I can still recall vividly in July of 1012, when my prostate biopsy results came back and my urologist informed me (in a post-biopsy office visit) that I had adenocarcinoma in 5 cores, Gleason scores of 3, 3 in two and 3, 4 in the others, At the one hour meeting he wanted me to realize that I had no choice regarding some kind of treatment and that passive waiting wasn't an option. It had to either be a radical prostaectomy or radiation therapy. He leaned toward the first given that he was an expert in the field of da Vinci robotic suergery.
But I'd made my mind up a week before, to have the radiation therapy, in no small measure because of Dr. Mulhall's book. (Chapter 1, on 'The Basics of Sexual Function' is especially useful for brushing up - irrespective of the type of treatment chosen). There were two factors that swayed me: 1) reading in Dr. Mulhall's book (p. 45) that "positive margins" (remnant cancer cells) can be left behind in radical prostatectomy - something I learned that can even happen to the most experienced surgeons - especially using da Vinci robotics, and 2) the fact that my wife had already worked 20 years in a radiation therapy setting (brachytherapy software corporation) and knew where I could get the optimum treatment.
When my urologist heard my choice of treatment he also concurred, saying tha for my age (then 66) the results were pretty much the same whether one chose surgery or radiation.
So, I opted for high dose rate (HDR) brachytherapy, at the Helen Diller Cancer Center at the University of California San Francisco (UCSF). I was also extremely fortunate, in that only a few months before I arrived at UCSF the multiple treatment form of HDR was replaced by the one time HDR brachy treatment based on a study done by Dr. Alvaro Martinez at William Beaumont Hospital-Center which showed that the results for a single treatment were good, with low toxicity. (See, e.g. the William Beaumont Hospital-Center site on Alvarez techniques, or Google 'IPSA for HDR brachytherapy' )
My treatment was carried out Sept. 25th of 2012, after being admitted at 8 a.m. then having the implant procedure about two hours later, after receiving epidural anesthesia (I chose to be awake the whole time, as I like to do in the case of colonoscopies - call me weird!) The implant surgery - in which a template is sutured to the perineum to allow the introduction of the transfer tubes bearing the Iridium 192 needles into the prostate - took barely 45 minutes, after which I was wheeled into the recovery room before being taken (2 hrs. later) for a CT scan, then the actual radiation delivery.
The whole administration lasted about 20-25 mins. I received a total dose of 1930 cGy (centigray), with bladder-rectal sparing contours - optimized by UCSF's specialized IPSA planning software. The rectal-bladder sparing radiation was at 90 percent of the full dose. The most painful part of it all? Probably when the Foley (catheter) was removed.
Following the treatment, I was pretty well prepared for the effects to follow - thanks again to Dr. Mulhall's book. Mulhall, for example, superbly describes how radiation works to effect a cancer treatment (p. 78):
"Radiation therapy works by killing cells. It kills not just cancer cells but normal cells. However, those cells that are the most rapidly dividing are the most sensitive to radiation (as is true for chemotherapy). Fortunately, most cancers have cells that are dividing more rapidly than normal cells.
Radiation attacks the DNA in our 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."
Alas, 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."
Another aspect is "loss of ejaculatory volume". Mulhall again on p. 80:
"Radiation therapy results in reduced ejaculate volume as the function of the prostate and the seminal vesicles is to produce ejaculatory fluid, and in most men, will result in loss of ejaculation completely".
Reading this is critical because the information helps to allay groundless fears. Thus, in my own experience post-treatment, I found the effects indicated by Dr. Mulhall fit my own situation markedly. The knowledge meant that I didn't become as frustrated as I might have. Since I now understood the physiology better. After one year, of course, efficacy has decreased further because of increase blood vessel damage from the radiation (this increases as time goes on).
Another effect, dysorgasmia (i.e. orgasmic pain) As Mulhall observes, p. 113:
"This is a peculiar problem which is seen more frequently after surgery than radiation, but is seen in both cases, and believed to be related to spasms of the muscles of the pelvic floor at the time of orgasm. The bladder neck is supposed to close at the time of orgasm, and the belief is that the bladder neck muscle and the muscle surrounding this in the pelvic floor may in some men go into spasm at the time of orgasm with pain referred to the penis, testicles, lower abdomen or rectal area."
Mulhall goes on to state the pain "typically lasts from seconds to a minute" but in some men can last for hours after orgasm. In my case, the pain was much like that experienced as the first needle entered for my prostate biopsy back in 2012, with an incinerating pain referred to the whole urethra. That lasted maybe a minute, but the first orgasm after radiation treatment saw the pain lasting up to five minutes afterward, and of such intensity that I nearly passed out. Again, I'd have been shaken to the core had I not been informed in advance of what was going on!
Why such harsh results? Never mind the inflammation aspect, i.e. "radiation causes inflammation in the prostate, urethra and bladder" (p. 79), Mulhall also notes (ibid.):
"The amount of radiation needed to cause endothelial damage is tiny, ranging from 0.1 to 1 Gy. It is estimated that between 15 to 20 Gy is required to injure large blood vessels (when given in a single dose). This damage to blood vessels is known as endartertitis obliterans and may take up to a decade to manifest itself maximally."
The negative indicator here, with which I certainly concur, is that such orgasmic pain can impede a man from any sex activity altogether. This is quite understandable! Why would you want to repeat a pain that is so horrendous via a sex outcome (orgasm) presumed to be pleasurable? The form of rehab or prescription for avoidance of the pain as Mulhall notes, is Flomax (ibid.) However, I wanted to try to avoid the use of drugs entirely so chose what one RN website advocated: a full body massage. This was found to work, thanks to my wife's masseur, a female massage therapist who'd helped other cancer patients. I found that after the 4th or 5th massage, for whatever reasons, the acute pain had subsided.
Another aspect to consider: after surgery or high dose radiation it may be exceedingly difficult to gain erections. The danger is that if not attained - and regularly - the blood vessels and tissues can be adversely affected. In this regard, Dr. Mulhall
s Chapter 7: 'Penile Rehabilitation and Preservation' comprises a very key chapter in his book.
Dr. Mulhall notes (p. 99) the average healthy male gets 3-6 erections every night of his life, during sleep, but after surgery (or high dose radiation)this isn't the case because of "nerve injury".or blood vessel damage (radiation) He goes on to observe that the penile rehabilitation program aims to ensure or at least encourage, men to get at least 2-3 erections per week at a level of at least 6 (e.g. 6/10) on the hardness scale. He emphasizes that neither orgasm or penetration as in intercourse is required, just ensuring the erection, to get blood and O2 into the penis.
The aim throughout is to protect the erectile tissues from degeneration. If these PDE5 rehab procedures don't work then more radical methods have to be considered such as: 1) penile injections, 2) intra-urethral suppositories, 3) vacuum devices, or 4) penile implants. None of these is exactly "enjoyable" but the alternative may be quite depressing and also pose latent health risks (i.e. penile tissue rigidity leading to a U-shape)..
For example, in terms of (1) Mulhall recommends a 29-gauge needle 1/2" in length for penile injection, and he provides a close-up diagrammatic view of where to inject on p. 145,
Fortunately, I have not had to go to such extreme measures, but it's nice to know they are there. It's gratifying, especially, to know this book exists for men who fall victim to prostate cancer which claims frmo 29,000- 31,000 lives a year and annually affects nearly 900,000 men in the case of recommended biopsies.
Needless to say this is an indispensable resource, even if a guy doesn't have prostate cancer. The odds are you will get it eventually!(As my urologist informed me, 3 of 5 males over age 65 have it, though it hasn't yet impacted their lives and PSA tests may not have disclosed it.)