Episode 155: Navigating Sexual Health After Prostate Cancer

I'm very excited to welcome our new sponsor, Higher Nature, who have created Rekindle, which I'm currently trying out and is working a treat. A 100% natural libido-enhancing supplement for women which contains clinically backed ingredients to give your sex life a a boost. And who doesn't want that? This week's episode has been sponsored by Oh My Bod, shifting the evolution of pleasure. Hi, this is Suzanne Noble, and you're listening to Sex Advice for Seniors. Do you know, it rarely happens, but when it does happen, it's so delightful that one of my listeners becomes one of my guests and then subsequently suggests someone else as a guest who is someone that I'm going to be speaking to now. That has never happened, but it's always great because when I do speak to listeners as guests, then I get an insight into what people want to hear more about. And I subsequently did a survey recently which highlighted that one of the things people wanted to hear more about was about how health conditions can impact on sexual function, how they can adapt to chronic health conditions, which might be either vascular health conditions, prostate, mobility issues, etc. So I'm really delighted today to be speaking to someone who knows quite a bit about that. Welcome, Dr. Sambolis, and he is the Associate Professor of Urology at Northwestern University. At the Feinberg School of Medicine, coming at us all the way from Chicago, in Porto in Portugal. So the wonders of the internet have brought us together, combined with this wonderful software that I use called Riverside. So welcome to Sex Advice for Seniors.

Thank you so much for having me.

No, thank you for, for waiting so long to get here. We've been trying to arrange us for a while. And I know that one of the reasons why Bob Mizek was so keen for me to speak with you was about how you supported him when he was diagnosed with prostate cancer, especially around sexual function. So tell me about why that is a specific interest for you.

Well, it's something that can be made so unique for each individual, and without going into Bob's details, With everybody, we come in and we say, what's your goal now? And then when we help men take ownership of where they want to end up and how we can get them there, it's a really rewarding field. Prognosis is really good, but it does take time. So we get as doctors to build that combination of a relationship, but then share some, some advice and eventually more and more treatment options emerge as we get further and further down this pathway.

Yeah, so I mean, it's really hard to know even where to start, whether— because most people, obviously most men want to prevent prostate cancer. So maybe we could start there. Are there things that men can be doing throughout their lives to make sure that they don't end up with prostate cancer, or is it one of those things that's just going to ultimately happen to a significant proportion of men?

So yes and yes and no. The biggest thing that, that you can do to avoid prostate cancer is don't smoke. I mean, it, it's a horrible modifiable risk factor. Uh, it's absolutely increases risk of prostate cancer, but a lot of things you can't control, right? You can't control your family history. We can control to a degree our diets and try and be healthy in general, but I would caution against overthinking that component. My mantra for my patients is if it's good for your heart, it's good for your penis.

Yeah. Well, that makes sense.

Yeah, it's a very vascular organ. So cardiovascular health usually means good sexual health and actually good urinary health as well.

Yeah. And what about things like masturbation? More, less? Does it matter?

I would never tell somebody to change what they want to do sexually with the goal of changing their prostate cancer risk. Like, if you're moving the needle, it's by such a small amount.

Okay.

I would rather you have better sexual satisfaction in your life by doing what you want to do, approximately the amount of time you want to do it.

Okay, cool. And so, you know, in Bob's case, and in the case of lots of men that I know, because we're dealing with an age group where quite a significant proportion of men have some issues around their prostate, and that tends to— not always, but it seems to impact erectile function. What are some of the ways that you support men who are going through treatment?

We would have to separate what type of prostate issues we're talking about. So benign prostatic disease absolutely has an impact on sexual health, and prostate cancer and prostate cancer treatment specifically is very, very different. So it's all about customization. I think it's easy to talk about prostate cancer treatment because we've kind of got these pathways laid out, we sort of know what's gonna happen. And unfortunately, after prostate cancer surgery in particular, most men are gonna take a tremendous step back. And if I could have them be ready for that, that would be a great step one. And then we support them by trying to balance how aggressive do you want to be and, and how much invasiveness are you willing to accept with the goal of being better, not today, but a year from now and 2 years from now. So we can augment your recovery with some of the tools that we have now that are all non-surgical. In that early stage.

