Transcription:
Erectile Dysfunction After Prostate Cancer Treatment

Melanie Cole (Host): Patients with prostate cancer that hasn't spread beyond the gland itself have a broad range of treatment options including surgery, radiation therapy, and active surveillance. However, with those treatment options comes certain side effects such as incontinence, bowel function, and erectile dysfunction. Many men will have erectile dysfunctional occasionally. However, if it becomes a consistent problem, it might be time to look to the experts at City of Hope for help.

My guest today is Dr. Jonathan Warner. He's an assistant professor of the Division of Urology and Urologic Oncology in the Department of Surgery at City of Hope. Welcome to the show, Dr. Warner. First of all, men have prostate cancer, they have surgery or certain treatments, what are some of the risks of erectile dysfunction becoming a side effects of some of those treatments?

Dr. Jonathan Warner (Guest): There’s several factors that really play into that. Preexisting erectile dysfunction is probably one of the biggest risk factors for after treatment erectile dysfunction, so a good understanding of how strong the erections are before the operation or before radiation therapy can really be the best predictor of how they’re going to be after therapy. The other factor that comes in with surgery is if the disease is not that advanced, then often times we can perform a nerve-sparing procedure to spare the nerves that run next to the prostate that really controls that erection. Those two factors combined are really the most important factors when it comes to postoperative erectile function.

Melanie: Before they start prostate cancer treatment, do you -- is this a question that is asked, “Have you had erectile dysfunction previously?” you know what kind of baseline you’re starting with?

Dr. Warner: Absolutely, yeah. Most of the surveys we have patients fill out -- or the questionnaires we have patients fill out before the operation at any of the visits -- address that issue. I think for patients it’s also important to bring that up to the physician when you’re deciding on treatment therapy.

Melanie: Do you feel, Dr. Warner, that this helps a patient or makes a patient decide on certain types of treatments for their prostate cancer? Do you think this is a big part of their decision whether or not this is going to be a side effect because this is a big deal for men?

Dr. Warner: It is, and I do think, probably inappropriately, a lot of men will base their treatment decision on their erections, honestly. And why I think it’s inappropriate because if we’re comparing surgery to radiation, the long-term effects of the radiation -- it might take a long time for those to develop --but if we compare surgery to radiation, the erectile dysfunction rates are equal. The nerves, though you’re not having an operation, the nerves are still going to be affected by the radiation negatively. A lot of men think that “Oh, I’m not going to get surgery, I’m going to have erections no problem,” but in truth, their erectile dysfunction rates are, by four to five years, going to be the same as somebody who has had surgery.

Melanie: So you would really like men to make this decision on their treatments, not based on this particular side effect, and to really put that aside when they consider their different treatment options?

Dr. Warner: Absolutely, and I think that the side effects from surgery are very predictable and very manageable. Radiation -- and the majority of men do fine -- but it does result in many, many unpredictable side effects, and the treatment options of those side effects can often be very challenging. I think the best analogy I’ve ever heard is that getting radiation is like throwing superglue at your body, and you just imagine all of these structures stuck together that are supposed to be free and mobile that any treatment that we offer you after the radiation therapy are not going to be as successful just because of the effects of radiation long-term.

Melanie: So then, what do you do for men after they’ve gone through -- whether it’s radiation therapy -- and they do start to report a recurring incidence of erectile dysfunction, what’s the first line of defense? What do you do for them?

Dr. Warner: Right, I think the first line is prevention. We are becoming more and more aggressive about our -- what we call penile rehabilitation after the operation, or after radiation therapy. This may include early oral medications such as sildenafil to help increase the blood flow to the penis during the recovery period. And we’re not expecting people to go out and have sex right away, but we think of it as any other body part. We need to have physical therapy. The penis needs to stay healthy during the recovery period, and for us, we use vacuum erection devices during the recovery period. And for us, we use oral medications in the recovery period to maintain the health of the penis while they’re going through recovery.

Melanie: And then what about the medications? They’re all over the commercials. They’re all over the media. You’ve got Viagra, and Cialis, and all of these things. Where do they come into play?

Dr. Warner: Yeah, so that is a good first-line option for a lot of men. I think the important thing to understand is that these medications rely on those nerves that run next to the prostate to function. For example, if somebody has had a non-nerve-sparing prostatectomy because of advanced disease, then, the oral medication should be skipped entirely, but for somebody who is going through radiation therapy, or somebody who had a nerve-sparing, this is a great option. It will allow the nerves to function more effectively.

