Deep Dive

Why That Bathroom Map in Your Head Means It's Time to Talk Treatment

A lot of men tend to put off their health checkups and procedures until they finally have more time—usually after retirement. Between work and family, it’s easy to push these things aside.

But once retirement rolls around, those lingering health issues, like prostate concerns, start demanding attention.

Then there is the guy who has seen me for years for prostate symptoms, doing all he can to avoid a procedure, trying hard to make the most of meds, but essentially 'getting by' with a roadmap front and center in his mind of all the restrooms from home to anywhere.

Whether it’s an enlarged prostate (BPH) or prostate cancer, men have a hard decision to make when it comes to treatment—prostate cancer treatment typically involves either surgery or radiation.

And with so many BPH treatment options available, it can feel as overwhelming as trying to pick something off the menu at The Cheesecake Factory. In both situations, the risk of sexual dysfunction after treatment is real. Let's unpack this!

4 Daily Disruptions That Signal It's Decision Time

For men with BPH, surgery often becomes necessary when symptoms start interfering with daily life, such as:

• Recurrent urinary infections

• Trouble emptying the bladder

• Frequent trips to the bathroom

• Disruptive urinary symptoms that affect sleep and activities

For those diagnosed with prostate cancer, the decision to undergo surgery or radiation is a big one. The main goal is to treat the cancer, but it's also important to think about possible side effects and how they might affect your quality of life if this is important to you.

The Bedroom Conversation You Need Before Surgery Day

One of the biggest concerns after prostate cancer surgery is its impact on sexual function. The nerve bundles that control erections sit on the surface of the prostate, and these nerves can be affected during surgery.

Erectile dysfunction (ED) is common after surgery, with the extent depending on factors like the surgeon’s skill, whether nerve-sparing techniques were used, and a man’s sexual health before surgery.  No treatment for prostate cancer will resurrect erections for a man who is already having problems.

Fortunately, advances in robot-assisted prostatectomy have made it more likely to preserve these nerves. If both nerve bundles are spared, many men see gradual improvement in erectile function over 12 to 18 months in 65-75% of men.

However, things may not return to how they were before surgery. Sometimes, nerve-sparing is not performed because leaving the nerves behind risks leaving cancer behind. In this scenario, erections without assistance won’t happen after surgery.

Sadly, I commonly hear from men that the urologist who did their surgery was hesitant to treat their erections in the initial months after surgery.

This frustrates me, and men need to know they don’t have to wait the full recovery period to seek treatment for ED or get back to sexual activity.

Another major change is the loss of ejaculation due to the removal of the prostate. This can be a tough adjustment, but many men find that orgasms are still satisfying in terms of how they feel, but nothing comes out.

What Nobody Tells You About The Radiation Timeline

Radiation therapy affects sexual function differently than surgery. Rather than immediate changes, the effects develop gradually.

Erectile dysfunction can creep up slowly over time as radiation impacts the nerve bundles and blood supply that support erections. Studies show that about 50% of men experience ED within five years of completing radiation therapy.

Radiation also leads to dry orgasms, where ejaculation no longer occurs. This might take some getting used to, but it doesn't mean men can't enjoy intimacy or climax.

A helpful way to think about the difference between surgery and radiation:

• Surgery: The potential damage happens all at once on the day of surgery, like putting all your eggs in the basket on surgery day and in recovery you 'get the eggs back' as the tissues heal.

• Radiation: The effects build up slowly, like adding eggs to the basket little by little over time.

Making Sense Of The BPH Treatment Menu

BPH treatments can have different effects on sexual function, especially when it comes to ejaculation and less so erections. Balancing how well the treatment impacts urination with sexual side effects can be confusing—even for us!

Retrograde Ejaculation: This happens when semen enters the bladder instead of exiting through the penis, leading to dry orgasms. It doesn’t affect pleasure, but it can take time to adjust.

Common Treatment Options

Medications

• Alpha-blockers can cause retrograde ejaculation in 30% to 90% of men.

• 5-alpha reductase inhibitors may lower libido and occasionally cause ED, with less semen and weaker orgasms.

Surgical Procedures

• TURP and Laser Therapies: Retrograde ejaculation happens in 65% to 90% of cases, but ED is rare.

• UroLift: Preserves ejaculation and erections, with less than a 10% chance of retrograde ejaculation.

• Rezūm Water Vapor Therapy: Retrograde ejaculation occurs in 10% to 20% of cases, with minimal impact on erections.

• iTind: A temporary implant with a low risk of sexual side effects.

• Aquablation: A water-based technique with a retrograde ejaculation rate of around 10%.

• Simple Prostatectomy: Typically for larger prostates, almost always results in retrograde ejaculation but usually doesn’t impact erections.

3 Things To Remember Before Making Your Decision

When considering prostate surgery or radiation, it’s important to keep in mind:

• Prioritizing health: Addressing urinary symptoms or cancer is crucial for your well-being.

• Medical advancements: There are better treatment options today than ever before.

• Communication is key: Talking openly with your healthcare provider and loved ones can make the process easier.

Starting Your Treatment Journey

BPH Treatment Considerations

• Choosing a BPH procedure is about improving urinary symptoms—think about how important sexual function is to you when making the decision. If it's not that important, you may choose a procedure that improves urination better.

• Many men wonder why they waited so long to have their BPH procedure done, as they often experience significant relief after treatment. I hear this all the time!

Prostate Cancer Treatment Considerations

• When it comes to prostate cancer treatment, there’s no perfect choice. Sometimes the situation dictates the best option.

• Many men who undergo treatment for prostate cancer feel a sense of relief knowing they’ve taken action against their cancer, but then they're left with side effects.

• Your recovery after prostate cancer treatment will be a journey of ups and downs—know this and remember that your urologist is there to help.  Sex doesn't have to wait until the 12-18 month recovery phase.

Every Treatment Journey Looks Different

Don’t get overwhelmed by all the details—ask yourself what your priority is, and focus on that. And don’t worry if your urologist only offers a few of the treatments available—each option is like a tool in their toolbox, and they’ll recommend what’s best for your specific situation.

Whether you are considering treatment for prostate cancer or BPH, I get it—it’s clear as mud. Ask your urologist questions and get to the best 'imperfect' decision.