"Don't suffer in silence with your Erectile Dysfunction and Incontinence"

Dr. Sidney B. Radomski, Urological Surgeon, Toronto Hospital

Dr. Radomski spoke to us about erectile dysfunction and incontinence - the two complications that in his words we often get from having a radical prostatectomy and/or radiation. His area of expertise is as a urologist but he doesn't do radical prostatectomies any more, he hasn't done them in ten years, He says his area of research is treatment for incontinence, urinary dysfunction and erectile dysfunction and that's basically all that he does. In his own words he doesn't do radicals any more, he refers them to his partners.

The following is a condensed version of Dr. Radomski's talk. He said, I'm going to start off talking to you about erectile dysfunction. I'm going to dispel some of the myths. I don't have to be biased because I don't do the surgery. I will tell you the truth as opposed to your surgeon who's going to operate on you or the radiation oncologists who are going to tell you some things they hope are true. So, what is erectile dysfunction? It's basically the inability to maintain an erection that is adequate for sexual intercourse. People don't think that this is a common problem. The fact that Viagra is such a popular drug is evidence that it is. Let's look at statistics. There's a wonderful study that looked at a huge number of patients, it showed that 50% of the men between 40 and 70 have some degree of erectile dysfunction and impotence. This is without having a radical prostatectomy, so it doesn't surprise me that a lot of people after surgery or radiation are affected this way. What's important to realize is that both partners are affected in the relationship. Why do people get impotence? There are two reasons. One is that the nerves are affected or the blood vessels are affected. A lot of you may have heard about male menopause, andropause, it's a very sexy topic now for people. The problem with male menopause and the giving of testosterone, is that patients who have had prostate cancer cannot receive testosterone. So it's a non-issue for people who have had prostate cancer. We used to think that erectile dysfunction or impotence was psychological, it was all in our heads. Now we know that 85% of cases are physical, it's due to some problem with the blood vessels, or the nerves, or a combination. The good news is, and I tell my patients this all the time, I can give anybody an erection, it depends how motivated they are. And that's the bottom line. Now, what are some of the myths? Premature ejaculation is a sign of impotence. That's not true. It often occurs at the same time but it's not in any way connected to impotence. Low sex drive is a sign of impotence. That's not true. Low sex drive is connected to low sex drive. If you're not interested, you're not going to have sex. Impotence and infertility are connected. That's not true. Impotence is a natural consequence of aging. Not true. Aging is a non-issue. If you have a wonderful partner and you both enjoy having sex, there's nothing wrong with that. That's what God made it for.

So, what are the common causes? Well, diabetes is a very common problem. Vascular problems. Pelvic surgery such as a radical prostatectomy are a common problem. Neurological disorders, if you have Parkinson's, M.S., not as common. Medications, often related to other problems. And smoking! Smoking is the number one cause of erectile dysfunction. It never ceases to amaze me, patients come to me and say, Dr. I've been smoking for 40 years, why all of a sudden? Hello… It takes 40 years for the arteries to get clogged. That's why you shouldn't smoke. Alcoholism? Alcohol is not really a problem with erectile dysfunction and hormone problems are not pertinent to people who have prostate cancer. We classify erectile dysfunction in a number of ways. This is one way to do it. It is important to understand that the psyche of a patient is important. For instance, if you've had a radical prostatectomy and you're surgeon said you have an up to 30% chance of erectile dysfunction, that's going to stick in your mind. So there's going to be some anxiety. So it is psychologically related to some degree but it's not the main problem.

In a radical prostatectomy there are two things that happen. The nerves are damaged and/or the blood vessel supply is poor. So, you can imagine somebody who's 70 years old, they've smoked all their life, and they have this surgery where they tie all these blood vessels off and the arteries are not that great anyway, their erectile function wasn't superb before the surgery, even if they spared the nerves, there may be a problem with blood flow. And that's exactly what happens. I don't know what your surgeons tell you but the reality is, if you take all those who've had a radical prostatectomy, probably 80%/90% of them are impotent. This may be a shock to you. The reason that we know that, is that Dr. Walsh, the great nerve sparing surgeon - he operates on healthy 50 year old men - he selects those patients. So, of course, if you're younger and buy a lot of nerve sparing, the results are going to be better. The reality is that in Canada, most people are not 50 years old, most people are over 65, they have some problems like diabetes and smoking, therefore the results are very poor. That's unfortunately the reality.

Now, what about radiation. Most people seem to think that it's benign, doesn't cause any problems. Not true. The problem with radiation is that the effects of radiation continue on, even after you complete the radiation. What does radiation do? Radiation destroys blood vessels, as time goes on, you get fibrosis and as a result, what we see at Princess Margaret in our clinic, is that people one, two, three years after the radiation become impotent. The reason is that the blood vessels are effected. If you smoke, have diabetes, you can make that occur much faster. 50% eventually become impotent after radiation. It's not as bad as surgery.

If you have prostate cancer, you can't take testosterone because it makes the cancer grow.

