A Man’s Guide to Sex and Cancer

Dr. Diane Reidy-Lagunes:

True confession: In my practice, I rarely, if ever, talk to men about their sex lives, and shame on me. And guess what? Men's sexual function is not just about the hardness of the penis. Other things like flagging libido, ejaculation function, anxiety, confidence, orgasmic pain, all these issues are real. They happen. And some men don't ever find the solutions because nobody talks about it. So let's talk about it right now. Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier, healthier lives. For more information on the topics discussed here, or to send your questions, please visit us at mskcc.org/podcasts. As cancer docs, we do everything possible to save your life, but apparently it's too rare that we address your sex life. But cancer and cancer treatment can endanger normal sexual function. And news flash: for many patients, like Michel Kiernan, it's a big deal.

Michel:

Back in 2014, I was given five to seven years to live. Having aggressive prostate cancer and neuroendocrine carcinoid cancer that had metastasized, we were devastated. I didn't ask about love-making until the treatment was over, which was weeks of radiation and Lupron for a year, which crushed our love life. We asked Sloan for some help about the problem and they spearheaded a treatment which was awesome. A daily dose of Viagra at night, and then on love-making, you had to have a full dose. So we designated Thursdays as naked Thursdays. I'm an old goat, married to a young caring wife. Naked Thursdays are the best days of the week.

Dr. Diane Reidy-Lagunes:

We should try naked Thursdays on this podcast. Today on Straight Talk, we're gonna talk about men's sexual health and how to bring it up with your doctor before, during and after treatment. Joining me is Dr. John Mulhall. A native Dubliner, he's the director of Male Sexual and Reproductive Medicine here at MSK. He's also editor-in-chief of The Journal of Sexual Medicine. John, welcome to the show.

Dr. John Mulhall:

It's my pleasure to be here.

Dr. Diane Reidy-Lagunes:

It's really an honor for us as well. John, our patient Michel who we just heard from, was looking death in the face, but then he went back to his docs and said, "Help me get my sex life back." On a scale of one to 10, how important is sexual performance to the men we treat? And, if asked in a different way, how big of a problem is sexual dysfunction?

Dr. John Mulhall:

It's very common. It's routine. How big of a problem depends on the patient and the couple. And there's tremendous variability in where people put their sex lines. At the time of diagnosis, people are very focused on surviving, of course, understandably. But in certain situations, let's take, for example, somebody like Michel, who had prostate cancer. Going long periods of time without having erections is lethal for the health of erectile tissue, so there's a time component that needs to be addressed early on in the treatment, the cancer treatment.

Dr. Diane Reidy-Lagunes:

Got it. You call yourself a survivorship physician, but the problem may actually start before the treatment actually begins. So are men given a realistic expectation on what to expect by their doctors? And do we have to give them additional information? How are we doing there, as docs?

Dr. John Mulhall:

Yeah, I think we're doing less than perfectly. I understand that oncologists are by definition oncologists and their focus is cancer, whether it be PSA for prostate cancer or CEA and bowel cancer, etc. And so they're not fully equipped with having that conversation. I think they would admit to you that it's important to have the conversation, but I think they would also admit to you, on the other side of their mouth, that they prefer somebody else to have that conversation.

Dr. Diane Reidy-Lagunes:

Yeah. Is there a way that we can educate our patients to keep their eyes wide open? Because they may not get to you until perhaps it's even too late in that respect, in terms of understanding these needs that they may have to do before or during the treatment?

Dr. John Mulhall:

I think that's really, really important. So I'm a big fan of empowering the patient. And, you know, I speak to several patient organizations most years – at least pre pandemic – and one of the messages there is that you have to go in with what you want out of the consultation. And if your sex life is important to you, it's important that you declare to the physician: "My sex life is very important to me. How can we maximize or optimize my preservation and or recovery?" The challenge for most physicians, whether they're oncologists or not, is they get almost no sexual health training during medical school. So they're ill-equipped with doing this. So I think empowering patients to say, "This is important. What can we do?" is a very important first step.

