Chapter 15: Sexual twists and capers

One Sunday afternoon I received an urgent call from the Ski Rescue Service on the nearby mountain resort stating that a 17-year-old girl had ‘collapsed’. Her problems were headache, tightness in the chest, dizziness, and difficulty with speech, walking and breathing. The first aid attendant thought she had ‘mountain sickness’ (hypothermia). Her condition was deteriorating despite treatment, yet she was still conscious.

There was a blizzard on the mountain where the task of transporting her 56 km to my clinic began. She was placed on a special stretcher and towed by a snowmobile to the chairlift. The stretcher was hitched to the lift and, with difficulty, the patient was carefully and slowly lowered to the chairlift base where a special Forests Commission vehicle transferred her to a waiting ambulance. With great drama, police escort and entourage, she arrived in my surgery about five hours after the distress call.

Examination revealed an agitated, prostrate, attractive girl who could not offer a coherent history. Her vital signs were temperature 36.5 °C, pulse 124 and regular, respiration 26/min, and BP 120/75. There were no neurological abnormalities but she indicated that she had paraesthesiae of the extremities and around the mouth.

DIAGNOSIS AND OUTCOME

The provisional diagnosis was acute anxiety and ‘hysteria’ with hyperventilation. We gave her a lot of positive reassurance and encouraged her to breathe into a paper bag. After 10 minutes she sat upright, looking very normal and enthusiastically accepted an offer of a cup of tea. The stunned countenances of her anxious entourage were a sight to behold. One of these embarrassed characters was the enterprising young stud who was responsible for provoking this startling chain of events by threatening the patient’s virginity within the snowbound confines of their chalet.

Diane, aged 30, was a very intelligent and attractive primary schoolteacher who was a regular attender at my practice with a variety of complaints. Her diagnostic list included tension headache, irritable bowel syndrome, anxiety state and infertility. She had an episode of endogenous depression at the time I took over the practice some 12 months previously. She and her husband had been investigated in the past at an infertility clinic. The diagnosis was ‘idiopathic infertility’, after five years of marriage, and the couple had subsequently adopted two children.

At this particular consultation she looked her usual sad, tense self but was particularly fidgety and tremulous. She said that she was concerned that her husband, who was an elite athlete, was paying undue attention to an attractive young lady in the town and was not being particularly attentive to her. I then decided, for the first time, to explore her marital relationship in depth.

I felt quite annoyed and distressed to discover that the marriage had not been consummated. She claimed that her husband, a very handsome man with a super physique, was a very poor communicator during their love making. He would ‘get very passionate, agitate all over the place and then “come” somewhere near her navel’ or around the outside of her vagina. When she tried to talk about it he seemed too proud and embarrassed to get involved. She had never experienced an orgasm and felt ‘not like a woman and terribly frustrated’.

OUTCOME

I arranged to see them together and so very basic marital and sexual counselling was initiated. I stressed the importance of improving their general communication in all areas. The change in Diane in particular was dramatic. The melancholy lady with a litany of complaints was transformed into a sprightly, contented, irregular attender. She confided that since experiencing her first climax she had felt a complete woman and that the marriage had grown in strength with the general improvement in their communication. It was not long before their first natural baby arrived.

Background

J is a dynamic and colourful 25-year-old sportsman who has won many accolades in football and athletics. This delightful character was starting to worry me about several uncharacteristic appearances over a period of about eight weeks for relatively trivial complaints, mainly of a musculoskeletal nature.

His problems included headache, neck pain, back pain and groin pain, all of a relatively minor nature with no significant findings on clinical examination. When I confronted him about his general health he admitted to feeling lethargic and uninterested in his beloved sport, claiming that his training program was virtually at a halt. ‘I feel stale, Doctor—just can’t be bothered.’

I advised J that this flat spot was commonplace in super athletes and that a break in routine including a ‘holiday’ to a ‘different’ training resort would be beneficial. Shortly after this consultation a letter was hand-delivered to my mailbox.

The problem

The problem was now obvious, and so I rang J and told him that I had encountered this situation several times in the past. He should not feel too embarrassed about it and should come along one evening so that we could clarify the problem.

J seemed quite at ease during the consultation. The examination did reveal a normal-sized penis albeit at the lower end of the normal range. On direct questioning he did experience normal heterosexual impulses, and did have erections of 11–12 cm. When I asked him why he thought that he was so ‘small’, he said it was based mainly on comparisons with the other guys in the showers at the change rooms.

I counselled him that his ‘problem’ was a common complaint of men when they compared themselves with others, and one explanation might be that some men with homosexual or bisexual tendencies could be stimulated by the sight of other naked men in the change rooms so that their penises could be observed in the semi-erect state. He understood this and said that such a possibility had crossed his mind.

A knowing, sheepish grin transformed J’s face when I casually said: ‘Now you’ve fallen in love haven’t you? You’ve probably met your match and you’re thinking about getting married and you have some anxiety about your manliness, your sexual performance and your ability to father children’.

‘That would be close to the mark, Doctor, but is it possible to carry out a hormone test to make sure?’

A serum testosterone was ordered because I could see that counselling would not reassure him completely. A normal result made him feel relieved and reassured. He gradually regained his confidence and his normal zest for life.

Now, years later, he is happily married with three children and claims that his sporting activities are as enjoyable as ever.

