Saving Your Sex Life: A Guide for Men With Prostate Cancer

emulate

ACKNOWLEDGMENTS

No work of this nature can be accomplished alone. While this book has been written by me, many of its chapters have been reviewed by internationally recognized experts. For the past six years, I have had the distinct honor and privilege of practicing sexual and reproductive medicine at Memorial Sloan-Kettering Cancer Center in New York, a center that I believe offers the best cancer care anywhere in the world. I would like to thank the leadership at Memorial Sloan-Kettering Cancer Center for allowing me to develop a sexual and reproductive medicine program within the Division of Urology, where much of my focus has been the management of patients with sexual problems after prostate cancer treatment. In particular, I would like to acknowledge Dr. Peter Scardino, whose book Dr. Peter Scardino’s Prostate Book I have used as a reference for this book. I would also like to thank Dr. Scardino for his unerring support and vision in the development of a sexual and reproductive medicine program at MSKCC. I believe that this program over the course of the last six years has made a difference in many people’s lives.

I would like to thank Dr. James Eastham and Dr. Jonathan Coleman of the Division of Urology, for reviewing the chapter on radical prostatectomy. These two highly recognized surgeons have made sure that the information on surgery is both accurate and up-to-date. I would like to thank Dr. Michael Zelefsky and Dr. Marisa Kollmeier from the Department of Radiation Oncology for their review of the chapter on radiation therapy. While I see many patients who have had radiation therapy, I am not a radiation oncologist and they have ensured accuracy of the information presented.

I would like to thank Dr. Michael Morris, an expert in the management of advanced prostate cancer, for reading the chapter on hormone therapy. I owe a debt of gratitude to Chris Nelson PhD, a clinical psychologist, for his review of the chapter on sexual intimacy. I have had the distinct pleasure of working with Dr. Nelson in my daily clinical practice for the past 5 years. Joe Narus, nurse practitioner on the sexual & reproductive medicine team and the coordinator of the penile rehabilitation program, graciously and expertly reviewed the chapter on penile injection therapy.

I would like to thank Mrs. Vicky Frohnhoefer for her expert transcription of this manuscript, Rockelle Henderson from Hilton Publishing, and Clarence Haynes, whose insightful editing has helped me deliver critical and often complex medical information in a reader-friendly way.The illustrations drawn by Tony Riley BFA, a medical artist at Memorial Sloan-Kettering speak for themselves. Many thanks to him for the beautiful images.

Mention must be made of some of my mentors. My introduction to Urology occurred during my earliest years as a surgery resident in Ireland under Professor John Fitzpatrick at the Mater Hospital in Dublin. Indeed, it was Professor Fitzpatrick who encouraged me to seriously explore Urology as a career. I am forever grateful to him for his guidance. My career in the United States started under Dr. Myron Walczak, then Chief of Urology at the University of Connecticut Medical Center. While he has since passed away, I am eternally grateful to him for his foresight and guidance. My original interest in sexual medicine was inspired by Dr. Jim Graydon at Hartford Hospital, while my sexual medicine training was conducted under Dr. Irwin Goldstein and Dr. Robert Krane (RIP) and my infertility training under Dr. Robert Oates, all three of whom were at Boston University Medical Center. I would like to thank Dr. Robert Flanigan from Loyola University Medical Center for his mentorship during my early years as an academic urologist. It was he and his patients who sparked my interest in sexual health following the treatment of prostate cancer.

I would like to recognize the physicians and surgeons, famous and not-so-famous, who have contributed to the field of prostate cancer treatment over the course of the last 50 years. We must not forget those physicians whose shoulders we stand on, who have made great efforts and sacrifices before our time. I am also indebted to my sexual medicine colleagues alongside whom I have worked over the course of last decade. Your curiosity in and critique of my research has only made me a stronger surgeon-scientist.

I would like to pay particular tribute to two such scientists who have been a source of great inspiration to me, namely Dr. Irwin Goldstein and Dr. Tom Lue. These founding fathers of modern sexual medicine within urology have been a constant driving force for me in my efforts to conduct the best research and to deliver the best clinical care to patients.

