Conversations With Prostate Cancer Experts

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Are Male Survivorship Treatments Experimental?


Dr. 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

Miner Head PhotoHow 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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(Subscribers were sent a copy of the issue on September 1!)


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Erectile Dysfunction After Prostate Cancer

AM headshot for MHBDr. Abraham Morgentaler is the Founder of Men’s Health Boston ( and an Associate Clinical Professor of Urology at Harvard Medical School, Beth Israel Deaconess Medical Center. He is a regular contributor to television and radio shows addressing male issues and has appeared on NBC Nightly News, CBS Evening News, CNN with Anderson Cooper, and The Connection on NPR.

Dr. Morgentaler frames this month’s Prostatepedia conversations on erectile dysfunction and testosterone after prostate cancer.

Erectile dysfunction (ED) affects a very high percentage of men who get any form of treatment for prostate cancer. And yet, ED is an issue that has not received enough attention. I’ve certainly seen many men who didn’t want to have any treatment for their prostate cancer because they were afraid they were going to lose their ability to have sex. Some men say it’s not worth it: “If I can’t have sex, I’m not a man. I feel like I can’t provide sexually for my partner.”

In my last book The Truth About Men and Sex, I discuss a number of cases from my practice. I think that people have misunderstood what sexuality is for men. The stereotype is that men are stuck back in their spring break years regardless of how old they are or how much they’ve evolved and matured and that they’re only into sex for themselves and their own satisfaction.

The truth is that many of the men I see who are in established relationships feel terrible about their erectile dysfunction not only for themselves but also because they feel like they’re letting down their partner.

Sex, as I like to say, is the special sauce of relationships. It’s the thing we don’t talk about much, but most happy couples are having sex and most unhappy couples are not. That doesn’t mean that happiness comes directly from the sex, but it’s part of it certainly.

Now, the good news for men is, thanks to advances in modern medicine, we can help pretty much any man be able to have sex, even if he’s got erectile dysfunction from treatment of his prostate cancer. It may not be quite as easy and simple as sex was beforehand, but losing one’s erections after treatments of prostate cancer doesn’t mean that it’s the end of a man’s sex life.

The reasons why men develop ED after prostate cancer depend on the form of treatment he’s had.

For surgery—one of the most common prostate cancer treatments—the issue is likely related to the nerves that control erections, which run to the penis but are plastered along the sides of the prostate itself.

In 1982, Dr. Patrick Walsh of Johns Hopkins figured out how to save the nerves in what’s called a nerve-sparing procedure. Before that, 100% of men who had the surgery had ED afterward. But even this nerve-sparing technique, which has been used for 30 years, is imperfect.

Subscribe to read this month’s conversations about ED after prostate cancer.

Almost allT men will lose their erections for a period of time after surgery. A good number will get them back, but it’s much less than 100%. Some estimates say 20% will be able to recover erections fully, and others say 50%. Based on my experience and the literature, I’d say probably about 25% of men are able to regain full erections without the need for aids like Viagra (sildenafil) and Cialis (tadalafil).


Radiation and brachytherapy, in which radioactive pellets, or seeds, are placed within the prostate, can cause trouble in two ways. One is by damaging the tissues of the penis through the radiation, as the deep structures of the penis are not that far from the prostate. The second is that they may hurt the nerves that control the erections just like with surgery.


The difference with radiation is that ED is delayed so that right afterward, men who were fine before treatment are still fine. Two years following treatment, the number of men with good erections is pretty much the same for both radiation treatments and surgery.


For men about to go into treatment, I think it’s important to consider that ED becomes more prominent as you get older. The number of men in their 60s and 70s who have erectile dysfunction is very high. The Massachusetts Male Aging Study published in the 1990s showed that men between the ages of 40 and 70 had a 52% self-report rate of some degree of ED.


For those men who already have ED, the decision to have surgery or radiation for their prostate cancer is a little bit easier. Regardless of the cause of ED, there are doctors who care and offer services to help men to have sex again, whether they’ve had prostate cancer treatment or not.


It’s a difficult question about how to balance treatments that may save one’s life 10 years down the road with the unpleasant and unwanted side effects that may begin right after treatment. That decision is complicated further by confusion about which prostate cancers need to be treated. We’ve been treating too many men, leaving them with little in the way of upside for benefits and with all the complications that come from treatment.


If you have been diagnosed with prostate cancer, the first step is to determine if yours is the type of cancer that’s going to affect you in your lifetime. The second step is to have an honest, open conversation with your physician about what it means in terms of sexual function.


I see a lot of men before they decide on a treatment: they want an opinion about how likely it is that the radiation or surgery will affect them sexually before deciding on a path.


At that point, we go over the options available to them after treatment. If you have that conversation, you may then have a clearer mind about getting treatment. One of the relatively nice things about prostate cancer, as compared to many other cancers, is that it does tend to grow slowly, giving you the luxury of being able to make decisions and gather all the information over a period of time without really affecting your outcome.