Ralph and Barbara Alterowitz are authors of the second edition of “Intimacy with Impotence: The Couple's Guide to Sex After Prostate Cancer” Ralph is a prostate cancer survivor and his wife Barbara, a prostate cancer survivor partner and mate, Together, they explore the questions that doctors may leave unanswered, or patients may not ask. They explain the causes of impotence in layman’s terms, outline how to actually talk to your partner about it, and offer tips for doctor visits. They tackle what could be an embarrassing issue with the combination of candor and compassion necessary to really teach a couple to make changes and how it can. Ralph Alterowitz is the founding vice-chair and former Director of the National Prostate Cancer Coalition, and is currently the President of the Education Center for Prostate Cancer Patients and Barbara Alterowitz is a marketing executive with an international technology firm. Here is an excerpt from the book. (Reprinted with permission.)
How Fulfilling Sex Can Happen After Prostate Cancer Surgery
It’s Over. Or Is It?
Millions of men have given up on lovemaking because of their erection problems. In the prostate cancer community, one study found that the level of expressed “sexual interest” dropped by half after treatment. Actual sexual activity dropped by almost two-thirds as measured by the “frequency of ... passionate kissing, sexually touching and sexual intercourse,” according to “Prostate Cancer and Prostatic Diseases” in a 1998 article.
The physical problems men have are worsened by their “mind trips.” They create excuses such as:
- “I’m not interested anymore.”
- “I’ve got other things to do.”
- “I’m getting too old.”
- “There is nothing I can do about it.”
- “What’s the point? It won’t work anyway.”
The fact is that men can continue to have a strong sex drive even if they have erectile dysfunction. It is possible to have good loving for the rest of your life regardless of age, whether you have erectile dysfunction or not. Many men with ED still have some erectile capability. And even without intercourse, you can still have a good love life. It is not necessary to have an erection for either partner to have an orgasm.
It is normal to be interested in sex throughout your life. Men and women can remain sexually active throughout their entire lives. No one has to apologize for an interest in sex. Some people believe that sex is only for the young and that as people get older, they lose their desire for sex and their ability to perform. The fact is that we are sexual beings our whole lives. One doctor told us that his eighty-year-old father asked him for a prescription for Viagra, but asked that he have another doctor in the practice sign the prescription because “your mother doesn’t want you to know that we are still having sex.” The doctor was delighted because this could mean he would be able to have sex in his eighties.
As men get older, arousal takes longer for a number of reasons. This can be seen as a blessing in disguise because it can make loving much better. In general, women take longer than men to become aroused. Therefore, if a man takes longer to become aroused as well, his partner may be aroused or nearly there by the time he is. This synchronicity of arousal can help both parties to experience the same pleasure during the lovemaking cycle and can remove one of the main complaints younger women have about their love life.
Trollope Works for Me
Before I turn 67 next March I would like to have a lot of sex with a man I like. If you want to talk first, Trollope works for me.
Jane Juska, a sixty-seven-year-old divorced mother of two, placed this personal ad in The New York Review of Books, and went on to write a book on what happened after she placed the ad. (In case you’re wondering, Trollope was an English novelist in the nineteenth century.)
She and others every day are debunking the myth that older women aren’t interested in sex and loving, as they get older. That is true for some women, but studies have shown that many women over fifty become more interested in sex because the danger of pregnancy is reduced or gone, and there are fewer family-raising pressures in their lives. In one instance, a woman whose partner introduced her to lubricants at age sixty says she “can’t get enough of it [sex].” Again, the only way to find out if your partner is interested is to talk with her.
Since pelvic cancers usually affect older couples, the women in these relationships can end up being deprived of sex when their partners have impotence problems due to cancer treatment. Many men project a lack of interest onto their partners and create other rationales to absolve themselves of the need to make any effort at physical intimacy.
Female partners of pelvic cancer patients complain that their men see impotence as a reason for not having sex. Many women who had good pre-cancer sexual relations are unhappy because their men withdraw due to erectile dysfunction. Some men believe that, if they are incapable of penetration, their partner will see them as less manly and be disappointed by their sexual activity.
Juska writes in her book that by the time she emerged from her chrysalis, she realized she’d never had a chance at pleasure. Similarly, some partners of pelvic cancer patients have not had satisfactory physical intimacy even prior to their partner’s treatment for cancer. Often before cancer treatment, the man focused on the erection and penetration--on his own pleasure--and so the loving, nurturing, and caressing the woman finds so important never happened.
Quite often, the self-esteem of a man drops when he has impotence problems. He withdraws, hoping that his partner will retain her former image of him. Sometimes, men use the excuse that they are not having sex anymore because their wife or partner is not interested. Or they believe that, since being treated for prostate cancer, they cannot please their partner.