I am indebted also to my clinical and support staff at Memorial Sloan-Kettering Cancer Center, especially all of the nurses/nurse practitioners with whom I have had the privilege to work. They have worked tirelessly to educate and support my patients. I would also like to thank the residents and fellows that have trained under me, for working with me to construct and refine the penile rehabilitation program.

Finally, I would like to pay tribute and offer my sincerest gratitude to the patients whom I cared for over the course of my 12 years in the practice of sexual and reproductive medicine. I have strived to offer nothing short of the best, most state-of-the-art medical care, and this has been driven by their honesty, by their needs, by their curiosity and inquisition. I believe that at Memorial Sloan-Kettering Cancer Center, the Sexual & Reproductive Medicine Program has made large contributions to the field of medicine over the course of last several years and this is in no small part due to these patients.

PROLOGUE

HOW TO USE THIS BOOK

Prostate cancer is the most common form of cancer in American men other than skin cancer. It is estimated that about 185,000 new cases of prostate cancer will be diagnosed in 2008 in the USA alone. Almost 30,000 men will die of the disease this year alone in this country. It is the second leading cause of cancer death in men after lung cancer. While a man has a 15% chance of being diagnosed with prostate cancer in his lifetime, only 3% die of the disease. In the modern era, the vast majority of men live for very long periods of time.

Over the course of the last 20 years, numerous discoveries and refinements in management have occurred in this disease. There have been refinements in prostate biopsy technique, in imaging of prostate cancer, in surgical technique (for example, the introduction of laparoscopic and robotic prostatectomy), in the delivery of radiation therapy and in the treatment of advanced disease. Furthermore, the use of PSA as a screening tool has resulted in a far greater number of men being diagnosed with prostate cancer at its earliest stages. This has also translated into younger men being diagnosed with prostate cancer. Thus, a man’s long-term sexual function has become an even bigger issue now, given these factors.

Being diagnosed with cancer for any person, and prostate cancer for any man, is a major stressor in one’s life. It is easy in the early stages after diagnosis to become overwhelmed with decisions. These decisions often center on what treatment to choose, surgery or radiation therapy or watchful waiting? Each of the three has its respective pros and cons.

So, why have I written this book? The simple fact of the matter is that most physicians and patients do not talk about sexual health in a routine medical interview. Both are uncomfortable with the topic and avoid it. Secondly, physicians treating patients sometimes shy away from discussing in detail the side effects and complications of a treatment and so patients are left with unrealistic expectations. Thirdly, there is a dire need for the dissemination of credible information on the sexual effects of prostate cancer treatments, whether it be surgery, radiation or hormone therapy. While there are excellent books written by physicians and patients on prostate cancer in general and its treatment, this is the first book written entirely about sexual function in the prostate cancer patient. We know prostate cancer is common and treatment with surgery or radiation occurs in the majority of patients. Thus, sexual problems in this population are common, some short-lived, some permanent. Finally, this is an area of medicine to which I have devoted most of my 12 years in academia, both in treating patients and in research. In my practice at Memorial Sloan-Kettering Cancer Center, I see more than 600 radical prostatectomy patients, around 150 radiation patients and about 100 hormone therapy patients per year.

This book is not designed to be a resource in your decision-making about your treatment nor will it give a comprehensive account of what’s involved in radical prostatectomy or radiation therapy treatment. Rather, this book is aimed at giving you state-of-the-art, up-to-date, comprehensive information on the impact of prostate cancer treatments on your sexual function and what options are available to you for the treatment of such sexual problems.

The book opens with a chapter on the basics of sexual function: how do erections, libido, and ejaculation work? The next chapter discusses benign prostate enlargement and lower urinary tract symptoms. This chapter discusses the treatments available for benign prostate enlargement (BPH) and their effect on your sexual function. The ensuing chapters deal with the impact of radical prostatectomy, radiation therapy and hormone therapy on your sexual function. There is an important chapter on penile rehabilitation and preservation of erectile function. This concept is unheard of by most patients and, indeed, is alien to many doctors and even to some urologists. There is accumulating evidence that using medications in the early stages after treatment, whether it be surgery or radiation, and while on hormone therapy, may positively impact the health of erectile tissue and thus maximize the chances of a man retaining long-term sexual function. A chapter on miscellaneous problems discusses the non-erection sexual problems that occur after these treatments, including orgasm and penile length problems, and the development of Peyronie’s disease. The ensuing five chapters are devoted to discussing treatments available to you for erection problems. These include pills (Viagra and the like), suppositories, vacuum devices, penile injections, and penile implants. The book ends with a chapter on future therapies for sexual dysfunction, a chapter on the very controversial subject of testosterone supplementation and a final chapter on restoring your sex life.

