Prostatodynia produces symptoms that are basically identical to those of nonbacterial prostatitis; the difference is made in diagnosis (see below). Prostatodynia can be caused by many things, particularly muscle spasms in the bladder neck, prostatic urethra, perineum, or pelvic floor.

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So what are you supposed to do? When you read about a breakthrough in the newspaper or hear about it from a friend, how should you evaluate it?

Here are some basic principles:

Beware of the Placebo Effect. This is the first “grain of salt” to take into consideration in any study. Researchers are always wary of the placebo effect, an inexplicable improvement in the so-called “control” group who are taking “sugar pills,” which they believe to be real medication. In almost every study of a drug or treatment for any disease, there is some improvement in the control group. This phenomenon is almost always attributable to a boost in mental health that comes from taking part in a study, or from the belief that some new medication is making a real difference in symptoms. (However, it also reminds us never to underestimate the powerful effect of a positive attitude on physical symptoms!)

With BPH, there is a tremendous placebo effect to any form of treatment. In one series of studies that included a placebo group, 30 percent to 75 percent of placebo-treated men reported subjective improvement in their urinary symptoms—this means that they believed their symptoms were better—and as many as 15 percent to 20 percent reported significant improvement in urinary flow rates.

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But another big surprise in recent research is the discovery that growing prostates aren’t making scads of new cells. How can this be? If there’s not a huge increase in cell birth, what’s making the prostate grow? Apparendy, something’s also happening to cell death; the cells in question are leading abnormally long lives, and this is resulting in a cellular overcrowding, or population explosion.

Finally, scientists are beginning to investigate the role of substances called growth factors, which serve as switches that activate processes to promote cell division in this balance of cell birth and death. Investigators have found higher levels of some growth factors in tissue with BPH than in normal tissue. Current thinking is that these growth factors have a major impact on the stromal, or smooth muscle, cells. (These growth factors are produced by cells in the prostate and act locally, either on the cell of origin or on adjacent cells. One, such as basic fibroblast growth factor, is known to stimulate glandular cells to grow. Others, such as transforming growth factor-beta, stimulate the stromal and smooth muscle cells.)

Spurred by the growth factors, these cells somehow revert to a more primitive state, which allows proliferation of the lumpy masses of lobes in the prostatic tissue surrounding the urethra. Whatever stimulates the stromal cells also seems to restrain other cells, particularly the epithelial cells, the tiny factories that make the prostate’s secretions. This would explain two of BPH’s more significant characteristics: The build-up in cells and the drop in prostatic secretions.

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The other truth we have to face is that hormone therapy does not cure prostate cancer. And if a man lives long enough, this cancer will progress. Despite so many refinements in hormone therapy, the death rate for advanced prostate cancer is about the same as it has always been. And the reason these men are dying has nothing to do with the hormone-responsive cells; we can control those cells. It’s the hormone-insensitive cells we can’t seem to kill. So what we need, urgently, is a better way to target this group of cells.

But until we have such a treatment, perhaps the best strategy with hormone therapy is to find ways of lowering its costs or minimizing its side effects. Are the most expensive hormone treatments necessarily the best? Probably not. Surgical castration and one milligram a day of DES are equally effective. Even though one milligram does not lower testosterone dependably to the castrate range—as three milligrams a day does—this might not be necessary, since castration and one milligram of DES seem to be equal in terms of survival. DES is a lot cheaper than LHRH agonists, which can cost several hundred dollars a month. And DES’s biggest side effect, painful breast swelling, can be taken care of relatively cheaply with radiation treatment. However, men with a history of heart disease or thrombophlebitis should not use DES as their main form of treatment.

Another way to improve hormone therapy would be to diminish its side effects—particularly impotence. One hope in this area may be flutamide, perhaps combined with finasteride—both preserve potency in most men. The theory here is the “one-two punch.” Flutamide blocks the binding of testosterone and DHT to receptors in the prostate (the “keys-in-the-lock” idea). With help from finasteride, which decreases the amount of DHT floating around inside the prostate, only testosterone is left to bind to the receptor. Therefore, because testosterone’s link to the receptor is relatively weak, it becomes easier for flutamide to jolt testosterone out of the way—to knock the key out of the lock.

