Managing Impotence – A Patient Guide
Contents
1. hormonal therapy used to treat prostate cancer will decrease libido and impair erections Vascular Causes of Impotence Diseases such as high blood pressure high triglyceride and cholesterol levels in the blood cigarette smoking and diabetes mellitus and treatments such as pelvic irradiation to treat prostate bladder and rectal cancers may damage blood vessels to the penis over time There is strong epidemiological association between heart disease hypertension low levels of high density lipoproteins HDL and impotence Patients with Peyronie s disease which causes curvature of the penis trauma diabetes or old age may have damage to the spongy tissue of the penis causing the veins to be more leaky which can lead to impotence Drugs and Impotence Certain anti depressants or anti psychotics have been associated with impotence especially those drugs that regulate serotonin noradrenaline and dopamine These include Prozac Zoloft and Paxil Beta blockers and thiazide agents used to treat hypertension are associated with impotence Cimetidine a drug to treat acid reflux disease chronic alcoholism estrogens and drugs with anti androgen action such as ketoconazole and spironolactone can cause impotence decreased libido and male breast enlargement Even moderate alcohol intake may have an effect See Table VII Aging and diseases which cause impotence Aging even in healthy men causes a progressive decline in sexual functio2. Rosenbaum 2008 ISBN 0740768573 Coping with Erectile Dysfunction How to regain Confidence and Enjoy Great Sex by Michael E Metz and Barry W McCarthy 2004 ISBN 1572243864 Couples Confronting Cancer Keeping your Relationship Strong by Joy L Fincannon and Katherine V Bruss American Cancer Society Atlanta GA 2003 ISBN 0944235255 Discovering Your Couple Sexual Style Sharing desire Pleasure and Satisfaction by Barry W McCarthy and Emily McCarthy 2009 ISBN 9780415994699 Going the Distance Finding and Keeping Lifelong Love by Lonnie Barbach and David K Geisinger Plume 1993 ISBN 0452269482 Wonderful and realistic book about maintaining intimacy Hold Me Tight Seven Conversations For a Lifetime of Love by Sue Johnson NY 2008 ISBN 9780316113007 Stellar book on couples communication and intimacy Intimacy and Impotence The Couple s Guide To Better Sex After Prostate Disease by Ralph Alterowitz and Barbara Alterowitz De Capo Lifelong Books 2004 ISBN 0738207896 Written in an honest compassionate style by a patient with prostate cancer and his wife Discusses impotence in non medical terms with information about commercial treatments Gives practical advice about making love Includes everything from getting into the mood to common sense suggestions for having sexual satisfaction and intimacy when erections are not possible To Love and Be Loved by Sam Keen Bantam Books NY NY 1997 ISBN 0553375288 This is
3. a cure for prostate cancer www ustoo org Us TOO International Prostate Cancer Education and Support Network www prostatehealthcenter com A prostate health directory with links to prostate health prostate conventional treatments and prostate cancer websites www menshealthnetwork org Mens Health Network MHN is a non profit educational organization comprised of physicians researchers public health workers individuals and other health professionals www pcref org Prostate Cancer Research and Education Foundation www paactusa org Patient Advocates for Advanced Cancer Treatments www directorycancer com A health directory with links to cancer resources Other Sources American Association for Marriage and Family Therapy 112 South Alfred Street Alexandria VA 22314 3061 Phone 703 838 9808 Fax 703 838 9805 20 American Association of Sex Educators Counselors and Therapists P O Box 5488 Richmond VA 23220 0488 Phone 804 752 0026 www aasect org American Cancer Society Phone 800 227 2345 www cancer org CancerCare Inc Phone 800 813 HOPE 213 712 8400 www cancercare org fertileHOPE Phone 866 965 7205 www fertilehope org Sexual Function Health Council American Foundation for Urologic Disease Inc 1000 Corporate Blvd Suite 410 Linthicum MD 21090 Phone 410 689 3990 or 800 828 7866 Fax 410 689 3998 www afud org The Sexuality Information and Education Council of the United St
4. office Penile Injection e Generally performed with insulin syringe and small needle e Skin and injection site prepared with alcohol swab e Medication is drawn up in sterile manner with insulin syringe e Medication is injected on either side of the penis e Pressure is held on injection site for three to five minutes up to 10 minutes for those on blood thinners Table V Penile Injections continued properly rare Remember Side Effects e Occasionally associated with fainting dizziness low blood pressure e Priapism or prolonged erection occurs rarely e Can cause pain infection bruising and scarring if patients are not trained Things to e May require self stimulation to increase blood flow to the penis e If erection persists for more than six hours seek medical care at local emergency room or with your urologist e May be ineffective if patients have vascular disease or blood flow problems an Figure 4 Intra cavernous injection therapy After cleaning with an alcohol swab insert needle into side of penis and inject medication Figure 5 Auto injection technique The medication is drawn into the auto injector The side of the penis is cleaned with an alcohol swab and the injector placed against the penis Pressing a button then activates the injector and the needle is automatically inserted Vacuum Erection Device In patients who only have partial erections or who either do not r
