PROLOGUE
HOW TO USE THIS BOOK
Prostate cancer is the most common form of cancer in American men other than skin cancer. It is estimated that about 185,000 new cases of prostate cancer will be diagnosed in 2008 in the USA alone. Almost 30,000 men will die of the disease this year alone in this country. It is the second leading cause of cancer death in men after lung cancer. While a man has a 15% chance of being diagnosed with prostate cancer in his lifetime, only 3% die of the disease. In the modern era, the vast majority of men live for very long periods of time.
Over the course of the last 20 years, numerous discoveries and refinements in management have occurred in this disease. There have been refinements in prostate biopsy technique, in imaging of prostate cancer, in surgical technique (for example, the introduction of laparoscopic and robotic prostatectomy), in the delivery of radiation therapy and in the treatment of advanced disease. Furthermore, the use of PSA as a screening tool has resulted in a far greater number of men being diagnosed with prostate cancer at its earliest stages. This has also translated into younger men being diagnosed with prostate cancer. Thus, a man’s long-term sexual function has become an even bigger issue now, given these factors.
Being diagnosed with cancer for any person, and prostate cancer for any man, is a major stressor in one’s life. It is easy in the early stages after diagnosis to become overwhelmed with decisions. These decisions often center on what treatment to choose, surgery or radiation therapy or watchful waiting? Each of the three has its respective pros and cons.
So, why have I written this book? The simple fact of the matter is that most physicians and patients do not talk about sexual health in a routine medical interview. Both are uncomfortable with the topic and avoid it. Secondly, physicians treating patients sometimes shy away from discussing in detail the side effects and complications of a treatment and so patients are left with unrealistic expectations. Thirdly, there is a dire need for the dissemination of credible information on the sexual effects of prostate cancer treatments, whether it be surgery, radiation or hormone therapy. While there are excellent books written by physicians and patients on prostate cancer in general and its treatment, this is the first book written entirely about sexual function in the prostate cancer patient. We know prostate cancer is common and treatment with surgery or radiation occurs in the majority of patients. Thus, sexual problems in this population are common, some short-lived, some permanent. Finally, this is an area of medicine to which I have devoted most of my 12 years in academia, both in treating patients and in research. In my practice at Memorial Sloan-Kettering Cancer Center, I see more than 600 radical prostatectomy patients, around 150 radiation patients and about 100 hormone therapy patients per year.
This book is not designed to be a resource in your decision-making about your treatment nor will it give a comprehensive account of what’s involved in radical prostatectomy or radiation therapy treatment. Rather, this book is aimed at giving you state-of-the-art, up-to-date, comprehensive information on the impact of prostate cancer treatments on your sexual function and what options are available to you for the treatment of such sexual problems.
The book opens with a chapter on the basics of sexual function: how do erections, libido, and ejaculation work? The next chapter discusses benign prostate enlargement and lower urinary tract symptoms. This chapter discusses the treatments available for benign prostate enlargement (BPH) and their effect on your sexual function. The ensuing chapters deal with the impact of radical prostatectomy, radiation therapy and hormone therapy on your sexual function. There is an important chapter on penile rehabilitation and preservation of erectile function. This concept is unheard of by most patients and, indeed, is alien to many doctors and even to some urologists. There is accumulating evidence that using medications in the early stages after treatment, whether it be surgery or radiation, and while on hormone therapy, may positively impact the health of erectile tissue and thus maximize the chances of a man retaining long-term sexual function. A chapter on miscellaneous problems discusses the non-erection sexual problems that occur after these treatments, including orgasm and penile length problems, and the development of Peyronie’s disease. The ensuing five chapters are devoted to discussing treatments available to you for erection problems. These include pills (Viagra and the like), suppositories, vacuum devices, penile injections, and penile implants. The book ends with a chapter on future therapies for sexual dysfunction, a chapter on the very controversial subject of testosterone supplementation and a final chapter on restoring your sex life.
The advice offered in this book is based on my own research, my interpretation of other people’s research, and my clinical experience over the 12 years that I have been practicing sexual and reproductive medicine. I have tried to be comprehensive, but where I believe a better resource exists I have mentioned it. Furthermore, at the end of the book, there is a Suggested Reading list. There is also a section on Resources, including books, websites, and organizations that have expertise or interest in sexual health in the prostate cancer patient.
The goal of the sexual medicine physician is to ensure that the couple (should one exist) or the patient has the ability to resume satisfactory sexual relations. My goals are as follows: (i) to provide you with well-researched, well-thought-out educational material so that you can make a rational decision regarding your treatment, (ii) to give you the tools necessary to ensure that you get the best care possible, and (iii) to encourage you to be proactive about your sexual health, all in an effort to maximize your sexual function recovery. At this moment, it is easy to feel overwhelmed. You are worried about surviving your cancer, you are worried about being incontinent after surgery, and you are worried about the sexual function consequences of radiation therapy, surgery, and hormone therapy. The good news is that almost 90% of men who walk into my office with sexual dysfunction related to prostate cancer are treatable. That is, 90% of men can resume satisfactory sexual intercourse with a partner using available treatments. You should finish reading this book with a sense of optimism with regard to your future sexual function. You can be helped! Good luck!
JOHN P. MULHALL, M.D.
CHAPTER 1
THE BASICS OF SEXUAL FUNCTION
| I.Penile Anatomy II.How Erections Work III.Reproductive Organs IV.How Ejaculation Works V.How Libido Works VI.Sexual Difficulties Are Common |
I. Penile Anatomy
Leonardo da Vinci described the penis as follows: “. . . it disputes with the human intellect, and sometimes has intellect itself, and although the will of a man may wish to stimulate it, it remains obstinate and goes its own way, sometimes moving on its own without the permission or thought of the man. Whether he is asleep or awake, it does what it desires, the penis having a mind of its own.” This organ has been a source of fascination for thousands of years. It facilitates not just urination and sexual activity, but is the seat of masculinity and virility in many cultures. This organ is perfectly designed for its functions and is composed of multiple types of tissues and structures, which, like a good orchestra in concert, function perfectly together in the healthy male.
About two-thirds of the penis is external (that is, outside of the body) and one-third is internal (Figure 1). The erection chambers are paired cigar-shaped structures that travel from the head of the penis into the body and run along the bony structures known as the ischiopubic rami. These bony structures are what we sit on when we sit on a bicycle seat, for example. The paired erection chambers are technically known as the corpora cavernosa (singular: corpus cavernosum). They are composed of two major types of tissue. The outer lining, which is approximately 2mm in thickness, is known as the tunica albuginea, more commonly called, simply, the tunica. Housed within the tunica is the erectile tissue, which itself is composed of numerous types of tissues (Figure 2). This tissue includes muscle, blood vessels, nerves, elastic tissue, collagen, and a tissue very important to erectile function known as the endothelium. I will talk more about this tissue toward the end of this chapter and you will see it pop up again and again in this book.
The erectile tissue is fashioned into a lattice-work of spaces. The simplest way to think of it is that erectile tissue