Dr. Diane Reidy-Lagunes:

Absolutely John. And when it comes to the cancer and the cancer treatment, there are quite a few issues, as you've taught me, that can impact men's sexual health: diminished libido, weight gain, orgasmic pain. We're gonna talk about the list in a moment. But the most frequent complaint is ED – erectile dysfunction – and many diseases can cause this. But if we start with prostate cancer, can you tell us why that might happen? Is it the cancer? Is it the treatment? Is it surgery or chemo or radiation? And give us a perspective on what men should know.

Dr. John Mulhall:

You refer to the concept of survivorship, and survivorship for me begins with the impact of the diagnosis of cancer on a man's sexual health. So it's very common that men who are given a diagnosis of cancer, irrespective of what that is, it's a traumatic stressful event. And that impacts upon their sex drive usually. And of course it generates adrenaline, the stress hormone, the world's most potent anti-erection chemical: adrenaline. So both of those cause problems even before any treatment. But prostate cancer is the kind of perfect example of how cancer causes sexual problems for men. So surgery can damage the nerves that supply the penis, right? Those nerves frequently recover, but that can take 18 to 24 months after the operation. Radiation also could have negative effects on the structure of the penis. And what's interesting about radiation is that it has very little negative effect in the first year after treatment, and typically has its peak negative effects somewhere between three and five years. And then of course the use of hormone therapy – drugs that deprive men of testosterone – doesn't just reduce the testosterone level, but obliterates, gets rid of all the testosterone production. That's very, very dangerous for the health of erectile tissue. So I say to men, if you put your hand around your penis, Mr. Jones, most of what's inside your hand is a muscle, just like your biceps. Now think of you putting your arm in a plaster cast for a year or two. And when you take the cast off, what has happened to your bicep? It has undergone atrophy. And if the penis is not being used, either with a partner on your own or getting nocturnal erections, then that muscle degenerates. And the problem with degeneration of the muscle in the penis is it's permanent.

Dr. Diane Reidy-Lagunes:

So after surgery, like you said, there may have been some trauma, but is there a time for recovery in which you may say, "Well, this may get better"? And when do you have to sort of say, "Houston, we have a failure to launch here"? I mean, is there a period of time for which you don't have to worry about it?

Dr. John Mulhall:

So the trauma to those nerves, the maneuvers that surgeon has used to protect those nerves, cause those nerves to go to sleep. And they typically go to sleep for nine to 12 months, and it takes another nine to 12 months to wake up fully. That's why erectile functional recovery after radical prostatectomy is an 18 to 24 months timeframe. And while most men who have good nerve sparing will have recovery of those nerves, if the muscle has degenerated over that 12 to 24 months, then it can not respond to the nerves when they recover. So it is our job as clinicians in rehabilitation to protect the muscle while we wait for the nerves to recover from the trauma of the operation. So early intervention is critically important to maximization of recovery.

Dr. Diane Reidy-Lagunes:

And I've heard you say before, a man is only as good as his last erection. What do you mean by that?

Dr. John Mulhall:

Well that goes back to the adrenaline concept, right? Adrenaline is the stress hormone – stress, anxiety, frustration – and adrenaline is the world's most potent anti-erection chemical. And so if a man has had an encounter that didn't live up to his expectations, the next time he's in a sexual encounter, there's anticipatory anxiety. And that generates even more adrenaline. And then in the bedroom, we start spectating our own function – "How am I doing? Am I getting soft? Yes, I'm getting soft." – generating even more adrenaline. So that's a real problem. Men get into this spiral when they've had one or two or several negative encounters, where it's very difficult to get out of that.

Dr. Diane Reidy-Lagunes:

And along the lines of hormone therapies, what about androgen deprivation therapy, which many of our patients with prostate cancer have to go on? Any observations about that one?

