Table 2 • Questions You May Be Asked by a Doctor about Your Sexual Health
| •For how long have you had difficulties? •Were these difficulties sudden or gradual in onset? •Have the difficulties been getting worse? •How often do you have sex with a partner? •How often do you masturbate? •How hard does your penis get during sex/masturbation? •Is there a difference in erection hardness between sex and masturbation? •How difficult is it for you to get an erection? •How difficult is it to maintain an erection? •How often do you fail to penetrate because you lose the erection? •Is erection painful for you? •Is penetration painful for your partner? •Does your penis bend/curve? •Do you ejaculate (semen)? •Do you ever see blood in your semen? •Do you have an orgasm (climax)? •Is it difficult for you to achieve an orgasm (climax)? •Is orgasm painful? •Do you leak urine at orgasm? •Have you noticed any loss of penis length? •How would you grade your sex drive? •How would you grade your partner’s sex drive? |
Having your partner with you if you have one is sometimes helpful. Indeed, even having a family member with you, if you are comfortable discussing urinary and sexual issues in front of them, is of some benefit. I tell patients that most patients remember no more than 50% of what is said to them during a medical interview and if the patient has somebody with them, then that will probably increase the amount of the discussion that is remembered. Under the stress of the diagnosis of prostate cancer and discussion regarding incontinence and erectile function, patients often forget what is told to them. If all the ground has not been covered in a single encounter, then a return visit to that physician is definitely worthwhile. Many physicians will be reluctant to conduct such a conversation by phone as a face-to-face encounter is usually far more effective in communicating key issues.
VI. Questions You Should Ask Your Doctor
Patients often ask us what would we do if we were in their shoes. This is not a useful question, particularly in the setting of prostate cancer. Unless the physician has had prostate cancer himself which has been treated, it is not likely that this question will yield any useful information. However, asking the physician what he or she would recommend to his or her brother or father is sometimes valuable. Remember that physicians are human and they will have biases toward or against particular treatments. It is important that you be the judge when talking to the physician.
Experience is a critical factor in outcome, particularly when it comes to sexual and urinary function recovery. So simply asking the physician how many brachytherapies, external beam radiation treatments or radical prostatectomies he or she has performed annually is a good starting point. Another major factor is how long he or she has been doing this. It is well recognized that there is a learning curve in all of these treatments. For example, it is recognized that the positive margin (some cancer cells left behind) rates at the time of radical prostatectomy are higher during a surgeon’s first 100 prostatectomies compared to those during surgeries performed afterwards. So if a surgeon is performing 20 prostatectomies a year, which is a significant number, and has only been doing it for a couple of years, then this is not the same level of experience as somebody who does 20 a year but has been doing it for a decade.
It is also worth asking about or finding out about the physician’s training, including the center he or she trained at and who he or she trained under. The experience with radical prostatectomy surgery or prostate radiation is highly variable from one residency training program to another. Asking your physician about his or her change in philosophy over time is also potentially useful. For example, for a physician who has been in practice for 10 years, has he or she changed his or her opinion regarding the role of prostatectomy versus brachytherapy if he or she is a urologist, or if your physician a radiation oncologist, has he or she changed their opinion regarding seed implantation versus IMRT? This may give you a sense of his or her ability to keep up with new techniques and medical literature.
The surgeons work as part of a team, so asking them about the facilities at the medical center is also important. The surgeons work in an operating room alongside residents or fellows as well as alongside operating room nurses and anesthesiologists. It may be worthwhile asking the physician for a reference of one, two or three names of anesthesiologists that he or she likes to work with. Unfortunately, historically, there have been surgeons who spend very little time in the operating room other than being present for the most important part of the procedure and much of the surgery is done by a resident or fellow. As an academic physician, I am fully committed to the training of residents and fellows, and it is my intention to train future leaders in sexual medicine and urology. However, there are critical portions of the operation that an experienced surgeon should be closely involved in, for example, the nerve sparing portion of a radical prostatectomy. As for the radiation oncologist, he or she works very closely with a physicist and radiologist, and asking about the experience of these personnel may also be of some benefit.
While experience is important, it is not the only factor important in defining outcomes or complications with these treatments. Indeed, it has now been well documented that even surgeons with high volume may have poor outcomes. The concept is that you either do good nerve sparing at the time of surgery or you don’t. And whether you are doing 20 or 200 radical prostatectomies a year may not impact directly upon this. To do nerve sparing, for example, at the time of radical prostatectomy requires a very meticulous nature and great patience. The top surgeons at Memorial Sloan-Kettering take anywhere from two and a half to three and a half hours to perform nerve sparing surgery. Much of this time is spent teasing the nerves away from the prostate, not using any electrocautery, and applying nothing more than gentle traction to the nerve bundles. Thus, expertise is a critical factor, although admittedly, this is particularly difficult to glean from a discussion with the physician. I recommend that you ask your treating physicians what the specific figures on continence, erectile dysfunction and PSA recurrence are in their particular patients. It is easy to quote the literature, but remember that this literature is usually generated from so-called centers of excellence with vast experience. Such figures may not be replicated at smaller centers. Along with that, they should be able to define what they believe to be the potential outcomes for somebody of your age, your medical condition and with the cancer factors that were previously mentioned. Experienced physicians should be able to tailor the discussion and the risk for complications and outcomes to your particular case.
I encourage all of my patients who are undergoing a surgical procedure performed by me to speak to one of my patients who has previously undergone that procedure. I think it is entirely reasonable for you to ask the surgeon or radiation oncologist if you can speak to patients who have undergone such treatment. Speaking to a single patient may be of limited benefit, however, as it is not likely that the physician is going to have you speak with a patient who had a less than excellent outcome. The quality of the physician is not just assessed in his or her ability to evaluate a patient or conduct the procedure. It is also directly linked to how he or she manages any complications that occur during or after the procedure, and his or her accessibility and willingness to spend time in discussion with you. When choosing a surgeon, it is important to evaluate not just the erectile function recovery rates in his or her experience, but also the surgical margin positivity rate. High rates of erectile function recovery can be obtained at the risk of leaving cancer behind along the nerve, and likewise, excellent cancer control with very low levels of positive margins can be accomplished at the risk of causing significant nerve damage and future erectile dysfunction.
There are a number