The Quest for the Prodigal Hard-On

BY RALPH BLUM

There is no doubt that all the main prostate cancer treatments—surgery, radiation or hormone therapy—are likely to affect erections. And although many men who are diagnosed with prostate cancer are older, and may therefore already be subject to the ordinary fatigue and malfunction of nature’s ultimate erector set, the degree to which sexual function returns—or fails to return—after treatment is still a matter of major concern for a number of us.

 

There is no set formula or predictable schedule for recovery of sexual function after prostate cancer treatment. If you choose surgery, your chance of recovering potency is partly dependent on the experience and skill of your surgeon. The minuscule nerves that control erections are located dangerously close to the prostate, and damage to or actual removal of those nerves during surgery causes permanent erectile dysfunction. Viagra or Cialis only works if the nerves can be spared. And even with successful nerve-sparing surgery it can take up to 12 months for the restoration of the natural ability to have an erection.

 

The radiation options—seed implants or IMRT—are associated with a significantly better chances for maintaining erectile dysfunction. But the reality is that radiation therapy still can cause erectile dysfunction because of the inflammation or scarring that occurs around the nerves.

 

Hormone therapy, another treatment alternative, causes total dissolution of sex drive, and you don’t even care that it’s gone! Fatigue, joint pain, depression and hot flashes are not exactly a turn-on either. And yet even without a libido, an erection can be achieved through the manipulation of modern pharmacology—that is if you can dredge up enough desire to give it a try for your partner’s sake—but even with a pharmacological assist, personal satisfaction is often seriously diminished.

 

There is, moreover, a “use it or lose it” caveat: many doctors who specialize in erectile dysfunction encourage sexual activity as soon as possible after treatment (or in the case of hormone therapy during treatment) on the grounds that the nerves and muscles that control erections can atrophy if they are not used for a long period of time.

 

If prostate cancer has already affected your ability to achieve erection, there are various options that might help—penile injections, a vacuum pump device, implantable pellets, or penile implants. I will present the pros and cons of these methods for inducing an erection in my next Blog. In the meantime, keep in mind that there are ways you can express your love for your partner and attain sexual gratification that don’t include penetration. Ways that include intimacy and tenderness, lest we forget.

How to Find the Right Specialist

BY RALPH BLUM

When your primary care physician suspects that you have prostate cancer, your first, and arguably most important task, is to find a specialist who is skilled at diagnosing and treating the disease, and with whom you have a good rapport. Meaning, you feel comfortable with that doctor.

Usually your primary care doctor will refer you to an urologist for a definite diagnosis, but before you take this step you need to be aware that all urologists are not created equal. Most urologists—aka surgeons— have a medical practice at least half of which involves treating problems like impotence, incontinence, infections, and kidney stones. The majority perform only a handful of prostate surgeries annually. So ask your primary care doctor if he can recommend an experienced urologist in your area who specializes in treating urologic cancers.

If you are uncertain about your doctor’s referral or want to go beyond your local area to find a urological specialist—perhaps in a larger hospital or major medical center—just remember that you have time. It’s a good idea to take several weeks to network with friends who’ve been through it and support groups.

By all means, do research on the Internet. Make sure that you select a specialist with extensive experience. By consulting “Dr. Google” you can locate the best prostate cancer web sites and doctors. And under the heading “Resources” on the Prostate Cancer Research Institute web site, pcri.org you will see a section called “Finding expert physicians.”

The kind of urologists you want will thoroughly discuss all appropriate treatment options with you—radiation, seed implants, different kinds of surgery available—in an even-handed manner. If board certified, they are obligated by law to do so. And if, for example, you express interest in radiation, they will refer you to a radiation therapist to discuss that option.  But unless your age or physical condition make it inappropriate, most urologists likely to recommend surgery. Surgery is, after all, their specialty.

Regarding radiation, the latest studies (although not perfect) indicate that for most men, either permanently implanted radioactive seeds or intensity modulated radiation therapy (IMRT) are at least as effective as surgery, with similar cure rates, and are, in most cases, performed without the risks associated with a major surgical procedure.

You should also, if you can locate one, consult with a medical oncologist who specializes in treating prostate cancer. Not being directly involved in either surgery or radiation, these specialists are not as likely to have any bias in their recommendation.

Whichever specialist you consult there are a few basic questions it’s a good idea to ask:

•  How long have you been treating prostate cancer patients with this treatment?

•  How many prostate patients have you treated? How many radical prostatectomies and robotic procedures have you performed?

•  Why do you recommend this particular treatment for me?

•  What are the possible side effects of this treatment?

•  What are your success rates for patients with a diagnosis similar to mine?

The following questions which, since they all relate to surgery, apply only to a urologist:

•  How many prostatectomies do you perform each year?
•  What is your success rate with the preservation of sexual potency
•  What about urinary continence?  How frequent is it? How do you deal with it?

•  Do you perform nerve-sparing surgery? (Nowadays most surgeons do.)

•  Do you perform robotic surgery? If so, how many robotic procedures have you performed to date? (Anywhere up to 150 procedures, and you are still part of a surgeon’s learning curve.)

•  What percentage of your patients are approximately my age?

This last question is important because if you are in your 50s and most of the doctor’s patients have been over 70, he may be less knowledgeable about preserving your potency and continence than a doctor who treats more men of your age.

Choosing the right specialist is a decision that will have a significant effect the rest of your life. So I repeat, take your time. And make sure that the doctor you choose gives you confidence that the treatment he recommends will be successful.