Meeting the treatment expectations of men who have been left impotent and incontinent after prostate removal for cancer requires a careful understanding of their priorities. Understanding patients allows us to embark on a step-by-step approach to address each problem.  I was taught by one of my mentors (and my experience has confirmed) that it is often difficult to treat a man’s impotence if he is still leaking urine, especially when this occurs during arousal and sexual activity.  We call this climacturia, and most men are never told that it will happen after their prostate is removed.

Nearly all men after prostate surgery have experienced some leakage during arousal. Fortunately for most men, as they regain control of urination, fewer men continue to have leakage during sex. For obvious reasons, many couples are bothered by actual urine leakage, but climacturia is also associated with shame and embarrassment. This can lead to men and couples avoiding being intimate, prevention of good erections, and frustration in a relationship.  

Being aware of a few simple practices has the potential to reduce how much this type of incontinence can affect intimacy:

1. Keep an open mind and be creative
2. Remember to do your Kegel exercises
3. Empty your bladder before engaging in sexual activity
4. Have hand/paper towels nearby
5. Consider using a condom to catch drips
6. Experiment with different positions

Where do we go when this doesn’t solve or settle the issue?

1. Have a discussion with a urologist
2. Ask about seeing a physical therapist specialized in male incontinence/pelvic muscle rehabilitation
3. In select cases, we might consider minimally invasive surgical procedures, such as a urethral sling designed specifically for men

In the past, we would consider doing surgery at the same time as a penile implant if this was required, but currently I think it is in a man’s best interest to approach each problem (even though connected) one at a time. This doesn’t mean men cannot use medications like Viagra, penile injections or vacuum erection pumps in the meantime. One of the other reasons to delay surgery, gets back to my initial statement that impotence often doesn’t improve until we have adequately controlled urine leakage.  Occasionally, men are surprised that when they are finally dry during sex, they feel more ‘in the mood’, are more likely to pursue intimacy and  have better erections or respond better to the therapies– and that, of course, is a great thing!

Keeping an open mind, knowing your options, and speaking with a trusted urologist can make all the difference for men and couples experiencing climacturia.

Image attribution
Site: flickr.com [Image 1]

When it comes to being a urologist, some would say that sexual dysfunction isn’t sexy. Historically urologic surgeons chased the big cases like kidney, bladder and prostate removal. While there is tremendous need for these important operations (and I respect the skills and care of the urologists performing those surgeries) I eventually discovered that it wasn’t for me.  What I learned over time was that quality of life after cancer surgeries was just as important to a man’s survivorship.

I counsel men weekly about treatment options for a new diagnosis of prostate cancer.  Most of these men are in good general health, active, working, in relationships and enjoy being sexually active. Whether they choose surgery or radiation to treat their cancer, I acknowledge that what I am asking them to consider is like asking them, “If I were going to push you in front of a bus, which bus do you prefer [surgery or radiation]?” Even though most men do very well after prostate cancer treatment, a man’s quality of life can suffer. Until we address the treatment-related side effects, such as erectile dysfunction (ED), we fail our patients.  I explain that the reason you go through treatment is so you will be “around for years to come,” and hopefully with a quality of life not at all different from what they enjoy before treatment. I invite all of my patients to return anytime after their treatment to discuss their sexual and/or urinary dysfunction if their needs are not being met.

Addressing underlying conditions
This type of encounter, year after year, made me understand that the care that happens ‘after the cancer is cured’ is just as important– and even becomes the priority– yet historically we have not be great at carrying this torch. I quickly appreciated that the impact of successful treatment for ED was significant and life-changing for both men and their partners.  Furthermore, I learned that this benefit is experienced by all men who develop sexual dysfunction, whatever the underlying cause: diabetes, heart disease, hypertension, high cholesterol, low testosterone, trauma/injury, Peyronie’s disease.  

I’ve had to respond to comments like, “That’s great, but you’re not really treating disease.”  I explain that after thorough evaluation for underlying causes, I diagnose men with diabetes, hypothyroidism, and vascular disease. In doing so, I am able to help men begin to receive the care they need for these problems. Erectile dysfunction (ED) is a precursor for serious conditions like stroke, angina, and heart attack, often preceding those events by only a few years. People are surprised to learn that working up a ‘trivial’ sexual complaint can essentially save a life.

More than a ‘shot clinic’
In recent years, there has been a surge in the number of what we call “shot clinics.”  Anyone who listens to talk radio has probably heard an ad for a men’s health clinic, with an offer of a ‘free consult’ and ‘guaranteed success on the first visit.’  Men are taught to do penile injections and/or given testosterone, with little evaluation or discussion of all their options. Men are then asked to purchase large quantities of medications, and many clinics have a ‘subscription service for the meds: as long as you’re buying, they’re interested. I have seen countless men who went to one of these clinics, feeling frustrated with unsatisfactory results, seeking answers to their unanswered questions. To me it’s obvious that offering only one treatment for sexual dysfunction is not enough, and the information and treatment gap is huge.  In fact, it is out of this need that this specific business model for ED prospered.  

Good information, thorough evaluation, and comprehensive care options are needed to fill the void. Sadly, there is often no time at the end of a visit with your PCP or urologist to fully address sexual dysfunction. It’s easy to prescribe a ‘blue pill’ as the appointment wraps up, but what if that doesn’t work, or didn’t work the last time you tried it?  This is can add insult to injury for men already frustrated with poor performance.  As urologists, we are uniquely qualified to care for these problems with training in both the medicine and surgery for the genitourinary system (penis, testicles, prostate)– if we take the time to ask the questions.

Communication is key
Meeting with men and their partners has become a very rewarding part of my practice. Sexual dysfunction encompasses a lot of conditions, not just erectile dysfunction.  It’s rare that men tell me anything that I haven’t heard before, whether it is about problems with orgasm, ejaculation, pain, injury, deformity, sex drive, desire or identity. As a trainee, I approached these visits with dread, then early in my practice I accepted my own challenge: making men feel comfortable talking about intimate personal details within seconds of meeting me had to be the goal. Unless I was able to understand the whole picture and the impact the problem was having, (not just the mechanics) I wasn’t offering much more than the docs who don’t like treating sexual dysfunction. Quickly, I discovered that I was able to do this with a surprising amount of ease. Giving men a place to speak discreetly and honestly allows me to better treat them successfully, helping them restore healthy sexual functioning. How great is that?

In closing, I guess you could say that I stumbled into sexual medicine as a specialty, and I am glad I did. The feedback that I receive from my patients confirms that I am helping men/couples find solutions to important problems and improving quality of life.I can live with that.

Image attribution
Site: flickr.com [Image 1]