Melanie: How long can they be using those medications?

Dr. Warner: As long as they work.

Melanie: That’s a good answer. Then, what if the medications don’t work, then what?

Dr. Warner: Yeah, so then we go on to our second-line therapy. Our second-line therapy includes a vacuum erection device, which essentially is a cylinder that goes over the penis. It creates a seal at the base of the penis, and with a vacuum effect, it will pull blood, giving an erection.

There’s also an ejection that we can put right into the penis. What that does is that bypasses those nerves, so if those nerves are completely damaged or gone, as long as there’s still good blood flow to the penis the injections are usually effective. A lot of men prefer that option over the vacuum, just because it’s a little more discrete, a little bit more on-demand, a little bit more spontaneous than the vacuum erection device.

Melanie: The vacuum erection device is a little bit cumbersome?

Dr. Warner: Exactly.

Melanie: And it’s something that they have to do at the time that they’re going to have intercourse --

Dr. Warner: Correct.

Melanie: And then they have this band placed, so it’s a whole thing that they have to do. Men really do choose penile injection therapy?

Dr. Warner: Yeah, believe it or not. I think -- what I tell most of my patients is that people are very surprised at how little it hurts and how well it works. I think a lot of these guys have already been trying the oral medications, and there’s a long delay time between when you take the pill and when you get the erection -- or when you get the effect. Men have to anticipate. With the injection, it’s more on-demand. A quick injection, within five minutes you have an erection.

Melanie: They give themselves this injection?

Dr. Warner: Yeah, yes.

Melanie: Wow, so you teach the men how to do this, and they’re willing to do this?

Dr. Warner: Absolutely, yeah. We have quite a number of patients who are on this therapy.

Melanie: And how often can they use this type of therapy?

Dr. Warner: Up to every 24 hours it’s safe.

Melanie: Wow, okay, so you’ve got vacuum erection device, you’ve got the medications, you’ve got the penile injection therapy, and then -- is there ever a time when surgical intervention is required?

Dr. Warner: Yes, absolutely. When those therapies quit working, or when someone who doesn’t tolerate the needle injections -- or doesn’t like the vacuum erection device -- there is a surgical option available. To be honest, everybody gets the idea that having an operation that is somehow wrong, or somehow bad. We use the analogy that it’s like a knee replacement for the penis. When the knee goes bad, you get a knee replacement. What happened to the penis is the blood flow is no longer sufficient to provide adequate erections, so we are going to replace that aspect of the erection.

It’s called a penile prosthesis -- an inflatable penile prosthesis. It’s very physiologic in the sense that it’s flaccid when you’re not in use, and then it becomes erect when you want to use it. If we compare patient satisfaction rates comparing oral medications, injections, vacuums, and the penile implant, far and away patients are happier with the penile implant than any of the other options. The reason is because everything is contained within the body. There’s no injections, there’s no pills, there’s no devices you’ve got to put on, and people are quite satisfied with it once they make that decision.

Melanie: Does it stay in for the rest of their life?

Dr. Warner: Yeah, the device -- it is a mechanical device. It’s got some working parts, so the expected lifespan of one of these devices nowadays is about 15 years with regular use.

Melanie: Then wrap it up for is, Dr. Warner, because this is really great information for men to hear, to put all these out there so that they know what their treatment options are, and the ones that they love, their partners can also understand. Wrap it up for us in what you tell patients every single day about the side effects of prostate cancer, treatments, and those options that they have if erectile dysfunction is one of those side effects.

Dr. Warner: Yeah, I think what I like to tell my patients is that don’t let the erections be the decision for treatment. Really look at the side effects beyond erectile dysfunction, and beyond urinary incontinence, because those problems can be treated. If you have good erections, we can guarantee you are going to have good erections after the operation. One way or another, we can get your erections back. It all depends on how important that aspect of your life is, but if it’s important, then we have really, really good options for you to make sure that you are able to preserve that aspect of your life.

Melanie: That’s certainly great information, and it’s really about the quality of life for the men that are going through these treatments. Thank you, so much, Dr. Warner, for being with us today. You’re listening to City of Hope Radio, and for more information, you can go to CityOfHope.org. That’s CityOfHope.org. This is Melanie Cole. Thanks, so much, for listening.