Conversations With Prostate Cancer Experts

ED After Cancer

Miner Head PhotoDr. Martin Miner is the Co-Director of the Men’s Health Center at The Miriam Hospital in Providence, Rhode Island.

Prostatepedia spoke with him about how his center helps men who have erectile dysfunction after prostate cancer treatment.

How common is ED in the general population? What causes it?

Dr. Miner: Most studies show that ED occurs in 50% or more of men. The public thinks it’s related to aging, but in truth, it’s more prevalent with aging because there are more comorbidities (meaning coexisting medical problems) that occur in men as they age. As men age, they tend to develop high blood pressure, elevated lipids, and type 2 diabetes. Many become obese, and specifically get visceral adiposity, or belly fat. Erectile dysfunction is related to all of these conditions.

Once present, ED is not only related to the issue of vascular filling but also to psychological issues. Men are devastated when their sexual function is impaired. They become anxious and performance-focused. That only makes attaining an erection more difficult.

What kind of an impact can ED have on a man?

Dr. Miner: For most men, ED affects every phase of their lives. We’re pretty simple creatures. From youth, we are used to waking with morning erections, and whether we used them or not, they can be validating, making us feel virile and healthy.

When that no longer happens or when we have difficulty achieving erections, it impairs our self-esteem. We can become depressed and frustrated, which can cause us to seek to blame and distance ourselves from those we love, especially our sexual partners. We no longer initiate lovemaking and are unreceptive to lovemaking because we don’t want to do something at which we consistently fail.

Most cases of ED begin with difficulty keeping erections and then progress to difficulty getting and keeping an erection. It’s a gradual process, almost insidious in nature. You know that your erections are no longer rigid or hard. Your partner is aware of it as well, so you can become ashamed.

Does that shame prevent men from seeking help?

Dr. Miner: At some point, most men will seek treatment. Medications like sildenafil have revolutionized the way we look at sexual functioning. They’ve allowed men who previously might have been quiet and accepted this as a normal part of aging to address an impairment that they no longer feel they need to accept.

They’ll bring it up to their clinician.

It may be difficult for them to raise that issue with their clinicians, though, since they might feel embarrassed. Often it’s an end-of-the-visit discussion or what we call a backdoor complaint: “By the way, Doc, do you have any samples of Viagra?”

Studies show that patients appreciate when providers initiate discussions about their sexual functioning. Even if they have no problems, they feel validated because they know they can raise the issue of sexual functioning if necessary.

Women now outnumber men as primary care clinicians. While many women have no difficulties asking men about sexual function, some do. We need to retrain those female providers to help them feel comfortable.

How common is ED after prostate cancer?

Dr. Miner: We know that erections occur normally due to an increase in blood flow, or vasodilation, of the very small blood vessels that fill the penis. It’s also related to neurologic excitation, or release of a gas called nitric oxide, which is why meds like Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadalafil) work; they prevent the breakdown of that gas. A neurologic, vascular, endocrinologic (hormonal) insult, or compromise, can cause ED.

In prostate cancer, there are insults in all three of those spheres, the most significant being the complete loss of erections following surgical treatment, which has an incidence of 98%. It is also associated with complete incontinence.

The nerve bundles around the prostate gland are like tendrils of a spiderweb, and it’s very difficult not to harm those bundles. When those bundles are even exposed to the atmosphere, opened, or touched, they go to sleep. Not even the best surgeons can spare them. After surgery, they have to return to function over time.

The first thing that happens after prostate cancer is men have an overwhelming fear about their incontinence. They wear pads, which can be very humiliating. Their first desire is to get dry and we recognize that. Then we work on a program to reawaken these nerve bundles to the penis while we continue to keep their penile tissue healthy until recovery.

There are some emerging treatments for less aggressive prostate cancer, like proton beam therapy, which may have less of an impact on sexual function. But most, if not all, therapies for prostate cancer have a significant and direct impact on sexual function. Male survivorship treatments, including the return of sexual function, are not covered by insurance because they’re termed experimental.

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