Certainly, men and their partners do themselves a great disservice and decrease the quality of their lives when they shy away from physical intimacy when in reality both partners want it. Creating artificial blocks and refusing to talk about impotence and intimacy are very damaging behaviors to the relationship. Women can experience close physical intimacy and be highly satisfied even by a totally impotent man. Moreover, men can also achieve sexual satisfaction with any level of erectile dysfunction. But that would mean the man needs to set aside some old concepts that lovemaking can be successful only with a full erection. Maybe it is time to think about making love instead of just having sex.
The Effects of Prostate Cancer Treatment:
What’s the Truth?
Am I the only one with a problem? Survivors often assume, “I’m the only one who has a problem. Everyone else came out of therapy okay.” The truth is that seventy to ninety percent of prostate cancer survivors have erectile dysfunction for some time or permanently.
Leslie Schover, Ph.D., of the Cleveland Clinic Foundation, reported that “the prevalence of sexual problems may be as high as ... 70 percent in prostate cancer survivors.” (Journal of the National Cancer Institute, Vol. 90, No. 8, April 15, 1998, p. 566). Dr. Schover goes on to note that, “Problems faced by survivors include loss of desire, erectile dysfunction, painful intercourse, and difficulty reaching orgasm.”
As many as ninety percent of men, who have surgery for prostate cancer, will face erectile dysfunction immediately following treatment. Recovery varies widely. One prominent medical center known for prostate surgery estimates that about forty percent of their surgery patients will recover “full function” within six months and about sixty to seventy percent will recover within eighteen months.
A relatively high potency recovery rate may be expected with surgical excellence. The surgeon’s skill is an important factor, but not the only one. For instance, recovery for younger men (under sixty) is higher than for older men. However, every procedure results in some loss of erectile capability. The nervous system is like a tree, with large, small, and tiny branches. Even if major nerves are not cut during surgery, some nerves are damaged. Nerves are also damaged during radiation. When radiation therapy is used, erectile dysfunction appears to be delayed. About twenty to thirty percent of radiation patients have erectile dysfunction right after therapy. Radiation damages the small blood vessels supplying the pelvic region. This leads to fibrosis (scarring that causes toughening) of these small blood vessels.
The scarring process builds on itself by interfering with nutrients, blood flow, and oxygenation. In time, the tissue goes from soft to leathery. As a result, within four years after traditional external beam radiation therapy, the percentage of men with erectile dysfunction is the same as among surgery patients. Therefore, although potency is higher in the near term compared with surgery, ultimately the level of impotence resulting from radiation may be comparable to that resulting from surgery. Some new radiation therapies may reduce the likelihood of erectile dysfunction.
Is nerve sparing or nerve grafting surgery a miracle treatment?
One of many prostate cancer myths is this: After a nerve sparing operation the man has the same level of potency as he had before the surgery. We all wish it were true, but it’s usually not.
The nerves responsible for erections run alongside the prostate, not through it. They are distributed in the tissue near the prostate gland. Although nerves are not visible to the naked eye, surgeons generally know the surgical landmarks.
Therefore if the disease is confined to the gland, it may be possible to spare these areas and preserve some nerves. However, even when the neurovascular bundles are spared, the nerves are traumatized, and many smaller ones are cut.
In 1997, the FDA approved a nerve-locating tool, the CaverMap Surgical Aid. UroMed, the manufacturer, said that the patented technology helps surgeons map the microscopic cavernous nerves. The system is currently being used at The Johns Hopkins Medical Institution and other centers of excellence. While the device is still imprecise, more precise technologies may come along now that a breakthrough has been made.
So the doctor does not actually know if the nerve sparing procedure was successful. His or her determination is based only on the observation that “nerves look good at the end of the case.”
We know of a support group formed by a number of survivors who were operated on by a prominent surgeon noted for his nerve sparing surgical technique. They shared their experiences and tracked how everyone fared. They found that, although the doctor’s self-reported statistics looked good, almost everyone experienced significant erectile dysfunction. Maybe there is a gap between what doctors consider “full function” and what patients perceive as “good.”
For the past forty years, the sural nerve in the ankle has been used for radical prostatectomy patients to provide a neural bridge because one or both cavernous nerves were cut. Sural nerve grafting is not a one hundred percent effective technique for retaining potency.
Study results show that one-third of a small group were able to have spontaneous erections, but their erections improved when they also used Viagra, one fourth of the group had no erectile capability at all. Other studies that cite somewhat higher percentages for potency retention note that this was possible with Viagra¨. The nerve sparing technique and sural nerve grafting are discussed further in the surgery section in Chapter 8.
Is potency known immediately after surgery?
A patient’s future level of potency is rarely known immediately after treatment. Any therapy is a shock to the system. After surgery, it may take two years (and sometimes longer) to recover and to find out how potent you really are, although some medical centers quote shorter times. Several survivors have confirmed this, but most survivors tell us that no one ever told them this in advance. Rather than trust to chance, men may want to ask their urologists about penile rehabilitation therapy. This approach is initiated for surgery patients within three months after surgery and is described in more detail in Chapter 8.
