Testicular cancer forum

Prostate cancer continues to attract research funding and political attention as the complexities of the disease are unraveled and debated in a uniquely public men's health forum. Screening guidelines and treatment modalities have been featured in prostate cancer research. However, some areas worthy of research are conspicuous by their absence. One such area that has attracted little research is a common diagnostic procedure for prostate cancer, the trans rectal ultrasound prostate biopsy (TRUS-Bx). The TRUS-Bx procedure involves the passing of needles through the rectal wall into the prostate gland in order to retrieve six-12 prostate tissue specimens for analysis. This ethnographic research study explores 14 Anglo-Australian men's experiences of TRUS-Bx, administered without local or general anesthesia, as a diagnostic procedure for suspected prostate cancer. A social constructionist gendered analysis reveals intricate connections between participants' experiences of the TRUS-Bx procedure and masculinities.

Keywords: prostate cancer, men's health, treatment modalities, trans rectal ultrasound prostate biopsy (TRUS-Bx), gender analysis, masculinities

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The majority of prostate cancer research is focused on virtues of screening, potential causes, risk factor identification, treatment modalities, and side effects. However, between prostate cancer screening and diagnosis there is an examination that often takes place: the trans rectal ultrasound prostate biopsy (TRUS-Bx). There has been little published research about the TRUS-Bx and in particular men's experiences of the procedure.

Men with prostate cancer are often asymptomatic (Kozlowski & Grayhack, 2002). Prescribed or requested prostate cancer screening with prostate specific antigen (PSA) blood tests, usually in conjunction with a digital rectal examination (DRE), may reveal an abnormality that indicates the need for further investigation. The TRUS-Bx is often the subsequent test in which a definitive diagnosis of prostate cancer is confirmed or rejected. The TRUS-Bx procedure is performed by placing an ultrasound probe in the rectum. Sound waves emitted by the probe transmit graphics that show the prostate gland, which is usually viewed on a television screen. A spring-loaded needle attached to the ultrasound probe enters the prostate gland through the rectal wall. Tiny pieces of tissue, usually between six and 12 samples, are removed from the prostate via the needles. The samples are examined for prostate cancer cells, and a diagnosis of prostate cancer and its severity can be made (University of Toronto, 2000). Pre TRUS-Bx procedure prophylactic antibiotics are often prescribed to minimize infection risk, and an enema is administered to evacuate the rectum of feces to facilitate visualization and reduce the likelihood of prostate biopsy specimen contamination. The TRUS-Bx is usually administered without anesthetic (Kim, 2000).

No previous TRUS-Bx research utilizing social constructionist gender frameworks was found in the literature, and therefore a review of the literature that informs this study is presented. First, literature pertaining to previous patient-informed research of the TRUS-Bx procedure is described. Second, because a social constructionist gender analysis is used in this research, a brief review of this literature and the implications it has for interpreting the research data is presented.

Much of the TRUS-Bx research investigates biomedical areas, including accuracy of histopathology interpretation and evaluation of techniques for collecting biopsy specimens. Despite this trend, three recent studies investigated men's self-reported symptoms related to TRUS-Bx. Zisman, Leibovici, Siegel, and Lindner (1999) conducted a study that investigated the morbidity associated with TRUS-Bx. Ninety-eight consecutive biopsy patients were enrolled and completed survey questionnaires at three consecutive appointments. Zisman et al. (1999, p. 3) concluded "TRUS prostate biopsy commonly causes a vast variety of complications and has a substantial impact on the patients' well-being." Specifically the findings from their study showed that, prior to TRUS-Bx, 9% of participants reported sexual impairment resulting from anticipation of the scheduled TRUS-Bx and 65% of participants reported anxiety. During TRUS-Bx 96% of participants reported pain (42% reported mild pain, and 16% reported severe pain), and 86% of participants reported discomfort (28% reported mild discomfort, and 30% reported severe discomfort). Following TRUS-Bx, 21% of participants reported sexual impairment, 20% reported decreased libido, 48% reported pelvic pain one-day post-biopsy, and 75% reported anxiety awaiting biopsy results.

