The good news about urinary incontinence caused by treatment for prostate cancer is that in most cases the problem improves over time. This is especially true of incontinence due to surgery, which initially may be a serious difficulty. Most studies suggest that incontinence continues to be a long-term major problem for approximately 5 to 10 percent of men treated for prostate cancer but can be improved with help.
Table 6. UCLA Prostate Cancer Index for Urinary Function
1. Over the LAST 4 WEEKS, how often have you leaked urine?
Every day 1 (Circle one number.)
About once a week 2
Less than once a week 3
Which of the following best describes your urinary control during the LAST 4 WEEKS?
No control whatsoever 1 (Circle one number.)
Frequent dribbling 2
Occasional dribbling 3
Total control 4
3. How many pads or adult diapers per day did you usually use to control leakage during the LAST 4 WEEKS?
3 or more pads per day 1 (Circle one number.)
No pads 3
4. How big a problem, if any, has each of the following been for you?
(Circle one number No small Small Moderate Big on each line.) problem problem problem problem problem a. Dripping urine 0 12 3 4 or wetting your pants?
b. Urine leakage 0 12 3 4 interfering with your sexual activity?
5. Overall, how big a problem has your urinary function been for you during the LAST 4 WEEKS?
No problem 1 (Circle one number.)
Very small problem 2
Small problem 3
Moderate problem 4
Big problem 5
source: Website of the UCLA Department of Urology (www.uclaurology.com); used with permission.
The first step is to control the leakage with absorbent pads of some kind. A wide variety are available at pharmacies and medical supply stores. They range from what are essentially adult diapers to thin pads that can be tucked into one's underpants. The adult diapers are variously labeled as absorbent "underwear," "undergarments," or "fitted briefs'' and are sold under brand names such as Attends, Depends, Poise, and Serenity. The next level down is underpants with an absorbent pouch in front, for instance, Sir Dignity briefs. As men develop increasing continence, they graduate to absorbent pads similar to those used by women during their menstrual periods. The pads come in a variety of sizes, shapes, and levels of absorbency, from extra plus, extra, and regular to light and ultra thin. Many have attachments and can be fitted easily into jockey-style underpants.
The next step in improving continence is to ask your urologist to rule out a urinary tract infection that could be making the problem worse. This can be done readily by checking the urine. In cases of severe and persistent incontinence, the urologist may want to carry out additional tests, such as putting a dye in the bladder and then viewing the bladder by X-ray (a cystogram) or by placing a thin tube up the penis to view the bladder (a cystoscopy).
Minimizing caffeine intake is a valuable step in controlling incontinence. Caffeine increases the frequency and urgency of having to urinate; thus, eliminating coffee, tea, and caffeine-containing soft drinks may improve matters. Medications being taken for other medical conditions may also worsen incontinence. Those known to do so include alpha-adrenergic blockers used to treat hypertension, including doxazosin (Cardura), prozasin (Minipress), and terazosin (Hytrin). Individuals taking these medications should ask their physicians to switch them to another type of antihypertensive medication.
Most urologists encourage patients undergoing prostate cancer treatment to do Kegel exercises to increase continence. These exercises were developed by Arnold Kegel in the 1940s for use by women who wanted to strengthen the muscles in the pelvis after childbirth. The difficulty is locating the correct muscles to be exercised. One set is used to stop urine flow; halting the flow in midstream and holding it for several seconds is the recommended way to identify these muscles. The other set is used to tighten the buttocks. One author suggests imagining that ''you're trying to hold a quarter between your cheeks,'' while another, perhaps to greater effect, suggests the following:
Imagine that you are standing on top of a hill, naked, with a $1,000 bill tucked between the cheeks of your buttocks. You are not able to use your hands, but you need to hold onto the bill during high gusty winds. That squeezing of your buttocks, pulling up internally and tightening down with your pelvic muscles, is a Kegel exercise.3
The true efficacy of Kegel exercises for men apparently has never been formally tested, so recommendations vary widely. Some urologists advise doing them ''at least every hour for five minutes,'' while others suggest much less often. Some urologists say they should only be done standing up, while others urge doing them in any position, ''while watching TV, driving a car, sitting in church, or anywhere at any time.'' Intriguingly, some claim that ''Kegel exercises are also great for improving virility and achieving greater ejaculation and arousal control.'' In 2004 the National Institutes of Health funded a research project that is studying the best way to teach men to do Kegel exercises.4
Sometimes urinary continence can be modestly improved with medication. Decongestants, such as those used for colds, have been recommended; an example is pseudoephedrine (Sudafed). Imipra-mine (Tofranil), a commonly used antidepressant, may help the muscle tone of the sphincter. Oral anticholinergic drugs are widely used to improve continence in elderly persons and are worth trying; the most frequently prescribed are tolterodine (Detrol) and oxy-butynin (Ditropan, Oxytrol). Dry mouth, blurred vision, constipation, and sleepiness are common side effects of anticholinergics. Men should always check with their urologist before starting on any of these drugs and ascertain that the new medication does not interact with those being taken for other conditions.