Jeanie E, aged 29, presented with recurrent vaginal thrush with an interesting associated effect—insomnia! Upon initial presentation she had the typical cottage-cheese-looking vaginitis and I prescribed nystatin cream.

I repeated this treatment when she represented two months later. She then started treating her own pruritus vulvae with the cream. After another two months she came in with her husband, both looking worn out and glum. ‘Doctor, you’ll have to do something about the thrush—I’ve had it’, exclaimed the bleary-eyed husband. ‘Jeanie finds that the only relief for her itchy vagina is intercourse. She tapped me on the shoulder three times during last night. I’m not that good.’ ‘Well I can’t scratch it and sex soothes it at least for a little while’, explained Jeanie.

DIAGNOSIS AND OUTCOME

The gauntlet had been thrown down to me to stop the self-perpetuating itch-intercourse-itch cycle. I examined the vagina and could not find any evidence of significant vaginitis. ‘I always seem to be itchy now and I’ve done all you told me: no deodorants, no tampons, no jeans, no pantyhose, no antibiotics.’

I went through my check list and decided to get her to pass a specimen. Glucose +++. A random blood glucose was 17 mmol/L. The old diabetes had tricked me again.

The devoted married couple

Mrs CP, a 42-year-old with non-insulin-dependent diabetes, presented with a several days history of migratory polyarthritis. Examination revealed a fever, tachycardia, a few non-tender, subcutaneous nodules and a tender, swollen right knee, on which she was unable to bear weight. Initial investigations showed an ESR of 84 mm/hour and raised C-reactive protein. A working diagnosis of rheumatic fever was made and she was admitted for bed-rest and treatment with aspirin and penicillin.

We had all noticed the devotion of her elderly husband who sat by her bed almost all day, every day, chatting and doing crossword puzzles. We had also noticed that she had a young male visitor ‘waiting in the wings’ who would appear only after her husband had gone.

After a week the subcutaneous nodules had disappeared, but the right knee remained painful and swollen and she was still unable to walk. Thus it was decided to aspirate this knee. Imagine our surprise when four days later the laboratory phoned to say that gonococci had been cultured from the joint aspirate. Contact tracing revealed that her husband had not been sexually active for years and she was having a relationship with the young man.

Suspicions alerted

Mrs AT, a 34-year-old, presented 12 days after Mrs CP with a two-day history of fever and pain and swelling of the wrists and metacarpophalangeal joints so severe that she was unable to feed or dress herself. There was no history of illness. On examination, a systolic murmur was detected. I remembered that she had had gonorrhoea six months ago, so in addition to the usual investigations for polyarthritis I took an endocervical swab. While waiting for the results she was admitted and treated with indomethacin, which had little effect on her symptoms. Luckily, the visiting orthopaedic surgeon, who visits every three months, arrived two days later and aspirated frank pus from both her wrists. She was commenced on intravenous antibiotics, but after three days of treatment was able to feed and dress herself and left hospital. Gonococci were isolated from the endocervical swab and joint aspirate.

Mrs S was the formidable 81-year-old widowed matriarch of a large family in a rural township. Her dutiful daughter would bring her in for a check-up because she would ‘throw wobblies’. Her ‘wobbly’ was described as a ‘turn’ or ‘space-out’ in which she would collapse, become aphasic and sometimes throw her arms around. I could not find any abnormality on examination or investigation. One day I received an urgent call to attend to mother because she was found lying unconscious on the laundry floor. I had to travel 14 km and when I arrived 20 minutes later I could see that there was no sign of trauma and her breathing was normal. Then the prone patient said, with eyes closed, ‘Why has it taken you so long?’ I realised that it was a conversion reaction (hysteria). Physical examination was normal.

When the family left the room she quietly said (still lying prone with eyes closed) ‘What I need is a good man and a good bang’. Her rather naïve young doctor was dumbfounded.

I was attending to the immediate post-delivery stage of a complicated obstetric case when the nurse said that a woman had appeared at our small hospital at 1 am with vaginal bleeding. I said to settle her down and I would eventually see her (wondering where I would get norethisterone at that hour!). After about three minutes she returned looking agitated ‘you should come quickly’. I did and found a small 39-year-old single woman who was having profuse vaginal bleeding and her circulation was compromised. She told me that she had been working at a nearby fish and chips shop and after work had intercourse with the boss and the bleeding started soon after. I could see that the bleeding was profuse and coming from the vaginal vault so a large pack was put in the vagina to arrest the bleeding and an intravenous line inserted. Once the poor embarrassed patient was stabilised we arranged for my partner to come and administer a general anaesthetic. Repair of the wound was difficult as there was a 7 cm laceration in the vaginal vault and oozing of blood was profuse. A blood transfusion was required.

David, a 22-year-old post-graduate student presented with what he described as ‘a sensitive issue’. It was our first consultation but I knew him as a rather reclusive earnest young man around the district. He came from a very religious family and was a devout Christian. David was embarrassed as he described lumps on his penis that he thought may have been a sexually acquired problem, ‘perhaps from toilet seats’, although he said that he was a virgin. Inspection revealed the somewhat common problem of benign pearly papules on the corona of his penis. Upon diplomatic questioning he did admit that he wondered if they were caused by masturbation. However, he was most relieved by the assurance that all was well and he appreciated the opportunity to chat about important facts of life for the first time.