Wednesday, July 12, 2017

'Penile Rehabilitation' After Cryo Surgery - Not Like After Radiation

In a blog post five years ago I cited the work of cancer specialist Dr. John P. Mulhall, and the need for "penile rehabilitation" in prostate cancer patients who've undergone surgery or radiation, e.g.

Mulhall is the author of an academic monograph entitled: "Sexual Function in the Prostate Cancer Patient,"  and also wrote a less technical book for actual prostate cancer patients and their significant others, entitled: "Saving Your Sex Life: A Guide for Men with Prostate Cancer".  In this book, Dr. Mulhall takes the 'bull by the horns' and shows that men who've had prostate cancer treatments - whether radical prostatectomy, radiation or hormone therapy, actually face immense work to overcome the attendant sexual problems.

The incipient damage is called "atrophy" which increases in probability the longer a patient goes without erection,  post-surgery. (p. 98) Atrophy is, in fact (op. cit..):

"a scarring of the erectile tissue, and if the erectile tissue scars, the patient will never get his own erection back and will always struggle with medication".

Dr. Mulhall goes on to note (ibid.) that "the incidence of erectile tissue damage, as measured by the presence of venous leak is very uncommon before the fourth month after surgery. However, at eight months after surgery it "occurs in about 30% of men and at one year 50% of men".  This also occurs or can occur after high dose radiation which I had in September, 2012.

Radiation attacks the DNA in cells. It causes breakages in the DNA, and when this occurs, the cells commit suicide, a process known as apoptosis. Normal cells have better repair machinery to fix some radiation damage while cancer cells do not.  As well as killing off the actual prostate cancer cells, radiation causes injury "to the blood vessels that supply the cancer."

As Mulhall notes later, these blood vessels- many of them - also supply blood to the erectile tissues. Most shocking to me was to read that erectile success rates are the same for surgery and radiation after 24 months, and while radiation oncologists tend to look at sexual function after 12 months or so, Mulhall indicates it needs to be 3-5 YEARS after (p. 83) . He refers to this as a "glaring deficiency" (ibid.) and adds:

"Any study looking at erectile function outcomes should really assess these outcomes at no sooner than 24 months, if not 36 months, after the completion of radiation."

So, bottom line, I knew going into focal cryosurgery salvage treatment (treatment after initial radiation) the chances were not good to recoup erectile success. What I wasn't prepared for after the cryo is that this would plummet even more than after the high dose radiation (5 year mark). Of course, you are informed that though the targeted cryo can eliminate the localized tumor there is no assurance that adjacent nerve networks can't be damaged. This is because, unlike the tumor, these nerves branch out and aren't so localized.  The risk is also much greater for older patients, i.e. over 65 (I am 71).

On Monday I returned to UC Health in Aurora for the follow up appointment (after the procedure done on June 20th). This was with Dr. Crawford's professional assistant, Kristen -  a 26- year old woman and Columbia University grad. She had me fill out a "sexual and urinary function" form and then went over it with me afterward. The form covered about 15 aspects, i.e. urinary frequency, urgency, erectile quality, maintenance etc. - each on a 0 to 5 scale.  

I also, since I reported urinary frequency beyond the norm, had to submit to a bladder ultra sound in the office, performed by a medical assistant. Kristen noted that if the urinary retention was too high in the bladder (over 100 ml, after urinating) I might have to have a bladder dilation performed. Naturally then, I was relieved the retention volume was barely 30 ml.

In terms of the sexual -erectile aspect, and interestingly connected to the urinary issues as well, Kristen pointed out that both could be improved by taking 5 mg of Viagra or Cialis each day. As also noted by an American Cancer Society website., this is not enough to produce erections but it is sufficient to keep some blood flow going to those tissues which otherwise would receive little or no oxygen.  Thus, she sent in a prescription for our pharmacy.

The ACS site in relating similar information, points out that - typically - erectile quality, if it is to return at all, usually happens after two years. It takes the nerves roughly that long to heal, so we see that cryosurgery, like radical prostatectomy - is not exactly without its issues (including some incontinence).  In the meantime, it is important to be doing the low dose PDE inhibitor .  Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells, which promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this, since else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion the PDE5 enzyme.

In terms of orgasms, Kristen pointed out that these were still possible even without erections.  As noted on a UCLA website:

"An erection is not necessary for orgasm or ejaculation. Even if a man cannot have an erection or can only get or keep a partial erection, with the right sexual stimulation you can experience an orgasm. Your orgasm has little to do with your prostate gland. As long as you have normal skin sensation, you can have an orgasm."

As far as "supplementary aids", Kristen did mention possibly using special vibrators which "we could discuss at a later date", which was fine with me.

The session lasted about an hour, including the ultrasound, and the takeaway I came away with was that I was certain most men didn't have clue one what they were sacrificing when they opted to have prostate cancer treatments of any kind.  It also helped me understand the many thousands of men who refused to have any treatments, opting to do "watchful waiting" instead. (Alas, as Dr. Crawford had told me in our November meeting, that wasn't an option for me given the Prolaris score)

The tragedy is that this cancer can wreak so much havoc especially on younger males, some in their early 40s, who've reported serious marital problems, e.g. on the 'Team Inspire' group.   Once you're in your 70s this isn't so much of an issue, but still you don't want to see certain organs just waste you kind of do whatever the dr. (or his P.A.) suggests.

My primary hope is that the physical (also mental - see my post on memory loss) sacrifices are worth it and this is the final end of this damned cancer. Kristen said I need to get a first PSA test done early next week and then another in three months. I hope that all future PSA test results are as close to 0.0 as possible!

When I jokingly told Kristen: "No more biopsies!"  She laughed and said "We'll see."

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