Despite all of the above suggestions, urinary incontinence will continue to be a problem for 5 to 10 percent of men following prostate cancer treatment. Injections of collagen through the urethra may strengthen the sphincter for approximately half of the men who try it, but it is expensive and the effects are usually not lasting. Out of desperation, some men use a foam rubber penile clamp, which can be released when the man wishes to urinate, or a condom catheter (widely known as a Texas catheter), which is worn on the penis and collects the urine, but both solutions bring their own complications and are not recommended by most urologists.
The definitive solution for severe, prolonged urinary incontinence is an artificial sphincter. It can be surgically implanted around the urethra and operated by a small bulb placed in the scrotum. When the man wishes to urinate, he squeezes the bulb, which opens the urethra; after a minute or two the sphincter automatically closes again. Despite its high cost and possible complications, such as infection and the need for replacement, the artificial sphincter has given a normal life back to many men previously plagued by incontinence.
My own experience with incontinence was fortunately brief. I found it strange and embarrassing to buy what is essentially an adult diaper but was impressed by how much pharmacy shelf space was allotted to these items; I was reassured that I had plenty of company! Luckily, my external sphincter took charge almost immediately after removal of the catheter, and I was able to discard the adult diaper and heavy pads within a day. By the end of three weeks I did not require any pad, and thereafter have had only occasional minor dribbling when I increase my abdominal pressure. The dribbling is less than what I experienced in the years immediately prior to surgery. Al-
The Artificial Sphincter: A Paean to No Longer Being Peed On
It isn't until after a shower the next morning that I begin to feel like a whole person again. Save for the quirky little maneuver I have to go through to urinate, it is a heady feeling to feel like the same man I was before. No more a prisoner locked in solitary, I can walk in the sunlight, free of the Velcro shackles.
I'm neither a nudist, nor have I flasher tendencies, but it is a thrill to be able to walk around without anything on. Not to be able to perform the simple, most natural act of walking naked from a shower to a bedroom a few feet away can only be described as living in a cell without walls; it is days before I can allow myself to appreciate their disappearance. . . .
I sleep deeply, dream-free and, not since the night before the first operation, in the raw. The nightmare is over. I think I can hear the fat lady singing.
—Bert Gottlieb, describing what it's like to have an artificial sphincter, in The Men's Club though radical prostatectomy is much more likely to cause urinary incontinence than to improve it, studies have shown that for some men the surgery does, in fact, improve urinary symptoms.5
IMPOTENCE: THE PROBLEM
Impotence, or erectile dysfunction (ED), as it has become known, is the gorilla in the prostate cancer closet. It lurks just out of sight but never out of mind. Choosing between various treatments for prostate cancer based on the likelihood of impotence is a little like choosing how you wish to die—the outcome of all the choices is remarkably similar.
Normal male sexual functioning is complex. A man must feel some desire—libido—and this urge is instigated by a mix of testosterone and psychological factors. The penis must become erect, which is determined by the arteries, veins, and nerves that supply it. Orgasm is initiated in the brain and involves the ejaculation of sperm and seminal fluid through the contraction of muscles. And all of this must be orchestrated smoothly if it is to be successful.
The problem in cases of prostate cancer is that the arteries, veins, and nerves that control erections run alongside the prostate. To treat prostate cancer by any method means risking damage to one or more of these. The arteries are needed to carry blood to the penis. The nerves cause the smooth muscles in the penis to relax so that it can fill with blood. This filling, in turn, shuts the veins, thereby trapping blood in the penis. An erection, therefore, is simply a penis engorged with blood, and erectile dysfunction occurs when blood does not fill the penis as it is supposed to. Even when a nerve-sparing procedure is used in the surgical removal of the prostate, arteries and veins may still be damaged, with resultant erectile dysfunction.