5. released from the seminal vesicles and the prostate into the urethra The bladder sphincter then closes and the seminal fluid becomes trapped As the amount of fluid builds in the urethra the pressure increases and the sensation of the inevitability of ejaculation is experienced The bulbocavernous muscle contracts and expels the semen forcibly from the urethra Orgasm normally coincides with ejaculation Detumescence or loss of erection occurs shortly thereafter and is produced by the breakdown of the factors that cause erection N Cavernous nerve autonomic Deep dorsal vein Pe Dorsal artery Dorsal nerve somatic Dorsal artery Dorsal nerve somatic Circumflex artery Circumflex Sinusoidal vein spaces Helicine arteries Deep dorsal vein Tunica albuginea Trabecular smooth muscle Sinusoidal spaces P Corpora cavernosa Subtunical venular plexus Figure 8 Mechanism of Erection 16 Anatomy and Mechanism of Penile Erection The cavernous nerves travel from the underside of the penis to the prostate These nerves regulate blood flow within the penis during erection and flaccidity In the flaccid state inflow through the arteries is minimal and there is free outflow via the small veins exiting the spongy tissue just under the thick tunica thick membrane surrounding the spongy tissue During erection the smooth muscle in the penis relaxes while the arteries widen to pump in more blood that e
6. see that there are ways to ease the process Thousands of men will testify to the ease and effectiveness of injections The most commonly used agents include alprostadil or a combination of papaverine phentolamine and alprostadil Trimix The reason for using a combination of all three medications is to allow for a combined effect of the three medicines while keeping the dosages of each individual medicine low enough to prevent side effects Further the response rate for the Trimix solution is as high as 90 percent Men must have appropriate training and education before beginning home injection therapy The goal of the injection medication is to achieve an erection that is sustained for sexual intercourse but not prolonged or painful The injections must be given in proper amounts with the appropriate technique to minimize the risk of scarring in the penis or priapism prolonged erection The medication is injected along either lateral side of the penis First the medication is drawn into the syringe usually an insulin type syringe with a small very fine needle The medication is given into the spongy tissue of the penis called the corpora cavernosa After choosing the proper site to inject clean it with an alcohol wipe poke the needle through the skin of the penis and then inject the medication into the penis Immediately afterwards press firmly on the injection site with either an alcohol pad or gauze with your thumb and first finge
7. systemic side e Less natural erection effects e Effective in 66 71 percent of patients e Trapped ejaculate e Some find awkward to use Penile Prosthesis e Highly effective e Small risk of infection e For men who have e Requires anesthesia and surgery failed or are not satisfied with medical treatment of impotence e May require replacement after many years of use Oral Medications Three oral medications are commonly given for the treatment of impotence sildenafil Viagra tadalafil Cialis and vardenafil Levitra These medications improve erections by working locally on the penis by inhibiting an enzyme phosphodiesterase 5 PDE 5 Following sexual stimulation chemicals like nitric oxide are released at the nerve terminals causing relaxation of penile smooth muscles This occurs via a sequence of events beginning with nitric oxide and involving a compound cyclic guanine monophosphate CGMP PDE 5 breaks down cGMP and returns the penis to a flaccid state These medications by blocking the action of PDE 5 cause a resultant increase in the cGMP levels in the penis This improves smooth muscle relaxation and erection In the absence of sexual stimulation nitric oxide production will be minimal and these medications will have little effect on the penis These oral agents must be followed by sexual stimulation in order to achieve the desired erection Compared with those taking a placebo of an inactive or su
8. you and any possible partners ability to feel pleasurable sensations from cuddling or genital caressing remains unaffected With the right kind of stimulation including the possible use of a vibrator you should be able to reach a pleasurable orgasm even without an erection and with little or no semen A good way to resume your sex life is to use a gradual progressive approach and to make sure that you and your partner feel comfortable at every step Sensual mutually pleasuring activities with no performance goal can allow you to be intimate in a relaxed way A man and his partner may need to redefine what is important about their sexual relationship Although mutual caressing and kissing may be thought of as preparation for intercourse arousing each other and even reaching orgasm through hand or oral stimulation is an important component of intimacy and a common way to share physical pleasure and emotional closeness Your sex life should be based on what you and your partner mutually define as sexually satisfying and pleasurable and may or may not include penetration Men often overestimate the need for their partner to have penetration So although the physicians are going to advise you on the many ways to have an erection at those times when you may not be able to have or maintain an erection it is important to remember what it is that your partner desires Sexual intercourse is only one way of showing affection towards your mate If y
