problem, retarded orgasm, where they have difficulty reaching orgasm or find it impossible. Any distraction during sex, for example, worrying about the ability to get or keep an erection, may actually reduce or decrease the ability to obtain an orgasm. I see men who routinely spend more than 30–60 minutes thrusting away in an effort to achieve an orgasm and fail. Some of these men achieve an orgasm only with masturbation, which suggests that the cause is likely psychological in nature. For the post-menopausal woman, who has vaginal lubrication problems even when using an external lubricant, 30 minutes of penetration will often result in vaginal pain during or after sex.
A diagnosis of any kind of cancer is not good for the sexual function of men or women, and you should not be alarmed if you experience some erectile problems after your diagnosis of prostate cancer. A supportive partner will go a long way toward helping this. The last thing a man with erectile dysfunction needs is increased pressure or resentment from his partner, as this will just increase the adrenaline level during sexual encounters. My recommendation to you is that should you be experiencing weakening of your erections after your prostate cancer diagnosis even prior to your treatment, you speak to your physician. Your doctor may consider starting a medication to boost your erection hardness as soon as possible. This may be combined with a suggestion that you speak with a psychologist. Initiating treatment early will “stop the rot” and may limit the severity of the decrease in erectile dysfunction. Interestingly, about 15% of my patients who have pure psychogenic erectile dysfunction (normal blood flow, normal hormone levels) do not respond to Viagra-like drugs. This is a testament to how important adrenaline is in turning off erections. When it is present at high enough levels, it will result in inhibition of the effect of these medications.
III. Complications of Treatment: Overview (Table 1)
While watchful waiting is not associated with any specific complications, it does require that a man be comfortable not treating his prostate cancer and keeping a close eye on his PSA with perhaps repeated prostate biopsies conducted periodically. Men often opt for a treatment because of the anxiety of knowing that a cancer is present within the body and is not being treated. Both surgery and radiation share erectile problems and urinary problems, but otherwise, they each have their own individual potential complications. Understanding these complications is critical to making a decision as to which treatment you will choose.
Table 1 • Overview of Long-Term Complications of Prostate Cancer Treatments
For example, surgery is an operation, and therefore, men are exposed to anesthesia and its potential risks. The older and more unhealthy a man is, the greater the risks are from anesthesia, whether it is a general or spinal anesthetic. Likewise, surgical procedures of this nature are associated with the development of clots in the veins of the legs (deep venous thrombosis, or DVT) and potentially dislodging one of these clots into the lung (pulmonary embolus). These concerns are serious and sometimes life threatening. They are, however, very uncommon today with the use of compression boots that are worn on the operating table during the operation and for sometime after the procedure. An incision is made in the abdomen whether the surgery is done in an open fashion, laparoscopically (using a telescope passed into a small incision in the abdomen) or robotically (using a telescope as above but with the surgeon sitting away from the patient and using a robot to perform the operation), and whenever an incision is made, there is a risk that a wound infection may occur. Wound infection, again, is currently very uncommon.
At the time of radical prostatectomy, the lymph glands (nodes) are generally removed, and sometimes this can lead to the collection of lymph fluid in the pelvis area, known as a lymphocele. It is not well known what percentage of patients actually have a lymphocele present. To answer this question, every patient undergoing radical prostatectomy would need to have a CT scan or an MRI in the first weeks after surgery, and this is not done. However, lymphoceles, for the most part, do not cause any symptoms, but some do cause problems (some lymphoceles may get infected and others may cause leg swelling) and need to be drained for complete resolution. This involves the placement of a narrow tube through the abdominal wall into the fluid collection; sometimes, this tube will need to stay for a few days to ensure complete drainage.
Because the prostate is removed, the bladder at its neck needs to be joined to the urethra (the urine channel). Where these structures are joined is called an anastomosis. This is achieved by using sutures. Sometimes one of these sutures breaks, and a leak of urine occurs behind the bladder. This is known as an urinoma. Again, this is very uncommon in the hands of an experienced and technically proficient surgeon, but all the same it is a recognized complication. More common in the old era and rare now is injury to the rectum. Remember, the prostate sits on top of the rectum as you lie on your back and upon its removal, particularly if there is a lot of scarring around the back side of the prostate, an injury to the rectum can occur. In the vast majority of cases, this can be repaired at the same time in the operating room without any problems.
These complications are generally experienced in the early stages after surgery and, after several weeks, most of these are fully resolved, with the exception of erectile dysfunction and, sometimes, urinary incontinence. However, some people are innately adverse to the concept of surgery because of the fear of needles, incisions or bleeding.
Radiation therapy, whether external beam or seed implantation, is also associated with erection and urinary problems.There are others that are specific to radiation as well. Because of the close proximity of the rectum to the prostate, radiation to the prostate and the surrounding 1 cm will include the front wall of the rectum. This can result in a condition known as proctitis. Proctitis is typically associated with mucous passage in the stool, some bleeding and urgency for passing stool.
One of the differences in complications between surgery and radiation therapy is that proctitis and urinary problems with radiation therapy may occur early on (the latter particularly with seed implantation) and may take several months to resolve as opposed to the several weeks that most men after surgery take to resolve any potential complications. In contrast to surgery, when most men in the earliest stages after surgery have erection problems, most men in the first year after radiation do not have erection problems but may develop these erection problems between years one and five after treatment. In fact, the low point in erectile function after radiation probably is between three and five years after completion of the radiation therapy.The reason for such a delayed effect on erectile function is due to the slow and progressive damage that radiation can cause in the endothelium (lining of the blood vessels). This may lead to a steady reduction in blood flow into the penis over the first five years after treatment.
IV. Factors to Consider when Deciding on Treatment
The first factor that needs to be given consideration to when diagnosed with prostate cancer is the availability of treatment. For example, there are medical centers where expertise in IMRT is extremely limited. The equipment required for this is not available at every single medical center in this country. Likewise, a particular region may have little expertise in seed implantation. Likewise, certain areas of the country may have surgeons who have limited experience or expertise in nerve sparing radical prostatectomy. Even if you opt for watchful waiting, you need to be monitored by somebody with significant expertise in this approach for prostate cancer. And so, you have to decide, if all options are not available to you in your area, whether you wish to pursue one of the available options or you are willing to travel to an area where other options are available.
In trying to identify whether there are experts in your area, utilizing the list of physicians covered under your insurance plan is generally not an excellent way to define this. Even though all urologists are trained in the performance of radical prostatectomy, for instance, not all of them do it in practice. Indeed, the majority of urologists in the USA perform none or very few radical prostatectomies. It is estimated that if a