What are the treatment options available today? We have to weigh the invasiveness of the treatment. The more invasive the treatment, the people don't want it. They'd rather have a pill and that's why Viagra is so popular. There are going to be two other drugs coming out in the next year. One of them looks like it might be better for people who have had a radical prostatectomy. The other option is a vacuum device. Some people don't like it because they say it's very mechanical. Other people rave about it. The problem is that people get tired of using these devices. but it works very well for the right patient. It gives most people a very good erection. It's a bit tedious but it works. Injection therapy works so so. There are two types of injection therapy, they work very well, the problem is that most people get tired of sticking a needle into their penis. Eventually people drop out, they stop using it - but it works very well. Then Muse, which is a little pellet, which works so so. Muse is a little suppository which goes into the tip of the penis and it's absorbed through the lining. It's the same drug that we inject with a needle but it's in pellet form. We're finding that it doesn't work so well and only about 25% of the people get a response. The vacuum devices work very well. Some people don't like them because they're very mechanical. Others rave about them. Again, the problem is that people get tired of using these devices. Then there is penal prosthesis. If all else fails, these are the option. They basically come in two types, the K-car and the Jag. The K-car gets you from point A to point B, it's a simple rigid rod in the penis. Whereas the Jaguar has a lot of moving parts, it's a fancy deal and you've got to love it because it's always in the shop. That's what an inflatable is. Because it has a lot of moving parts, things will break down with time and therefore you need a re-operation. They're very good, the inflatable closely simulates a normal erection. Now, what about Viagra. The four other options we've talked about work very well in people who have erectile dysfunction due to a radical or radiation. The problem is that Viagra, in some cases, doesn't work as well. The drug relaxes the smooth muscle of the penis to give increased blood flow to give an erection. If you take all comers, the results are about 85% able to have intercourse. For people who've had a radical prostatectomy the results are very poor. The literature says that 50% of people who have both nerves spared have good results. That's not my experience, I would say around 25%.

The second topic is incontinence, which is involuntary loss of urine, you're leaking when you don't really want to leak. There are a number of types, urge incontinence, stress incontinence, urgent stress, overflow and functional. Stress incontinence is the one that people get concerned about after a radical prostatectomy. Urine is stored in the bladder and the urethra is a tube that carries the urine from the bladder to the outside and there's two muscles, one at the bladder neck. When you do a radical prostatectomy you ruin this bladder neck muscle and potentially you can ruin the external sphincter muscle and that's why people leak. Because the prostate sits right on here, it's sometimes almost impossible not to do that. It doesn't mean that the surgeon's been terrible it's just unavoidable.

After a radical, 40 to 60% of men report some degree of incontinence. That can mean when your playing a game of golf and you have a full bladder and exert yourself, you may leak a few drops. That, to me, is not horrible. But what's significant is the guy who walks around with pads, who wears a diaper all the time. That's significant and that occurs in 10 to 20% of people after a radical prostectomy. Sometimes incontinence resolves 6 to 12 months after surgery. Often times it may take up to 18 months but if at one year it's still leaking, it's probably not going to get better. So why does this surgery cause incontinence? It's very simple. The outside or the external sphincter is damaged and that's the main reason.

Now, how do we deal with it? Well first, what about fluid intake. How many of you have been told by your family doctor to drink lots of fluid? It's the wrong thing to do. It's an old wive's tale. If you drink a lot, you'll leak a lot, so why would you drink 8 to 10 glasses of water a day. We tell patients not to drink so much. Caffeine and alcohol are bad - they're diuretics. Certain medications will get you up in the middle of the night, so don't take them at bed time. The incidence of incontinence after radiation therapy is a lot less - it's about 1 to 2%. It's still a curse, but it's not much of an issue. What's available to help? Monitor your fluid intake. Don't drink caffeine. Go on a regular basis.

Indwelling catheters are not a good idea. All kinds of problems can occur with those. What about bio-feedback? I'm sure you've all been told to do those Klegal exercises after a radical. There is absolutely no evidence that this will work. There are drugs but the drugs don't work because the problem is the sphincter muscle's damaged. Electrical stimulation doesn't really work. Some of you may have had your surgeon talk about bulking agents where they inject material into the urethra. We first did that in the late 1980s, because we thought this was going to be the answer instead of an artificial sphincter. The problem is it takes a great deal of this material to inject and it doesn't work that well and it doesn't last. The mainstay of treatment has been an artificial sphincter. Some of you may have heard that there's a new thing happening called the male sling which is a piece of material which goes under the urethra. I'd be very careful about it as it's new and there's not a lot of data available.

So, what is an artificial sphincter? It's a device for males who have post prostatectomy stress incontinence. 85% are cured or significantly improved. Complications are minimal. The revision rate is about 20% at five to eight years. It's the only thing that's effective and really works well.

Dr. Radomski concluded his talk and participated in a lively question and answer session for the next half hour.

Q Is there a shelf life to Viagra.
A Every drug has a shelf life and the reason is that there are fillers in the drug. The problem is that the compounds in the fillers can become toxic if you leave them sitting for five years. If you have any drug and the expiry has gone by two years ago, you shouldn't take it because it could make you sick.

Q I tried Viagra two years ago and struck out. Should I try it again?
A Research has shown that the greatest success of Viagra occurs at about 18 months. If it's not working in the first six months, there's no reason not to try it again. Studies have shown that Viagra needs to be taken six to eight times before you know if it's going to work or not.