9. NY 1994 ISBN 0609805797 and 0684802414 Results of over 20 years of research pointing out the danger signals for troubled marriages with suggestions to help marital communication Sexuality amp Cancer For the Man Who Has Cancer and His Partner by Leslie R Schover American Cancer Society Go to http www cancer org search for Sexuality and Cancer Excellent comprehensive booklets that outline the effects of cancer and treatment effects on sexuality with suggestions for staying healthy Sexuality and Chronic Illness A Comprehensive Approach by Leslie R Schover and Soren Buus Jensen Guilford Press NY NY 1988 ISBN 089862715X Sexuality and Fertility After Cancer by Leslie R Schover Wiley 1997 ISBN 0471181943 A useful book about sex and fertility that is helpful in learning how to enjoy sex again and how to make informed choices about pregnancy after cancer treatment Sex When You re Sick Reclaiming Sexual Health After Iliness or Injury by Anne Katz Praeger Publishers Westport CT 2009 ISBN Websites www phoenix5 org Phoenix 5 s mission statement is to help men and their companions overcome the effects of prostate cancer http www prostatepointers org mailman listinfo pcai PCAI offers an open and frank discussion about the problems associated with intimacy and prostate cancer www prostatecancerfoundation org The Prostate Cancer Foundation funds high impact research to find better treatments and
10. UCSF Medical Center Your Health Matters Managing Impotence A Patient Guide Peter R Carroll MD Tom F Lue MD Stan Rosenfeld and James F Smith MD Department of Urology UCSF Comprehensive Cancer Center University of California San Francisco Greetings These guidelines are designed to address impotence and the treatment for men with this problem and their partners We hope that this information will give you confidence about addressing any erectile problems you may experience no matter the cause For some people this information is completely new Others may be well informed about impotence and its treatment options and much of what is discussed may be familiar Either way don t feel that this material has to be fully absorbed in one sitting Also reviewing the information presented here with your physician may make it more specific to your needs We would be grateful if you could fill out the questionnaire at the end of the booklet and return it to us with your feedback This will help us ensure that future editions of this booklet address your questions and concerns If you would like to discuss the various treatment options UCSF has medical professionals and patients available to speak with you To talk with a medical professional contact the UCSF Center for Reproductive Health at 415 353 3075 To receive the contact information for a patient who has had an erection problem and tried available aids contact the UCSF H
11. a beautifully and simply written book on the various aspects of loving relationships and how to establish and maintain intimacy in communication The Lovin Ain t Over The Couple s Guide to Better Sex after Prostate Disease by Ralph and Barbara Alterowitz Health Education Literary Publisher Westbury NY 1999 ISBN 1883257034 Man Cancer Sex by Anne Katz Hygeia Media 2010 ISBN 9781890504878 Men s Sexual Health Fitness for Satisfying Sex by Barry W McCarthy and Michael Metz Taylor amp Francis Group LLC 2008 ISBN 9780415956383 Men Women and Prostate Cancer A Medical and Psychological Guide for Women and the Men They Love by Barbara Rubin Wainrib Michael Droller Jack Maguire and Sandra Haber New Harbinger Publications Inc Oakland CA 2000 ISBN 1572241829 The New Male Sexuality Revised by Bernie Zilbergeld Bantam Books 1999 ISBN 0553380427 A common sense practical discussion of the fantasy model of sex and myths of male sexuality discusses the importance of an individual s conditions for good sex and includes specific self help chapters that deal with common male and couple s sexual problems Our Journey Through Prostate Cancer by Jim and Julia Miller JJM Publishing San Francisco CA 2003 ISBN 0974317209 Overcoming Impotence A leading urologist tells you everything you need to know by J Stephen Jones Prometheus Books Amherst NY 2003 ISBN 1591021286 A Patient s Guide to Male Sexual D
12. ates SIECUS 130 West 42nd Street Suite 350 New York NY 10036 Phone 212 819 9770 Sexual Medicine Society of North America Inc 1111 N Plaza Drive Suite 550 Schaumburg IL 601731 Phone 847 517 7225 Fax 847 517 7229 www smsna org 21 22 Managing Impotence Questionnaire Please take a few minutes to answer the following questions Your answers will help improve future editions of this guide Please check the appropriate box Neither Strongly agree nor Strongly Statement agree Agree disagree Disagree disagree Overall the guide was helpful L Q m m m The information was presented o o o o o clearly and in a way that was easy to understand Statement Too much Just right Too little The amount of information presented was Q Q Q 1 What was most helpful about the Guidelines 2 What was least useful about the Guidelines Why 3 Should anything have been made more understandable 4 Should anything be added or discussed in more detail 5 Was anything in conflict with what you already know about erectile dysfunction ag over If you would like to talk about the Managing Impotence Guide with a member of the group that prepared it please write your name and phone number at the bottom of the questionnaire and one of the authors will contact you Please detach the questionnaire and either bring it in to the reception desk in the Uro Oncol
