For several years we have prescribed Viagra, Cialis and Levitra to men recovering from prostate surgery.  Before that, we recommended regular use of penile injections or a vacuum erection device.  We call this approach ‘penile rehabilitation’.  The goal is to keep the blood vessels in the penis ‘limber’.  By doing this, the hope was that men would be left with better erections after the treatment and healing period.  It is not so clear and some studies show and improvement.  Other studies suggest there is no benefit.  So what is a man recovering from prostate supposed to do?

A recent article in the Journal of Sexual Medicine, sheds some light on issue.  It is not a study but an article called a meta-analysis.  This type of article reports the findings of many existing studies.  After very careful selection of the better studies  the data is analyzed.

In a nutshell it’s a bit confusing but here’s my read:

1. In terms of erectile function / recovery:  penile rehab does not improve the degree / amount of recovery. Men who are on penile rehab do not fare better at the end of recovery with medications like viagra.
2. Men who used medications, injections or vacuum for rehab however experienced better sexual function during the period of rehab.  They had better erections as they recovered.  I deduce that this is probably a happier patient.

My opinion:

1. Penile rehab helps in the psychological recovery of men who wish to be sexually active. It allows them to experience better erections during recovery.  I think it gives them more confidence.
2. Even though the end function is not improved, there are benefits to the vascular tissue of the penis. As a result of rehab less stiffness in the blood vessels develops, compared to not doing it…. use it or lose it.

Last word:

In summary, I think that penile rehab is a good idea for a man who is recovering from prostate removal surgery, if he wants to be sexually active during the recovery.  His erections will be better than the guy who wants to be active but isn’t on rehab.  And probably as important is that for men who aren’t interested in being sexually active during the recovery, they are not missing an opportunity if they aren’t treated with penile rehab.  There are various approaches, but usually it involves taking a low dose of the erectile function medications on a daily basis.

This weekend, I received an email from a man, who described a history of prostate cancer, impotence / erectile dysfunction (as a result of prostate surgery) and penile curvature (Peyronie’s disease).  At the present time he is no longer responding to medications for erectile dysfunction.  He has already seen another urologist who suggested that he undergo surgery to place a penile implant for his condition.  His question for me was about my approach.  Here is a snippet of how I replied:

•  In general, men with erectile dysfunction and Peyronie’s disease (curvature) are best treated with a penile implant, which can correct 20-30 degrees of curvature just by placing the device. This will recover some of the lost length that comes with Peyronie’s disease. Additional sutures are sometimes placed to further straighten the penis, but have the risk of some shortening of the penis.  More invasive reconstruction is an option, and it involves incising the scarred area on the penis then placing the graft.  It restores some of the lost length but has the added risk of temporary numbness because usually we will have to elevate the nerves that give sensation to the penis to place the graft.  Permanent numbness is rare, however.

Further questions

He then asked about which implant I use and why:

• In my practice, I only use Boston Scientific penile implants because they feel more natural and have antibiotic coating, lowering the risk of infection.  Specifically, in men with curvature I will only use the CX700, because use of the LGX700 will result in an erection, but it won’t be firm enough because of the scar tissue in the shaft of the penis where the scar originates.

Finally, he asked about sex drive (libido) and insurance coverage:

• Libido is a separate function and is not affected by penile implant.  Similarly, men will still orgasm.
• Many insurances cover penile implant and Peyronie’s surgery, and Medicare covers both.  We obtain authorization at the time of scheduling surgery to confirm.

Having implant surgery for incontinence with an artificial sphincter or undergo penile implant is an important decision.  Preparation in the days and weeks before surgery is also critical.  Achieving a good outcome starts before you arrive at the hospital and it is my primary goal for men.

• You will be notified if your urine culture or nose swab is positive for MRSA bacteria, in which case you will need to have this cleared before surgery.

• Skin care / preparation
  • Do not shave or clip the hairs in the groin or around the penis for 2 weeks prior to surgery;  I will do this at the time of the operation
  • Purchase the skin cleanser, Hibiclens.  
  • Starting 3-4 days before your surgery you will use the cleanser daily.  In the shower, lather up the soap from the naval / belly button to the top of the thighs and include the penis and scrotum.  Leave on the skin for 5 minutes then rinse.
  • If you develop open sores, rash or cuts in the skin leading up to surgery please let us know.  This will need to be examined.  Rarely, surgery is postponed until these things resolve.