Will my penis be shorter after radical prostatectomy surgery? If it is, can I still have intercourse?
The penis may be anywhere from one quarter of an inch to about one and half inches shorter. The main reasons are lack of use, less circulation, and scarring. Initiating a penile rehabilitation program as described in Chapter 8 may improve circulation and keep the penile tissue from atrophying. The length of the penis does not affect potency. An erection satisfactory for intercourse may be achieved naturally or with medication. Penis length may not be changed substantially with other therapies, such as radiation, seeds, or cryoablation.
Ladies: Although men know intellectually that you don’t love them for their “size,” they have a lot of anxiety related to this issue. As a couple goes through the difficult time after diagnosis and treatment, it’s very important for you to keep telling the man why you love him and what you love about the relationship. Don’t leave out what you love about the physical relationship--most of its quality is not related to his size anyway!
While size can be a visual stimulant for a woman, most women are much more affected by touch than by visual factors. A woman doesn’t marry an “erection machine.” She marries a man with whom she wants to spend her life because he is a great guy. Maybe a part of that is that he is a great lover. And he can still be a great lover, even without a giant erection! In fact, without any erection at all.
Do I need testosterone injections to increase my desire or treat my erection problems?
ED is associated with many conditions such as getting older and lifestyle. A number of studies have shown there is no relationship between total testosterone levels and ED, regardless of the severity of ED.
Does hormone treatment destroy desire and potency?
With complete hormonal blockade, desire and potency will be minimal. However, current research on monotherapy with nonsteroidal antiandrogens such as flutamide and nilutamide show that some desire and potency may be retained in seventy to eighty percent of men.
Can sex stimulate cancer? Can I transmit cancer to my partner through sex?
A recent study reported that some patients decide not to pursue lovemaking because of concerns related to the disease itself. These concerns include a belief that sex will stimulate the cancer and possibly transmit the cancer to their partners. Both of these are absolutely false. There is no risk of passing the cancer to your partner.
Will my partner have any effects from my radiation treatment for prostate cancer during intercourse?
One study showed that there was no significant increase in the level of radiation in the home from men undergoing radiation treatment.
What are the effects of treatment for benign prostatic hyperplasia (BPH)?
Patients with benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate with resulting bladder outflow obstruction and lower urinary tract symptoms, can receive a treatment called transurethral resection of the prostate (TURP). Although providing the highest likelihood of relief of both prostatic symptoms and urinary flow obstruction, surgical intervention for BPH with procedures such as TURP can have a significant impact on the patient’s sexual function. Two main symptoms affect sexuality: The first is erectile dysfunction, with rates reported as high as fourteen percent. The second is retrograde ejaculation, which means that the ejaculate flows back into the body instead of flowing out of the penis. This affects sixty-eight percent of TURP patients.
General Questions and Answers about Impotence
Do I need an erection to have an orgasm?
An impotent man can have an orgasm. An erection is not needed for an orgasm. The facts are:
- Men without prostates do have orgasms and simulated ejaculations. Pelvic muscles contract, so that you feel as if you had an ejaculation. As we will discuss in Chapter 4, different sets of nerves are responsible for erections and orgasms, so it is possible to have an orgasm when the penis is limp. Without a prostate, these orgasms are usually not accompanied by ejaculate. Some men may have a small amount of fluid, but most men will have a “dry” orgasm. Nevertheless, the orgasm feels the same as with ejaculate. The issue is not the fluid, but the feeling.
- Even without an erection, men can have sensations and release during orgasm that is similar to men with an erection.
- Orchiectomy patients (those who have had their testes removed) can have orgasms. Even orchiectomy patients in their eighties have had “wet dreams.” The key to having orgasms is that these men have known desire and experienced orgasms, thus proving again that sex is in the mind.
Can my partner have an orgasm if I don’t have an erection?
Yes, yes, yes! A woman does not need penetration to have an orgasm. Men and women are anatomically fortunate because the organ that causes a woman’s orgasm is on the outside. There are many ways for a woman to experience pleasure and to achieve an orgasm, even with a partner who has no erection at all. Stimulation of the clitoris can be accomplished by several means. An erection is not required.
Does satisfaction require having an orgasm?
Many men believe that an orgasm is needed for a satisfying sexual experience. Most women know this is not true. Many men have never given themselves a chance to find this out. An orgasm is a wonderful benefit but it does not have to be the goal of lovemaking.
If one medication, such as Viagra), does not work for me, will another one work?
The different results in clinical trials point up the fact that not all the participants will react the same to a particular medication. Clinical trial subjects are chosen to limit the number of variables that can affect the results of the trial. Even with tight selection criteria, the medication being tested will be successful only on some of the trial population. Each person’s metabolism is different, as are each individual’s general health, diet, and level of exercise. Each erection-inducing medication is chemically different. So there is a possibility that one drug will work on one person when another drug does not at all or only partially. (ED NOTE: There are two other ED drugs now marketed Cialis and Levitra.)
September, 2004
