‘I realize now how much I have always used my abdominal muscles to
move and to bend and to lift myself up. Since I have become pregnant I
have found that I have to find other ways of moving.’ Jenny
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While Australians need not become obsessive toilet-bowl gazers, rushing to install European toilets with examination ledges, it is prudent to be aware of bowel habits so that unusual changes can be detected.

Men traditionally pay less attention to their health than women. They don’t talk about their bowels and don’t like to think about their stools. A survey conducted of Australian male war veterans found that 58 per cent never even looked in the bowl. Most didn’t look at the paper, either.

The statistics for males and colorectal cancer are not encouraging. According to the NSW Cancer Registry, men have an overall lifetime risk of one in twenty-nine for colon cancer and one in forty-four for rectal cancer, while for women the respective risks are one in forty-one and one in seventy-nine. From 1973 to 1991, the incidence of colorectal cancer increased steadily among males,- the incidence in females also increased up to 1985, but decreased thereafter.

After extrapolating from the NSW figures, it is predicted that nationwide there will be 9900 new cases of colorectal cancer and 5300 deaths from this cancer this year alone (1996). By the year 2001 Australia can expect 11 700 new cases and 5800 deaths.

Given that a lot can be done if bowel cancer is detected early, it makes good sense for men to take an extra few moments in the bathroom and check that there is nothing amiss. Inhibition about examining stools and examining bowel habits becomes dangerous when it comes to denial about changes and subsequent delays in seeking medical help.

The first and’ most significant thing to look for in the toilet is evidence of blood. This can be on the paper, in the stool or in the water. A blue rinse in the water may obscure blood.

Any man over forty who develops rectal bleeding as a new symptom should see a doctor. Even if there is a small amount of fresh-looking blood, indicating that it may not be serious, medical attention should still be sought.

Bright blood may be from haemorrhoids or from a small tear in the anus from straining, but it may be from cancer or a precancerous polyp.

Although rectal bleeding arises far more frequently from benign lesions than from cancer, blood splashing in the water or stools streaked or mixed with blood must always be promptly investigated.

Some men may delay reporting blood because they’ve heard that early diagnosis of bowel cancer makes no difference to survival. This is not necessarily so. Bleeding is a symptom of early rather than late colorectal cancer and early detection may catch the cancer while it is still in the bowel wall, before it spreads.

Besides bowel cancer, other diseases can be traced from the stool, too. Black tar-like stools can indicate bleeding higher up, perhaps from an ulcer. Blood that was fresh in the stomach will go black as it travels through the body.

Bulky, fatty, offensive-smelling pale stools, which are difficult to flush because they are unformed and float, may be a sign the body is not digesting fat, which could mean a damaged pancreas. These stools often leave a rim of fat around the water. Mucus or slime in the bowl is rarely sinister and commonly results from irritable bowel syndrome.

As bowel habit depends on diet, any interpretation of changes must be done in conjunction with a review of what has been eaten before. For example, anxiety about red material in a stool may be relieved by remembering beetroot was eaten the evening before.

There is little doubt that fibre helps to prevent bowel cancer. A high-fibre diet produces floating stools because, as the fibre ferments, it produces gas, which lightens the stool. The bigger a stool the better, as people who have bigger stools are less likely to be constipated. Those who do get bowel cancer tend to have a history of constipation.

However, about 20 per cent of people never have a stable bowel habit. General advice is that if you are over forty and see blood in the toilet or have a change in bowel habit which persists for two or three weeks, you should see your doctor.

Remember – the common causes of rectal bleeding are haemorrhoids and anal lesions. Haemorrhoids are so common that they may coexist in patients with colorectal cancer or polyps. Colorectal cancer occurs infrequently in people under forty but its incidence increases progressively thereafter. It is Australia’s most common malignancy.

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You can use a diaphragm when you are menstruating, that is when you are having your periods. It can collect the blood for several hours, as long as your period isn’t very heavy. It is particularly important that it is not left in place much longer than that when you have a period, because of the increased risk of infection.

Are there reasons why I may not be able to use a diaphragm?

You may not be able to use a diaphragm if your vagina can’t hold the diaphragm properly in place. You won’t know that until you are examined. If this is the case, you will most likely be able to have a cervical cap instead.