So one of the things that I've been told, and you can tell me whether this is an urban myth or not, is that the sooner you start to work on your pelvic floor and your pelvic floor health after you've had surgery, and also around things like pumping, for instance, the better chance of you recovering your erectile function. Yes or true or not?

I love pelvic health. I love pelvic floor physical therapy. I think the data on erections is mixed, but the continence data is, is fantastic. So no matter what, you have significant benefits and no risk. So I love getting pelvic health involved early. It can only be a positive thing. And for the continence, it's tried and true. It is the best thing we have.

Right. And things like pumping, Any views on that? I—

there's debate, and I am not a huge fan of vacuum pumps for erectile health. Now, the adage of if you don't use it, you lose it, I think is meaningful. But what we're talking about there is the elasticity, the size, the stretchiness. And I know guys are really disappointed when they get their first erection post-surgery, and it's a couple months out, and they go, this isn't what I had before, this is less. And that's really disappointing. And I think that's where that stretch and that elasticity and reminding the penis what it's like to be full of blood are really meaningful. Vacuums, however, do not produce a physiologic erection. They are using negative pressure to pull mixed blood, some venous, some arterial, into the spaces and create what is ultimately swelling. Yeah, so the vacuum in my practice is used as a means to an end. If that degree of invasiveness is tolerable and it allows you to participate in activities that you want to, typically penetrative sex, then I think that's reasonable. But I can't see how that necessarily, from a function perspective, obtaining and maintaining erections— I don't see where the value is. I would prefer either flaccid traction or penile injections, which actually do produce physiologic erections.

Yeah, yeah. And what about electrostimulation and devices like that?

They're emerging for sure. In the post-prostatectomy space, I haven't seen anything that's necessarily reliable. But I think vibratory stimulation is being investigated. It's already proven in spinal cord injuries, and I think that's a lateral move from spinal cord injury to post-prostatectomy health because those are both neurogenic erectile dysfunctions. So I think there's a lot of reason to be encouraged about that. And again, when the risk-benefit ratio is favorable, I'm going to support it. And there's not a lot of risk to these things.

No, no. And I mean, I think some of it is— must be psychological, right? I mean, if you look down and it looks full, it doesn't matter too much to a guy how that happened, you know.

Yeah, it is psychological in that it's so important. It is so important. It is not psychogenic ED. So guys will come in as, ah, I think it might be in my head. I said, no, this problem is not between your ears. It's between your legs. You had a surgery. Something happened that's different. The blood flow is not good. It is psychological in terms of its impact on men, but not in terms of its etiology.

Yeah. And the speaking about the psychological side of it, I think that's one of the things that I've certainly become aware of as a result of doing this. And also, you know, having friends who have gone through this kind of surgery is that it is traumatic if nobody tells you what's going to happen. So they're concerned, you know, that the consultants and the doctors that they've seen are more concerned with, you know, quite rightly, I get it, at getting them through the surgery. But then, of course, they're not really fully appreciative of the impact on their sexual health. You know, it can take a while, right? I mean, how long are we talking about? I know this is probably like, how long is a piece of string? But is it Is there an average in how long it takes a man who's gone through surgery to recover his erectile function, or is it again dependent on a variety of factors?

Absolutely dependent on a variety of factors, but we know that the healing that occurs takes place over 1 to 2 years, right? Okay, so to expect things to happen rapidly is unrealistic. And what I like to tell men who come in after prostate surgery is waiting for your erections to come back after a radical prostatectomy is like watching your kids get taller. It's happening, but you don't notice it unless you take these breaks and you don't see them for a couple months. And one day it feels like you healed because you can do something you couldn't do, and it feels like it happened all at once, but it never did. This is a gradual thing, and, and you put the work in and you do the right things and the reward will be there. But almost everybody does take a step back, in my experience. My experience may be a little more negative than the average person because people who have no problems at all and wake up the next morning with a wonderful erection they don't end up seeing me.

