Did I hear you say “direction?” That you’d lost your direction?

RALPH BLUM

Apparently loss of hearing isn’t the only loss we’re subject to in these latter years. Oh well, “Direction, erection—as long as you’ve still got your health, right?

The first breakthrough in treating erectile dysfunction (ED) came at the 1983 American Urological Association meeting in Las Vegas when Dr. Giles Brindley injected his penis with the drug phentolamine. Following the injection, Dr. Brindley appeared on stage and dropped his pants to display one of the first recorded, drug-induced erections to a startled audience of urologists and their wives.

It wasn’t until 1998, when the FDA gave Pfizer the go-ahead for their little blue pill, that erectile dysfunction (ED) came out of the closet, and, thanks to Viagra, men no longer had to self-inject their penis or use a vacuum pump in order to get and keep an erection, aka “hard-on.”

In case you wondered, “hard-on” is a synonym for “boner” or "blunder," 1912, baseball slang, probably from bonehead. The meaning "erect penis" is 1950s, from earlier bone-on (1940s), probably a variation (with connecting notion of "hardness") of hard-on (1893). Sure as shooting, many a hard on has resulted in blunders! Still, losing our “blunder-making ability—erectile dysfunction or ED—is of serious concern to a great many men.

Today, it is estimated that up to 30 million American men frequently suffer from ED. For those of us who are over seventy, the hydraulics of nature’s ultimate erector set are subject to ordinary fatigue and malfunction. Many of us are dealing with the after-effects of prostate cancer treatment. And there are dozens of other reasons, both medical and emotional, for the inability to get or maintain an erection.  So without a doubt there is a humongous market for what my young neighbor calls “boner pills,” and last year alone Pfizer spent $176 million on TV ads for Viagra.

Although it is almost impossible to turn on your TV without seeing a commercial about erectile dysfunction, until recently the content of those ads, while excellent fodder for comedians, has been fairly subtle—usually involving an attractive middle-aged couple making goo-goo eyes at each other, building up to the magic point “when the moment is right.” It may be hokey, and a trifle awkward to explain to your 10-year-old daughter what Viagra is all about, but the ads were not totally gross.  Then Pfizer changed their ad agency…

The latest Viagra commercial features a glamorous blonde in a slinky blue dress reclining on what appears to be a mattress. Looking directly into the camera, and in a sexy, sultry voice with a British accent, she addresses the viewer: “So guys, it’s just you and your honey. The setting is perfect. But then erectile dysfunction happens again.”  She then takes a stroll through a tropical setting and adds, “You know what, plenty of guys have this issue—not just getting an erection, but keeping it.”  (Incidentally, this is the first use of the word “erection” in a TV ad outside of the description of side effects.)

The new face of erectile dysfunction is an English soap actress called Linette Beaumont, and she is prompting a Twitter storm. One viewer tweeted: “Don’t need Viagra. Just need the hot blonde with the British accent.”  A less enthusiastic viewer tweeted: “Nothing is worse than sitting next to your grandma while a hot blonde British woman talks about erections. Thanks, Viagra.”  I haven’t yet seen any of the late night talk shows, but I imagine the hosts are having a field day.

No doubt about it, Viagra has helped countless men to maintain an active sex life.  But do we really need this kind of advertising to get a rise out of men (pun intended)?

Is Prostate Surgery Right for You?

RALPH BLUM

As I wrote in my last blog, once your family doctor has referred you to a local urologist and you have been diagnosed with prostate cancer, your first and most important decision is choosing a doctor with the necessary skill and experience to help you weigh all your options and determine your best course of action. This doctor may not be your community urologist.

Provided the cancer is still contained within the prostate gland, and provided there is no medical reason surgery is contraindicated, your urologist (who is a surgeon) will almost certainly recommend it. And in your emotionally vulnerable state, and with a natural desire to just get rid of the cancer, it is quite likely you will uncritically take his advice, without question or research.

After talking with your urologist you may come away with the impression that prostate cancer surgery is fairly straightforward. It is not. Anatomically, the prostate is in absolutely the wrong place for a simple surgical procedure. Located as it is within millimeters of the bladder and the rectum, there is zero tolerance for a slip of the scalpel. To make matters worse, there is prolific venous blood supply surrounding the gland, and on a bad day even the best surgeons can end up operating in a pool of blood, and with restricted ability to see clearly in order to spare the miniscule nerves (thinner than a human hair) that control erections. With such an intricate and complex procedure the high rates of impotence are hardly surprising.