Zisman, Leibovici, Siegel, and Lindner (2001) completed a subsequent study with 211 men, and the results supported the findings of the original study, that TRUS-Bx may cause pain, anxiety, and erectile dysfunction. In conclusion, Zisman et al. predicted that measures to relieve anxiety in patients may alleviate pain and recommended that analgesic therapy be used for "younger patients, those reporting moderate to severe intra-operative pain, and those with known prostatic inflammatory infiltrate" (2001, p. 454). They also suggested the risk of acute erectile dysfunction be discussed cautiously with patients who have erectile function before TRUS-Bx.

Kim (2000) conducted a study of 50 men undergoing TRUS-Bx. She found those who received rectally administered lidocaine gel (local anesthetic) before the biopsy experienced significantly less pain than those men who underwent the TRUS-Bx without anesthetic. Using a visual analogue score (VAS) to rate intra-operative pain, zero being no pain and 10 being the most pain, 52% of the patients who underwent the procedure without lidocaine rated their pain as five or higher on the VAS of one to 10. Scores of five or higher are considered moderate to severe pain. Only 4% of patients who received lidocaine rated their pain in that range. Kim (2000) concluded that lidocaine gel was an efficient, cost-effective method to reduce TRUS-Bx pain.

One common finding by Zisman et al. (1999, 2001) and Kim (2000) was that many men experienced pain when undergoing TRUS-Bx without local or general anesthetic. However, these survey questionnaire studies depicted pain as a physiological cause-effect reaction to TRUS-Bx. There was no discussion about the cultures and sexual identities of the research participants or contextual information about their TRUS-Bx experiences, including details of what preceded and followed the procedure.

Men's experiences of illness are increasingly being recognized as issues that are socially constructed and depend greatly on how men and their community define masculinity (Bergman, 1995; Charmaz, 1995; Connell, 1995, 2000; Courtenay, 2000; Gordon, 1995; Gordon & Cerami, 2000; Huggins, 1998; Moynihan, 1998). Most recently social constructionist gendered frameworks have been used by Chapple and Ziebland (2002); Fergus, Gray, and Fitch (2002); Gray, Fitch, Fergus, Mykhalovskiy, and Church (2002) and Oliffe (2002, 2004) to research men's experiences of prostate cancer.

Central to social constructionist frameworks is the concept that masculinity is socially constructed and influenced by society, history, social class, and culture (Courtenay, 2000). The type of masculinity the dominant group performs--a "culturally idealised form of masculine behaviour" (Connell, 1987, p. 83)--is referred to as hegemonic masculinity. Many men are strongly influenced by dominant social constructions of masculinity and replicate characteristics of hegemonic masculinity including stoicism, aggressiveness, competitiveness, sexual prowess, and control (Cheng, 1999). The adoption of such attributes also informs improper displays of emotions such as pain and grief (Kaufman, 1994; Nicholas, 2000).

Reliance on hegemonic masculinity is reported to negatively influence men's health and illness behaviours (Eisler, 1995; Connell, 1995; Courtenay, 1998; O'Hehir, Scotney, & Anderson, 1997; Huggins, 1998; Ziguras, 1998) because men respond to society's expectation of toughness and independence that informs a sense of invulnerability, social isolation, withdrawal, and hesitancy or unwillingness to ask for help (Good, Burst, & Wallace, 1994). When illness is discovered it can render men vulnerable, passive, and dependent, traits traditionally assigned as feminine and thus in direct opposition to hegemonic masculinist constructs of invulnerability, activity, and independence (Martino & Pallotta-Chiarolli, 2003). Therefore, anticipated, imagined, and real limitations associated with illness can result in socially constructed subordinate, marginalized, and emasculated forms of masculinity (Charmaz, 1995; Cheng, 1999; Farrell, 1986).