Yeah, sure.

But in general, I think there's a little step associated with a significant pelvic surgery.

And PDE5 medications— Viagra, Cialis— does that have any impact when you've gone through prostate surgery?

I love them as an option because, like we said, we know that those medications require the nerves to work. The penis and the brain must communicate in order for PDE5 inhibitors to work. But when the surgery occurs, these nerves aren't turned off. The signal's weakened, it's dampened, and it slowly gets stronger and stronger over time. And these pills allow us to, one, take ownership of the recovery. I think there's a really positive impact on doing something, knowing that you're trying to contribute to your own healing, but they're also absolutely going to allow you to perform sooner than if you didn't use them.

Yeah, yeah. I mean, I guess on the flip side of that, the other things, you know, the other side of that medication is that if you're using that to combat erectile dysfunction and you haven't gone to see a cardiologist or urologist and you are just using that to mask deeper issues, that's potentially not great.

Yeah, in general, not the prostate cancer space, but in general, PD-5 inhibitors work. They work even if your problem is cardiac.

Yeah, yeah.

And that's why you really want to have a doctor who you trust, whether that be a primary physician, cardiologist, urologist, who's actually going to do that assessment on you. It's my problem with a lot of the direct-to-consumer marketing. I've been pretty vocally opposed to that because I'm not sure those assessments are taking place.

No, I mean, in the UK, I don't know what it's like in the US, but in the UK we can get those medications over the counter now. So you can, as a man, just go into a pharmacist, you can fill in a very short questionnaire, and they'll just give them to you. Whereas for women, you can buy vaginal estrogen, for example, over the counter, but there's only one type. And for the most part, you have to speak to a GP, and you have to go through a proper assessment to be able to get that. But, you know, with the PDE5 inhibitors, now pretty much anybody can just pick those up, to be honest. Like, if a young guy wants to get them and he's just got psychogenic ED, like, he can still just get them.

Yeah, and functionally, that's what we have now with a lot of these internet-based places. Yes, these men are obtaining a prescription, but they're getting a prescription via a chat box with a provider who's maybe less invested than someone who would be on an individual basis. So I think it's really available. And the question is, is your ED the canary in the coal mine? Most people who have a cardiac event will have ED several years before that. And if you're ignoring that, you're setting yourself up for disaster.

Yeah, absolutely. So I know one of the questions that people are going to have is, how do I make sure that if I've been told I have prostate cancer, that I'm armed with all the facts so that I can take control of my sexual health before I get— before I'm traumatized by what's going to happen? You know, what are the kind of questions that patients should be asking their doctor?

Yeah, I think what's my prognosis is the best one because that actually frames everything that we're trying to accomplish. The best indicator of post- operative erectile function is preoperative erectile function. And of course, there's some surgical factors that I wouldn't get into, but in general, if you're doing well before, the chances that you will do well after your recovery are really good. So if you're someone who's taking Viagra or Cialis and you really can't get a high-quality erection before surgery, you should know not to expect one after, right?

Okay.

And you don't have to wait for a prostate cancer diagnosis to try to optimize your health. Same thing, if it's good for your heart, it's good for your penis. You can do diet and exercise, you can lose weight, and these things will all improve your sexual function overall. Hey, optimize your cardiac health. If you have high cholesterol, get it treated. If you have high blood pressure, get it treated. Yeah, and don't skip your blood pressure medications because you think they're making your erections worse. They are protecting your erections for the long term, so trust the system.

Yeah, so things like statins, for instance, have no impact on erectile function.