• Please read all of the paperwork provided by the surgery scheduler.  This is where your surgery time, arrival time and preop information will be found.
  • You will be instructed to call the hospital preoperative program (or attend the appointment if it was required).  They will instruct you on which medications to take and which to stop.
  • If you have a pacemaker or defibrillator, take blood thinners or have a history of heart problems, it is best to get clearance from your cardiologist or primary doctor.  This is elective surgery and we want to ensure that you are healthy at the time of the operation.

• Good blood sugar control, for diabetics, facilitates better healing and less risk of infection after surgery.

• If you use a C-PAP device, bring this to the hospital on the day of surgery.

• Likely you will spend the night in hospital, and you may be sent home with a catheter.

• Please contact us for clarification or if you have further questions about the preparation.

Consider reading my blog post on Recovering from Penile Implant Surgery.

• Photo by Erol Ahmed on Unsplash

Treatment is an important step for those suffering from depression–but treatment can also present an additional host of unexpected and uncomfortable circumstances for patients. Regardless of the side effects, treating depression is critical to maintaining optimal mental and physical health, and the benefits certainly outweigh the consequences. It can be frustrating, however, when treatment interferes with a patient’s sexual health. Commonly prescribed antidepressants can have a negative impact on libido and/or orgasm–but there are solutions that mean you won’t have to sacrifice your sex life to maintain your mental health.

Depression and sex

Anyone that has suffered from depression knows that it can have a significant impact on your overall physical well being. Oftentimes, this means a decrease in energy. Coupled with lower self-esteem and feelings of inadequacy, depression is a recipe for a sex drive disaster. From this perspective, there’s generally no place to go but up in dealing with depression; but patients undergoing treatment are often surprised to find that while other areas of their life are improving, their sex drive remains low and they may experience decreased sensitivity during intercourse.

Sexual side effects

Approximately 30-70% of patients taking an antidepressant experience some form of sexual dysfunction as a side effect of their medication. Typically men may experience a lower than normal sex drive or that it’s hard to achieve an orgasm during intercourse. While side effects can certainly contribute to sexual issues, low self-esteem or self-image may also be a factor. These negative thoughts can persist even after depression has been treated. Feeling bad about your body or yourself can be equally as damaging to a healthy sex life as the chemical impact of medications.

Reduce the impact

A study from the American Academy of Family Physicians found that “Decreased libido disproportionately affects patients with depression. The relationship between depression and decreased libido may be blurred, but treating one condition frequently improves the other.”

In addition to taking prescribed medication, therapy can help patients break out of negative thought patterns. Therapists can teach patients healthy coping methods to deal with the depressive thoughts and low-self esteem that impact sexual performance. Couples therapy can also be a good way to open the lines of communication between a patient and their partner.

If you’re still experiencing lowered libido, talk to your doctor about other options available to you. They’ll help you identify whether or not it’s your SSRI or some other factor that’s impacting your sex life. Under the direction of your doctor, you may be able to switch or reduce your medication, experiment with the time of day you take your prescription, add erectile dysfunction medication, or take a doctor-supervised “drug holiday,” a temporary break from your medication. There’s no reason to suffer.

Photo credit Pexels.com

This past weekend I received a text from mother, wishing me a ‘happy anniversary’!  Each year it takes me a moment to remember that she is referring to my surgery for testicular cancer 12 years ago.  It seems so long ago.  Mothers have a way of remembering 🙂

It is unusual for me to discuss an issue like this in my workplace, but occasionally, I have found it very helpful to disclose to men upon hearing that they have cancer.  Your world changes when you’re told you have cancer, even in the ‘best’ case scenarios, where the problem is lower risk (as mine was).  I understand how my world changed, and when I receive the annual anniversary text from mother, I give pause and am grateful to be healthy.  I found my cancer doing a Testicular Self-Examination, and since I’m a urologist I knew what I was feeling and I found it early.

This month is MOVEMBER  Men grow a mustache as a symbol of awareness to men’s health and cancer issues.  I’m not doing it this year, but have done it in the past.  It’s about men taking action about their own health, receiving screening and routine medical care.   Sooner is better than later, as it was in my case!

Here’s my MOvember pic from a few years back…  No captions please!

In the course of treatment for erectile dysfunction, some men may be treated with penile injections. This method involves men injecting medications directly into the penis,instead of taking a pill like Viagra. This is the most direct route, and a very effective treatment for ED. In general, obtaining medication to do this type of injection is different than obtaining other prescriptions.  

Penile injections for ED
Commercially available injectables include Edex and Caverject, and some insurances may cover them. However, most plans do not cover them, and they can be very expensive, from $50-$100 per dose! Obtaining the same medications from a compound pharmacy reduces the cost significantly, bringing it to $8-$20 per dose, depending on the type of medication, dose used, and compound pharmacy.