Will this work? It needs further investigation, but laboratory studies are promising. The result would be hormonal treatment that doesn’t make men impotent and doesn’t leave them feeling “unmanly,” or suffering any of the other side effects from conventional hormone therapy. This should be a major focus of research in the near future—developing effective hormone therapy with fewer side effects.

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These men are more likely to have complications. Understandably, operating on a prostate whose tissue has been damaged by radiation seeds is going to be more difficult than operating on an otherwise healthy prostate with just a bit of cancer. And in the medical literature there is no good evidence that salvage radical prostatectomy is actually curing many patients.

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There is nothing unusual about the homosexual offenders vs. minors in terms of drug use, alcohol use, or gambling.

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The incest offenders vs. adults are similar to the other incest offenders in having masturbated relatively infrequently during their premarital lives. The average (median) incest offender vs. adults always is found in the lower third or even quarter of rank-orders with masturbatory frequencies of 2 or 3 times a month. In mean frequencies the members of this group are even more restrained: they are at the bottom of the rank-order until age twenty and next to the bottom in age-period 21-25 which represents the chronological limit of our data for them. For a group to show such restraint in regard to masturbation, as well as in their heterosexual and homosexual behavior, is most unusual.

Low incidence of masturbation plus smallness of sample size make it impossible to calculate meaningful frequencies for the married incest offenders vs. adults.

Although the masturbation frequencies before marriage were low, so were the frequencies of their other sexual outlets, with the result that in their early teens these offenders derived 82 per cent of all their orgasms from masturbation, the second largest proportion recorded for that age-period. Thereafter, among the unmarried, the proportion is moderate and essentially the same as that of the control group. Among the married the proportions are usually small and often the smallest manifested by any group according to our limited data.

The incest offenders vs. adults began to masturbate later than the members of any other group, the median age after puberty being nearly fifteen years. However, one must bear in mind that these particular offenders also attained puberty later than any others, and their “late start” may simply reflect this fact.

Resembling the other incest offenders, who rarely had homosexual fantasy while masturbating, no incest offender vs. adults reported such fantasy. They are, as we shall confirm later, the least homosexual of any group. Aside from homosexual fantasy, the incest offenders vs. adults display a tendency toward a diversity of fantasy, ranking fourth in sadomasochistic fantasy (7 per cent), third in fantasy of animal contact (7 per cent), and fifth (14 per cent) in bizarre fantasy. On the other hand, 12 per cent never fantasied—a fairly large percentage compared with other sex offenders, though similar to the percentage reported by the control group.

Comparison of this fantasy record with the conscious response to various stimuli reveals various parallels. The minimal amount of homosexual fantasy is in accord with the tiny percentage (4 per cent) of men who reported some sexual arousal from thinking of or seeing other males and the absence of any who claimed a strong arousal. Similarly, the fairly large number who never fantasied agrees with the fairly large number (25 per cent) who claimed to have been never or seldom aroused by thinking of or seeing females and the very small number who found strong arousal from this stimulus.

While the incest offenders vs. adults had little masturbatory experience, they worried about it more than any other group. This is in keeping with their general restraint and feelings of guilt. Concern over masturbation does not characterize incest offenders as a whole: the incest offenders vs. minors, it may be recalled, had the least worry of all.

In the matter of the source of knowledge of masturbation, the incest offenders vs. adults display a low percentage (9 per cent) who learned by being masturbated by another individual. This finding might have been anticipated since they had very little prepubertal sex play and, moreover, did not socialize well with other children at ages ten to eleven. It is somewhat puzzling, therefore, that only another 9 per cent learned through self-discovery. As is typical of incest offenders, a large proportion (36 per cent, the second largest percentage) learned of masturbation chiefly from talking or reading.

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The first coital partners of the aggressors vs. adults were concentrated in the age categories 14-15 and 16-17 with approximately equal numbers in each (29 and 30 per cent respectively). Relatively few had their initial coitus with females younger or older. This is what one would anticipate in a group in which large numbers of the members began coitus early in life.

Our impression that aggressors vs. adults are not particularly interested in young partners was borne out when we asked them what age they preferred their sexual partners to be. More than twice as many expressed a desire for women from thirty-five to forty-four as for girls aged sixteen to seventeen; 13 per cent, a moderate figure, chose the sixteen- to seventeen-year-olds. Only 3 per cent, a rather low number, had preferences that included girls under sixteen. As with all groups, the controls included, the majority of aggressors vs. adults preferred women between eighteen and thirty-four.

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