13. clofen e Alcohol e Nonsteroidal anti e Marijuana Mechanisms of Penile Erection A normal erection requires the penis nerves and blood vessel systems to be intact and to have appropriate hormonal levels but also is moderated by psychological factors The penis is stimulated by both the autonomic nervous system the part of the nervous system that functions independent of our conscious thought and the somatic nervous system the nervous system responsible for sensation and contraction of muscles attached to the penis The glans or head and body of the penis have numerous sensory nerve endings that send messages of pain temperature and touch back to the brain The motor nerves stimulate the muscles in the pelvis and penis the ischiocavernosus and bubocavernosus muscles that are necessary to produce a rigid erection and ejaculation The autonomic nervous system stimulates the rectum bladder prostate and sphincters includes the cavernous nerve that stimulates the penis and controls the flow of blood during and after erection Figure 8 With sexual stimulation the cavernous nerves release chemicals that significantly increase blood flow to the penis The erectile tissue of the penis rapidly fills expands and becomes erect During sexual activity the bulbocavernous and ischiocavernous muscles of the penis are stimulated which compresses the base of the penis to make the penis even harder During emission seminal fluid is
14. d the prosthesis is then sized and the proper device is then placed The inflatable device a pump that contains the inflation and deflation mechanism is placed in the scrotum The patient can control his erection at will by pushing a button under the skin Although placement of the prosthesis requires a surgical procedure patient and partner satisfaction rates are as high as 85 percent Full penile length might not be restored to the patient s natural erect status Rare side effects include infection pain and device malfunction or failure As the nerves that control sensation are not injured the penile sensation and the ability to have an orgasm should be maintained Causes of Impotence Impotence can be due to psychogenic neurogenic vascular or drug induced factors or a combination these factors Many medical conditions have been associated with impotence See Table I Table VI Causes of Impotence Category of Impotence Conditions associated with Impotence Psychological e Depression e Sachizophrenia e Performance anxiety e Stress e Relationship problems low testosterone Neurogenic e Stroke e Spinal cord injury e Pelvic surgery injury e Diabetic neuropathy or radiation Vascular e Atherosclerosis s Trauma e Smoking e Pelvic surgery injury or radiation e Hypertension e Peyronnies disease e Diabetes Hormonal e Hypogonadism e Hyperprolactinemia high prolactin Drug Induced e Excessi
15. ecialist may be warranted For men with acquired penile curvature Peyronie s disease or complex sexual concerns an earlier referral may be warranted Data from Padma Nathan H McCullough AR Levine LA et al Randomized double blind placebo controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve sparing radical prostatectomy Int J Impot Res 2008 20 479 486 Montorsi F Brock G Lee J et al Effect of nightly versus on demand vardenafil on recovery of erectile function in men following bilateral nerve sparing radical prostatectomy Eur Urol 2008 54 924 931 Mulhall JP The role and structure of a postradical prostatectomy penile rehabilitation program Curr Urol Rep 2009 May 10 3 219 25 Urethral Suppository MUSE Prostaglandin E1 alprostadil placed inside the penile urethra medicated urethral system for erection MUSE has been used when oral medications have been unsuccessful Large studies from Europe and the United States demonstrated that MUSE was effective in 43 percent of men with impotence from various causes The major advantage of MUSE therapy is that it is applied locally and has few side effects The major drawbacks are that it may cause moderate penile pain and it can have an inconsistent response rate This pain can be decreased by applying intraurethral lidocaine jelly prior to placing the pellet Sometimes the use of a rubber r
16. elen Diller Family Comprehensive Cancer Center s Resource Center at 415 885 3697 Table of Contents Introduction What is Impotence Impotence and Cancer Surgery or Radiation 13 Causes of Impotence 15 Mechanisms of Penile Erection 16 Future Directions 17 Additional Resources Find a Doctor 888 689 8273 lt Patient Education Library www ucsfhealth org education Introduction Impotence is a relatively common problem affecting up to 30 million men of all ages in the United States and over 150 million men worldwide The ability to have an erection requires the normal integrative function of nerves blood vessels muscles and the brain Impotence may result from psychological neurological hormonal or vascular impairment or any combinations of these factors Our main goal in this Patient Guide is to explain how to effectively treat impotence as well as how a normal erection is achieved and what conditions may cause impotence What is Impotence Normal male sexual function involves several processes sexual desire or libido the erection when the penis becomes firm release of semen ejaculation and orgasm Erectile dysfunction commonly known as impotence is defined as the inability to achieve or maintain an erection that is sufficient for satisfactory sexual activity However almost all men who have impotence can overcome it Sexual desire the release and expulsion of semen emission and ejaculation a