Compound pharmacies
When I mention ‘compound pharmacy’ most men have never heard of it. Typical pharmacies sell only medications that are ‘pre-packaged’ and sold ‘as-is.’ Compound pharmacies are different. From the FDA website, “a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.” This allows us to tailor the strength and even combine 2, 3 or 4 medications, increasing the efficacy or potency of the compound solution.

In the Seattle area, a online search for compound pharmacy yields a few different results. We have worked with most of the pharmacies listed, and all of them have at least a couple of commonly used compounds readily available. Prescribing injections that are not part of that pharmacies ‘usual compounding’ results in a higher price, because each unique solution requires quality testing. Each pharmacy will also have a different price often for similar compounds. It pays to do some research, and some men find using an online compounder is the most convenient.  

It is important to note that the medications that go ‘into’ a compound are FDA approved, but once compounded into a solution, it is NOT FDA approved. This type of prescribing is called ‘off-label’ and in general is safe, however quality can vary. I encourage everyone to read this information from the FDA about compound pharmacies.

Image attribution
Site: flickr.com [Image 1][Image 2]

Testicular self-examination is a quick and easy way for men to catch issues quickly if/when they arise. Typically recommended for men over 18 years of age, self-examination takes just a few minutes and can be performed in the comfort of your own home. The process can help men identify lumps on the testes.  Personally, I found a lump of my own, which turned out to be cancerous.  Fortunately, it was small, and I received the treatment I needed at the earliest possible stage.

How to perform a self-exam

• Perform a self-examination once a month after a warm shower, when the scrotum is relaxed and changes can be more readily identified.
• Grasp the testicle with your thumb on top, and pointer and middle finger on the bottom and roll gently, yet firmly.
• Feel for swelling, hardness, lumps, or changes to the texture of the scrotum.
• Familiarize yourself with the epididymis, the tube at the back of your testicles that stores and carries sperm to the vas deferens. This tube can often be mistaken for a lump. Its equally important to become familiar with how it normally feels.  If it is sore to touch, this could be a sign of a common infection called epididymitis.

Causes of testicular lumps
Testicular lumps are not always a cause for alarm. While they can indicate cancer, there are many other benign conditions that can present themselves as lumps. Varicoceles can cause swelling due to enlarged veins in the cord above the testicle, while hydroceles causes swelling as a result of fluid build-up around the testicle. Epididymal cysts may cause one testicle to feel heavier than the other, are generally painless and will usually feel like they are above or behind the testicle. Swelling caused by infection may often be painful and accompanied by fever or unusual testicular placement or redness and thickening of the skin.

If you’re experiencing pain, collection of fluid in your scrotum, an ache in your groin or abdomen, or swelling in your chest, it’s important to schedule a doctor’s appointment as soon as possible.

When to contact your doctor
If you found a lump, you might panic or be scared, but don’t minimize or think it ‘will go away’.  Contact your doctor any time you detect a change in your testicles. Identifying the cause of a lump in its early stages is critical for treatment–whether it’s cancerous, or caused by other medical conditions. Your doctor will use a variety of methods and tests to determine the cause of any testicular abnormalities, and work with you to find the best treatment solution. Often a simple examination in the office is all that is needed to rule out serious causes.  When indicated, an ultrasound is a very good test to evaluate the testicles.

Image attribution
Site: flickr.com [Image 1]

Erectile dysfunction rarely happens on its own. More often, it is the result of an underlying medical issue, from heart disease to mental health problems. One of the leading causes of ED is diabetes–and it can begin unexpectedly years after your diagnosis. According to research from Boston University, “Of those diabetic men who will develop impotence, 50% will do so within 5-10 years of the diagnosis of their diabetes.” Diabetes directly causes erectile dysfunction when unmanaged blood-sugar levels damage nerves and blood vessels, or when diabetes contributes to co-occurring conditions, like coronary artery disease or high blood pressure.

When you have ED caused by diabetes, it can often feel like you’re fighting two separate battles. The fortunate reality of the situation is that with proper diabetes management, you can “kill two birds with one stone”–by reducing the impact of your diabetes, you can minimize its tendency to prevent erections and interfere with intimacy.

Addressing diabetes
Proper daily glycemic control is a critical step in minimizing ED. Not only will your chances of getting an erection be improved, but your response to ED medications, like Viagra, will be more successful when your day-to-day blood sugar levels are stabilized. Following your diabetes care plan will not only improve your quality of life, but can improve your sexual health as well.

