Halachik Guidelines for Prostate Treatment

Before we deal with the Halachic problems involved with prostate treatment, let us review the pertinent rules pertaining to this problem that are found in the Shulchan Aruch, Even Hoezer, chapter five.

There is a biblical prohibition that forbids sterilization of a male. If, however, his intention is not to sterilize but to heal, and there is at least a small probability that the procedure will not sterilize him, then the procedure is permitted.

If the standard procedure of the operation is to make him unable to bear children temporarily but upon conclusion of the operation the damage is repaired, this operation is permitted. This is comparible to taking a medicine that sterilizes for a few hours, but afterwards the effect of the medicine wears off, and he returns to normal. This is based on the Shulchan Aruch, paragraph 11, that describes the prohibition of Sirus to be the destruction of his reproductive organ. Therefore, if it is only very temporary, it is not considered destroyed. If, however, his intention is to sever the vas deferens permanently, although it is reversible through minor surgery, he violates the prohibition of Sirus because it will not automatically reverse itself as with certain pills when their effect wears off.

Even though the surgeon is permitted to operate, but, if he damages his reproductive organs even if only by accident, the patient becomes a "Petzuah Dokah" and he is forbidden to marry or remain married to an Israelite. If, however, the damage done to his reproductive organs was an act of G-d, meaning that he was born that way or damaged by lightening or damaged through an illness, he does not become a "Petzuah Dokah." Even if the illness itself does not do the damage to the reproductive organs but it forces him to damage them in order to save his life and there is no alternative method or there is only a minority chance that the alternative method will work, the damage is considered a result of an illness and thus an act of G-d.

The damage to the reproductive organs that makes him a "Petzuah Dokah" does not necessarily mean that there is no possibility for him to have children in any and all cases. The Tosafos commentary on Gemorah Yebomot page 75a states that some people who are missing one testicle are able to have children; yet the Shulchan Aruch states that he is a Petzuah Dokah but does not disagree on the point that some may have children. We conclude from this that the law of Petzuah Dokah is a Chok for which we do not understand the complete reason. The general guideline is that in most cases he cannot bear children. Today with modern medicine the statistics have increased in his favor.

We will not concern ourselves here with all the different manifestations of Petzuah Dokah.

The Gomorah Yebomot describes three types of damages done to three parts of the reproductive organs; penetration with a sharp instrument, crushing, and one part being severed from the other part. If these damages were done to the testes including the epididymis, or to the vas deferens extending until the urethra and therefore, including the ejaculatory duct, he is a Petzuah Dokah. If these damages were done to the penis he is a Korus Shifcha. The general guideline is that a Petzuah Dokah is damaged so that usually he can either no longer produce proper sperm or the semen cannot enter the urethra. A Korus Shifcha cannot deliver the sperm properly, or in a healthy state, into the vagina for it to conceive in the fallopian tube due to damage done to the penis.

The Shulchan Aruch defines Petzuah Dokah as one whose testes were damaged and later explains that this includes the ducts or chords that are attached to the testes and are therefore, considered part of them, because in them the semen is ripened or completed. The term "Shichvos Zeroh" or semen, includes the matured sperm mixed with the secretions from the seminal vesicle and the prostate gland. Therefore, all genital organs having to do with the completion of the semen and its transport to the urethra are called reproductive organs. If any of them or any part of them are pierced, crushed, or severed, so that generally rule this will inhibit him from having children, he becomes a Petzuah Dokah. Consequently, this includes the seminal vesicle that is attached to the duct because without it the sperm would not be able to exit the urethra nor remain functional out of it. This does not include the prostate gland whose secretions help fertility but without it he can still bear children, as a general rule. The amount of prostate fluid being produced is proportional to the amount of prostate that was damaged.

The Shulchan Aruch states that if the duct was damaged so as to stop the flow of sperm through the duct he is a Petzuah Dokah. From the simple meaning we are to conclude that this refers to the entire duct from the testes until the urethra.

We will now deal with the Halachic problems and guidelines pertaining to prostate operations. The guidelines will try to avoid medical detail since as the medical procedures improve, guideline preferences will change.