Well, they don't have negative impact, right? Okay, so letting cholesterol go out of control wildly is going to have a long-term negative impact on erections. Blood pressure medications are a more complicated discussion because I have lots of men who come in and say, when I take my blood pressure pills, my erections are worse. Interesting. I know your body, because of your high blood pressure, relies upon these very high pressures to push blood into the penis to produce the erection, and when you take your blood pressure medicine, it can't do that. But take your blood pressure medicine anyway, because 5 years from now, when your blood vessels have been thickened by that high pressure, my therapies won't work. You are protecting your long-term erectile health by controlling your blood pressure now, even though it feels like today you made things worse.

Interesting. And would you say to those same men that in the same way, modifying their diet, modifying their lifestyle, less alcohol, you know, basic stuff like that is going to contribute just generally to better erectile function.

Absolutely. It's the best advice that we can give people.

Yeah. Yeah. So one of the things you mentioned that you specialize in that I know absolutely nothing about and have spoken to no one about is Peyronie's disease. I don't know what that is.

So Peyronie's disease is a structural disease of the penis associated primarily with penile curvature. Okay, it's an abnormal scarring disease, but the injury that sets off the scar is inherent to sexual activity. Like, everybody at some point in their sex life will zig when their partner zags, and they'll look down and say, okay, it's okay. They don't have to go to the ER. But 30 years later, and most commonly in the 6th decade of life, there's a new curve that changes over the course of 12 to 18 to 24 months and then stabilizes. And some guys pursue action, some men get it treated, and some live with it not realizing that this is something they don't have to live with. Well, the classic version is a curve.

And when we say, and how does that impact on their sexual health other than that there's a change in the way, in the look of it?

That's how half of my visits start. And I say, I should be asking you, That's what I asked the patient. I said, how does it impact your sexual health? Because not only is there individual factors and degree of curve and, and direction, you know, for penetrative vaginal sex, an upward bend, a dorsal curve, is much better tolerated than anything to the sides or down, for example.

Yeah.

And so we find that the same degree of curve can be much more or less bothersome depending on who we ask. And if someone comes in and says, I have a new curve, but it doesn't bother me at all, I say, then, then really think about how much we need to treat, because some of these treatments are invasive or even surgical.

Right. And what— and when we're talking about what you can do, what do you— it sounds like it would be quite, quite a serious procedure, but maybe I'm wrong. Yeah.

The bad news is pills don't work. We can't straighten out an erection with pills. So our mainstays of therapy are one of three things: traction, which is mechanical stretching. That's like braces, right? We know that applying mechanical force to the human body can generate a change. But the question is, how do we do it in a meaningful way without you wearing some sort of mechanic device on your penis all day?

Yeah.

And so by actually directing how that force is being distributed with certain devices, we can counteract the bend and restore lost length. And reduce the curve. The only FDA-approved medication is an injectable, and that's called Xyflex or collagenase, where we actually inject into the scar with the goal of dissolving the scar with associated reduction in curve. And the third option is surgery, and that can be done a number of different ways, but the most common one is by shortening the long end. So if you imagine a banana We would put stitches on the outer long end of the banana to shorten it so that the two sides match up, and we can achieve very high levels of straightness through that process.

And does any of this impact on erectile function, or it's just a visual issue?

If you have very severe Peyronie's disease such that the kink is impairing blood flow, we can see improvements. Okay, you've already alluded to the psychological aspect of when the penis is different than what you expect it to be or what you want it to be. And we've certainly seen boosts in performance associated with improvements in curve. And then there's the logistical and practical components, right? If you can finally do the things that you want to do, you tend to perform better. And we've also tested PDE5 inhibitors in Peyronie's disease, and they're just as safe as people who don't have Peyronie's disease. So you have those same options for the erection itself.

Interesting. Yeah, I have to say, because I didn't know what it was. And now that you've said it's a curve, and I have noticed that there are certain people I know, you know, again, in their late 50s, early 60s, where there is a curve, but I just, I never, I never thought about it. I didn't think about it as being anything other than the shape of their penis.

Yeah. And there's absolutely variations on normal. And if you've had it your whole life, it's probably not Peyronie's disease. But if there's a change that has occurred suddenly and it bothers you and it has a functional impact, there's no reason not to talk to a doctor about it. And you'll get directed to someone who can probably help you.

