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In this episode, Dr. Diane Reidy-Lagunes talks with Dr. José Flores, urologic surgeon at MSK, about the often overlooked but vital topic of men’s sexual health after a cancer diagnosis. They delve into the broad spectrum of sexual dysfunction, how to address this sensitive subject with your doctor, and break down common myths and taboos that surround it. Discover how patients and doctors are finding solutions to maintaining a healthy sex life before, during and after cancer treatment.
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Show transcript
Dr. Diane Reidy-Lagunes:
Real confession. In my practice, I rarely or never talk to men about their sex lives. What a shame. And guess what? The sex life of men is not limited to the hardness of the penis. Other things, such as the ejaculatory function, anxiety, trust, orgasmic pain, all of these problems are real. They happen. And some men never find the solutions because no one talks about it. So we're going to 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 bring together 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 choices and live happier, healthier lives. For more information on the topics covered here or to send us your questions, visit us at mskcc.org/podcast.
As oncologists, we do everything we can to save your life. But apparently, we very rarely deal with your sex life. Cancer and its treatment can endanger your sex life. Today we're going to talk about men's sexual health and how to talk about it with your doctor before, during and after treatment. I am accompanied by Dr. José Flores, a urologic surgeon at MSK and a specialist in male sexual and reproductive health. José, welcome. Thank you so much for being with us.
Dr. José Flores:
It’s a pleasure for me to be here. Thank you very much for inviting me.
Dr. Diane Reidy-Lagunes:
What is the importance of sexual dysfunction?
Dr. José Flores:
Saving lives is always our priority. But then, especially when the channel is tied up, we want to return to our routine, to our normal life and sexuality is part of our normal lives, part of the quality of life. Therefore, in the post-treatment part, sexual dysfunction tends to be relevant, it tends to be important. However, if you want to preserve your sex life, it is very important to worry before, during and obviously after treatments.
Dr. Diane Reidy-Lagunes:
Understood. And you focus on sexual and reproductive medicine, but the problem can begin, as you say, before treatment begins. So what can we do? Do we need to give patients additional information?
Dr. José Flores:
Well, it's very important when we have the first contact with the patient. I know that we talk about a lot of things with patients, especially from an oncological point of view, but it's very important to evaluate what their sex life is like or what their sexual routine is like. If you have any degree of dysfunction, especially men, this is my area of specialty – if you have any degree of erectile dysfunction or sexual dysfunction.
As you pointed out in the beginning, sexual dysfunction is not just linked to hardness or stiffness of the penis. Sexual dysfunction is a much broader concept. It doesn't just cover erection or erectile dysfunction. It may also cover what is a decrease in libido, problems with testosterone or problems with orgasm, problems with ejaculation. The sexuality part is much broader, much broader. Therefore, when one is starting out as a patient, if your sex life is relevant, is important, a wall must be broken. Because I know it's a difficult topic to talk about. I know it's a taboo topic. It's a topic that we have a hard time discussing, especially by doctors or by the patient. There are many factors that have been researched that can, in the end, elucidate why this barrier exists. That's why I always invite patients and doctors to break that wall and to be able to speak about sexual life and talk about any degree of sexual dysfunction at any stage, before or during or after treatments, because the prevalence of sexual dysfunction in men is quite high. It is quite high. But I think that the most precise answer to that question is simply if the patient has a problem with his sexual life, that's where everything starts.
Dr. Diane Reidy-Lagunes:
Very important for the doctor can ask. And if not, try to find out what the patient is trying to ask. “Doctor, am I going to have problems like this?” or, “If I've had problems like this, can we talk about it?” I know it's complicated, but it's important.
Dr. José Flores:
That's right, that's right.
Dr. Diane Reidy-Lagunes:
What are some of the taboos or myths that exist in the Spanish-speaking community?
Dr. José Flores:
Well, as I said, there are a lot of taboos. First, simply talking about the sexual routine is very private, but it's important. And since it's important, we have to open up, we have to start talking. And one of the taboos among Hispanic men is that men must always be ready to be prepared for a sexual encounter. That's taboo.