Cancer of the prostate is life threatening. The decision on the type of treatment to use should be based on a consensus of experts who agree on the procedure with the strongest chances of keeping him alive for the longest period of time. If one procedure is assessed to have a majority sixty percent chance or more to extend his life for a year, and another procedure has a ten percent chance of curing him and a majority chance to extend his life for a year, the second procedure is done. If the second procedure has a majority chance to extend his life only half a year,then the first procedure is used, because the minority chance of a cure is only a factor when the chance to extend his life is equal in both procedures. It is only in a case when the odds are that he has only one or two days to live (Chayai Shoh'oh) that he may select a high risk procedure where there is a small chance it will extend his life a week or more and a majority chance that it will shorten his life even more so.

Once the procedure is selected, if there is a choice how to perform it, the procedure that causes less halachic problems should be used. For example, if the cancer is confined to the prostate and radical prostatectomy (removal of the prostate) has been selected, then the nerve sparing method pioneered by Dr. Lepor and those following him, should be used. This method significantly increases the chance that he will be able to develop an erection after the operation and fulfill his obligation and mitzvah of Onoh with his wife.

The more complicated problems are with procedures treating benign prostate enlargement, causing obstruction to urinary flow. We will divide this problem into two parts. The first is when there is no urinary backup in the bladder, and he can clear the bladder but only with difficulty. This case is not life threatening. The second case is where he cannot fully clear the bladder and there is backup. This problem begins as a small danger to his life and the danger increases in time.

There are various methods of treating this problem. Inserting a catheter intermittently, or for an extended period, is not an approved method for treating this problem and should only be used when there is backup, and then only until he can be treated properly. The major objections are that the catheter causes infection, twenty to twenty- five percent of the time it sterilizes him and makes him a Petzuah Dokah and eventually he will have damaged the prostate to such a degree that the catheter will not be of much use and he will, most probably, have to undergo an operation.

He will know if he has a problem if when during intercourse he does not release semen. This does not mean that he is sterile. He may have damaged the bladder neck muscle so that it cannot close the bladder neck opening during ejaculation resulting in the semen entering the bladder and not the urethra. This is called retrograde ejaculation. A simple urine analysis can determine the type of damage. If semen or sperm is found in the urine then he is not sterile and it is retrograde ejaculation. Being that he did not damage any of the reproductive organs he is not a Petzuah Dokah.

Furthermore, the laws of Petzuah Dokah apply even to an elderly man who is "dry" and does not produce sperm. The "chok" is dependent only on damages done to the reproductive organs. The elderly man does not have any physical reason to suspect that he has become a Petzuah Dokah, although a minority of the time he becomes one. He is a questionable Petzuah Dokah that cannot be verified with certainty, not even by a TRUS ultrasound test, nor during prostate surgery. We therefore, go according to the majority of times that the catheter does not make him one. However, if during an operation they see he is a Petzuah Dokah, then he is forbidden.

If, however, there was backup and all alternative procedures where no risk is involved and no chance of making him a Petzuah Dokah or sterile (Sirus), were ruled out, he does not become a Petzuah Dokah by use of a catheter. It is considered an act of G-d through an illness. At this point, however, the proper procedure should be surgery and not the insertion of a catheter, as explained.

We will now evaluate the alternative methods used today.

The balloon dilation procedure inserts a balloon through the urethra into the prostate. The balloon is then inflated, thus widening the bladder neck opening by pushing away the walls of the enlarged prostate. This procedure is successful with smaller enlarged prostate. There is no risk involved and no chance of making him a Petzuah Dokah or sterile (Sirus). This method should be used first, even if there is only a minority chance, but a good chance, that it will relieve the backup. However, he is not required to try it if there is only a minority chance that it would work. He would have to return for treatment every year or two.

The hyperthermia procedure inserts a microwave apparatus into the prostate that uses microwave heat to burn away the prostate tissue that is closing off the bladder neck and causing backup. The heat temporarily reduces sperm production by about twenty five percent. With this procedure there is no risk and no chance of making him a Petzuah Dokah or sterile (Sirus). The halacha with this procedure is the same as with the balloon dilation procedure. In practice, however, due to the limited success with the hyperthermia method, it is used for patients who cannot undergo surgery. With the new laser surgery that permits prostate operations on weaker patients, this method may cease to be used.

The drug treatments using Alpha blockers, Hytrin, or Proscar have the same halacha as the balloon dilation procedure. If the testosterone blocker drug will definitely sterilize him, then taking it is a violation of the prohibition of Sirus. We now have a situation where there is a backup, and theoretically, he may be allowed to violate the prohibition of Sirus to cure him if the other safe methods were ruled out. However, since with the operation option he does not violate any prohibitions, he should not take this drug.