17. er a high fat meal e If you do not achieve an erection with stimulation you can increase the dosage of medications used the next time sexual activity is planned After surgery most men require doses of 100mg of Viagra or even more e Take 10 mg of Levitra one hour before you are ready to engage in sexual activity e Levitra works best 30 minutes to four hours after taking the pill If you do not achieve an erection you may need to increase the dosage For Cialis take 10 mg up to 36 hours before you are ready to engage in sexual activity Cialis can be taken after meals If you do not achieve an erection on 10 mg higher dosages can be taken Consult your doctor regarding higher doses Most common side effects include headache facial flushing and upset stomach s A small number of patients taking Viagra or Levitra may complain of a blue cast to their vision sensitivity to light or blurred vision Cialis is not associated with visual side effects Back pain and joint aches can occur with Cialis Things to Remember Do not use Viagra Cialis or Levitra more than once per day Do not use Viagra Cialis or Levitra if you take medications such as nitroglycerin Nitrostat Nitro Bid Nitro Dur Isordil and Ismo or Deponit e Do not use Levitra if you are on medications such as Flowmax Hytrin or Cardura e Do not use Cialis if you are on Hytrin or Cardura Flowmax in doses of 0 4mgq is well tolerated Peni
18. espond to other treatments or prefer not to use them a vacuum erection device maybe useful The device consists of a plastic cylinder connected to a pump and a constriction ring A vacuum pump uses either manual or battery power to create suction around the penis and bring blood into it a constriction device is then released around the base of the penis to keep blood in the penis and maintain the erection A vacuum erection device can be used safely for up to 30 minutes which is when the constriction device should be removed The advantage of such a device is it is relatively inexpensive easy to use and avoids drug interactions and side effects Side effects may include temporary penile numbness trapping the ejaculate and some bruising Figure 6 Vacuum Erection Device Figure 7 Example of a three piece inflatable penile prosthesis Penile prosthesis For men with erectile dysfunction who have failed or cannot tolerate other treatments a penile prosthesis offers an effective but more invasive alternative Prostheses come in either a semi rigid form or as an inflatable device Most men prefer the placement of the inflatable penile prosthesis The placement of the prosthesis within the penis requires the use of an anesthetic A skin incision is made either at the junction of the penis and scrotum or just above the penis depending on which prosthesis and technique is used The spongy tissue of the penis is exposed and dilate
19. gar pill men taking PDE 5 inhibitors report a higher satisfaction rate in overall sexual function orgasm penile rigidity and maintenance of erections A patient s response to these medications may reach from 70 to 80 percent depending on patient age health etc For those men who have undergone radical prostatectomy early and aggressive use of these medications may be associated with a more rapid return of sexual function by preventing smooth muscle atrophy of the penis Levitra has very similar duration of action compared to Viagra 6 8 hours Cialis has similar mechanism of action but may be active for longer periods up to 36 hours Studies show that all three drugs seem to be well tolerated with few side effects Men at risk for heart attack or stroke should consult with their physicians before beginning these medications as there could be serious side effects of this drug in this group of patients Patients who are on medications such as Hytrin Cardura and Flowmax to improve urinary symptoms should not take Levitra Patients on Hytrin or Cardura should not take Cialis however Flowmax at 0 4 mg per day is well tolerated Table II Oral Medications How to take Oral Medications Viagra Levitra Cialis Side Effects e Take 50mg of Viagra one hour before you are ready to engage in sexual activity e Viagra works best 30 minutes to four hours after taking the pill e Viagra works best on an empty stomach Do not take Viagra aft
20. ing used as an adjustable penile constricting device and applied at the base of the penis improves results Patients should have the first application performed in the physician s office as complications such as urethral bleeding decreased blood pressures sustained and prolonged erections as well as a vasovagal reflex feelings of lightheadedness or decreased blood pressure may occur rarely Table IV MUSE Therapy How to Use MUSE Therapy e Patients partners should be trained in the office e Pellet of medication is inserted into urethral opening e Medication is absorbed to produce erection Side Effects e Penile pain e Can rarely cause priapism a prolonged erection greater than six hours e Fainting dizziness low blood pressure Things to Remember e After placement stimulation is required to increase blood flow to the penis e Medication should be refrigerated e Maximum use is limited to one suppository per day Pellet inside urethra Figure 3 Application of intra urethral suppository and constriction device Application for intra urethral delivery of alprostadil Depressing the end releases the pellet into the urethra Constriction ring may enhance penile response Penile Injection When oral medication fails penile injections to induce erection are another alternative to treat impotence Even if you are among the many men who shudder at the thought of injecting into the penis please read on to
