Dr. Costabile presents a thorough review of the biological causes of
erectile dysfunction after cancer treatment and of our current range
of medical treatments to restore erections. I believe, however, that
despite the technical progress made in understanding and remediating
erectile dysfunction during the last 20 years, the majority of men
who develop such problems following cancer treatment still do not
resume a satisfying sex life.
For example, after localized treatment for prostate cancer, whether
with radical surgery or definitive radiotherapy, most men have
impaired erections.[1-4] Several studies of this group of patients
concur that 30% to 50% are distressed about their sexual
dysfunction.[5-9] Yet, only a much smaller percentage of men ever
seek medical help for their problems, and, of those who do, less than
one-third find their treatments beneficial. This quite modest
satisfaction rate is very similar to that found in three long-term
follow-up studies of diverse groups of men who sought treatment at
impotence clinics for erection problems.[11-13]
Although the introduction of sildenafil (Viagra) may increase
satisfaction rates somewhat, its strongest effects occur in men whose
problems are based on anxiety alone, or those who have very mild
organic impairment of the erectile reflex. Erection problems
following cancer treatment are typically more severe than those
associated with anxiety or mild organic impairments, however.
Importance of Counseling
How can we close the gap between our technical knowledge on how to
stiffen the phallus and our rather disappointing success rates in
giving couples back a satisfying sex life? The key, I believe, lies
in Dr. Costabiles brief paragraph, headed Counseling.
Although urologists have staked their claim to the wonders and
mysteries of the penis, mental health practitioners are often left
with the considerable territory of the man attached to it and his
partner. In fact, the urologic view of sexuality often reminds me of
a line Mae West uttered in the movie, Myra Breckenridge (1970).
Playing a casting director, she meets a new hopeful who states that
he is 6 foot, 6 inches. West suggests that he just tell her about the
Barriers Preventing Men From Seeking Help
Emotional barriers prevent men from seeking help, and despite Bob
Doles willingness to serve as the courageous, World War
IIera poster boy for impotence, most men still feel stigmatized
admitting that they have a sexual problem. And if they do win the
struggle to broach the topic with their physician, they may, in many
cases, be met with impatient dismissal. To be fair, time constraints
play an important role in producing this attitude among physicians.
In this era of managed care, the average visit with a family
physician lasts only 10 minutes, including both the physical
examination and all verbal communication.
Just this week, my lunch companion at a medical conference, a young
female family physician, told me that she and her office nurse had
laughed when a pharmaceutical company representative had brought them
sample questionnaires on erectile dysfunction, suggesting that they
administer them to patients to increase the percentage of men who
would discuss a sexual problem. Who needs questionnaires? We
already hear too much about those problems, she said.
Counseling Must Include Adequate Patient Education
For those men who conquer the hurdles and actually reach the
treatment stage, drop-out rates are extremely high. Although it seems
simple to try a pill that may improve erections, sildenafil is often
prescribed without instructions about its effective use.
I cannot count the number of times that I have heard of a man who
took his little blue pill and then sat disconsolately, waiting for
the automatic erection so that he could surprise his
partner. But the erection never appeared. The need for mental and
physical sexual stimulation, in addition to the medication, was never
mentioned by his physician.
Following cancer treatment, a man and his wife should undergo joint
counseling on how to comfortably resume sexual activity. They should
be encouraged to attempt noncoital sex even if erections are
insufficient for intercourse.
Information about other aspects of sexuality besides erection should
also be provided. For example, the majority of cancer treatments do
not diminish a mans capacity to feel sexual desire, enjoy
erotic sensations on his genital area, or feel the pleasure of
orgasm. Nonetheless, these facts are rarely included in the
doctor-patient discussion about erectile function. Having a hard
erection is viewed as the sine qua non of sexual normalcy.
Including the Partner in Discussions
Leaving out the partner is another source of treatment failure. A
partners acceptance of a mans need to inject his penis
with medication or to use a vacuum pump in order to have an erection
depends on her understanding of the problem so that she does not
misinterpret the absence of tumescence as an absence of attraction or
desire. Even the use of sildenafil can be frightening if a woman
fears that it will threaten her partners health.
The mental health professional who is best trained to provide this
type of patient education and sexual counseling is often the least
valued member of the treatment team. Third-party insurers typically
exclude the treatment of sexual dysfunction from whatever paltry
mental health benefits they still offer. Cancer survivors and their
partners are often delighted to try herbal remedies, aromatherapy,
acupuncture, or drumming, but are embarrassed and anxious about
seeing a sex therapist.
We are a nation that believes in better life through chemistry. I
believe, however, that all our talk about phosphodiesterase
inhibitors and veno-occlusive dysfunction remains so much sound and
fury when we forget that sex is a sharing of pleasure and intimacy
between two people.
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