Okay, I made that up.
Let me say that this next part is not easy for my wife or me. Especially her. Donna is an intensely private person, and, though I am less so, I do not routinely discuss our sex life. Sex is all you talk about when you’re 20 and something you barely mention when you’re 60. I didn’t say you didn’t do it; you just don’t talk about it. But post-prostatectomy sexual reports have to be part of this account, so I’m going all in.
So to speak.
The first post-op sexual encounter, which happened about three weeks after the catheter was removed, had a lab-experiment feel to it. I didn’t expect anyone’s earth to move, least of all the section on which my wife was reclining, and it didn’t. I felt aroused like always—even after 40 years I find my wife very attractive very quickly—but I couldn’t get a full erection. And I am used to achieving full erections quickly. I would put my erection at 60 percent, but perhaps that’s influenced by the normal male exaggeration about anything to do with sex, so let’s put it at 40 percent.
Being with my wife was certainly a pleasant way to pass the time, far superior to beating a path around the downstairs perimeter 137 times. We stopped and talked and started again and talked some more, much more talking than usual. Then we started again and, suddenly—
In their landmark sex study, Masters and Johnson coined the phrase “ejaculatory inevitability” to describe the moment during stimulation when a man feels orgasm is inevitable. They further concluded that men reach orgasm after two or fewer minutes of masturbation, or, as I prefer to call it, self-inflicted orgasm (SIO). I buy the inevitability fact—at least I’ve always found it to be the case—but disbelieve the SIO statistic. Two or fewer minutes seems a little quick, doesn’t it? Particularly if you’re in a bathtub.
I would guess that most post-prostatectomy patients aren’t confident about ejaculatory inevitability, or, in its amended form, dry-ejaculatory inevitability. A prostatectomy forces one to think about the whole complicated process of orgasm, a topic that, like sausage making, lessens in appeal when overanalyzed. The production of an orgasm necessitates a cooperative assembly line that involves the testicles, the epididymis (a tube that connects the efferent ducts at the rear of each testicle to its vas deferens), the vas deferens, the urethra, the penis, and, most of all, the brain.
The prostate is not needed for orgasm, but with all the bodily changes and your confidence level down, you don’t know if it’s going to happen and, if it does, whether you’ll recognize it. Perhaps it will pass by so fast that it will be vaguely familiar yet ultimately unidentifiable, like a particularly exotic make of foreign car whooshing by on the highway. But, suddenly—
It happened. I had an orgasm. It came (excuse verb choice) unexpectedly and with a limited erection. Consequently, it didn’t feel complete. But the feeling was intense, possibly because those muscles had not been used for a while. It might’ve been akin to the first time I ejaculated, though I don’t remember that. Afterward, my penis felt tingly, as if somebody had rapped it with one of those small hammers used to test reflexes.
My first response was that I could not believe there was no ejaculate. I looked for it. None. Completely dry. There are reports of men having full ejaculate after a prostatectomy, but, then again, there are reports of Virgin Mary sightings in chicken cacciatore. (Actually, a small amount of ejaculate fluid can be produced in the prostate’s neighboring Cowper’s glands, but even that is fairly rare.)
“What did it feel like?” Donna asked.
“I guess I would say its suddenness made it intense,” I answered. “But it felt kind of . . . incomplete.”
I thought about it for a while. “I think I have a new name for it,” I said. “The no-gasm.”
“You’re not being fair,” Donna said. “Men who can’t have an orgasm of any kind have no-gasms. This was at least a gasm of some kind.”
Point taken. No-gasm is officially stricken from my post-prostatectomy vocabulary.
How about half-gasm? Better yet—faux-gasm.
From a performance standpoint, the experience should not be in my top 100 sexual memories. But it is. It was a good moment. Life will go on. It will be different. But it will go on.
And as we lay there, Donna couldn’t resist this:
“How do I know,” she began, framing a question that has no doubt been asked by a thousand partners of prostatectomy graduates, “that you weren’t faking it?”