More misinformation probably exists about sexual function than about any other aspect of prostate cancer. One man was told that treatment would ''have no physiological effect on my libido or sensation of orgasm. . . . I would still be able to achieve orgasm, and it would feel much the same as before.'' A widely read book reassures men that after a radical prostatectomy, they will have ''normal sensation, normal sex drive, and can achieve a normal orgasm.'' And, even if they do have erectile dysfunction, it ''can always be treated.''6
The truth is quite different. Certain men have been shown to experience a decrease in libido following treatment for prostate cancer, although it is usually not marked. Some of the decrease may be due to a lessening of testosterone, although the mechanism for this decrease is not clear. Diminished libido may also be due to depression secondary to erectile dysfunction or other factors.
Ejaculation is abolished by prostate surgery, since the seminal vesicles, which supply most of the seminal fluid, and the vasa defer-entia, which carry the sperm, are both severed. As one man noted, ejaculation was ''visible proof of my manhood. . . . And now that integral part of my sexual expression was going to be taken away from me forever. . . . No semen, no ejaculation! It was as cut and dried as a beheading.'' As George Burns described it when, in his early 90s, he was asked about his sexual performance: ''I come dust.'' One man who had prostate surgery looked on the humorous side of not ejaculating: ''Now that I would no longer produce my ejaculate, I might even be able to fake an orgasm.''7 Ejaculation is also decreased by radiation treatments, although this effect takes place more slowly.
For most men the quality of orgasms is less intense after treatment for prostate cancer—hardly surprising, given the number of pelvic structures affected by the surgery. The same is true after radiation treatment. Michael Dorso, a physician who elected radiation treatment for his prostate cancer, wrote: ''I really miss my prostate gland! . . . What I didn't realize is that it produces about 80% of the pleasure of an ejaculation. That feel-good pulsing in my groin during orgasm is gone!''8
The principal loss in sexual function after prostate cancer treatment is the ability to achieve an erection sufficient for intercourse. Charles Neider calls it having joined ''the Limp Penis Club.''9 As noted in previous chapters, it now seems clear that the majority of men who undergo prostate cancer treatment of any kind will suffer some degree of erectile dysfunction.
Are there any predictors regarding which men are more likely to develop such dysfunction? The first key predictor is age. As men grow older, they progressively lose some of the nerves that supply the penis; in addition, the arteries, like arteries elsewhere in the body, may function less well. According to one estimate, ''by age 60, a man only has about sixty percent of the nerves he was born with.''10
The second major predictor of sexual function following treatment for prostate cancer is the man's sexual functioning prior to treatment. Studies have reported that approximately 20 percent of adult men are unable to achieve erections sufficient for vaginal intercourse, and an additional 30 percent have difficulty maintaining erections.11 The reality, therefore, is that at least one third of men suffer some degree of erectile dysfunction at the time they are diagnosed with prostate cancer; such men are certainly not going to function better after treatment. The scenario reminds me of the man who asked his urologist whether he would be able to play the piano after having prostate surgery. ''I don't see why not,'' said the urologist. ''Why, that's wonderful,'' said the man. ''I never could play before.'' The third predictor of posttreatment erectile dysfunction is
Is It Possible to Accurately Assess Erectile Dysfunction after Prostate Cancer Treatment?
It is difficult to get credible figures on the incidence of erectile dysfunction following prostate cancer treatment, in part because many men do not answer such questions honestly. Assessments also vary depending on the definitions used. Does a man qualify as having an erection if his penis, which normally hangs at 7 o'clock, reaches 8:30 or 9 o'clock? Does it depend on how stiff it is? Or how long the erection lasts? Or whether he can only get an erection while standing up? Or only with the assistance of medication? Some have defined an erection as one sufficient to achieve vaginal penetration, but that depends in part on the partner's anatomy and cooperation. And what about frequency—if one achieves an erection once every six months, is that sufficient to say that erectile dysfunction does not exist?