21. is defined by more than just the ability to have an erection Mutually satisfactory sexual relationships can be maintained in the presence of impotence For more information about this look at some of the books listed at the end of this booklet Impotence is common with age and in the presence of other medical conditions Prostate Cancer t Chronic Disease Healthy With Risk Factors Healthy Without Risk Factors c LS 5 Oo Cc 2 V gt QO 2 C2 O Q Ww f CO ww E L oO oO co O o D oO Le GU oO GH a 50 54 yr 55 59 yr 60 64 yr 65 69 yr 70 74 yr 75 79 yr 80 84 yr 85 90 yr Age Figure 1 Prevalence of Erectile Dysfunction with Age in Different Patient Populations Chronic disease includes other cancer hypertension cardiac disease diabetes or stroke Risk factors include antidepressant use consumption of more than two alcoholic drinks per day smoking obesity lack of exercise and watching television for more than 8 5 hours per week Data from Ann Intern Med 2003 Aug 5 139 3 161 8 Printed with Permission from the American College of Physicians Impotence and Cancer Surgery or Radiation Impotence following major pelvic surgery or radiation including prostate and bladder surgery has been widely reported During a radical prostatectomy the nerves which allow erection called cavernous nerve bundles and which lie within millimeters behind and on the side of the
22. lated to patient age pre treatment sexual function and the length of time hormone therapy is given Even if impotence is present after surgery or radiation alone the ability to achieve an orgasm should remain However with the prostate and seminal vesicles removed there is no ejaculate During orgasm there is no emission or expulsion of semen The ejaculate volume will decrease with radiation as well Treatment of Impotence yO LX The type of treatment will depend on AG ANN the reason s for impotence patient ay hy age health and patient and physician eil l preference Most often a step wise Blacider Tee Plexus approach will be taken beginning with an S ST Pudendal Nerve oral medication and depending on its VA Ne ie te f Rectum effectiveness and patient tolerance other he Ou 7 a MA approaches may be tried L L ia 7 A N A lt Cavernous Nerves Coping with Erectile Dysfunction AN 1 Dorsal Nerve The information provided below is what N X j you need to know when the best efforts by your physician still do not result in satisfactory erections Bear in mind though Figure 2 Nerves of the Pelvis Note the close relationship of the that penile rehabilitation takes time prostate to the cavernous nerves Nerves that allow erection Unfortunately erection problems are common after treatment for prostate cancer Although your treatment s may have lessened your chance for getting or maintaining an unassisted erection
23. le Rehabilitation Several recent studies suggest that maximizing blood flow to the penis after nerve sparing radical prostatectomy can improve erections and decrease the likelinood of needing treatment for impotence after recovery from surgery This penile rehabilitation protocol includes the following treatments Table Ill Penile Rehabilitation Two weeks prior to e 100mg Viagra 20 mg Levitra 2x week and 50mg Viagra 10mg prostatectomy Levitra on days not taking 100mg Viagra dose While catheter in place e Viagra 50mg daily Levitra 10mg immediately after radical prostatectomy or 10mg Cialis 3x week After catheter removal e Viagra 50mg daily Levitra 10mg or Cialis 10mg 3x week Also give Viagra 100mg Levitra 20mg weekly with sexual stimulation Evaluation of sexual function If you have a response to oral medications penile fullness or 8 12 weeks after surgery erection continue 50mg Viagra 10mg Levitra 4 5 days week and 100mg Viagra 20mg Levitra 2 3x per week Alternatively use Cialis 20mg 3x week If no response to oral medications begin Penile Injections and vacuum erection teaching Consider beginning injections 2 3x week or vacuum erection use 2 3x week Also give 50mg Viagra Levitra 10mg 4 5 days per week Evaluation of sexual function If no spontaneous erections after 1 year and unsatisfied with 12 months after surgery penile injections or vacuum erection device a referral to a sexual medicine sp
24. n Medical studies have discovered that as men age there is a decrease in turgidity or stiffness of erections as well as a decrease in the force and volume of ejaculation Also with normal aging there is an increase in the length of time required between erections after orgasm called the refractory period Further the sensitivity to touch decreases over time as do serum testosterone levels with an associated decrease in desire Studies indicate that half of all men with diabetes will eventually develop impotence In addition those with liver cirrhosis chronic renal failure or coronary artery disease have a high incidence of impotence 14 Table VII Drugs and Impotence Class of Drug Drug Antihypertensive e Methyldopa e Clonidine e Reserpine s Beta blockers atenolol propranolol metoprolol e Verapamil e Guanethidine Anti androgens e Ketoconazole e Cyproterone acetate e Finasteride e Gonadotropin releasing hormone EEE agonists Lupron e Flutamide Zoladex Cardiac Drugs e Digoxin e Clofibrate e Gemfibrozil Diuretics e Thiazides e Spironolactone Hydrochlorothiazide H2 antagonists e Cimetidine e Ranitidine Antidepressants e Tricyclic migraine e Serotonin Reuptake Inhibitors Prozac Zoloft Paxil e Pheothiazines e Benzodiazepines Vallium Xanax e Meprobamate e Barbituates inflammatory drugs e Lithium Other Drugs e Narcotics e Tobacco e Ba