So much skill is required to successfully perform a radical prostatectomy that being operated on by less than the very finest surgeons dramatically increases the chances for a poor outcome. Levels of ability vary widely from surgeon to surgeon even in prestigious university centers. In 2004, Dr. Peter Scardino, Chief of Urology at Memorial Sloan-Kettering, published a study documenting the differenced in “talent” in this unregulated field. The study evaluated the surgical skill of twenty-six urologists on staff at Sloan-Kettering and Baylor.  The indicator used to measure skill was the frequency of leaving cancer behind after the operation (the technical term is “positive surgical margin”). The study reported that the best doctor in the group left cancer behind in 10% of his cases. The positive margin rates of the other twenty-five urologists ranged from 11% to a shocking 48%.

 

Despite these disturbing statistics surgery is still the primary treatment of choice for those diagnosed with prostate cancer. Yet while a select few surgeons perform dozens, perhaps a hundred or more procedures, generally speaking, the average urologist performs fewer than half a dozen prostate operations a year. In the U.S. there are somewhere around 70,000 radical prostatectomies done annually, and there are 10,000 urologists. If you do the math it’s clear that your community urologist is probably not doing enough prostate surgeries to stay proficient.

 

So buyer beware. Before you consent to surgery be sure to ask your urologist how many nerve-sparing prostatectomies he has performed--it should be at least 50. Preferably upwards of 200. Did often he get positive surgical margins? What percentage of the men he operated on are sexually potent a year after the procedure? What percentage suffers from incontinence a year later? And if you are over 70 years old and your urologist is recommending surgery, find another urologist, or better still, a prostate oncologist.

 

I hope this short essay has helped convey the importance of not rushing into treatment.  It bears repeating: Go slowly. Do your homework. I have avoided surgery for almost 25 years. Consider the options, including—since surgery is only right for some of you—“Do nothing,” which for many men translates as “Die with prostate cancer, not from it."

Pay-Off Versus Collateral Damage

BY RALPH BLUM

Life is full of risks, but if you are one of the legion of men with prostate cancer whose urologist is recommending a radical prostatectomy, make sure you have considered the following risks of collateral damage:

Incontinence: 
Urinary leakage is usually a temporary problem after a prostatectomy, but even the best urologists report that about 7% of their patients are left with permanent and constant urinary drainage.  Less skilled surgeons have much higher rates. After surgery, most men experience some minor leakage when they cough, lift, bend over, or laugh.

Another problem is the formation of scar tissue in the urethra, the passage from the bladder to the penis. The suture site where the severed urethra is reconnected can become constricted by scar tissue that blocks the flow of urine. This may be correctable with urethral dilation, a process forcing oversized, stainless steel probes up the penis to stretch out the ring of rock-hard tissue. Unfortunately, scar tissue is notoriously uncooperative, often refusing to stretch at all. In some cases the stretching fractures the brittle ring of tissue, resulting in permanent incontinence. If that happens, another operation is required to implant an artificial sphincter.

Impotence:
Without nerve-sparing surgery permanent erectile dysfunction is virtually inevitable. With nerve-sparing surgery, the best surgeons hope to be able to save the nerve bundles (located very close to the back of the prostate on both sides) that control erections. If both sides of the nerve bundles can be saved, potency is around 40% to 75% in patients under 70 years old (depending on which expert you consult, and the patient characteristics). If only one side of the nerve bundles can be saved, potency drops to around 25% to 45%. However, until the doctor actually performs your surgery, he won’t know whether he can spare the nerve bundles.

Even men who recover their erections after surgery undergo a prolonged period of impotence, often lasting up to a year or more. During this time of enforced abstinence, as with any unused muscle, atrophy of the penis occurs. This means that of the men who end up recovering some degree of erectile function, only 5% report that their erections are as good as before surgery.  Additionally, despite claims from urologists who maintained for years that patients’ complaints of penis shrinkage were anatomically impossible, diligent researchers have finally collected the necessary measurements showing that shrinkage is common. The average amount is about one-half inch, although some men undergo considerably greater shrinkage.

Studies show that impotence can totally redefine a man’s self-esteem, his self-confidence and his relational satisfaction. In some cases Viagra can help with surgically induced impotence. However, penis vacuum devices, penis tourniquets, penis injections (yes, with needles) or the surgical implantation of a plastic rod into the penis is often required to restore function. In my case, lead me to the monastery!

Other Rare but Possible Risks from Surgery:

• Significant blood loss requiring transfusions
• Pain from surgery
• Blood clots in the legs
• Heart Attack
• Infection
• Temporary or permanent memory loss from anesthesia
• Miscellaneous surgery-related problems

 

So with these considerable risks, what is the pay-off for undergoing surgery? The major pay-off is, if you are lucky and have a successful nerve-sparing prostatectomy, it will cure the cancer and you will suffer minimal collateral damage. The only other advantage is you get a better idea of how serious your cancer is because the pathologist evaluates the prostate after its removal. If he finds that the cancer has spread even a little, you and your doctor can decide what to do next.