Urologists who advocate for one or another form of treatment assess erectile dysfunction differently in attempts to make their numbers look good. Their data are often not reliable.
whether the man has other causes of dysfunction. Diabetes often contributes, and many medications cause a degree of erectile dysfunction, including some of those taken for hypertension and depression. It is often possible for a man to substitute another medication that has fewer such side effects.
The final predictor of erectile dysfunction following prostate cancer treatment is the type of treatment the man received. Surgical prostatectomy produces immediate erectile dysfunction in almost all cases but then a slow recovery of function, peaking at eighteen to twenty-four months. Recovery is most likely when both nerves were spared but, at least in one study, almost as satisfactory when only one nerve is spared.12 Radiation produces little erectile dysfunction initially, but such dysfunction increases over the following months and even years. Cryotherapy and hormone therapy produce the most erectile dysfunction.
One other aspect of erectile dysfunction following prostate cancer treatment is rarely discussed: the possible loss of the man's sexual fantasy life. A study among forty-eight men who had been treated by surgery, beam, and seed radiation therapy reported the following:
The men became nostalgic when they described how they once enjoyed thinking about sex, now a lost pastime. They disclosed that they no longer enjoyed sexual feelings in response to seeing an attractive woman. They also expressed a profound sense of loss associated with a loss of a fantasy life in which they were able to imagine themselves as potential sexual partners. They were sadly conscious of their diminished libidos.13
These men had previously enjoyed seeing attractive women in their everyday lives and fantasizing about them. The experience was ''something that they had identified as part of their lives as men.'' Impotence, however, rendered these fantasies unrealistic. This study makes clear that a man's loss of potency following prostate cancer treatment leads to more than erectile dysfunction; it may lead to ''fantasy dysfunction as well.'' For some men, this can be a serious loss.
IMPOTENCE: THE SOLUTIONS
The importance of having an active sex life varies widely among men, especially among men of different ages. For a man who is diagnosed with prostate cancer in his 40s and who has a younger wife, the threat of impotence may appear catastrophic. For a man in his 60s, with a wife of similar age, the threat of impotence following treatment for prostate cancer may be something he can live with, especially if he believes that the treatment has cured his cancer. This willingness to accept partial or full impotence in exchange for a successful cancer treatment may explain why, in one survey, ''nearly half the men who experience erectile dysfunction after prostate cancer therapy choose not to seek treatment for their impotence.''14 It
I could not predict just how the loss of . . . sexual potency might affect me. I was certain it would not enhance my self-image, but perhaps I would handle it reasonably well. Important as it was in my life, sexual activity did not involve large blocks of my time on a daily basis. Most of what gives meaning—family, friends, teaching, reading, writing, movies, bicycling, squash, skiing, good food—would still be there and there was little reason to think that my capacity for any of them, with the short-term exception of bicycling, would be diminished in any way.
—William Martin, My Prostate and Me
Patients can have excellent quality of life even though erections and urinary control may not be perfect. I'm sure that there are many patients who have artificial hips and knees who cannot run and dance like they once did but are pleased with the outcome.
—Patrick Walsh, letter, journal of Urology, 2004
may also explain the wide disparity reported by researchers between men who are deeply distressed by posttreatment sexual dysfunction and men who are little bothered by the dysfunction.
A critical step in finding solutions to the impotence problem is open and frank discussion between the man and his partner. Michael Dorso advises that ''the silent male model doesn't work here'' and adds:
Men seem to have more trouble than women talking about their intimate feelings and erotic needs. You will have to overcome your chauvinistic leanings. It seems to be one of life's paradoxes, that sometimes a frank sexual discussion can be most difficult with the one sharing our bed! Bizarre, isn't it? You may have looked into her eyes as you shared thousands of orgasms, and yet find it difficult to look into her eyes and discuss your new sexual concerns.15
There are many ways to enhance whatever erectile function remains after prostate cancer treatment. Direct physical stimulation of the penis by the man or his partner is more effective than visual or fantasy stimulation. It can be assisted by lubricants such as K-Y jelly, Astroglide, or, least expensive of all, saliva. A standing position often helps erections, making it more difficult for blood to escape from the penis and return uphill to the heart. Another means of slowing the escape of blood is to place a rubber band or erection ring, available in sex shops, around the base of the penis prior to foreplay. Blood can then enter the penis through the central arteries but can less readily escape through the weaker-walled veins, which are constricted by the bands.