Yeah. Yeah. No, I can appreciate that. I think again, similarly, I went to a, um, to a conference last week about women's health. It wasn't about sexual health. But one of the things that encouraged us to do as women was to look down at our vulvas and to make sure that we were regularly checking them. And I think, you know, that's one of the things about women is that we don't check because we've never— you know, we— it takes getting a mirror out, doing something. But obviously when you're a man, it's much clearer when there have been some changes that are going on down there because you're looking down there every single day and you're you know, you're very familiar with it, whereas as women, we just aren't. We just don't— we don't examine ourselves, and we go through many different changes, again, in what goes on down there around aging. But unless we are encouraged to actually pay attention, often it's not until things have gotten pretty far along that we actually take any action, because it's just not, you know, it's just not something we do. So how can men take more control over Yeah, over their sexual health, over their erectile health, like, what are the things that you would encourage a guy to do on a regular basis?

Live a healthy lifestyle. So again, if it's good for your heart, it's good for your penis. So try and cut out those fried foods, you can skip dessert. Alcohol is detrimental to sexual health. And again, nothing's worse than tobacco. So if you can cut back on smoking, Absolutely do so. If you're considering starting, don't, obviously. Every doctor is going to say that, but sometimes the sexual health carrot is the one that we dangle that moves the needle. Someone, "Oh, well, I didn't realize it was going to hurt my erections." And then be proactive. If you think that there is a negative change, it's a really tough conversation to start, but I can assure you that the weird conversation that you're having with me is the conversation I'm having 30 times a day.

Right.

So I've heard it before. You're not going to surprise me. Like, tell me what the issue is, and the more you can share with me, the higher the likelihood that I can identify what's going on with you and maybe even offer a solution or a treatment.

Yeah. Do you think though that, um, because I've spoken to urologists who really do shy away from talking about sexual health, I have to say, they do. Not every urologist. And you know, this is the reason why we're having this conversation, right, is that not every urologist really wants to have these conversations with their patients, and some of them are actually pretty uncomfortable about the whole thing. And as a result of that, patients feel uncomfortable because, you know, if you're not uncomfortable as a urologist talking about it, then the patient's not going to be comfortable either. And I've, as I said, I've spoken to urologists who just say, we just want to get people through the surgery. We just want to get them through whatever issues that they're facing. It's almost like they think it's a privilege to want to still have sexual pleasure, right? That's kind of how I feel about it is, you know, you're 60-some-odd years old. You probably had a, you know, a good amount of sex. So it's not going to happen anymore. You know, just like—

I feel so fortunate that is not the environment we practice in here at Northwestern. And while the subspecialization of medicine, particularly in the United States, is a very real thing. And our cancer experts are some of the best cancer experts in the world, but they don't maybe focus as much on sexual health. But that team of urologic oncologists here loves having allies in the male sexual health field. So we say, well, if, if you're not going to be comfortable with it, or if your time is better spent making sure that your patient doesn't have cancer at the end of the day— and I absolutely support that— they still use me as a resource. We actually have a very large andrology department. I have 3 partners who have similar practices to mine, and we're busy because our urologic oncology colleagues want this resource. They want their patients to be successful and have wonderful quality of life. So I'm so glad that I haven't experienced the, uh, well, you had a good run approach to urologic oncology.

But I mean, look, we as women face this all the time, all the time. We get gaslit by doctors, by healthcare professionals. We get told as older women, pain is part of the getting older thing with sex, with sex, you know, we have to advocate for our own sexual health. That's what I always tell people. And similarly, I think that men often have to do the same in these sorts of circumstances because it may not be a priority for their urologist to be talking about this. As we've said, they just want to get through the surgery. So, you know, Would you say if your urologist is not a— is really seeming, you know, a bit insecure about all of this, that they seek somebody else, or is there some other specialist that they should look for? I spoke to a pelvic health specialist, for instance, and she works a lot with men in this, you know, that have had prostate surgery. Like, who can they go to? Yeah, I think they don't find a lovely person like you.