We now come to the operation procedure. There is open surgery, TURP surgery, TURI surgery, laser surgery, and a related procedure severing the vas deferens to prevent the spread of the epididymitis infection to the testis.

Open surgery is used ten percent of the time when prostates are too large to be safely removed by the TURP procedure, or when there are complicating factors, or when the bladder needs to be repaired. The surgeon makes an external incision and scoops out the enlarged tissue from the gland. Since the enlarged tissue is more completely removed than with the TURI and TURP operations the likelihood of prostate regrowth afterwards is significantly less than from the TURI and TURP procedures which takes ten to fifteen years. Regrowth after laser surgery would be sooner than that of TURP surgery because it removes less prostate tissue.

The TURP procedure inserts a resectoscope through the urethra and, with its wire loop, removes the obstructing tissue one piece at a time. The pieces are carried by the fluid into the bladder and then flushed out at the end of the operation.

The TURI is performed on patients with early or smaller enlargement of the prostate. Instead of removing tissue as with TURP, this procedure widens the urethra by making a few small cuts in the bladder neck, where the urethra joins the bladder.

Laser incision bores a hole in the prostate with relatively little loss of blood and removes the swollen tissue blocking urination. This method could be used on patients where TURP would be dangerous due to loss of blood.

Post- operative problems are as follows. Fifteen percent of the time there is no damage at all to his reproductive organs, and he may continue normal relations with his wife. Seventy percent of the time he suffers from retrograde ejaculation. Fifteen percent of the time the ejaculatory duct, passing through the prostate, is sealed off, not allowing semen to pass through to the urethra, and he becomes a Petzuah Dokah. Fifty percent of the time this is reversible through surgery and thereafter he will experience retrograde ejaculation.

The surgeon may perform the operation and the patient may undergo the operation without fear of violating the prohibition of Sirus, since his intention is to heal and it is not definite that he will damage his reproductive organs. If the patient is unlucky, he becomes a Petzuah Dokah.

If the patient has backup and the odds are that the other safe methods will not work, then he does not become a Petzuah Dokah, and it is considered as caused by an illness.

We will now deal with the problems due to retrograde ejaculation. Although most of the time, the patient suffers from retrograde ejaculation, he rarely suffers from a loss of potency or the ability to have an erection. Therefore, he can have relations with his wife and fulfill the mitzvah of Onoh even though there may not be ejaculation. Today there are surgical methods to help reverse impotency.

Ejaculation on the full bladder is a remedy for this problem and will result in a fifty percent pregnancy rate. The patient does not urinate three hours before intercourse and drinks water or tea during that period. Intercourse is then done in an upright position.

Post- operative statistics today estimate inflammation of the epididymis to be ten percent. The operative instruments push the infected urine into larger areas of the prostate and increase the chance that the infection will spread from the urinary tract into the sperm duct. To minimize this chance, the patient is treated post- operatively with anti- biotics. Laser surgery does not push infected urine and the statistics of post operative epididymitis should be much less than ten percent.

If the patient continues his post operative checkups, the epididymitis will not spread into his body, putting him at risk. If it is getting out of control, they will stop its spreading by removing his testicles. Therefore, anyone severing the vas deferens so that the epididymitis does not spread to the sperm duct and testes is violating the prohibition of Sirus and is a Petzuah Dokah. By reattaching the severed ends of the vas deferens he is no longer a Petzuah Dokah, although he may be a Sirus, because a severed vas deferens over the period of three to five years permanently damages sperm production.

If a person is in a third- world country where he cannot receive proper medical treatment, he may be permitted to sever the ends of the vas deferens if there is a small danger to his life. Likewise, if he is ill and cannot take these antibiotics, and there may be a small danger to his life, it may be permissible.

If the DNA fingerprints under ideal conditions, show that the child in question from an unwed mother came from this man, the DNA fingerprints are considered as two witnesses and we need two witnesses to contradict them. If two trustworthy urologists testify that it was impossible for him to have children at that time and in those years due to lack of sperm production or due to a severed vas deferens, we have a contradiction of witnesses. If we would simply disqualify all the witnesses then we do not know who is his father. If, however, there is a possibility that there are times when he could have a good evening where his sperm production could cause pregnancy, we assume that this is what happened and that he is the father. If the man said that he had his vas deferens repaired during this period of time in order to father a child, we accept his explanation. If the man died we may assume that he repaired the vas deferens. If the urologists say that even if he repaired the vas deferens he could not have had even a day that the sperm production could have caused pregnancy in those years, then we do not know who is his father.

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