The second is very important for the Hispanic community but can also be found in other cultures. It has to do mainly with the erection as the center, as the most important part of sexual life. And it's not like that. You may have, for example, especially in older patients, sexual activity without penetration. Therefore, the concept of our taboo has to do with the fact that the most important thing is the feeling of an erection. That isn’t so.
There are a lot of taboos and myths that I usually have to discuss with my patients because unfortunately that affects their self-esteem a lot. “I am no longer the same man that I was before,” and that really has a psychological impact in the end. Here in our unit, we have psychotherapists like Dr. Nelson, who really is an excellent professional who helps work on everything from a psychological point of view in these patients. I always tell my patients: 50% is physical, 50% is mental. Unfortunately I have to consider the culture because especially in my culture, the Hispanic culture, talking about sexuality is a taboo topic from a young age. So it's a topic that needs to be taught, especially in patients.
Dr. Diane Reidy-Lagunes:
Amen. I have a patient who received treatment for prostate cancer and he says that he and his wife have their favorite day, Naked Thursdays, because they say it's very difficult to have sex every day for him so they wait until Thursday. And now it’s their favorite day. So this is not something that has to be there every day, every moment. No, on the contrary, they wait and that is the important day for them. To prepare like this.
Dr. José Flores:
That's right. I mean, deep down I always tell them the sexual activity is between two people. Communication is very important. It's very important to know what the expectation is, what the couple wants. So I always tell the men I see, you need the talk, you need to talk to your partner, you need to know what you want and based on that, make a plan. And that's true. Here in our unit we always say choose a day, choose a day that you are going to have sexual activity. And a lot of men do. And the quality of the sexual route really improves a lot.
Dr. Diane Reidy-Lagunes:
Exactly. Speaking of the topic of fertility, what are the frequently asked questions about fertility? And what's important about keeping an eye on testosterone?
Dr. José Flores:
Oh excellent question because I can tell you that all the treatments we work here at MSK, and with cancer itself, all treatments – radiation, chemotherapy, surgery, immunotherapy, and bone marrow transplant – all directly or indirectly, can affect that man's fertile capacity or fertility. That's why I always recommend my patients before any treatment: keep sperm. That’s the first point.
And then a lot of men comment to me, “But how do I do it?” We have a whole system of sperm banks here, and we educate them on how to go. The nursing department is very well prepared. They are experts in fertility and how to preserve fertility. Here we have an exceptional group and we have the opportunity to work on what is called onco-fertility. If you want to preserve your fertility, please do so before any treatment. And if for some reason before treatment, you don't have sperm in your semen – because, as I told you, many times the same cancer can be a factor affecting fertility – then before starting any treatment, we can talk about some procedures to search for sperm that are called testicular sperm extraction. We go directly to the testicle and deep down we look for sperm and send them to freeze. I always tell my patients that's like a savings account for the future because you don't know what's going to happen after treatment.
And the most important thing has to do with testosterone, as you’ve said earlier. Many patients go outside or go to other doctors who don't have much experience in fertility and low testosterone and start treatments with exogenous testosterone, or testosterone cypionate, injectable testosterone. And what happens? When you are injecting testosterone, you suppress the axis. You suppress the stimulating axis from the brain, from the part called the pituitary to the testicular fundus. You suppress all the signs that are going to stimulate the production of sperm. Therefore, a man who is injecting testosterone has all these signs suppressed and the testicles stop producing sperm and the patient falls into what is called azoospermia. Usually, it is recoverable once you finish injecting exogenous testosterone. However, it can easily take three or six months and it is not guaranteed today that the patient will remain permanently with his sperm. So that's why it's very important. I tell my patients if you want to preserve fertility in the fund, don't use exogenous testosterone. There are other treatments that can help you increase your testosterone level without using exogenous testosterone, without using injectable testosterone or testosterone in patches or oral gel that are now available on the market. There are other treatments that are not testosterone that can help you increase your testosterone levels without affecting this axis, without suppressing sperm production, and thus sperm production is preserved and the patient manages to preserve fertility. So it's a very important topic.
Dr. Diane Reidy-Lagunes:
It's the only answer. In other words, there are a lot of things we can do. But how do you advise men who say they don't regain function? Does that happen? And what can we do next?