CHAPTER 12
... In which the author learns a few things he should’ve paid more attention to before surgery
ABOUT EIGHT WEEKS AFTER SURGERY, I got the contract to do this book. I had already begun taking notes, having been convinced by the response to my newspaper columns that there was much interest in, and confusion about, this subject. So I began talking in earnest to doctors and regular folks about prostate cancer.
My first surprise was the concern about biopsies, primarily the possibility of contracting infection, most commonly called urosepsis. I have nothing but overall praise for the information my doctors gave me throughout this process, but I will say that the potential perils of the biopsy were undersold—in fact, not sold at all. Perhaps that is my fault since I didn’t do any research on it. My main concern was to be blissfully unaware of the harpooning procedure, wake up, and go on my way.
Or perhaps doctors don’t say much about it because the risk of infection seems so self-evident. After all, the procedure involves inserting a needle that passes through the rectum en route to the prostate. That is problematic territory, and to not anticipate trouble would be like Custer expecting a cakewalk as he led the Seventh Cavalry through Montana.
The use of smaller needles has made the procedure better—“It used to be a horrendous undertaking,” says Dr. Pablo Torre, the Department of Veterans Affairs urologist—but “less horrendous” doesn’t necessarily translate into “less dangerous.” And “dangerous” is precisely the word used by my urologist, who is not given to scary proclamations for the hell of it.
“In the last two years we’ve had two 50-year-old men die from their prostate biopsies,” says Dr. Keith Van Arsdalen. “And it’s not like we’re doing something wrong. I suspect our record is pretty good, in fact. It’s just that a biopsy can be a dangerous procedure.”
Dr. Jerry Blaivas, the New York City urologist, says that at least 1 percent and possibly as many as 4 percent of men who have prostate biopsies get serious infections. “So if you’re a 62-year-old man and you keep getting biopsies,” says Dr. Blaivas, “eventually you’re going to get a life-threatening infection.”
Dr. Lee says he feels comfortable saying that the accurate figure is closer to 1 percent. “But that is still significant,” says Dr. Lee, “because the guys who get it are really sick. I have never lost a patient going through prostate cancer surgery, but I had a patient die going through a prostate biopsy. And the infections can be antibiotic resistant. So if the first two antibiotics don’t work, a guy keeps getting sicker and sicker, and by the time they find the right one he has one foot in the grave.
“What we should remember, though, is that antibiotic-resistant organisms are not exclusively a problem of prostate biopsies. They are a problem that affects all areas of medicine.”
Numerous studies have confirmed the existence of high infection rates and at least one postulated that after three biopsies a man could become impotent. “It is important for urologists to determine if a biopsy is appropriate for an individual patient,” says Dr. Ballentine Carter regarding a Johns Hopkins study, “and also if the patient is at increased risk for a biopsy-related complication.”
One of Dr. Carter’s distinguished colleagues isn’t quite so pessimistic. “A more recent study [from the University of California at San Francisco] showed that that wasn’t the case,” says Dr. Walsh. “And I absolutely don’t consider fear of biopsy a reasonable deterrent to intervention, if intervention is needed.”
But every man has to make that decision on his own. Would t
he possibility, be it 1, 2, 3, or 4 percent, of a serious infection make you reluctant to get a biopsy? I can only answer for myself: It would not. That’s just how I am. I would have taken that chance even if I had known about the infection potential. Somebody else might not.
“I do not buy biopsy danger as a deterrent to getting a PSA test, as the USPSTF does,” says Dr. Lee. “But the biopsy technology could definitely get better, and the profession knows it. There’s some research going on in Israel right now in the form of a new antibiotic-impregnated needle. And in those tests the infection rate has gone down to almost zero.”
As a further horror, there is in the prostate playbook something called “saturation biopsy.” You’ve heard of saturation bombing? This is metaphorically the same thing, but with your prostate as the target. Between 30 and 80 cores are taken, usually in men who seem to be at high risk for prostate cancer yet have had negative results on their previous biopsies. I’d talk that one over with my physician very, very carefully.
