Roughly two million American men are now living with prostate cancer or the aftereffects of treatment.
That’s largely because the ability to detect and treat prostate cancer has greatly improved. Now, about 90% of the nearly 250,000 American men who are diagnosed with the disease each year are alive at least 15 years after treatment.
The downside: Surgery and radiation, the main treatments, can cause serious side effects, including erectile dysfunction (ED) and incontinence.
Important recent study: Nearly half of men who had surgery for prostate cancer expected to have a better recovery than they actually did.
The complications of surgery (which typically involves total removal of the prostate gland) and radiation vary widely, depending on a man’s age, the presence of other diseases (such as diabetes) and the specific type of treatment he receives. For example, a 50-year-old who had good erections prior to surgery will probably have them again within a year or two. An older man with a history of health problems won’t do as well.
Some of the nerves that control erections are invariably damaged during prostate removal surgery. This occurs even with so-called nerve-sparing procedures that are designed to minimize damage to nerves that supply the penis. In many cases, a man’s ability to have erections can return within about 18 months, but there’s no guarantee of a full recovery. In fact, recovery varies widely depending on the age and health of the patient—overall, 50% to 60% have permanent ED.
Men who are treated with radiation may retain their ability to have erections initially, but damage to nerves and blood vessels from radiation increases in the weeks and months after treatment.
Even so, prostate cancer survivors and their partners can still have satisfying sex lives (though the man may have a somewhat lower level of performance). Here’s how…
Consider injections. The average man is unwilling to stick a needle in his penis when he wants to have sex. But I encourage my patients to consider this treatment because it is the most effective—and always the least expensive—approach.
The drugs that are injected, papaverine, prostaglandin and phentolamine, are often combined in one solution. The injection usually produces an almost immediate erection even when a man isn’t sexually aroused. The erection can last anywhere from about 10 minutes to four hours, depending on the dose.
The needle is so small that the injections are virtually painless. Once a man learns how to inject himself, he’s given a prescription for enough medication to provide at least 50 doses. Cost per shot: About $3.
Drawbacks: Apart from the fear of injections, the only likely side effect is an erection that lasts too long. This might not sound like a problem, but an overly persistent erection is painful and dangerous, potentially leading to permanent dysfunction. It can be prevented by reducing the dose.
Take a pill. For those patients who are unwilling to try injections, sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) promote blood flow to the penis when a man is sexually aroused and improve erections in about 60% of prostate cancer survivors who use the medications.
These medications work best in men who are in relatively good physical shape, don’t have other serious health problems and have had nerve-sparing surgery or radiation alone. They’re least effective in older men or men with low testosterone or complications from diabetes—and usually not effective at all for men who have had total removal of the prostate and surrounding tissue because they may have suffered nerve damage. Viagra, Levitra and Cialis can produce an erection in 30 to 60 minutes, and it typically lasts two to four hours.
Drawbacks: The medications cost $12 to $20 per pill (sometimes covered by insurance) and often cause headaches, dizziness, nasal congestion and other side effects. These drugs can also be dangerous or even deadly when combined with nitroglycerine medications, taken for heart problems.
Use a vacuum device. This can be a good choice for men in long-term relationships who are comfortable “tinkering” before intercourse.
What happens: Just before intercourse, a man places a plastic sheath over his penis. Then, a motor (or a plastic crank, in less expensive models) creates a vacuum inside the sheath, which pulls blood into the penis. Once a man has an erection, he slips a rubber band around the base of the penis to hold the blood in place for 30 minutes. Cost: $95 to $550, depending on the model. Important: Use a vacuum device that has FDA approval and is prescribed by a doctor—the devices sold at “adult” stores may lack safety controls and generate too much pressure.
Drawbacks: Some men experience bruising on the penis. Also, many couples find the mechanical aspect of the devices unromantic.
Ask your doctor about surgical implants. Men who can’t get an erection any other way or prefer not to use the ED treatments described earlier may opt for a surgical implant. Main choices: Semirigid, rodlike devices that are implanted in the penis and can be bent, like a pipe cleaner, into the proper position for intercourse…or a hydraulic device, controlled by a small bulb implanted in the scrotum, that pushes fluid into hollow tubes in the penis, causing them to inflate.
Most men who have these devices like them because they don’t need pills or injections or require the steps that are necessary to use a vacuum device. As a result, they can have sex whenever they want.
Drawbacks: Postsurgical infection is the main risk. This occurs in about 3% of nondiabetic men. In men with diabetes, the infection rate is about 8%. The devices are expensive but often partially covered by insurance. Out-of-pocket costs are about $5,000 for the semi-rigid device and $8,000 for the inflatable one.
Lack of urinary control is the second most common complication of prostate cancer treatments. Reason: The prostate gland helps control/block the flow of urine. When the gland is removed or damaged, the urinary sphincter (the muscle that controls urine) has to work alone—and often fails. Most men eventually regain bladder control, but this can take two years or more.
Surgery—to implant an artificial sphincter, for example—may be needed if a man accidentally voids or “leaks” large amounts of urine. My advice…
Expect some leakage. Most men who are treated with surgery and/or radiation for prostate cancer will experience some degree of stress incontinence—the leakage of a few drops of urine when they cough, sneeze, laugh, etc. It can be embarrassing, but as long as the amounts of urine are small, it’s usually nothing to worry about. It will probably improve with time. Some men who have radiation may also have urge incontinence—a strong, sudden need to urinate.
When men are leaking large amounts of urine or when they’re so embarrassed that they feel they can’t leave the house, over-the-counter pads can help.
Do Kegel exercises. Apart from surgery, this is the most effective way for men to regain bladder control. (Kegel exercises probably won’t help men who are leaking large amounts of urine, but it doesn’t hurt for these men to try them.) Start doing them every day after a diagnosis—before cancer treatments begin—to prevent future problems.
What to do: First, identify the pelvic-floor muscles. They’re the muscles that you contract to hold urine in the bladder—or to stop the flow of urine in midstream.
Several times a day, squeeze the muscles as hard as you can. Hold for about five seconds, then relax. Repeat this sequence a few times. As the muscles get stronger, try to do 20 or more contractions at a time. Do them a few times a day.
Source: Arnold Melman, MD, professor of urology at Albert Einstein College of Medicine in New York City, where he also has a private practice. A former president of the Society for the Study of Impotence, he specializes in prostate surgery and the diagnosis and treatment of male sexual dysfunction. He is the author, with Rosemary E. Newnham, of After Prostate Cancer: A What-Comes-Next Guide to a Safe and Informed Recovery (Oxford University).