LIMP, shrimp, wet and dry. That’s how one patient sums up his post-prostate cancer surgery state.
Limp because he could no longer get an erection, shrimp because his penis had shrunk a couple of centimetres, wet because he was incontinent and dry because he couldn’t ejaculate any more.
Every year in Australia about 20,000 men are diagnosed with prostate cancer, the second most common cancer after skin cancer. Survival rates are high, about 95 per cent in cases where it’s caught early and is still localised. But while treatment is often effective, it nearly always leaves scars, even in best-case scenarios.
“While we’re able to cure a lot of men with early prostate cancer, it comes at a price,” says doctor Phillip Katelaris, a consultant urologist and director of the Prostate Cancer Rehabilitation Centre in Sydney. That cost comes in the form of anxiety and depression, incontinence or lack of bladder control, and sexual problems, especially erectile dysfunction. Problems with incontinence and sexual function can lead to embarrassment, social isolation and relationship problems, which in turn feed into depression and anxiety.
But as delegates to this month’s Prostate Cancer Foundation of Australia International Conference heard, clinicians are getting the message that rehabilitation is possible. And it’s about time, says Katelaris, a conference speaker. He argues the focus has been on treating the cancer while ignoring a man’s quality of life: “This is unusual in medicine”
According to Katelaris, patients undergoing, say, total knee replacement or a heart bypass are routinely sent to a physiotherapist for an extensive rehabilitation program to get them back to a normal lifestyle.
One reason this doesn’t happen with prostate cancer is that men and doctors are often reluctant to acknowledge there is a problem. Many studies reflect an inflated sense of success with regards to a man’s ability to have sex following surgery.
This mismatch can arise from the questions researchers ask. Those inquiring if a man is able to achieve an “erection strong enough for intercourse” report more reliable outcomes than questionnaires asking men to compare their sex life before and after surgery. Similarly, some researchers ignore significant details, such as whether the sex was enjoyable, or whether it was spontaneous or frequent.
There may also be unintentional professional bias, claims Katelaris: “It’s well known that if you independently assess a man and his wife, their assessment is never as good as what the operating surgeon’s is, with respect to post-operative erectile dysfunction.” And claims that robotic surgery has better outcomes than open surgery in terms of sexual function also don’t stand up under available evidence, he says.
The fact is there’s a very real risk of diminished sexual function post-treatment, says Rosie King, a Sydney-based GP and sex therapist. She notes that after surgery many men find their penis may be as much as a couple of centimetres shorter, as well as claiming their erection isn’t as firm or the sensation isn’t the same as it once was.
“Most, if not all, men will notice some reduction in the quality of their erection, even though it may still be serviceable and functional,” King says. “It can have a tremendous negative effect on men’s psyche and cause problems with their sense of masculinity.”
That in turn can reduce their desire for sexual intercourse and “send ripples through the relationship”, she says.
To some degree sexual function after prostate cancer treatment is determined by factors beyond control, according to Katelaris: “It depends on a lot of things such as age, whether the person had problems achieving erections before and how extensive the cancer was”.
The men most likely to report good outcomes are young men with no history of erectile dysfunction and who are otherwise healthy and not taking medications.
But as papers presented at the Gold Coast conference reveal, there’s growing evidence that proactive rehabilitation can make a real difference, both in the bedroom and the bathroom.
As Katelaris told delegates, poor bladder control is caused by the weakening of a small muscle under the prostate that’s part of the pelvic floor group of muscles. There’s good evidence that men who start pelvic floor training before their operation and continue it during the recovery period have improved incontinence rates and recover more quickly.
Timely rehabilitation is the key, confirms doctor Michael Gillman of the Health Institute for Men Queensland, a member of national advisory boards concerned with erectile dysfunction and co-author of papers on the subject.
As he says, one of the most common treatments for prostate cancer involves surgically removing the prostate gland while sparing the two nerves that switch on blood supply to the penis. But it takes anywhere from three months to three years to know for sure whether that’s been successful, as even if the nerves remain intact they go into hibernation if they’re disturbed. Without assistance, they may remain in limbo.
“Men need regular erections to keep oxygenated blood flowing to their penis. A healthy man will have five to six erections every night during rapid eye movement sleep, but that stops when the nerves are temporarily damaged,” Gillman says.
“If the penis doesn’t get enough oxygenated blood flowing to it, fibrosis and scar tissue can develop. When that occurs there’s a possibility that the man can become permanently impotent, even after the nerves recover,” he adds.
“I think a lot of times men and their partners don’t see sex as a priority straight away,” notes Gillman. “They figure they will worry about that later, but you need to preserve the tissues for down the track.”
Fortunately, there are increasing numbers of options available to help men maintain erections during the recovery stage.
They include medications known as PDE-5 inhibitors — the most famous of which is Viagra — which improve blood flow into penis. But PDE-5 inhibitors only work if the nerves to the penis are intact post-surgery. If they’re not, penal injection therapy is a more suitable option, as it also stimulates blood flow into penis.
Gillman says there isn’t yet a consensus or a set of guidelines on exactly what protocol works best. However, Gillman says that may not be as important as it sounds.
“It probably does not matter what treatment is used as long as it is producing regular erections until spontaneous erections reoccur,” he claims.
While many men do have spontaneous erections again, some never do, or never get hard enough to actually have intercourse.
In those cases there are a couple of options. King suggests they can try love-making without erection and penetration: “Although the penis may no longer get hard it still retains the capacity for pleasure and orgasm with the right stimulation.”
Many couples, however, aren’t satisfied with that approach and find other methods aren’t always conducive for romantic sex.
That was the case for David Sandoe, who was diagnosed with prostate cancer in 1996 when he was just 51. After surgery, Sandoe used medications, injections and a special vacuum device to pump air out and make the penis erect, methods he describes as “tedious”.
But a few years ago he and his wife chose another option, a penile prosthesis. It’s an invisible device that’s implanted and activated by a tiny pump in the scrotum. It takes about 30 seconds of pumping for fluid to be transferred from a reservoir into small cylinders in the penis, allowing for unplanned sexual intercourse that’s about as close to pre-surgery as possible.
There’s a small risk of infection, about 1 per cent. Plus, the option can cost about $11,000, with patients usually paying $5000-$6000 out of pocket. Still, after about a decade of fiddling with less-than-ideal methods, Sandoe feels it was well worth the cost. “It’s an expensive solution but it’s satisfying to be able to make love normally and spontaneously again,” he says, delighted that he no longer shares his fellow patients’ complaint: limp, shrimp, wet and dry.
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