ANOTHER THING I STARTED TO HEAR A LOT ABOUT—after the fact—was Urorad facilities. The word sounds like something that might come from the mouth of a 17-year-old (“Dude, I just heard Toy, and they are totally Euro-rad”), but it refers to a fairly recent phenomenon in prostate cancer treatment—urologists opening up large radiation facilities to which—no surprise—they send patients they have diagnosed with localized prostate cancer.
In an article published in 2011 in Prostate Cancer Communication: Choices, the newsletter of the nonprofit group Patient Advocates for Advanced Cancer Treatments, Michael J. Dattoli, MD, called Urorad “an egregious scam being perpetrated upon prostate cancer patients, right under our noses and with the complicity of the federal government.”
Dr. Dattoli is himself a board-certified radiation oncologist who does not have a Urorad facility, so perhaps he has another agenda, a competitive one. But his concerns have been voiced elsewhere. Medicare reimburses IMRT (intensity-modulated radiation therapy) at a much higher rate than surgery: as much as $40,000 compared with about $7,000 for a radical prostatectomy and about $1,500 for seeding, according to Dr. Dattoli’s figures. He says that between 2003 and 2008, the period of time when Urorad facilities grew exponentially, reimbursements for IMRT increased by 84 percent, to $104 million.
One of the urologists I interviewed, Dr. Aaron Katz, brought up the subject himself and could barely contain his anger.
“A number of urologists around this country own these vast radiation centers,” Dr. Katz says, “and they have tripled their income. They get these little Gleason 6 cases [I was one of those “little” Gleason 6s] and refer them for radiation at facilities in which they have ownership. Here they are making $45,000 and $50,000 on every little Gleason 6. Every day. Five days a week.
“These guys were dying financially. Okay, the robot comes along and maybe some got good on that, but if you’re in your late 50s or early 60s, you’re not going to learn robotic surgery. ‘But wait a minute! I can just refer a patient for radiation, sit in my office, and collect a paycheck for the radiation center I own? Why don’t I do that?’
“And people wonder why medical costs are being driven up. It makes me sick to think about it.”
AS A FURTHER EXAMPLE of how complicated the prostate cancer picture can be, consider that while Dr. Katz rages about over-irradiating, he is an advocate for cryotherapy, also known as “focal ablation,” a treatment that is not without controversy.
In simplest terms, cryo freezes the cancerous tissue, causing the cells to die. Dr. Katz has been doing the procedure for 20 years and, after performing 2,000 procedures and teaching more than 100 other urologist–surgeons to do it, he stands squarely behind it.
“It is an excellent modality for men who have radiation-recurrent disease, or for men who had a small area of cancer and are uncomfortable with surveillance,” Dr. Katz told me. “You would’ve been an excellent candidate for focal ablation with your low level of cancer. It’s outpatient therapy. It takes me about an hour to do with minimal anesthesia.
“It’s [included] in the area of radiation, I suppose, because all radiation is ablation technology. But radiation is whole-gland treatment, while this is just focusing on the cancer, freezing the zone of the cancer shown by the biopsy.”
Most everyone agrees that cryo is effective for stopping cancer. But it’s the side effects that have some worried.
“I just operated on a guy yesterday who had cryotherapy,” says Dr. Blaivis, “and this guy’s life has been changed without any reasonable hope of a satisfactory outcome. Aaron has made an honest effort at looking at the science of it, but the complications happen later and there is always an intellectual reason to explain that it was a success. I respect Aaron’s efforts, but totally disagree with his conclusions.”
Dr. Van Arsdalen says much the same thing. “The side effects from cryo, especially getting a hole in the rectum, are typically worse than the side effects from radiation or surgery,” he says. “They may not be common, but that doesn’t mean they aren’t devastating.”
Dr. Lee takes a position somewhere in between.
“There are a lot of intellectual differences between doctors, and you are on thin ice when you start criticizing what other people do if you don’t do the procedure yourself,” says Dr. Lee. “You have to look at data and become really familiar with it before you say it is good or bad.