Dr. José Flores:
Well, that happens in a percentage. Fortunately, the level of that happening at MSK is much lower because the cancer results and rehabilitation programs in those can be quite successful. But there is a percentage of patients who do not manage to recover their erection after all. And in these patients we talk about possibilities, that there is a possibility of having choices. There is a chance of getting an erection and having sexual energy.
For a percentage, I would say that in less than 1% of patients, nothing works. Oral medications don't work, injections don't work. Usually that's because the atrophy or fibrosis of the erectile tissues, or this special smooth muscle at the penis level, is too big. There is a lot of fibrosis and there is something that we call veno-occlusive dysfunction. In other words, the patient is unable to retain the blood that reaches the penis and that is why this patient is unable to achieve an adequate choice.
So here's an important point I discuss with my patients: If you want to get an erection again or your goal is to have penetrative sexual activity, we probably need to talk about penile implants, or penile prosthesis, as they say in our Hispanic community, “La bombita.” I always tell my patients that you have the option to not have any more erections if you don't want sexual activity. However, the alternatives exist. There is always a possibility for that man who, deep down, sexual dysfunction does not affect his quality of life. There is always a chance that he may go back to having erections and that the patient will return to sexual activity.
Dr. Diane Reidy-Lagunes:
We are going to put an end to some myths to help us. Myth #1: Boxers that are too tight or too loose can affect performance. True or false?
Dr. José Flores:
No, that's absolutely a myth. No, it has nothing to do with anything of that quality. Nothing. It's absolutely false.
Dr. Diane Reidy-Lagunes:
Too much masturbation or not enough is bad for recovery. True or false?
Dr. José Flores:
Well, it's an important point that I should point out, that we have to look for a balance. Why? Because deep down one, it must be said, masturbation or sexual self-stimulation is one of the first components used by men to test their managerial quality. It's absolutely normal and it doesn't cause any harm. It doesn't cause any repercussions. It won't affect your erectile quality. What's more, I always tell my patients how important an erection is. If that erection is going to be to masturbate, or that erection is going to be to have sexual activity with your partner, that depends on you, but the most important thing is that you have erections. And in the end if you can have it two, three, four or five times a week, that is absolutely normal. You know that during the nights, a man has three nighttime erections and that's normal. That doesn't mean there is a magic number, but masturbation is a very effective way to achieve erections and maintain an erection. I highly recommend it, especially to test how your erections are later, especially right after a radical prostate surgery.
Dr. Diane Reidy-Lagunes:
And the last one: Hot tubs and jacuzzis are not good for fertility.
Dr. José Flores:
I would say that's true. Why? There's a reason why the testicles are outside the body. Because they are usually at a Celsius level. They are two, three degrees below the body temperature level. Why? Because sperm production depends a lot on the temperature. If the temperature rises by 2.3 degrees, sperm production begins to be affected. Therefore, for those men who are in the background looking for fertility, looking for a pregnancy, the first tip is not to take jacuzzis because that will increase the temperature of the scrotum at the testicular level. If it's once a month I think that's not going to have an impact, but if they do it frequently, routinely and practically daily, if that can affect them. One of the recommendations, and especially if we rely on the fertility guidelines of the American Association of Urology and the American Association for Reproductive Medicine, one of the first recommendations is to avoid hot tubs, especially if you are looking for fertility. Why? Because rising temperatures can affect sperm production.
Dr. Diane Reidy-Lagunes:
Doctor José, thank you very much for being with us. I have learned a lot and I am very happy that you are with us.
Dr. José Flores:
For me it's always a pleasure. I love it. I am very passionate about this topic, which is why I have been working in this area for almost ten years. It has been my area of specialty and I am always happy to help the Hispanic community, the Latino community, and Spanish-speaking patients to provide accurate information regarding fertility and male sexual health treatments.
Dr. Diane Reidy-Lagunes:
Amen. Thank you very much. And 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 valuable resource by rating and reviewing podcast on Apple Podcasts or wherever you listen. Any products mentioned in this episode is not an official endorsement of Memorial Sloan Kettering. These episodes are for you, but they are not intended to be a medical substitute. Please remember to ask your doctor any questions you have about medical conditions. I'm Dr. Reidy Lagunes. Onward and upward.