Even men who have complete erectile dysfunction can have a sex life after prostate cancer treatment. Since orgasms begin in the brain, not the penis, they are still possible, although they may be more difficult to achieve. As in all aspects of sexual function, practice makes perfect. People's physical needs and responses differ. As one author notes: ''Just as all artists have to practice with different brushes and mixing colors and how to apply them to get the desired result, if we want to improve our lovemaking, we have to do the same.''16 It has been said that as we deal with the problem of a flexible penis, it is best not to be too rigid; in fact, flexibility often produces greater rigidity.
Articles, books, and website advice abound regarding how to improve sexual functioning following prostate cancer treatment. Among the best sources of information is The Lovin' Ain't Over: The Couples Guide to Better Sex after Prostate Disease, by Ralph and Barbara Alterowitz (see Appendix B). The premise of the book is that ''you can have a loving and satisfying sexual relationship without having an erection.'' They suggest:
Don't focus on the erection. Instead, focus on loving and deriving pleasure from it. When erections were easy, we tended to focus solely on them. In reality, most of us missed out on other means of deriving pleasure, which could have made loving much more pleasurable even then.
Masturbation: Sweet Irony!
Authorities agree that exercising the penis early and often following treatment for prostate cancer increases the chances for return of function. The penis needs an abundant blood supply to nourish the tissues, and the arteries to the penis are often damaged during treatment. Books advocate activities such as frequent ''direct sexual stimulation'' and ''penile massage.''
Many of us older men remember hearing in our youths that masturbation was ''self-abuse'' and would make us become blind. I recall the story of the boy who was caught masturbating by his mother and told to stop. ''But mother, can't I continue just until I need glasses?'' he replied.
But now, sweet irony! In our youth, we were told that masturbation would cause a deterioration of our body. In our old age, we are now told that not masturbating will cause a deterioration of our body.
Similarly, Michael Dorso notes that ''making love does not have to equal sex; furthermore having sex does not have to equal intercourse.'' Women know this better than men do and, judging from comments posted on prostate cancer websites, it seems to be a difficult lesson for men to learn. Dorso's wife put it most succinctly: ''Michael, I married you for who you are, not for your penis.''17
For men who want to enhance their erections with artificial means, the five main options are oral medications, penile injections, vacuum pumps, nerve grafts, and surgically implantable penile pros-theses. Of these, oral medications are by far the most popular and most widely used. It is, in fact, difficult to watch a sporting event on television without seeing advertisements for sildenafil (Viagra), var-denafil (Levitra), or tadalafil (Cialis). These medications are helpful for many men, but they do not live up to the promise of instant pharmaceutical nirvana that the ads suggest. In one study of their
Oral Medications to Enhance Erections sildenafil (Viagra)
• 25 mg., 50 mg., and 100 mg. rectangular blue tablets
• peak action 30 minutes to 2 hours; may last up to 6 hours
• food affects action, so should not be taken less than one hour before or within two hours after eating vardenafil (Levitra)
• 2.5 mg, 5 mg, 10 mg, and 20 mg round white tablets
• peak action 30 minutes to 2 hours; may last up to 12 hours
• okay to take with food except for high-fat meals, which delay onset of action tadalafil (Cialis)
• 5 mg, 10 mg, and 20 mg oval sand-colored tablets
• peak action 30 minutes to 6 hours; may last up to 36 hours
Side effects: All three medications can have similar side effects: flushing, headache, dizziness, indigestion, and stuffy nose. Sildenafil also occasionally gives a blue tinge to vision. Rarely, the medications may produce a prolonged erection (priapism), which should be treated with ice packs and, if needed, a visit to the emergency room, or they may cause some loss of vision, which may be permanent.
DO NOT TAKE these medications if you are also taking nitrate medications for angina or chest pain. The combination can cause a severe fall in blood pressure and even death. (The nitrate drugs include isosorbide, Dilatrate, Isordil, Sorbitrate, Ismo, Imdur, nitroglycerin, Deponit, Minitran, Nitro-Bid, Nitradisc, Nitro-Dur, Nitrostat, and Transderm-Nitro.)
You should start at a low dose and take the new drugs cautiously if you are also taking any of the following:
• medications to lower blood pressure, especially doxazosin (Cardura)
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