Sexual Difficulties are Common
It is estimated that 50% of men over the age of 40 have erectile dysfunction. This is defined as the persistent inability to get and/or keep an erection sufficient for satisfactory sexual relations. The older a man gets, and the more medical problems he has (in particular, conditions such as high blood pressure, diabetes, high cholesterol, coronary artery disease and cigarette smoking exposure), the more likely he is to develop erectile dysfunction. Erectile dysfunction rates are estimated to be approximately 20% at 40 years of age and 70% at 75 years of age, with about 5% of 40–year-olds being completely unable to have sexual intercourse and 25% of 75–year-olds likewise. In contrast to what most people think, most men who have erectile dysfunction do not have a complete inability to have sexual intercourse. Indeed in the ED drug (Viagra, Levitra and Cialis) trials, something in the range of 25 to 30% of attempts before a man went on the trial drug resulted in the ability to have intercourse. However, the presence of erectile dysfunction is associated with a dramatic reduction in the man’s quality of life, which doesn’t just affect his function in the bedroom, but also affects his self-esteem and self-confidence and may carry over into his activities of daily living.
By far, the medical condition that is worst to have for erectile function is diabetes. Diabetes affects not just the blood vessels, but the erection nerves also, causing failure of the nerves to function properly and the health of the erectile tissue, which undergoes scarring. All of these issues cause problems with erection.
Other causes of erectile dysfunction include hormone problems, such as low testosterone and thyroid disease, neurological problems such as Parkinson’s disease, stroke, and lumbar disc disease, medications (in particular blood pressure medications and depression medications) and, of course, surgery. The surgeries that are most likely to cause erection problems are radical prostatectomy, radical cystoprostatectomy (for bladder cancer) and radical rectal surgery (for rectal cancer). Having described the anatomy previously, it is easy to understand how these surgeries may have a negative impact upon erections given the interference with the blood flow and nerves supplying the penis. The incidence of erectile problems after radical prostatectomy and pelvic radiation is very variable depending upon which literature you read. For example, after prostatectomy for prostate cancer, the erectile dysfunction rates in the literature range from 20 to 90%. Saying that, it is routine for the vast majority of patients in the early stages after radical prostatectomy to have some significant reduction in erectile function, at least temporarily. Recovery of erectile function after surgery may take 12 to 24 months and probably only 15% of men will have recovery of the same erection hardness after surgery that they had before surgery, at least without the use of medication. Likewise, the literature tells us that the incidence of erectile dysfunction after radiation therapy is highly variable, with rates ranging from 30 to 70%.
As I do not have a vested interest in which treatment you choose (as I do not perform prostatectomies or coordinate prostate radiation), throughout this book, I will call it as I see it! I believe that the medical literature is not likely, in its current format, to represent the true extent of erectile dysfunction after radiation therapy for prostate cancer. In contrast to surgery, it is the minority of patients in the first year after radiation who run into erectile function problems, but erectile dysfunction rates peak probably somewhere between three and five years after the completion of radiation.Understanding that there are no studies that compare radiation to surgery at the same center (absence of a randomized study), my review of the current literature suggests that the incidence of erectile dysfunction three years after both radical prostatectomy and prostate radiation are approximately the same. Thus, when I see patients who are deciding which intervention to pursue, surgery or radiation, I always tell them the same thing, “You should never base your decision on which intervention to choose on your future sexual function as it appears that the chances of you developing erection problems three years after both is approximately the same.”
CHAPTER 2
PROSTATE ENLARGEMENT AND SEXUAL DYSFUNCTION
| I.Prostate Anatomy II.Prostate Growth—Benign Prostatic Hyperplasia III.Treatment of BPH/LUTS IV.Surgical Treatment of BPH/LUTS V.How Does BPH/LUTS Affect Erectile Function |
I. Prostate Anatomy
The prostate gland is classically described as a walnut-sized structure that lies behind the pubic bone in the pelvis (see Figure 1, Chapter 1). This analogy is somewhat misleading as the prostate varies dramatically in size, practically being nonexistent in a young child to being very small in the young adult and increasing in size as we age. This increasing size, which we will talk about further later, is predominantly related to hormonal surges that occur. It is a structure known as a gland, which is filled with cells and tissues that produce fluids. Running through the tissue of the prostate are ducts (pretty much in the same way that your home’s air conditioning system has ducts) and the purpose of these ducts is to deliver the prostatic fluid into the urethra.
The prostate lies below the bladder and it surrounds the urethra, which passes from the bladder out through the penis. If you think of an apple that you have just cored, the apple itself is the prostate and the cored portion is the urethra. The prostate gland secretes fluid from many ducts into the urethra. Directly in front of the prostate is the pubic bone, and directly behind it is the rectum. It is important to understand that the pelvis, and particularly the male pelvis, is a relatively tight area with multiple organs and structures in very close communication. The prostate lies directly against the front surface of the rectum, and this is why when a physician places his or her finger in the rectum, the prostate can be easily felt and examined.
The primary function of the prostate is to produce a portion of semen. You will remember from Chapter 1 that semen is a combination of fluids coming from the seminal vesicles, the prostate and the vas deferens. The latter is the structure that transports sperm from the testicle. The seminal vesicles produce the vast majority of the semen, but a significant portion of it is produced by the prostate.The purpose of this prostate fluid is to balance the pH of the semen.The seminal vesicle fluid is predominantly alkaline and the prostatic fluid is predominantly acidic, so there is a balance once these two are mixed together. This balance is critical to the nourishment and protection of sperm as they are being stored and delivered into the vagina during sexual intercourse.The prostate,or more accurately the cells (epithelial cells) in the gland, produce an enzyme called prostate specific antigen (PSA). PSA is a chemical which gets delivered into the blood and is used as a screening test for prostate cancer. PSA has a vital function in semen in that it dissolves the semen clot once it is deposited in the vagina and allows sperm to swim out from the liquid toward the cervix.
II. Prostate Growth—Benign Prostatic Hyperplasia (BPH)
In a boy, the prostate weighs about 5 gm and in a young man it grows to approximately 20 gm. Beyond the fourth decade in life, it is inevitable that the prostate will grow, and prostates have been removed which are in excess of 200 grams. Increase in size is due to increase in the size and number of the glands within the prostate itself. As the prostate grows, it impinges upon the urethra, which results in an obstruction of urine flow from the bladder. This leads to symptoms known as lower urinary tract symptoms (LUTS). BPH (benign prostatic hyperplasia) is the pathological entity that causes the symptoms known as LUTS. Now, it is important to understand that BPH is a benign process and by no means does it infer prostate cancer. In fact, many prostate cancers occur in small glands with very small amounts of BPH. Hyperplasia is a word that means overgrowth of cells. It is important to understand that BPH is not a precursor to the development of prostate cancer.
| Table 1 • Symptoms of Lower Urinary Tract Symptoms (LUTS) Associated With BPH |
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•Decreased urine stream
•Having to strain to empty
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