You may not be able to use a diaphragm if you, or your partner, are allergic to latex rubber. The symptoms of an allergy like this are itching and soreness. It’s best to go and have a check up to make sure there is no other reason for the irritation. It could also be an infection. If you are using spermicide that may be the cause, rather than the latex.

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While drugs or illness may cause retarded ejaculation, in most men it is usually caused by a mental block of emotional issues strong enough to inhibit the ejaculatory reflex.

There are different degrees of retardation. In extreme cases, the man cannot ejaculate at all. In less severe cases, he can manage during solo masturbation or mutual stimulation but not during penetration.

Retarded ejaculation should not be confused with ‘ejaculatory fatigue’, which occurs predominantly in younger men who have intercourse several times in quick succession. Their erectile power is greater than their ejaculatory capacity, and after a while ejaculation lags behind and may eventually stop (for that session, at least).

Retarded ejaculation is also different from ‘retrograde ejaculation’, which occurs when the man ejaculates backwards into his bladder. This condition may result from prostate surgery, nerve damage, illness or drugs. Sometimes it can be rectified with surgery.

Retarded ejaculation is not a widespread problem, and less than 5 per cent of men suffer from it. It is most common in older men and often causes considerable anxiety. Their partners are usually older, too, and because of vaginal changes caused by menopause they cannot endure prolonged intercourse. The man ends up frustrated and the woman sore.

Female partners respond to retarded ejaculation in different ways. Although some say they enjoy it, many feel upset and suggest the man seek treatment. Other women never know. The man fakes orgasm, and if the woman is not experienced she might not realize there has been no ejaculation. The skin deep inside the vagina is not sensitive, and from internal sensations alone, most women cannot tell if the man has ejaculated. The faking is exposed when fertility is an issue because, of course, without ejaculation the woman cannot become pregnant.

Religious men often suffer from retarded ejaculation. Their entire lives they have been instructed not to masturbate, not to ‘spill seed’. Over the years, through strict control, they hold back, and eventually this becomes a learnt response. (Many of these religious rules date from the days when males married in their teens and restraint was not such a burden.) When the activity finally becomes legitimate, some religious men find they cannot let go. The old control still operates. They may need help to let go of this response.

Retarded ejaculation is not the same as ‘partial ejaculation’, which happens when men ejaculate but feel no pleasurable orgastic sensations. Instead of semen being ejected in spurts, it oozes or dribbles out. It is also different to ‘ejaculatory anaesthesia’, where there is normal ejection of semen but no orgastic pleasure.

Men may also experience normal ejaculation and pleasurable sensations, but their experience is marred by painful cramping during or after discharge. These men have ‘post-ejaculatory pain syndrome’. The pain can last from less than a minute to four hours and discourages some men from ejaculating. Again, this is not the same as retarded ejaculation.

With retarded ejaculation, the first thing to do is determine whether it has a medical cause – whether it is the result of drugs or illness. If not, the psychological issues need to be explored. Commonly, a man suffering from retarded ejaculation is found to be angry, angry against women and angry in general. They could be raging against things that happened in childhood, about their sexual education or about their mothers. They may be harbouring guilt about sexual pleasure due to early prohibitions or be experiencing difficulties with present partners. Or maybe women terrify them. It is possible to acknowledge this anger and, without entering into counselling, adopt a systematic desensitisation program.

One such program for men who cannot ejaculate on penetration might begin with the woman on the bed and the man sitting on a chair outside the room, masturbating behind a closed door. The next time he brings the chair inside and does the exercise with his back to her. Gradually, over several weeks, he gets closer and closer until he is sitting between her legs and can finally ejaculate during penetration.

This type of program is successful in more than 70 per cent of men whose problem is not being able to ejaculate during intercourse. Difficulties may arise if the man changes partner. However, if psychotherapy or sexual counselling is combined with the program, the transfer to a new partner is likely to be more successful. If behavioural therapy is unsuccessful, the problem may be treated with drugs.

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• While some people think that condoms are messy or that putting them on interrupts the natural flow of sex, other people have made putting on the condom a natural and sensuous part of having sex and they really like it.

