The Ins and Outs of Gay Sex (29 page)

E
ven before I pushed through the emergency room doors in the early-morning hours I could hear my patient begging for help.
His partner paced outside the curtained cubicle, his face pale with exhaustion.
I squeezed his shoulder and felt his relief.

“Thank God you’re here,” he said.
“We’re sorry to have bothered you, but Jim couldn’t take it anymore.”

“Don’t apologize.
I’m just sorry you waited so long to call.”

He motioned toward the cubicle.
“You know Jim.
When he couldn’t pee after dinner he thought he just needed to drink more.
So he drank all night until he thought he’d explode.”

“That’s a common mistake,” I said.
“It only filled his bladder even more.”

I asked him to wait as I slipped between the curtains.
Jim lay on the stretcher, his hands clenched across his lower abdomen and his white hair matted to his forehead.
He barely opened his eyes when I said hello.

I glanced at his swollen red nostrils and said, “You took some sort of decongestant tonight.”

He nodded.
“But what does that have to do with the fact that I can’t pee?”

“Everything.”
I tried to soothe him as I cleansed his penis with antibacterial soap.
I told him that in a minute he was going to feel
much better and that he’d even be able to go home.
He looked away as I forced the catheter through his swollen prostate and a gush of urine rewarded my efforts.

“Yes!”
he cried out as his bladder deflated.
He didn’t talk again until over a quart of urine had spilled out.
His relief made the early-morning disturbance worthwhile.
Few things we do in medicine provide such instant gratification for patients and doctors alike.

Our beloved male anatomy gives us so much pleasure but can also bring us so much pain.
If we live long enough, virtually every one of us will develop problems that require medical treatment.
As we age, our prostate grows, weakening our stream from the fire hose of youth to the leaky faucet of old age.
Many of us avoid doctors until the faucet refuses to run!

Our genitals are frequent targets of infection, both sexually transmitted or not.
But as with anorectal problems, we frequently avoid doctors out of a profound sense of embarrassment and fear of outing.
I assure you:
No infection will ever out you.
Straight men catch them too.
If you choose to keep your sexuality a secret from your doctor (something I advise against), then a secret it will stay.

Genitourinary infections are always serious and can spread throughout your body if ignored.
Read on.
If someday you find that the words in this chapter sound all too familiar, see your doctor.
Don’t put it off until you wind up in a hospital.

Urethritis is a sexually transmitted infection in your urethra (the tube that connects your bladder to the tip of your penis) caused by many different organisms.
You might notice mucus or pus dripping from your penis and burning when you urinate (dysuria).
Over 4 million men develop
urethritis annually, and like other sexually transmitted diseases, it makes HIV easier to transmit and to catch.
Anyone with urethritis should also get tested for HIV.

In one-third of men, urethritis is caused by gonorrhea, and doctors diagnose the infection by culturing the discharge.
The incubation period averages two to five days from the initial sexual encounter with an infected partner.
Although a profuse green or milky infected discharge often stains your underwear, occasionally you might not notice anything at all.
You can catch urethritis from your partner’s anus, but it is far easier to give gonorrhea during anal sex than to catch it.
If properly treated (see
Chapter 3
) antibiotics kill the bacteria quickly, but your discharge and dysuria linger until the inflammation resolves.

Nongonococcal urethritis (NGU) accounts for most cases of urethral infection and usually is caused by
Chlamydia trachomatis
or
Ureaplasma urealyticum,
both of which are frequently carried undetected by men.
Herpes simplex and human papillomavirus are other, less common causes.
(See
Chapter 3
.
) NGU symptoms are usually milder than gonococcal urethritis (less discharge) and the incubation period is longer (one to five weeks).
A doctor diagnoses NGU after examining the discharge under a microscope and seeing white blood cells without gonococcal bacteria.
When minimal, you may have to “milk” your penis to produce the discharge.
Because chlamydia is so difficult to culture, most doctors will treat you if they find white blood cells alone in your discharge.
Ureaplasma urealyticum
is even harder to culture than chlamydia, so again, doctors treat based on white cells and not organisms.
Fortunately, antibiotic treatment for both infections is the same:
100 mg doxycycline twice a day or 500 mg tetracycline four times a day for one to two weeks.

Fellatio is another frequent cause of urethritis in men who have sex with men.
Bacteria from your partner’s
mouth infect your urethra, causing dysuria and discharge.
Penicillin or erythromycin are effective treatments.

One day many years after your urethritis has been cured and the boy who gave it to you doesn’t even raise a glimmer in your eye, you may find yourself standing over a toilet unable to pee.
Chances are you’ve developed a urethral stricture (blockage) after years of scarring.
This is a frequent late complication of urethritis (twenty years is average), and you may need surgery to open it up.
Men who’ve had urethral gonorrhea are most prone to this complication.