 

No one knows for sure which prostate cancer treatment gives a better chance for cure or a better quality of life. But if you decide to go with a prostatectomy, make sure that the surgeon you are considering is experienced and skilled in the procedure.

Sexuality and Intimacy after Prostate Cancer Treatment

BY MARK SCHOLZ, MD

My life is turning into an evangelistic crusade to raise awareness about the risks of prostate cancer treatment.  Tens of thousands of men are undergoing unnecessary radical prostate cancer therapy with dire sexual consequences. These inappropriate and often fatefully wrong treatment choices are made because men are often completely unaware of the irreversible effects of the treatment itself.

Thankfully, I am not alone in this battle to inform men about the harm associated with prostate surgery. Another prostate oncologist, Dr. Celestia Higano from the University of Washington, recently published a scientific review on this very topic in the Journal of Clinical Oncology (JCO). For those of you who haven’t heard of the JCO, I consider it to be the most prestigious scientific cancer journal in the world.

Today’s blog will offer quote seven selected sections from Dr. Higano’s important article. To add some gravitas to the eye opening statements you are about to read, please realize that every one of her comments was referenced to a specific scientific report.  In other words, these statements have nothing to do with opinions. They are genuine outcomes from published scientific studies.

So without further ado let’s start with the first quote from the article:

Quote #1: “Unfortunately, many couples believe that even if they have problems with erectile dysfunction (ED) … they will be able to resume their normal sexual practices through the advances of modern technology.4 They are not informed that sexual function will never be the same after any form of therapy and they are often unprepared for the changes in their sexual and intimate relationship.” (Italics mine)

Quote #2: “PDE5 inhibitors (Viagra, Cialis) and other erectile aids are not successful for all patients with ED and, even when effective, half the patients stop using them within one year.11 Why couples stop using ED therapies has not been adequately investigated , but disappointment that sex life is not the same … likely contributes to this outcome.”

Quote #3: “In a Memorial Sloan-Kettering series of 475 men … 20% of men who had radical prostatectomy (RP) had climacturia at one year, and climactauria as associated with both painful orgasm and penile shortening.13” (Climacturia means that orgasm results in the ejaculation of urine instead of semen).

Quote #4: “At the Karolinska Institute, 1,288 patients had either open or robotic-assisted laparoscopic RP, and of the 691 men who were sexually active, 38% reported climacturia at least sometime during sexual activity. Of the men who reported climacturia, 72% had climacturia less than half the time, 17% more than half the time, and 11% all the time.14”

Quote #5: “In a review of 1,459 men who had RP at New York University, climacturia was found to decrease from 44% at 3 months to 22% at 24 months after surgery. Climacturia is a common complication of RP but is often overshadowed by concerns about ED and overt urinary incontinence.14-16”

Quote #6: “In a study of VED (vacuum erectile device) use after RP, the length and circumference of the penis decreased in 63% of patients who did not use a VED after RP compared with only 23% who did.18-20”

Quote #7: “Surgery can also result in Peyronie’s disease (also called, “crooked penis”) in up to 16% of patients.23"

When patient are informed of the dire consequences of surgery they are often mystified as to why urologists, who must be aware of the damage surgery causes, continue vigorously to recommend it. I have heard many patients voice the opinion that urologists are driven by a selfish desire for financial gain.   

The financial motive, however, fails to ring true. As medical procedures go, prostate surgery is poorly reimbursed. Also, when urologists are diagnosed with prostate cancer they themselves often proceed with a radical prostatectomy. So money is not the primary issue. Rather, consider that performing surgery is part of the very fabric of a surgeons’ persona. From a surgeon’s point of view, if you are not operating, you are not a surgeon.

Men considering surgery for prostate cancer need to be aware of its substantial risks. And when getting advice about which treatment to select, patients also need to realize that surgeons usually can’t provide balanced advice. They are too close to the trees to see the forest.   

A Landmark Study: Surgery for Prostate Cancer

BY MARK SCHOLZ, MD

Between in 1994 and 2002, 731 men with an average PSA of 7.8 and age 67 volunteered to have either immediate surgery or observation based on a coin flip. The New England Journal of Medicine reported the 10-year survival statistics this week. What follows is a summary of the statistical outcome of the study.  I think the raw numbers speak for themselves.

Of the 364 who had surgery, 21 men died of prostate cancer.  Of the 367 assigned to observation 31 men died of prostate cancer.  So with observation, the risk of dying was less than 9%.  However, there was still a 6% chance of dying even with immediate surgery.  The net difference between observation and immediate surgery was 3%.

During the first 30 days after surgery there were a number of very serious side effects including one death.  Additionally, there were two men with blood clots in their legs, one stroke, 2 with blood clots in the lungs, 3 heart attacks, 1 man with renal failure requiring dialysis, 10 who required additional corrective surgery, 6 who required additional blood transfusions and 6 who still had urinary catheters more than 30 days after surgery.