• Some men say that wearing a condom makes their penis less sensitive, so they don’t enjoy sex as much as they do without a condom. Sometimes this is because the condom is too tight over the head of the penis. If this is the case, it is worth trying a different type of condom, for example one that is flared may feel better because its shape allows a bit more room for the head of the penis.

• You need to remember to have a supply of condoms and lubricant ready in case you need them.

• If the condom breaks it helps to have thought about what you would do. You can get emergency contraception from Family Planning Centres and some doctors, but you need to take it within 72 hours of having sex. If you think that you would want to use emergency contraception if a condom breaks, find out the nearest place that you can get it so you are prepared. Some doctors are happy to prescribe emergency contraception in advance in case condoms break.

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With their new culturing techniques, they are now able to grow vast quantities of full-thickness skin from one small piece of foreskin. This cultured skin can potentially then be used for skin grafts.

Even those deeply committed to the anti-circumcision movement would have to acknowledge that using the foreskin in this way has considerable potential benefits. To date, cultured skin has been successfully used to treat bum victims and ‘cotton-wool’ children. Such children have skin like tissue paper that blisters and tears at the slightest touch.

When skin culturing began in the United States in the early 1980s, Sydney doctors quickly learned the methods and began experimenting with them here. By the late 1980s they had greatly improved the technique, and now they have developed it even further.

Dr Mark Eisenberg is a family practitioner who has been at the helm of this project since it began. He is highly motivated because one of his children suffers from the cotton-wool syndrome, a hereditary disease known as epidermolysis bullosa (EB). Initially Dr Eisenberg’s team experimented with fresh skin removed during cosmetic surgery but later

decided to use foreskins because, coming from infants, they are less likely to be tainted. Adults encounter a range of diseases and infections during their life and some of these may leave a legacy in the skin.

The foreskins used are not from newborns or from ritual circumcisions. They are mostly from infants, six months and older, who are circumcised under general anaesthetic in hospital. They are used only with parents’ consent. Before being used, the foreskins are, subjected to rigorous testing to ensure they are disease free. (At present, foreskins are also being used for research in other areas of medicine such as virology and melanoma research.)

During the 1980s, the Americans managed to culture cells and grow the top layer of skin called the epidermis. But they needed to work with skin from a related donor, or the graft would be rejected.

The Sydney team improved on the technique by finding a way to culture skin of full thickness which would not be rejected. They were able to take a piece of foreskin the size of a postage stamp and in six weeks make it grow into enough skin to cover half an adult. The average adult has about 1.3 square metres of skin.

They experimented on Australian soldiers who had tired of their tattoos and wanted to get rid of them. These soldiers volunteered to have cultured skin used.

The skin worked and Dr Eisenberg’s team successfully used it in twenty-two operations on children with the cotton-wool syndrome at the Prince of Wales Hospital. These children need repeated skin grafts because their skin breaks frequently, and when it heals, it scars. A build-up of scar tissue can distort joints and restrict movement.

The cultured skin operations were such a success that this has become an accepted method of treatment during the reconstructive surgery of the hands in children suffering from EB.

The skin was also used on one Sydney boy who was badly burned at a barbecue. The boy had cultured skin grafted onto his forearm. Now, a few years later, Dr Eisenberg says the skin on his forearm has pigmented and looks quite natural.

Dr Eisenberg’s goal is to complete all the research and testing so that a public skin bank can be opened. Such a bank would have a stockpile of cultured skin, stored frozen, which could be sent interstate and overseas whenever it was needed. Skin from the bank could be used for emergencies like motor and industrial accidents, bone-crushing injuries and skin cancers. It may also help people suffering from skin-disfiguring diseases.

Until recently, people needing skin grafts were given skin from cadavers or used their own harvested skin. But harvesting skin creates new wounds, and cadaveric skin grafts can involve up to twenty operations.

The Sydney team has now developed its culturing methods even further. Before, it could only get forty million cells from a humble foreskin. Now it can get billions. This incredible multiplication means the team no longer needs to collect foreskins. It has enough cells in stock.

As Dr Eisenberg explains, ‘In one foreskin there is the potential to produce enough skin to cover half a football held.’

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