects of having children on the family. Small families tend to be more favourable to the intellectual development of the children than large ones.

Whatever plan is adopted it has to be related to contraception. One reasonably effective plan is for a highly efficient contraceptive method such as the Pill to be started before the couple first have intercourse. The woman continues taking the Pill until about six months before the couple want to conceive their first baby. At this time the Pill is stopped and a condom or other barrier method used to allow time for the Pill’s effects on the body to wear off. After about three months the couple can start having unprotected intercourse, but it is important to remember that many couples do not conceive at once, whether or not the woman has been on the Pill. A woman having intercourse on an unrestricted basis and not protected by any contraceptive takes an average of 5.3 months to conceive. Twenty-five per cent of couples will have conceived in the first month, 63 per cent by the end of six months, 75 per cent by the end of nine months and 80—90 per cent by the end of one year.

If a couple decides to have a second child but timing is not too important then relatively ineffective methods such as vaginal foams, a diaphragm, or one of the natural methods such as relying on unrestricted breast feeding could be used. If no further children are wanted at all, the Pill can be used again until the woman is about thirty-five years old. Alternatively, one of the partners could be sterilised. After the age of thirty-five less reliable methods can be used, such as the progestogen-only (mini) pill.

Contraception needs to be continued until about a year after the periods end at the menopause, but as fertility is falling rapidly by this age in most women less efficient methods can be used.

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