Male sexual dysfunction -- and the underlying problems contributing to it -- is firmly on the agenda against a background of increasing longevity.

If you scanned the pages of almost any major newspaper today, you could be forgiven for thinking that Australians had suddenly discovered male sexual dysfunction.

Advertisements promising something approaching the medical equivalent of a full recondition abound. Under the heading 'Sex for life', one goes so far as to claim that "many patients can maintain potency for the majority of their lives".

Men have suddenly realised that they are living longer, says the director of the Institute of Reproduction and Development at Monash University, Professor David de Kretser.

"The treatment of heart disease and stroke has improved dramatically, and men are looking for a better quality of life. These ads raise expectations -- I don't have a problem with that, although I would hope that the patient gets the full treatment rather than a simple remedy."

Declining sperm counts

"Such publicity highlights the way in which men's sexual problems are beginning to be discussed openly, but it can also prey on the emotions. It's disappointing that one has to advertise these things. And it's disappointing that the doctor--patient relationship isn't such that it can be dealt with inside the GP's surgery. We need to train GPs to be more comfortable when dealing with these patients. If they aren't comfortable, then we need to train more specialists."

Sexual dysfunction is, however, the public face of an often very private problem. Research at the institute is also looking into the implications of less-publicised, male-specific conditions such as testicular cancer, prostate cancer and male infertility.

"One man in 25 is sub-fertile, and we don't know the cause of infertility in 50 per cent of those men with disordered sperm production, although genetic factors, for example Y chromosome disorders, are emerging as important."

In international scientific circles, debate is focusing on the reasons behind the decline in sperm counts. Some scientists suggest that molecules in the environment are affecting the development of the testes in prenatal life, resulting in decreased sperm production.

"It's very hard to compare studies from years ago with those today, but there is sufficient information to suggest that there is an increasing abnormality in the development of the male reproductive system. Evidence is mounting on several fronts -- undescended testes and hypospadias (where the urinary passage opens along the shaft of the penis and not at the tip) are becoming more common."

Testicular cancer, a disease of the young man, is also on the rise -- 400 new cases are detected in Australia each year.

"Testicular cancer is largely being ignored. Most sufferers will get it before the age of 40. Provided it is picked up early, however, 90 to 95 per cent of cases can be cured," Professor de Kretser says.

"Early detection is vital. It is important to encourage men to examine the topography of the testicles, for example under the shower when the scrotum is relaxed."

Prostate cancer

Prostate cancer is an even greater menace. The disease, which kills about 2500 Australians each year, is also at the centre of a growing scientific storm.

"Fifty to 70 per cent of all men will develop benign prostatic hypoplasia (BPH), or overgrowth of the prostate gland, and 30 per cent will require some form of treatment, for example a 'rebore' or a medical therapy such as drugs that interfere with the way male hormones are metabolised."

Prostate cancer, unlike prostate disease, can occur without symptoms such as problems with the urinary stream. And this, says Professor de Kretser, is where the debate begins.

As part of the initial diagnosis, a blood test is used to measure the patient's PSA (prostate specific antigen). If the PSA is elevated, it is possible that prostate cancer is present. PSA levels, however, can also rise in cases of BPH and inflammation of the prostate.

"People often undergo the test without fully understanding the subsequent steps and decisions involved. If the PSA is up, the doctor has to arrange tests, such as a rectal examination and a prostatic ultrasound, to determine the cause."

These tests don't always detect the presence of cancer. If a subsequent biopsy finds traces of the disease, however, this raises the question: do you have to treat it?

"Prostate cancer is ranked on a scale from one to 10: one is low-grade, 10 deadly. If it's an aggressive tumour, of course it will need treatment. But what happens if it's grade 3 or 4? Is it going to spread rapidly and kill, or will it just sit there?"

Unfortunately, the accepted patterns of mortality do not seem to apply here. Postmortem examinations of men who have died of causes other than prostate cancer show that a large percentage have the disease at the time of death. But surgery has its problems, too. In cases where cancer is confined to the gland, the surgeon usually removes the entire prostate. (The prostate sits beneath the bladder and above the penis. Removing it means joining the two.)

Prostectomy

"There are two consequences of radical prostectomy. First, it causes incontinence in 10 to 30 per cent of patients, although most will recover. The second implication is that 40 to 50 per cent of men will experience impotence. The problem is, however, treatable with intrapenile injections.

"Once a man has a PSA test, he is open to all these possibilities. At the moment we are conducting research into a better form of diagnosis without false positives."

Anxiety over the troublesome prostate appears to reflect men's growing concern about their health, particularly about specific issues affecting them alone, says Professor de Kretser.

"Increasing our lifespan makes men more likely to develop prostate cancer. A hundred years ago, men died before the age of 50 from a variety of other causes, and did not live long enough to develop the disease."