Over 230,000 men are diagnosed with prostate cancer each year, according to The National Prostate Cancer Coalition (www.pcacoalition.org). Thanks to the effective screening, the vast majority will be cured. But the aftermath of this condition can be devastating: following a radical prostatectomy, four out of five men will have difficulty with erection or ejaculation, or complain of pain during sex.
Eighty-five percent of these patients, some as young as 30 or 40, have some form of impotence, according to a nationwide study by Leslie Schover in the December 2002 issue of the journal, Cancer.1 The good news is that we have a variety of ways to help these men regain a satisfying sex life.
Prostate cancer is generally slow growing, and without any treatment, life expectancy is fifteen to twenty years. So I tell my patients, "We have time to consider the best approach for you."
The long-term survival rates are better for surgery than for radiation, so most men in their 40s to early 60s, are likely to choose a radical prostatectomy.2,3 The most skilled surgeons can claim the lowest rates of incontinence. But no one can guarantee full sexual function. The nerves which run from the prostate to the penis are likely be affected, even with the latest robotic techniques which allow the surgeon to see more of the nerve network while operating. So-called "nerve sparing" approaches, however, only allow us to minimize the damage to this fragile area.4 The bottom line is this: While younger men (40 and under) have higher rates of potency post-operatively,5 all patients should be prepared for at least some change in their sexual response.
Treatment Options
A man can still have an orgasm even if he fails to ejaculate, so post-surgical treatments for sexual dysfunction focus on the creation and maintenance of an erection. After prostatectomy, half of all men turn to Viagra or similar drugs to combat Erectile Dysfunction (ED). Studies show that this approach is only effective for prostatectomy patients 20 percent of the time. Viagra, and two newer medications, Cialis, and Levitra belong to a class of drugs called PDE-5 Inhibitors (phosphodiesterase-5 inhibitors) designed to increase blood flow to the penis. But the penis needs an intact nerve network in order to become engorged and that's why the results are unreliable for the prostatectomy group.
After nerve sparing radical prostatectomy, patients achieve a baseline reading of 8 points out of 30, with 30 representing full sexual function. With the aid of a PDE5, their score goes up to 15 points. Men whose erectile dysfunction is unrelated to prostatectomy start off with a baseline reading of 15 points. After taking a PDE5, their scores go up to 24 out of 30.6 The take home point is this: After prostatectomy, a man starts and ends much lower on the potency scale.
Many urologists and family doctors prescribe PDE5's with the expectation that these pills will solve the problem right away. When they don't work, patients become discouraged. Yet this is not the end of the story. It's simply time to move to our second-line treatment - one that has proven more effective. Penile injections have a success rate of 72 percent. While PDE5's are taken orally, injections bring the chemicals that cause arousal directly to the penis. Some men worry this approach will take the spontaneity out of sex, so we teach wives or partners how to give these injections and recommend that the couple consider them a part of foreplay.
A woman is still responsible for her partner's erection. When she says, "Honey, it's time for your needle," she cues her mate that she's interested in having sex. The injection replicates the biological process of arousal. (Men who are single or dating may prefer to self-inject 10-15 minutes before they are ready to be intimate.) Injections are composed of three substances: Papaverine, Regitine, and Prostaglandin. Used alone, Prostaglandin E-1 can produce a burning pain in the penis. If this occurs, the physician should mix it with papaverine and regitin (phentolaminemesylate). This will usually reduce or eliminate discomfort.
Another second-line option is the vacuum pump, less popular because it is cumbersome, but which has a success rate of 63 percent.7,8 The pump is a hand or battery-operated device that increases blood flow to the penis. An elastic ring at the base of the penis keeps it fairly hard, but produces a somewhat floppy erection. (It doesn't involve the muscles of the anus which make the penis stiffen and stand out from the body.) The pump is often chosen by older men who have been married to the same woman for a long time and who are extremely comfortable with their partners.
Our final option is the implant. We consider this the last line of treatment because it is the most invasive, but it's also the most effective, with about a 90 per cent success rate. An implant can restore size and bulk, give the man the most control of his sexual response, put spontaneity back into his sex life, and provide the most natural-looking erection.
About 20,000 men have implants each year, according to the Erectile Dysfunction Institute. Nearly 300,000 men have had this surgery since implants were first invented in the 1970s. There are now three options: three-piece inflatable implants (chosen by 75 per cent of ED patients), two-piece inflatable implants (chosen by 15 percent) and semi- rigid malleable rods that can be positioned by the man or his partner (chosen by 10 percent).
Costs range from $15,000 to $35,000 though most health plans, including Medicare will cover the procedure. The surgery generally takes an hour or less, and recovery takes three weeks to a month.
Here's how the three-piece implant works: Inflatable cylinders are placed inside the penis, a pump is positioned in the scrotum, a reservoir of saline solution is implanted deep in the patient's abdomen. A man gently squeezes the concealed pump in his scrotum. The saline solution then flows into the cylinder and the penis becomes erect and firm. When deflated, the penis appears soft and natural.
The two-piece system requires a bit more manual dexterity. The pump is inflated by repeated squeezing of the scrotum, which directly fills the cylinder in the penis withsaline solution.
The malleable implant consists of two bendable rods that can be positioned according to the patient's needs. (The disadvantage is that the penis remains fairly rigid, even in the "down" position.)
There are no major complications with implants. The chance of getting an infection is low - about as much as getting one from a hip implant: around 1 to 2 per cent. While implants have no effect on sensation or on a man's ability to have an orgasm, they can have a big impact on his performance, his overall enjoyment of sex and his self-esteem. I tell patients who have this operation, "From now, it's about relaxing and learning to have fun."
The Importance of Counseling
After prostatectomy, a man shouldn't have to just forget about being intimate. Men with younger partners are the most likely to seek treatment for sexual dysfunction, though there's no reason for an older couple to give up a satisfying sex life. The problem is not every urologist is qualified to deal with these issues. Only 5 to 10 percent have any training to deal with male sexual dysfunction. So it's important to find a physician with a background in sexual medicine.
That said, a man has also to feel distressed about the loss of sexual function before he considers any of the options presented in this article. Not all men do. Many who are in long-term marriages discuss their situation with their wives then decide that it's all right to let their sex lives wind down. Post-menopausal women often report a diminished a level of desire so they may be unconcerned about changes in their husband's sexual performance.9
Other men, however, come to me and say, "I'd like to get the implant, but how do I convince my wife to be interested and give me her support?" This is a decision that has to be made by the couple, and counseling can help them to address their individual needs. To find a qualified clinician, I recommend contacting the American Association of Sex Educators, Counselors and Therapists (www.aasect.org).
More information about sexual potency after prostate treatment can be found on the following sites:
Institute for Sexual Medicine at Boston University School of Medicine
Notes
1 Schover LR, et al, 2002
2 Yan Y, et al, 2000
3 Moul JW, 2002
4 Van der Aa F, et al, 2003
5 Standford JL, et al, 2000
6 Keating GM and Scott LJ, 2003
7 Marmar JL, et al, 1988
8 Sidi AA and Lewis JH, 1992
9 Avis NE, et al, 2000
This article is for educational purposes only and is not intended as a substitute for medical advice. Please consult with a clinician to review any current symptoms and address your medical concerns.