“Cancer cure–wise, cryo is actually pretty good. Side effect–wise, it may not be as good as other things.”
A final thought: The fact that cryo is controversial does not make it wrong, particularly in the hands of someone as respected as Aaron Katz. And it is certainly not wrong because I bring it up.
I have mentioned that I am not a doctor, right?
I CONFESS THAT I HAD A HARD TIME PLUGGING IN to the ED research process. Had I flatlined (so to speak) in that department, I would’ve had more motivation, but my supposition all along has been that things will get back to 100 percent, or near 100 percent, with only conventional auxiliary assistance, “conventional” being defined as an ED pill. That supposition continues to this day, even though I’m at about, say, 80 percent. But that might not be how you look at it, and there are plenty of options to consider, including the permanent one of a penile prosthesis, which is, obviously, introduced surgically.
A less radical and more common plan of attack is to use the penis pump, described at one Web site as “a tried-and-true device.” Well, not tried by me, although I include an anecdote about its usage among the personal stories recounted in Chapter 15. I would not recommend an Internet search if your goal is to find out the positives and negatives of the pump because there’s some pretty hysterical stuff out there. One example: “The unnatural method I employed for inflating my organ has resulted in a total loss of sensation in my organ. I have almost lost all sense of touch, and that is driving my wife up the wall.” Talk to your doctor about the pump. It is not some Bizarro World device. It is commonly used and, apparently, used with some degree of success.
There is also plenty of information about natural remedies for ED, including a supplement made from the bark of the yohimbe tree, an evergreen native to Africa. I wouldn’t advise sending off for a year’s supply of yohimbe without talking to a doctor, and, to be sure, some suggested herbal remedies are utter nonsense. But it’s a legitimate area for research. MayoClinic.com, a Web site that is well within the medical mainstream, has a section on “erectile dysfunction herbs.” At the same time, though, it urges caution. Here’s what it says about something called epimedium, which is also known as—I’m not making this up—horny goat weed. “This traditional Chinese medicine may help erectile dysfunction, [but] there’s little evidence about the safety or side effects of epimedium. It may cause blood thinning and lower blood pressure.”
The one remedy I was tempted to try was MUSE. As you would suspect, MUSE has nothing to do with artistic inspiration, but rather stands for the very unartistic “medicated urethral system f
or erection.” My friend Jeff Mohler, whose cancer and treatment profiles basically fit mine (close in age, PSA level, biopsy results, robotic prostatectomy success) had given it a try (with mixed results; he eventually stopped using it) and offered me a couple of “hits.” He left the package on his back porch for me; when I retrieved it I felt like I was making a cocaine pickup.
MUSE works like this: A thin applicator is inserted into the penis. (The instructions explicitly state that the applicator is to be inserted “inside the opening at the end of the penis,” though I can’t imagine where else it would go other than the “opening” if it is indeed to go into the penis.) You press a button on the applicator that releases a pellet of medication, which is absorbed through the membrane that lines the inside of the urethra. The medication theoretically relaxes the muscles in the surrounding blood vessels of the penis, thus increasing blood flow into the penis and producing an erection. I say “theoretically” since I can’t imagine any form of the verb “relax” having any relevance to this exercise.
I informed my wife that it was MUSE time.
“Since you couldn’t manage to give yourself a Fleet enema without help,” Donna said, “this I gotta see.” Then she thought about it. “On second thought, I don’t really have to see it. You can go this one alone.”
“But the information on WebMD says—and I quote—‘it’s important to include your partner in your decision.’ ”
“Consider me included,” she said, “just not involved.”
“It also says—and I quote—‘partners of men who have vision problems or who may have difficulty inserting the pellet can be taught.’ ”
“Your vision’s twice as good as mine,” she said. “Good luck.”
I wanted to do it. I really did. But eventually I decided against it. I want to keep working at this thing. I will take my Cialis and strive to get back to 100 percent without pellets or pumps or yohimbe or horny goat. Especially without horny goat.
The Prostate Monologues Page 10