If left untreated, urethritis can spread to your epididymis, the coiled mass of tubules draped over the back of your testicles.
Infection inflames the epididymis, creating a tender, swollen mass.
Your scrotum may redden and infection can even spread to the adjacent testicle.
Fevers are common and may be quite high.
In young men, the most common causes of epididymitis are STDs (chlamydia and gonorrhea).
Although older men can catch epididymitis from STDs, bacterial causes from bladder and prostate infections are more common.
Older men are also more likely to need urologic procedures (catheter insertion or prostate surgery), all of which increase their chances of epididymitis.

A urethral discharge characteristic of the inciting infection (pus for gonorrhea, clear or mucus for chlamydia) is a frequent symptom, as is painful urination.
Epididymitis develops days to weeks after untreated urethritis, with many men never even knowing they had urethritis.
Some men develop a more chronic infection characterized by months of dull pain or heaviness at the back of the testicles.
The discharge can be so minimal that it becomes evident
only after prostatic massage (rubbing your prostate through your rectum) or urethral milking.

As with urethritis, the doctor examines your discharge under a microscope and obtains cultures to help identify the offending organism.
Treatment targets whatever caused the infection.
If it’s gonorrhea, expect a ceftriaxone injection followed by oral doxycycline.
For chlamydia, tetracycline and doxycycline are both effective.
In older men, bacterial causes of epididymitis are much more varied, and doctors prescribe antibiotics aimed at the specific organism.

Untreated epididymitis can spread to your testicle (orchitis) and throughout your body.
Occasionally an abscess develops in your scrotum that requires surgical drainage.
If you see your doctor early, oral antibiotics usually suffice.
Delay, and you may need hospitalization for intravenous medication and possibly surgery.

Gay men who bike or lift weights risk developing an epididymitis from traumatic injury.
Thankfully the condition is rare and treatment involves warm compresses and anti-inflammatory medication (ibuprofen or aspirin).

I smiled as I walked into the exam room, but my new patient’s frown only deepened.

“Something wrong?”
I asked.

“Everything!”

I tried my most reassuring expression.
“Can you be a little more specific?”

“I’m sick of going from doctor to doctor and no one helping.”
He glanced at a sheet of paper.
“You’re my ninth.
I’ve tried so many different treatments that I have to make a list to keep them straight.
The antibiotics work for a month or two and then it’s back.
I can’t take the pressure in my ass anymore.”
His eyes moistened.
“The last one told me I was crazy.”

“No, you’re not.
If you’ll let me, I’d like to try to help.
I can’t guarantee that I will, but I’ll try.”

He rolled onto his side, bending his knees to his chest.
My finger went in and pressed against his swollen prostate.
He tensed, holding back a scream.
Maybe I could help.

Prostatitis is a bacterial infection of the prostate gland that can be either acute or chronic.
In its acute form, prostatitis can be a severe, life-threatening infection.
When chronic, it can be a nightmare, impossible to cure.
Acute prostatitis often begins as a dull ache or pressure in the lower back, pelvis, or rectal area.
The rapidly advancing infection causes severe pain, high fever, shaking chills, and prostate swelling.
Swelling can become so severe that it blocks the urethra and prevents you from urinating.

Bacteria enter the prostate through a duct that connects it with the urethra, so any urethritis or urinary tract infection can progress to prostatitis.
Passing objects into the urethra (especially unsterile toys) also can lead to severe prostatitis.
Men who need catheters for urination are also at risk for prostatitis.

Treatment for acute prostatitis is urgent, and usually you are too sick to think about avoiding a doctor.
The doctor performs a rectal exam and feels the inflamed prostate.
Often the doctor cultures bacteria from either the urethral discharge or urine.
When prostatitis is caught early, oral antibiotics may be strong enough.
Severe cases require intravenous medication and hospitalization.
Most doctors prescribe antibiotics called quinolones (Cipro, Floxin) or trimethoprim-sulfamethoxazole (Bactrim or Septra) for as long as one month to cure the infection and prevent chronic prostatitis.
Don’t be afraid to ask for pain medication.
Prostatitis hurts.

Chronic prostatitis results from either a partially treated acute infection that never quite went away or from an untreated
infection that was so mild you didn’t even know you had it.
Most men complain of dull, vague pain or pressure in their pelvis or rectum.
They know something is wrong but often can’t tell their doctor what or where it is.
Some notice burning with urination or ejaculation.
Fever is absent, and symptoms often wax and wane for no apparent reason.
Doctors have difficulty diagnosing chronic prostatitis because symptoms are mild and your prostate often feels normal.

A smart physician suspects the diagnosis based on your history, but obtaining a positive bacterial culture is nearly impossible because your discharge is often minimal.
You will probably be asked to bend over while your doctor vigorously massages your prostate.
(Although most guys find this painful, my secretary has turned away patients who’ve come back for more!
) Any discharge produced is cultured, but most often nothing comes out, no matter how vigorous the massage.
Your doctor will then ask you to urinate into a cup in the hope that any prostatic secretion washes out in your stream.
Your urine is cultured (it’s normally sterile) and, with luck, a treatable infection turns up.