Forty-nine men (17%) who had surgery compared to 18 men (6%) who underwent observation “have a lot of problems with urinary dribbling,” some losing larger amounts of urine than dribbling but not all day,” others who “have no control over urine,” and the remainder who “have an indwelling catheter.”

Two hundred thirty one men (81%) who had surgery compared to 124 men (44%) who underwent observation had erectile dysfunction defined as the inability to attain an erection sufficient for vaginal penetration.

Further statistical analysis of a subgroup of men with High-Risk prostate cancer indicated an 8% improved chance of not dying of prostate cancer compared to observation. Also, men who had surgery who were in the Intermediate-Risk or High-Risk category were 10% less likely to develop bone metastases within 10 years compared to the men on observation.

There was no difference in the incidence of mortality or metastases between surgery and observation in the men in the Low-Risk category.

This high-quality study, published in the most prestigious medical journal in the world evaluating the risks and benefits of surgery, required 18 years to perform.  It shows a barely discernible benefit resulting from immediate surgery for men with High-Risk prostate cancer. These findings are quite similar to another large randomized trial of surgery versus watchful waiting that reported 15-year results in the New England Journal of Medicine in May 2011.

The bottom line is very clear:  For men with Low-Risk disease, where surgery is concerned, the treatment is definitely worse than the disease.  Even more striking, is the relatively small survival benefit for surgery in men with High-Risk disease. One can’t help but wonder if the substantial risks of immediate treatment-related side effects outweigh the small benefit in survival.  

A Question of Blood Flow?

BY RALPH BLUM

Have you been watching the TV commercials for drugs that combat erectile dysfunction?  I don’t know about you but I’ve been conditioned PR wise—only in the wrong direction. I mean, I’ve become like one of Pavlov’s dogs gone bonkers - every time the bell rings, instead of salivating, I tend to piss on the bell-ringer’s leg. It’s gotten to the point where I grab the mute button whenever I hear any one of the brand names, or see a shot of a couple lying in his-and-hers bathtubs on a cliff overlooking the Promised Land. “A question of blood flow,” my keester! Still, in case you’re still in the “Help me get it up” market, let’s review a few of the offerings.

In addition to Viagra, Cialis, and Levitra, I found 12 other erectile dysfunction drugs listed; drugs with names like Staxyn, Yohimbe, Erex and Testomar . . . Compared with the big three, the others received very few, if any, reviews. However, ED commercials are ubiquitous on the Internet. When I last looked, I found over 300 “male enhancement” products on the market, each of them promising “bigger and better erections.” But what if you’re just not interested? What if one’s desire for sex is totally absent?

We know certain things for sure about prostate cancer and one of them is that it is, to various degrees, testosterone driven. Unfortunately, so is sexual desire. So what controls the cancer—a radically diminished testosterone level in the blood, aka TIP, as Mark has christened, it is a part of the formula for staying alive.

Attending Support Groups over the past two decades, I’ve heard a lot of discussion about erections and the absence of same. I’d bet that 96% of the complaints concerning the ED resulting from hormone therapy (and the resulting suspension of intercourse) do not come from our partners. It’s a guy thing. As one woman summed it up at a Support Group at the PCRI Conference last year, “If it’s a choice, believe me, we would rather have you alive than have sex.” So we’re talking ego versus reality.   

Yet all is not lost. Some couples, like my old Ojai friends, J and L, have replaced coitus with massage and cuddling and exploring touch, only to find that they actually have greater intimacy. As they have told one another, “I can’t see you too well, and I can’t hear you . . . But it feels really good.”

With all the horror stories, stories of fear and shame, of loss and self doubt, I find it heartening to see the lighter side. So when it comes to a catalogue of all the possible unpleasant side effects of erectile dysfunction drugs—ranging from dizziness and stuffy nose to seizure or sudden decrease or loss of hearing or vision—my favorite warning concerns priapism: “To avoid long term injury, seek immediate medical help for an erection lasting more than four hours.” By all means, call your doctor. In fact, you could make two calls, one toThe Guinness Book of Records!

In Chapter 16 of Invasion of the Prostate Snatchers, Mark talks about the effects of testosterone reduction and how to minimize its negative impact. While Viagra would permit most men to attain a workable erection, the problem proved to be more basic. When he was conducting a study, Mark found that many men simply “forgot” to take their Viagra. He wrote:  “To complete the study I had to resort to phoning them at home to remind them to take their pill.” While helping to preserve their lives, TIP had actually sapped all their interest in sex.

I have ridden the edge for what is now approaching a quarter of a century.  I have undergone no invasive treatment. Only hormone blockade.  There are no guarantees. Things may change, making treatment advisable at some point in my future. But so far so good.  For me my low libido has been a small price to pay to keep my show on the road.