25. nd the ability to have an orgasm occur as a result of several different physical mechanisms Due to a variety of reasons they can be dissociated or separate from one another For example orgasm and ejaculation can occur without erection Sexual desire or libido is determined mainly by the amount of a hormone called testosterone in the body As men get older the amount of testosterone that circulates throughout the body slowly declines decreasing libido A decrease in libido also may result from depression and various medical problems that affect overall mental and physical well being Ejaculation the release of semen during sexual activity is affected by testosterone levels and medications as well as by the normal anatomy of the prostate and bladder Decreasing amounts of testosterone often occurring as a result of normal aging will affect the volume of the ejaculate Certain medications may also affect ejaculation With aging the volume of the ejaculate decreases Surgery on the prostate or bladder and radiation can affect the amount of secretion produced as well as the ability to have normal ejaculation Orgasm occurs as an experience of intense physical and emotional pleasure during the sexual act and can occur separately and independently from erections emission or ejaculation Many factors including emotional and psychological considerations contribute to the experience of orgasm It is important to realize that male sexual function
26. ogy Department at the UCSF Comprehensive Cancer Center or mail it to Your Health Matters Managing Impotence A Patient Guide Department of Urology Box 1695 University of California San Francisco San Francisco CA 94143 1695 SDURO0095 e Rev 9 10
27. ou would like access to sexual or marriage counseling please ask your physician for a referral Table Treatment for Impotence Type of Therapy Advantages Disadvantages Oral Medication Viagra Levitra or Cialis e Pills taken by mouth e Effective in many men e Not effective in patients who have prostatectomy unless nerve sparing approach used e Requires sexual stimulation to be effective e Side effects including headache Viagra and Levitra may cause blurry vision e Cialis may cause joint or back pain e Should not be used in some patients e 30 60 minute wait for response e Cannot be taken with some medications Intra Urethral Suppository MUSE e Small pellet placed in the urethra without needles e Few systemic side effects e Effective in 43 62 percent of men e Can cause penile pain e Requires training e Refrigeration required e May require tension ring placed at base of penis for best effects e Side effects include rarely painful and prolonged erection of more than six hours fainting dizziness Penile Injection e Highly effective up to 90 percent e Few systemic side effects e Works in three to five minutes e Some medications require refrigeration e Requires injection e Requires office training e Can cause penile pain e Can cause prolonged erection and penile fibrosis or scaring Vacuum Device e Least expensive e Can cause numbness or bruising e No
28. prostatic capsule may be injured by being cut or separated from the prostate This may cause temporary or permanent impotence although sexual desire and the ability to achieve orgasm should remain Radiation to the prostate the bladder or rectum can damage the cavernous nerves as well The nerve sparing radical prostatectomy or radical cysto prostatectomy procedures to remove a cancerous prostate or bladder attempts to preserve these cavernous nerve bundles without compromising complete cancer removal In the hands of an experienced surgeon if both nerve bundles are spared 50 to 90 percent of patients depending on age and health may have an eventual return of unassisted erectile function over time When only one nerve bundle is spared the percentage of patients that have return of erections over time is 25 to 50 percent If a non nerve sparing technique is used the potency rate drops to 16 percent or less depending on patient age Aside from the degree of nerve sparing surgery performed other factors are associated with impotence after radical prostatectomy The biggest risk factor is age Studies have shown that while the majority of men under 50 years of age are potent after radical prostatectomy only 22 percent of men over the age of 70 are potent after the procedure Other medical conditions that increase the risk of impotence include hypertension smoking diabetes elevated cholesterol hyperlipidemia and heart disease Depres
29. r to compress the area for at least five minutes or up to 10 minutes for patients taking blood thinning medication such as coumadin The medication tends to work better if you stand as it allows more blood to go to your penis Also external stimulation to the penis increases blood flow to the penis and allows the medication to take effect faster An auto injector is a spring loaded device that inserts the needle into the penis very quickly minimizing the discomfort and psychological hesitancy It comes in two forms a simple non prescription device designed to insert the needle for you and a prescription device that also depresses the plunger for you You can check with your local drug store for the non prescription simple auto injector Many men prefer the auto injector that does not inject the medications for them because they maintain the necessary feel to know that they have injected in the right place and to the right depth Improper injection and any subsequent scarring can lead to penile curvature and nodules in the penis so it is important to get the proper training before beginning injection therapy Most men and their partners find that injection therapy is easy to perform and are very pleased with the results Some patients will use injection therapy early on after surgery and then switch to oral agents as their sexual function improves over time Table V Penile Injections How to Perform e Patients should be trained in the
