Antidepressants in the selective serotonin reuptake inhibitor category SSRIs

efficacy in men who had had a radical prostatectomy, they were said to be helpful two thirds of the time in men younger than age 55 but only one third of the time in men 60 or older.18

The oral medications, first introduced in 1997, work by blocking an enzyme (phosphodiesterase type 5) in the penis, thereby allowing the smooth muscles to relax and the penis to fill with blood. They do not produce an erection by themselves, but only when accompanied by erotic stimulation. The effective dose varies among men; some men, but not all, get a better response at a higher dose. These medications should never be taken by men who are also taking nitrates for angina or chest pain; the drug interaction can be fatal.

Another rare but important side effect is their propensity for causing blurred vision and/or partial blindness, usually in one eye, a condition officially called nonarteric ischemic optic neuropathy (NAION). At least forty cases have been reported, and the eye changes are usually permanent. Men who have hypertension, diabetes, hy-perlipidemia, and/or a small optic cup (which can be assessed via an exam by an ophthalmologist or optician) are at higher risk for this side effect.19

No controlled studies have yet been done comparing the three medications. If a man does not respond to one of them, it is not clear what his chances are of responding to another one. All three medications are priced similarly, at approximately $10 per pill.

Some research has suggested that oral medications to enhance erections not only have an immediate benefit—a stronger erection— but may also have longer-term benefits by preventing fibrosis and atrophy of penile tissue. Biopsies of penile tissue were performed at six-month intervals in two groups of men: one group took sildenafil every other night for six months and the other did not.20 If additional, longer-term benefits are definitely proven, these medications will be routinely prescribed to preserve penile function in men undergoing treatment for cancer of the prostate.

Another form of the same type of medication can be placed directly into the urethra as a suppository. Called MUSE (Medicated Urethral System for Erection), it has been used less since the oral medications became widely available.

Men for whom oral medications are not effective may choose to try injections directly into the penis. The medications dilate the blood vessels, allowing the penis to fill with blood, and may produce a serviceable erection lasting for about an hour. Self-injection is not for all men, however, and, as noted by one author, ''obviously is not ideal for men who can't see well [and] men with poor hand-eye coordination.''21 Penile self-injections are well described by Robert Hitchcock in Love, Sex, and PSA and by Michael Korda in Man to Man (see Appendix B).

The other three options for erection enhancement are vacuum pumps, nerve grafts, and penile prosthetic implants. The pump is placed over the penis prior to intercourse and, by creating a vacuum, draws blood into it. Some men find it quite satisfactory, while others do not; for example, Charles Neider complained that ''the penis doesn't seem to be sensitive'' and ''it's erect, but not stiff.''22 Nerve grafts are still experimental and are usually done at the time of surgery on men in whom neither nerve can be saved. Penile prosthetic implants must be inserted by a surgeon and come in a variety of styles. Chuck Wheeler in Affirming the Darkness describes having such an implant. Vacuum pumps and implants are both explained in detail in Sheldon Marks's Prostate and Cancer and Paul Lange and Christine Adamec's Prostate Cancer for Dummies (see Appendix B).

My own experience with erectile dysfunction has been reasonably satisfactory. Like most men, I had almost complete erectile dysfunction immediately following surgery. After a few weeks, I was able to achieve orgasm, but, as noted by others, it was less intense than before. The initial orgasms were accompanied by minor pelvic pain and some loss of urine; both have been described by other men, and both resolved spontaneously.

I found vardenafil (Levitra) to be the most helpful of the three available oral medications. Other aids were a standing position, which forces the blood in the penis to run uphill to the heart; a rubber band at the base of the penis to partially constrict the veins and thereby slow the outflow of blood; and sexual activity in the morning hours, when it is known that testosterone levels, and thus libido, are highest.

I noted a slow improvement in erectile function between three and six months postsurgery, at which time I successfully had vaginal intercourse. I had mentally prepared myself to possibly never have this experience again, so it was a memorable event. Between six and twelve months, erectile progress was more rapid. According to one study, the maximal erection recovery following prostate cancer surgery does not occur until after an average of eighteen months, but it can continue for two years or longer.23

Despite all of the available aids for recovering erectile function, the single most important factor, in my experience, is having a loving and understanding wife or partner. In this, I feel truly fortunate and would wish the same for every man who must confront recovery from prostate cancer.


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