Dr. John Mulhall:

Yeah. We've spent many years researching that and contributing to the literature, of course, in that regard. And first of all, I'll say I am not an oncologist and I never interfere in the decisions of the cancer doctors at Memorial. Androgen deprivation therapy, or let's call it ADT, plays a critical role in the management of prostate cancer in a variety of scenarios. So it's an important tool. However, when you have no testosterone, it is going to have some negative impact upon your life. The non-sexual consequences of ADT include osteoporosis, development of pre-diabetes – or in a diabetic, worsening sugar control – and the potential for having heart attacks or strokes over the long period. Now, the longer you are on hormone therapy and the longer your testosterone level is almost zero, the bigger the risk of these problems occurring. From a sexual function standpoint, the overwhelming majority of men who are actively on hormone therapy – androgen deprivation – have no sex drive, they have an inability achieve an orgasm, and you need testosterone for ejaculation. So if you are of the ability to ejaculate and you go on ADT, that ejaculatory volume will go to zero. And most importantly – just as with failure to be able to get an erection and that atrophy with post-prostatectomy – in the ADT patient, hormone therapy alone causes problems with the health of the erectile tissue, and it basically turns to scar. So there's permanent erectile tissue damage when you're on hormone therapy,

Dr. Diane Reidy-Lagunes:

It's important to really have those discussions with your doc before, you know, weighing the risks and benefits, as you said. Besides ED, which is obviously the most that we hear about in terms of the problems, what are the other big issues that you often and frequently have to treat and deal with when you're having your patients come to visit you?

Dr. John Mulhall:

Yeah, so one of them would be ejaculatory distress. So let's say for example, men who've had a radical prostatectomy, who've had prostate radiation whether they're on hormone therapy or not, men who've had a retroperitoneal lymph node dissection for testicular cancer – many of them no longer ejaculate, at least temporarily. And for many men, about a third of our straight men, there's a distress associated with that. And for the vast majority men who are gay, there's distress associated with not being able to ejaculate ever again. So we see a lot of ejaculatory dysfunction at the cancer center. Delayed orgasm, for example, is very common. It's interesting in my practice, it's very uncommon for us to see a man who has only one sexual dysfunction. We'll see a man with ED and low sex drive, or delayed orgasm and ED. The five most common causes of delayed orgasm: SSRI medications like Celexa, Prozac and Zoloft; low testosterone; absence of penile sensation – some of our operations and treatments causes problems with penile sensation. We have men who had chemotherapy who have what we call "glove and stocking neuropathy" whose hands and feet are less sensitive than they used to be. Well, the penis is an extremity also, and of course it undergoes some penile sensation loss, and that's a problem for orgasming. We have men who have orgasmic pain, classically post-prostatectomy or post-radiation. But can you imagine being a man having perfect erections, perfect ability to ejaculate, perfect orgasms, other than the fact that every time you have an orgasm, you get excruciating pain in your penis or testicles or lower abdomen. So these are real entities. So it's a very broad and diverse group of dysfunctions that our patients have.

Dr. Diane Reidy-Lagunes:

So getting to the treatment. Again, number one ED, and sort of the use of the PDE-5 inhibitors – Viagra, Levitra, Cialis – what's the best therapy and approach that one can take?

Dr. John Mulhall:

So I'm a big believer in what's called a "process of care" model, which means you start low down on the totem pole and you go to more invasive and advanced intervention. So the first thing to do, you know, are there any psychological issues that need to be addressed? We work very closely with Chris Nelson, the psychologist who works with our program, and we've done so for the last 18 years. Are there any medical comorbidities that need to be addressed? So, you know, the classic causes of ED outside of a cancer center are things like hypertension, dyslipidemia, diabetes, coronary artery disease, sleep apnea, cigarette smoking – do any of those factors need to be addressed? But the first line therapy is, as you've mentioned, the PDE-5 inhibitors – those drugs introduced in 1998: Viagra Levitra, Stendra and Cialis. And this is an excellent class of drugs which, across the pantheon of ED patients, 70% of men are going to respond. There are certain populations who respond more poorly, for example, diabetics or men who have had a prostatectomy or a radical cystectomy for bladder cancer. And there are men who respond, you know – almost certainly 90% of men with psychologically-based ED who have no other cause – will respond to these pills. So it's an excellent strategy early on in the treatment of these patients with ED.