30. sion as well as other psychogenic factors may affect psychological well being and recovery of potency Unfavorable clinical and pathological stage of cancer also is associated with worse potency outcomes as these men may not be candidates for a nerve sparing approach because it may leave cancer behind It should be remembered that even if both nerve bundles are spared with their proximity to the prostate See Figure 2 these structures will likely suffer some injury that will take time to heal Healing of the cavernous nerves and return of any unassisted sexual function may not begin until six months or more after surgery however it usually continues to improve over the next two to three years Indeed a large percentage of men may not recover sufficient function for 18 to 36 months With prolonged disuse the smooth muscles of the penis may atrophy which worsens erections Early and aggressive treatment of impotence with erectogenic therapy oral or injection medication vacuum erection device may improve and speed up recovery of erectile function For men undergoing radiation the amount and extent of radiation as well as whether or not they are treated with hormone therapy correlates with the likelihood of impotence either temporary or permanent The reduction in libido and possible difficulties with erections from the use of hormone therapy is generally reversible when the therapy is discontinued The likelihood of irreversible effects is re
31. ve alcohol consumption e Androgen deprivation LHRH agonists i e Lupron e Anti hypertensives e Anti depressants e Chronic renal failure Zoladex Other Conditions e Older age e Obesity aaia dili aiaa e Diabetes e Peripheral vascular disease e Heart disease Psychological Causes of Impotence Common causes of psychogenic impotence include depression and performance anxiety Depression is associated with decreased energy interest and decreased libido or desire Performance anxiety work stress or strained personal relationships can affect erectile function in both conscious and subconscious ways Neurogenic Impotence Penile erection depends on an intact nervous system so any injury to the nervous system involved in erections may cause impotence Diseases such as Parkinson s disease Alzheimer s disease stroke or head injury can lead to impotence by affecting the libido or by preventing the initiation of the nerve impulses responsible for erections Patients with spinal cord injuries will have decreased erections related to the extent of the injury Patients who have undergone pelvic surgery such as radical prostatectomy cystectomy or colectomy may have injury to the cavernous nerves that control erection Long standing diabetes may affect some nerves as well as causing impotence Hormonal Causes of Impotence Diseases and conditions that decrease circulating testosterone in the body such as castration or
32. xpands the three cavities of the penis also called sinusoidal spaces to lengthen and enlarge the penis The expansion of these cylinders compresses the small veins and reduces the outflow of blood Lue T F Erectile Dysfunction New England Journal of Medicine June 15 2000 1802 1813 Reprinted with Permission from the Massachusetts Medical Society Future Directions Innovative research over the past several years has resulted in significant strides and improvement to understanding the anatomy and physiology of sexual function For instance increasing knowledge about details of the cavernous nerves in the pelvis led to refinement of nerve sparing prostatectomy Understanding the biochemistry of normal sexual functioning led to the development of medications including Sildenafil Cialis and Levitra Current research is focusing on further understanding of the specific physiologic pathways responsible for normal sexual function developing new more effective agents for managing impotence and understanding how cavernous nerves heal and what factors can hasten the healing process Use of gene or stem cell technology may be possible in the future allowing men and their partners to enjoy better sexual health Additional Resources Books Becoming Sexually Active Again by Christine Derzko David Bullard Ernest Rosenbaum and Malin Dollinger in Everyone s Guide to Cancer Therapy by Andrew Ko Malin Dollinger and Ernest
33. ysfunction by Tom E Lue M D Handbooks in Health Care Co Newtown Pennsylvania 2000 ISBN 1884065821 Perfect Love Imperfect Relationships Healing the Wound of the Heart by John Welwood Random House Inc 2006 ISBN 1590302621 Eloquently describes how our deepest longing for love is in fact the key to healing our personal wounds and the world at large Echoes Buddha with the message that we have direct access to the love and happiness we most long for as our very essence Prime Time Sexual Health for Men over Fifty by Leslie R Schover Holt Rinehart and Winston 1984 ISBN 0030640288 Provides validation and useful suggestions for men and their partners Prostate Cancer What Every Man and His Family Needs to Know Revised by David G Bostwick Gregory T MacLennan and Thayne R Larson Villard NY 1999 ISBN 0375753192 Rekindling Desire A Step by Step Program to Help Low Sex and No Sex Marriages by Barry W McCarthy and Emily J McCarthy Brunner Routledge NY NY 2003 ISBN 0415935512 An excellent programmatic way of working with low sexual desire that can be adapted to regaining sexual function after medical treatment Recommended in concert with the help of a qualified psychotherapist The Seven Principles for Making Marriage Work by John Gottman and Nan Silver Three Rivers Press NY NY 1999 and Why Marriages Succeed or Fail And How You Can Make Yours Last by John Gottman Fireside Simon amp Schuster Inc NY
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