Well, I think that the, the cancer providers do have their patients' best interests at heart. And I don't think it's about find somebody else. I think it's find another person to add to your team.

Right. Okay.

So, I mean, my patients, their cancer care is still continued by their cancer team. But I'm just another team member and it is really easy to accumulate urologists at Northwestern, if I'm being honest, like you can end up with 4 of us. But if we're all providing you a different service and making your life better in a safe way, then I think there's value there. So I think most urologic oncologists would love to have somebody else own the sexual recovery side of this. Yeah. And they probably have somebody who they like or trust. They know that they're— nobody's afraid that I'm going to take your radical prostatectomy away from you. I don't even know how to do that surgery anymore. So it's a really easy way to be a team, work towards the same goal.

Yeah. And so what I'm hearing is, if your doctor is uncomfortable talking about sexual health issues, say, I want to speak to somebody on a team, whoever, who is comfortable talking about this, can you refer me to someone else that might be able to support me alongside the support that you're giving me. That's—

Yeah, exactly. Alongside. I think anybody who's not receptive to that is being a little bit unreasonable. Yeah, yeah.

And I think that's a completely fair thing to ask. And I think that's often what we need to do in, you know, like I said, the many circumstances where we may find ourselves with a healthcare professional who's just not comfortable talking about sexual health issues is just go, look, I want to discuss you know, what's going to happen to my sexual health after this surgery? Is there somebody on your team who might be able to have those conversations with me, or someone else you can recommend who can have those conversations, right? Rather than just being fobbed off, because often we get— sometimes we do get fobbed off, you know.

Yeah, I mean, and if you— obviously, if you have physician listeners, I would ask, just be transparent if you're not comfortable about this topic. It's okay. Like, I'm not comfortable talking about how to treat prostate cancer. Yeah, yeah, that's fine. But be transparent about it so you can help your patient get to somebody who is comfortable and who maybe has some resources to offer that you don't.

Yeah, no, 100%. And that, that makes absolutely perfect sense. So is there anything else that we haven't talked about that you would like to discuss? Wow.

I mean, it's such a vast topic. I think if I can tell the men who are listening one thing, it's figure out what your goals are before you talk to someone like me. And it just makes the visit so great because then we can work together towards helping you achieve them. Whether that's after surgery, whether that's, I've taken a drop-off in my performance, but I didn't have a prostatectomy. Whether it's, I want to understand what's going on with me in the case of Peyronie's disease versus actually change it. Because we can spend a lot of time talking about your goals. But since most of this is quality of life, which is what drew me to the field, I would much rather do quality of life discussions than quantity because those can get dark.

Well, yeah.

If this is a quality of life thing, then your goal should direct everything we do.

Yeah, yeah, yeah, absolutely. That makes perfect sense. It's been so lovely to talk to you. And I think, you know, one of the takeaways, and it's the takeaway with, with pretty much every conversation that I've ever had over 150+ episodes is one, make sure that you're in optimum health and your chances of, you know, encountering a chronic illness are going to be a lot lower. Look after your diet, exercise, do all those things that a lot of us really don't enjoy doing, but we just have to do it, right? And the second thing is, is learn how to have these conversations, be comfortable around talking about these intimate health issues so that you don't end up at the end of a surgery or a procedure just traumatized because you weren't expecting whatever happened to happen because no one told you. So, you know, speak up and advocate for your own health and your own sexual health.

Yeah, I totally agree. As much as I care about my patients, you really need to care the most about your own outcomes.

Yeah, completely. Yeah, completely. Anyway, Peter, it's been lovely to speak to you. Please do not leave immediately after I say goodbye. Otherwise, our little recording won't upload. But yeah, it's been fabulous. I'm so glad that Bob recommended that I chat with you. I've learned some things that I didn't know, and hopefully our listeners did too. Thank you.

It's been an absolute honor.