Dr. Diane Reidy-Lagunes:

Beautiful. And what about for the men that may have, for example, nerve trauma, that you said before? Are there therapies and interventions that we can go further there?

Dr. John Mulhall:

Michel gave a beautiful story about penile rehabilitation. So the problem for these PDE-5 inhibitor drugs is if your erection nerves were traumatized, even temporarily, these pills do not work very well. And that's why about 85% of our patients, within the first six months of a radical prostatectomy, fail to get a penetration-hardness erection with a PDE-5 inhibitor. Saying that, we use these pills in low dose regularly – you heard him talk about daily dosing and Thursday night being the full dose – these pills have been shown to protect critically important components of your erection tissue by taking them on a regular basis, even if you do not get a good erection. And for the man who doesn't respond well to, let's say, a Viagra pill at full dose, does not get a penetration-hardness erection, then we use penis injection therapy, which is a really large part of our rehabilitation program in our radical pelvic surgery patients.

Dr. Diane Reidy-Lagunes:

You mentioned penile injections. Here's a patient who had a radical prostatectomy. Let's see what he has to say.

Patient:

In 2005, I was diagnosed with prostate cancer. I had a radical prostatectomy as a treatment for cancer. It cured my cancer, but it left me with ED. The first treatment prescribed was Viagra, which did not work for me. It made my head feel funny, too much planning before having sex. I very reluctantly switched to penile injections. I couldn't imagine sticking myself with a needle in my penis. What could possibly be worse? After careful instructions of where to place the needle, I learned that it wasn't as bad as I thought. It has now been 17 years that I've been using injection therapy. To my delight and to my wife's delight, I have a firm erection that gets the job done.

Dr. Diane Reidy-Lagunes:

John, can you talk to me about these injections and what that's about and what it entails?

Dr. John Mulhall:

Yes. Penile injection therapy, which was introduced in 1985 in the world, is a highly effective, very safe form of treatment, and is really a cornerstone of our rehabilitation program in our radical pelvic surgery patients. The biggest problem with penis injections is the word "penis" and the word "injection" appear in the same sentence, right? So people get very stressed with the concept. It's a diabetic needle injected into the middle of the shaft of the penis. Mosquito bite. The average man gets an erection from 5 to 10 minutes and with this, gets an erection that's lasting 30+ minutes. The only risk is getting a prolonged erection, and that's a dangerous thing, but the chance of the happening in our program is about 0.2%. So very safe and very effective.

Dr. Diane Reidy-Lagunes:

Beautiful. Switching gears, how should family discussions take place? I think we probably have some misperceptions that someone with prostate cancer, for example, may be not interested in family planning. And should they be having any conversations before they take any types of treatment?

Dr. John Mulhall:

Yeah, that's an excellent question. It has largely been unexplored in literature until fairly recently. But you know, I work in Manhattan and we've got plenty of 65-year-old men who have 35-year-old girlfriends or wives for whom having a child is very important. So we do talk about, "Have you banked sperm before your intervention?" So if a man – any kind of cancer, any man pre-chemotherapy for whom fertility is important – if there's one message you take away from this conversation, it will be that: if you're going to have some treatment – pelvic radiation, chemotherapy, or radical pelvic surgery that may interfere with your ejaculation – you really should give serious consideration to banking sperm. And it would be important for you, as I said earlier on, saying to your doctor, "My sex life is very important, and so is my fertility." Then we will help direct you to the right places to store that sperm. I think every man for whom sexual function or fertility is important should have that conversation before treatment begins. There is a concern and this feeling that when you get the diagnosis of cancer – “The Big C” – that there are panic stations and "Let's get treatment going as soon as possible" when nearly always, for the vast majority of patients, there is time during which you can bank sperm or have a conversation with your doctor or a sexual medicine physician about these problems ahead of time. You know, it's interesting that patients think that the doctor will tell the patient everything they need to hear, when in fact the doctor will tell the patient everything the doctor thinks the patient needs to hear. So you need to define for the doctor what it is you want to know.