The advice offered in this book is based on my own research, my interpretation of other people’s research, and my clinical experience over the 12 years that I have been practicing sexual and reproductive medicine. I have tried to be comprehensive, but where I believe a better resource exists I have mentioned it. Furthermore, at the end of the book, there is a Suggested Reading list. There is also a section on Resources, including books, websites, and organizations that have expertise or interest in sexual health in the prostate cancer patient.

The goal of the sexual medicine physician is to ensure that the couple (should one exist) or the patient has the ability to resume satisfactory sexual relations. My goals are as follows: (i) to provide you with well-researched, well-thought-out educational material so that you can make a rational decision regarding your treatment, (ii) to give you the tools necessary to ensure that you get the best care possible, and (iii) to encourage you to be proactive about your sexual health, all in an effort to maximize your sexual function recovery. At this moment, it is easy to feel overwhelmed. You are worried about surviving your cancer, you are worried about being incontinent after surgery, and you are worried about the sexual function consequences of radiation therapy, surgery, and hormone therapy. The good news is that almost 90% of men who walk into my office with sexual dysfunction related to prostate cancer are treatable. That is, 90% of men can resume satisfactory sexual intercourse with a partner using available treatments. You should finish reading this book with a sense of optimism with regard to your future sexual function. You can be helped! Good luck!

JOHN P. MULHALL, M.D.

CHAPTER 1

THE BASICS OF SEXUAL FUNCTION

I. Penile Anatomy

Leonardo da Vinci described the penis as follows: . . . it disputes with the human intellect, and sometimes has intellect itself, and although the will of a man may wish to stimulate it, it remains obstinate and goes its own way, sometimes moving on its own without the permission or thought of the man. Whether he is asleep or awake, it does what it desires, the penis having a mind of its own. This organ has been a source of fascination for thousands of years. It facilitates not just urination and sexual activity, but is the seat of masculinity and virility in many cultures. This organ is perfectly designed for its functions and is composed of multiple types of tissues and structures, which, like a good orchestra in concert, function perfectly together in the healthy male.

About two-thirds of the penis is external (that is, outside of the body) and one-third is internal (Figure 1). The erection chambers are paired cigar-shaped structures that travel from the head of the penis into the body and run along the bony structures known as the ischiopubic rami. These bony structures are what we sit on when we sit on a bicycle seat, for example. The paired erection chambers are technically known as the corpora cavernosa (singular: corpus cavernosum). They are composed of two major types of tissue. The outer lining, which is approximately 2mm in thickness, is known as the tunica albuginea, more commonly called, simply, the tunica. Housed within the tunica is the erectile tissue, which itself is composed of numerous types of tissues (Figure 2). This tissue includes muscle, blood vessels, nerves, elastic tissue, collagen, and a tissue very important to erectile function known as the endothelium. I will talk more about this tissue toward the end of this chapter and you will see it pop up again and again in this book.

The erectile tissue is fashioned into a lattice-work of spaces. The simplest way to think of it is that erectile tissue is like Swiss cheese; you have solid tissue interspersed with spaces. In the flaccid (soft) state, these spaces are tiny. However, when men are aroused, these spaces expand, become large, and actually fill with blood to allow an erection to occur (Figure 3). Each of these spaces (known as sinusoids or lacunar spaces) is lined on its inside by endothelium. The endothelium is a major regulator of blood flow into the penis. It produces numerous chemicals, the most important one of which is nitric oxide, which I will discuss in greater detail shortly. Outside of the endothelium is the muscle. This muscle is similar in nature to the bladder and bowel muscle in that it is not under your direct control. In the flaccid state, it is kept contracted to make sure the spaces are tiny, but under arousal, it relaxes greatly and allows these spaces to expand significantly. Coursing outside of the smooth muscle between the spaces are blood vessels and nerves, which, of course, are essential to erection.

