Prostate pain: a long, long storyBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4213 (Published 04 August 2010) Cite this as: BMJ 2010;341:c4213
- Christopher Martyn, associate editor, BMJ
Back in the 1970s, before student railcards had been invented, it was OK, if you were a bloke, to stand at the roadside and thumb a lift. Being poor at the time, I did it quite a lot. The discomfort and unreliability were offset by the idea that this was a countercultural, romantic way to travel. Even when cold and wet you could kid yourself that you were following in Jack Kerouac’s footsteps. The most exciting rides were in big articulated lorries for their lofty view of the landscape and the casual aplomb with which the drivers controlled their huge loads. The dullest were from lonely old codgers who picked you up because they wanted someone to talk to. Until I learnt to say “biology” when asked what I was studying, admitting that I was a medical student usually provoked the telling of a long story featuring baffled doctors, an operation in the nick of time, and the largest gallstone (or hernia or aneurysm) that the surgeon had ever seen.
The first 200 pages of Teach Us to Sit Still reminded me of such stories, although its author is far less restrained than the kindly people who gave me lifts. He describes in unembarrassed detail not only his chronic intermittent lower abdominal pain, nocturia, and other difficulties with micturition but the circumstances in which they occur. We learn, for instance, that he needed to defecate four times just before embarking on a kayaking trip and what a serious problem this poses if you’re wearing a wet suit. On another occasion, in a restaurant lavatory, his urinary stream is so feeble that the light, on an automatic timer, goes out, leaving him in the dark with a half emptied bladder and unable to locate either the pan, the switch, or the way out.
Fortuitously he has a friend who is a urologist. It’s not clear whether a history is taken or an examination performed, but prostate specific antigen measurement, bladder ultrasonography, radiography, and cystoscopy are arranged. Everything turns out to be normal—or at least insufficiently abnormal to explain the symptoms. He declines an offer of transurethral resection. A trial of α blockers leads to unacceptable adverse effects.
At a conference in India he takes the opportunity to consult an ayurvedic practitioner who detects a block in the flow of “vata” (not a joke: vata is one of the three ayurvedic bodily humours, along with kapha and pitta) and recommends enemas of sesame oil and herbs and the construction of an astrological birth chart, both of which he rejects. Then comes a trip to Harley Street, where his symptoms are given a label of bladder neck dyssynergia, and a second trial of α blockers is recommended. For reasons he doesn’t fully explain he’s sure that drugs aren’t the answer and vows not to see any more doctors.
Instead he resorts to the internet. Googling “prostate pain” produces endorsements for royal jelly, zinc supplements, fresh parsley juice, and much else. In the end he realises that the multiplicity of cures on offer can mean only that none of them works. He does, however, order a book with the ridiculous title A Headache in the Pelvis. When it arrives he reads that he really needs to travel to California for a special type of anal massage, but he makes do with exercises to promote something called respiratory sinus arrhythmia breathing, which is a preparation for something else called paradoxical relaxation. He finds that this helps a bit. Next he tries shiatsu massage.
By now you must be as bored as I was. And we still haven’t reached the dénouement. I don’t think that I shall be spoiling anything for anyone if I say that eventually he found that learning to meditate brought an end to the pains, although he doesn’t say whether he can pee any better.
Obviously this book wasn’t written for doctors, and I’m doubtful whether they will enjoy it much. They will have heard versions of this story many times before from their own patients whom they tried hard, but failed, to help. Indeed at one level this particular narrative is little more than a long and self absorbed account of the inner journey of a man desperately seeking meaning in and relief from chronic (but not incapacitating) symptoms, who eventually manages to find both through visipanna meditation. Yet before dismissing it entirely it’s worth remembering that the author is a successful writer and academic—one of his novels was shortlisted for the Booker prize—and probably a lot cleverer than we are.
Recently John Launer suggested that the abbreviation MUS, usually taken as shorthand for medically unexplained symptoms, should really stand for medically unexplored stories (http://pmj.bmj.com/content/85/1007/503.full). He argued that the narrow focus of the typical clinical encounter fails to give patients an opportunity to construct a meaningful narrative about their symptoms. Although the way in which doctors interpret signs and symptoms often leads to beneficial results, patients frequently find the explanations they offer inadequate and unsatisfying. These explanations, Launer thinks, must often seem like the substitution of an authoritarian medical account for the specific individual description brought by the patient. Perhaps he’s right. If so, the moral of the story told by Parks is that intelligent, educated, and apparently rational people may think about their health and illnesses in ways that hardly begin to overlap with ours.
Cite this as: BMJ 2010;341:c4213
Teach Us to Sit Still: A Sceptic’s Search for Health and Healing
Harvill Secker, £12.99, pp 352