Dr. Diane Reidy-Lagunes:

And John, sometimes acceptance is the only answer. How do you counsel men who may not recover the function, despite these interventions?

Dr. John Mulhall:

Yeah, I mean, there's a large population of patients for whom I unfortunately have to deliver bad news. But there are plenty of patients in my practice for whom intercourse is not the only thing, and they actually lead a very fulfilling sex life having sexual outercourse, not intercourse-based relations. And so through me and through Chris Nelson, we can guide them through that process. Chris runs a very large program on acceptance and commitment therapy about accepting the situation you're in, and we help restore some form of sex life for these couples very frequently,

Dr. Diane Reidy-Lagunes:

We're going to end with some myth busters – myths versus reality – and some old wives tales for you to help us out with. Shorts worn too tight or too loose can affect performance, i.e. boxers or briefs?

Dr. John Mulhall:

They'll have no effect on sexual function. I think if your testicles are so tightly squeezed against your body or retracted into your groin, then the temperature chronically is not good for sperm production.

Dr. Diane Reidy-Lagunes:

Okay. Too much masturbation, or not enough, is bad for recovery.

Dr. John Mulhall:

Listen, the penis is designed to be used, right? Remember, we get three to six erections every night of our lives as a man, and the purpose of those erections after 12 years of age is to keep blood flowing, oxygen and stretch of the muscle. We're doing auto-rehab even when we're not sexually active. There really is no major negative effects other than two things. First of all, you can desensitize the penis if there's overly aggressive and overly frequent masturbation, such to the point that with sexual relations with the partner, it makes it more difficult to achieve an orgasm. And then there are, of course, patients who have obsessive compulsive masturbation, and they frequently have delayed orgasm and they need the help of Chris Nelson.

Dr. Diane Reidy-Lagunes:

The "George Costanza syndrome" – shrinkage in the cold pool.

Dr. John Mulhall:

The penis is a muscle and that muscle is under adrenaline control, but it's also temperature sensing, right? So in cold, our scrotum contracts – the scrotum is a muscular organ – as does the penis. When the nerves are traumatized, whether it's a diabetic or a radical pelvic surgery patient, those nerves cause that muscle to be hyper-contractile, and that's permanent and can be treated with drugs like Viagra and Cialis, etc. But it is a real phenomenon.

Dr. Diane Reidy-Lagunes:

Hot tubs are no good for fertility.

Dr. John Mulhall:

Yeah. So going back to the concept that our testicles hang outside our body, they should always be two to four degrees lower than our core temperature for a reason. Optimum sperm production occurs in the correct environment, and if you're, in a hot tub twice a year during your ski vacation, that's not gonna cause any major problem. But if you happen to live in an environment where you're in hot tubs all the time, then that theoretically could cause a problem with sperm production.

Dr. Diane Reidy-Lagunes:

And last, vacuum devices can stretch and elongate the penis.

Dr. John Mulhall:

So that is probably a correct statement, at least in the post-prostatectomy population. So the literature would show, fairly definitively, that you can preserve penile length using a vacuum device after radical prostatectomy. That is not saying that your penis is going to end up longer than it was before your prostatectomy. So there's no means by which you can truly stretch out the erect penis, okay? You can make the flaccid penis hang longer – there are operations that most urologists don't do – but you could use a vacuum device to stretch the penis, but in general, they maintain length and don't increase it.

Dr. Diane Reidy-Lagunes:

Thank you so much for being here, Dr. John Mulhall, director of Male Sexual and Reproductive Medicine here at MSK, and the undisputed king of erectile dysfunction. John, thank you.

Dr. John Mulhall:

My pleasure.

Dr. Diane Reidy-Lagunes:

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information, or to send us any questions you may have, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing this podcast at Apple Podcasts or wherever you listen to your podcasts. Any products mentioned on this podcast are not official endorsements by Memorial Sloan Kettering. These episodes are for you, but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes. Onward and upward.