The third chamber inside the penis is known as the corpus spongiosum. This sits beneath the paired erectile bodies and houses the urethra (the urine channel). It travels from the opening of the bladder (bladder neck) as the urethra passes through the prostate, all the way out to the head of the penis. In fact, the head of the penis (known as the glans) is in direct continuity with the corpus spongiosum and has no direct connection with the erectile bodies. Strictly speaking, the corpus spongiosum is not a true erectile body as it has very little spongy tissue in contrast to the corpora cavernosa. The corpora cavernosa are tightly joined along their external two-thirds and share an intervening wall known as the septum. This septum has numerous channels passing from right to left side so that there is equalization of blood flow and pressure between the two erectile bodies. For example, with a penile injection (where a patient injects his penis to get an erection; see Chapter 11), an injection on the left side of the penis causes an erection in both right and left erectile bodies.

Figure 1 • Side view of the male pelvis illustrating relationship between the bladder, prostate, and penis (corpora cavernosa).

Outside the erectile bodies, there are numerous layers of tissue, but most importantly, on the top surface of the penis (that is, the surface of the penis that a man looks down on), there is a vein (dorsal vein), a right and a left artery (dorsal artery), and a right- and left-sided set of nerves (dorsal nerves). The deep dorsal vein is a major route of blood flow leaving the penis. The dorsal arteries supply the penile shaft, skin, and subcutaneous tissue, as well as the head of the penis,with fresh blood.They also have some branches that travel into the erectile chambers as the dorsal artery passes from the base to the head of the penis. In some men, these arteries (known as perforators, as they perforate the tunica) are significant contributors to erectile function. The nerves running on the surface of the penis beneath the skin, known as the dorsal nerves, are sensory in nature. That is, they supply sensation and only sensation to the penis. Thus, they are not intrinsically involved in erectile function.

Figure 2 • Cross section of the penis demonstrating the corpora cavernosa and corpus spongiosum. The outer lining of the tunica albuginea is a multi-layered structure. The erectile tissue has a honey-comb appearance.

Blood Supply

The major source of blood flow for erection is the deep or cavernosal artery. Given how erections work (to be discussed later), increased blood flow during erection is critical to gaining maximum rigidity and maximum sustaining capability. The cavernosal artery starts its journey in the pelvis, where it is known as the internal pudendal artery. This artery takes a circuitous course and travels underneath the ischiopubic ramus (remember, that bony structure that we sit on while on a bicycle seat). It travels in a special canal along with the dorsal (sensory) nerves. The right artery travels on the right side, the left artery travels on the left, and they pass about one-third of the way into the erection chamber and give off numerous branches to supply blood to the lacunar spaces inside the erection tissue. This artery at rest is approximately 0.5 mm in diameter and during erection dilates (expands) to approximately 1 to 1.2 mm in diameter. When you appreciate that the coronary arteries are 1.5 to 3 mm in diameter, you can appreciate why we now believe that there is a link between penile blood flow problems and hidden or future coronary artery disease. There is accumulating evidence to suggest that men who have erectile problems are more likely currently or in the future to develop blockage of their heart arteries, which, of course, is a risk factor for heart attack.

Figure 3 • High power view of erectile tissue. The lacunar spaces are lined by endothelium beneath which is smooth muscle. In the space between the lacunar spaces run the nerves.