Just as important as your daily diabetes management is your long-term glycemic control. Your primary care provider, along with your urologist, can help improve your outcomes by looking at the bigger picture of your health care and figuring out how you’ll manage your diabetes moving forward. In conjunction with medications, lifestyle changes like losing weight, exercising more often, and quitting smoking can contribute to regulating your blood sugar over the long-term.

Urology solutions
If you find that you’re still experiencing ED even with proper diabetes treatment, consider consulting a urologist to learn more about other options that are available to you. Whether you’ve been diagnosed with ED or not, it’s important to be screened for the condition as it can lead to early detection of more serious diabetic complications, like heart disease.

Your urologist can offer a number of different solutions to eliminate your erectile dysfunction, from prescribing medication and injections to recommending a penile pump or implant. Certain penile implants, like the AMS line, are prefered for diabetics, as they are antibiotic-coated to prevent infection. If you chose to receive a penile implant, managing your blood sugar level will be even more important to ensure that you don’t contract an infection during or after your surgery.

Relief from diabetes-related erectile dysfunction is possible, whether you’ve just been diagnosed or have been struggling for a while. By involving your PCP and consulting a urologist, you can address both your physical and sexual health for the best outcome and a future free from ED.

Image attribution
Site: flickr.com [Image 1][Image 2]

A good night’s rest is essential in maintaining peak performance–physically, mentally and emotionally. It’s also an important part of maintaining healthy testosterone levels. Recent research suggests that interrupted or short sleep can have a negative impact on your sexual function, contributing to low levels of testosterone and erectile dysfunction.

The sleep apnea connection
One of the leading causes of interrupted sleep in adult males is sleep apnea. The condition is caused by a blockage of your airways while you sleep, causing you to wake frequently (even if you’re not noticing it). This can be a result of obesity, age, physical factors (large tongue, tonsils or small jaw), or nasal obstruction as a result of allergies or other sinus issues.  Left untreated, it can increase a man’s risk of heart disease, hypertension and stroke. Many men seeking treatment for erectile dysfunction also fit this profile of a sleep apnea patient.

Taking a holistic approach to your sexual health can improve your overall quality of life. Experiencing symptoms associated with low testosterone, like sexual dysfunction or muscle loss, while also experiencing daytime fatigue can be an indication that sleep apnea is causing your hormones to go haywire. Low testosterone can also be an indication of other physical issues, like injury or illness.

According to a CNN article from sleep specialist Dr. Lisa Shives, “testosterone is produced during the night; the levels climb steadily throughout the night and peak in the morning. There are studies showing not only that a decrease in the total amount of sleep can lower a man’s testosterone, but also that REM sleep is important to the production and release of testosterone. We know that REM sleep is often decreased or absent in patients with sleep apnea. Therefore, it seems that both the quantity and quality of sleep are important for testosterone production.”

Finding a solution for better sleep & sex
The quickest way to overcome sleep apnea is with a CPAP machine. The CPAP (continuous positive air pressure) device keeps your airways open while you sleep by increasing the air pressure in your throat. There are many different models that you can choose from to ensure the best fit for a comfortable night’s sleep. The best part? Studies suggest that typically after just two weeks, your sleep quality will return to normal.

While some newly diagnosed people with sleep apnea may be initially put off by the machine, there are a whole host of reasons to give it a shot. While you may find the machine cumbersome at first, or feel embarrassed about wearing it around your partner, you can rest easy knowing that you’re doing both of you a favor! You’re not the only person suffering from your untreated sleep apnea–many partners report loss of sleep or being awoken by the gasping or snorting sounds associated with the condition. By wearing the mask, you’ll also be preventing some of the other common issues associated with sleep apnea: weight gain, stress, hypertension, GERD, and frequent nighttime urination.

A CPAP machine isn’t the only way to solve sleep apnea and related sexual health complications. While addressing the issue immediately is helpful, eliminating the causes of the condition will not only improve your sleep, but your sexual health as well. Obesity is a significant contributor to both sleep apnea and low testosterone, so a proper diet and exercise routine can work wonders in both arenas. Untreated sleep apnea can also contribute to diabetes, which in turn contributes to erectile dysfunction. Stopping sleep apnea in its tracks can prevent sexual health complications down the road.

As a urologist, I do not personally diagnose or treat sleep apnea, but I will recommend obtaining a sleep study if low testosterone is an issue for a patient.

Image attribution
Site: flickr.com [Image 1][Image 2]