To make matters more complicated, there are a series of arteries that travel very closely to the prostate, known as accessory pudendal arteries. It is important to understand that the prostate sits on a layer of muscle known as the urogenital diaphragm known officially as the levator ani muscles but more commonly referred to as the pelvic floor. The two erection arteries, the cavernosal arteries, sit beneath this and cannot be injured at the time of prostatectomy. However, with radiation, these arteries fall into the field of radiation exposure. The accessory pudendal arteries, on the other hand, sit above the pelvic floor muscles and travel very close to the prostate. They are also potentially threatened and injured at the time of prostatectomy and during radiation therapy. How common these arteries are is variable. It is generally believed that somewhere in the range of one in four men have an accessory pudendal artery, and in a majority of these men, these arteries are contributors to erection. Indeed, in some, these blood vessels are the major source of arterial blood flowing into the penis for the purpose of erection. Thus, you can see that, if they are injured at the time of radical prostatectomy or exposed to radiation, this may, in fact, impair erection function recovery after both of these treatments.

The anatomy of the venous drainage from the penis is complicated and highly variable. There are numerous veins that leave the penis traveling on the top and bottom surfaces. These veins carry blood from exits the lacunar (erection) spaces through the emissary veins. These veins are tiny veins that travel from the erection tissue through the tunica albuginea into the subcutaneous veins that drain blood back into the general circulation.

Nerve Supply

I previously mentioned the dorsal nerves of the penis, which are purely sensory. However, erection nerves are entirely different. While the sensory nerves travel with the erection artery underneath the ischiopubic ramus, the erection nerves travel very much like the accessory pudendal arteries I mentioned earlier alongside the prostate. Many men equate penis sensation or even orgasm with erection nerve function. In fact, the erection nerves can be completely damaged and sensation will be unaffected.

The complex neuro-anatomy was only first described in great detail for surgeons in the early 1980s, and this is how Dr. Patrick Walsh at Johns Hopkins Medical Institutions first developed the nerve sparing (also known as the anatomical) prostatectomy. Prior to 1982, all prostatectomies were conducted with little attention paid to the erection nerves. These erection nerves, known as the cavernosal nerves (also known as the cavernous nerves), start their journey from the spinal cord. They start at the lowest portion of the spinal cord known as the sacral area, and then travel out of the spinal cord and the vertebral column to join a plexus of nerves. Think of an old telephone switchboard with numerous wires traveling in multiple directions, and this best describes a pelvic nerve plexus. From this pelvic nerve plexus sitting along the front of the rectum, they travel forward alongside the prostate, pass under the pubic bone into the penis to supply the erection tissue that I previously described. While the nerve anatomy is somewhat variable, it is well accepted that the major fibers travel in intimate contact with the prostate.

The simplest way to think of it is if you imagine an orange that represents the prostate, covered on its top half with Saran Wrap. Inside the Saran Wrap layer are the cavernous erection nerves. Thus, during dissection and removal of the prostate, one can easily see how these nerves can be injured. Even in the hands of a highly experienced and skilled surgeon who does excellent nerve sparing, when these nerves are handled, their response is to go to sleep.This dormancy period can last 12 to 24 months.This is why men after radical prostatectomy often have a highly delayed recovery of erectile function.These nerves supply the smooth muscle in the penis,and they supply this tissue with nitric oxide, which is the main factor that causes the smooth muscle to relax, allowing the lacunar spaces to expand and fill with blood. During radiation therapy for prostate cancer, the nerves are in the field of radiation as they are in close contact with the prostate; radiation is usually delivered not just to the prostate but also to a margin of about 1cm around the prostate.

II. How Erections Work

The simplest way to think of an erection is to think of a simple hydraulic process like the inflation of a bicycle tire. To inflate a bicycle tire, you need a hose to transfer air into the tire, and when the hose is removed, there is a valve that is closed tightly to maintain that air pressure. I have already described the two erection arteries that carry blood into the penis (the hoses), and as the blood fills up the lacunar spaces and they expand, the previously mentioned emissary veins get trapped and compressed (the valve). The valve mechanism is critical to the generation of good rigidity and maintenance of an erection. Indeed, the most common cause of men losing an erection in the middle of intercourse is because this muscle, under adrenaline control, contracts precipitously allowing the veins to carry blood out of the penis rapidly.

So for erection to function, there are a number of key elements that need to be in working order. Firstly, the arteries need to be healthy. Next, the nerves need to be functioning. And finally, the erectile tissue needs to be in good condition. Arterial blockage will reduce the blood flowing into the penis, and this will lead to erection dysfunction. Cavernous nerves that are injured will not supply nitric oxide to allow an erection to occur, and erection tissue which is injured due to diabetes, cigarette smoking, radiation therapy or the chronic absence of erections will also lead to erectile dysfunction.

The nerves are not the only source of nitric oxide, as the endothelium also supplies nitric oxide and is a key regulator of maintenance of erection. In addition to erectile smooth muscle needing to be healthy, so too must the endothelium. It is now known that conditions such as high blood pressure, high cholesterol, diabetes, and cigarette smoking, all cause endothelial dysfunction and this is why these men have a higher incidence of erectile dysfunction than the general population. There are more than 20 neurotransmitters (chemicals that come from the nerves) that are involved in erectile function, but the most important ones are nitric oxide, which is a pro-erection chemical, and adrenaline, which is the world’s most potent anti-erection chemical. Adrenaline, which is known as the fight or flight hormone, is released by the adrenal glands during periods of stress, such as being in a fight or running away from something. Increased adrenaline levels are noted in men during high stress, chronic fatigue, and when they are anxious, irritated, annoyed, upset, or worried. This is why stress is a cause of erectile dysfunction.

When a man is aroused, areas within the brain and within the spinal cord increase nerve signals, which causes increased blood flow through the cavernosal arteries. These signals also cause relaxation of the erectile tissue with an increase in the size of the lacunar spaces. As the blood flows into these spaces, the erectile tissue expands in a three-dimensional fashion, compressing the emissary veins, and a rigid erection occurs. Upon removal of the sexual stimulus (generally after orgasm), the nitric oxide level drops precipitously and adrenaline assumes its usual role of keeping the penis flaccid. Then the erectile tissue contracts, blood makes its way back into the general circulation, and erection dissipates.

III. Reproductive Organs

Besides the penis, there are a number of other reproductive organs that should be considered, including the seminal vesicle and the prostate itself. The prostate is a small, walnut-shaped sized organ in the healthy male that sits beneath the bladder and surrounds the urethra. It is separated from the erectile bodies by a muscle layer (the urogenital diaphragm), which is about 1 cm in thickness. The prostate is composed of two major types of tissue: glands, which secrete fluid that is part of semen, and the tissue between the glands known as a stroma. Within the stroma is muscular tissue, and the tone of this tissue in some men dictates urinary function. The prostate produces an acidic fluid, which makes up about 20 to 25% of the seminal fluid (that is, the fluid that is ejaculated). Sitting behind the prostate are two sets of paired structures, the seminal vesicle on the outside and the vas deferens on the inside (Figure 4). The vas deferens travels from the testicle up through the scrotum and the inguinal hernia canal into the pelvis and enters the prostate. This, of course, is the delivery mechanism for sperm. Much to people’s surprise, sperm constitute only 5 to 10% of the volume of the semen that is ejaculated. By the way, normal men produce about 50 million sperm in each cc of semen!

The seminal vesicles are paired structures, which on x-ray look a little like rabbit ears. These structures are glands that produce the vast majority (approximately 70 to 85%) of the seminal fluid. The fluid produced by the seminal vesicle is alkaline in nature and, thus, semen is generally alkaline, as the seminal vesicle fluid amount is larger than the acidic prostate fluid. The seminal vesicles and the vas deferens on each side actually join to form the ejaculatory duct. A right- and left-side ejaculatory duct is present. The ejaculatory duct travels through the prostate and opens into the urethra. The urethra travels through the prostate much in the same way as if you core a whole apple so that there is a channel running through the apple.

Figure 4 • Rear view of the prostate. Sitting behind the prostate are the seminal vesicles (one on each side) and inside these the vas deferens (one on each side). The seminal vesicle and vas deferens join to form the ejaculatory duct, which passes through the prostate.

At the time of radical prostatectomy, not only is the prostate removed, but the seminal vesicles are also removed. Also during the procedure, the vas deferens is cut and ligated (closed off with suture or metal clips) behind the prostate. This is why patients who have had a radical prostatectomy do not ejaculate despite the fact that most of them achieve a normal orgasm. Furthermore, patients who have had a radical prostatectomy are sterile, although they do produce