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Saving Your Sex Life: A Guide for Men with Prostate Cancer, by John P. Mulhall

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Product details

Paperback: 307 pages

Publisher: Hilton Publishing (September 1, 2008)

Language: English

ISBN-10: 0980064961

ISBN-13: 978-0980064964

Product Dimensions:

6.1 x 0.7 x 8.9 inches

Shipping Weight: 14.4 ounces

Average Customer Review:

4.6 out of 5 stars

38 customer reviews

Amazon Best Sellers Rank:

#695,413 in Books (See Top 100 in Books)

I can still recall vividly in July of 1012, when my prostate biopsy results came back and my urologist informed me (in a post-biopsy office visit) that I had adenocarcinoma in 5 cores, Gleason scores of 3, 3 in two and 3, 4 in the others, At the one hour meeting he wanted me to realize that I had no choice regarding some kind of treatment and that passive waiting wasn't an option. It had to either be a radical prostaectomy or radiation therapy. He leaned toward the first given that he was an expert in the field of da Vinci robotic suergery.But I'd made my mind up a week before, to have the radiation therapy, in no small measure because of Dr. Mulhall's book. (Chapter 1, on 'The Basics of Sexual Function' is especially useful for brushing up - irrespective of the type of treatment chosen). There were two factors that swayed me: 1) reading in Dr. Mulhall's book (p. 45) that "positive margins" (remnant cancer cells) can be left behind in radical prostatectomy - something I learned that can even happen to the most experienced surgeons - especially using da Vinci robotics, and 2) the fact that my wife had already worked 20 years in a radiation therapy setting (brachytherapy software corporation) and knew where I could get the optimum treatment.When my urologist heard my choice of treatment he also concurred, saying tha for my age (then 66) the results were pretty much the same whether one chose surgery or radiation.So, I opted for high dose rate (HDR) brachytherapy, at the Helen Diller Cancer Center at the University of California San Francisco (UCSF). I was also extremely fortunate, in that only a few months before I arrived at UCSF the multiple treatment form of HDR was replaced by the one time HDR brachy treatment based on a study done by Dr. Alvaro Martinez at William Beaumont Hospital-Center which showed that the results for a single treatment were good, with low toxicity. (See, e.g. the William Beaumont Hospital-Center site on Alvarez techniques, or Google 'IPSA for HDR brachytherapy' )My treatment was carried out Sept. 25th of 2012, after being admitted at 8 a.m. then having the implant procedure about two hours later, after receiving epidural anesthesia (I chose to be awake the whole time, as I like to do in the case of colonoscopies - call me weird!) The implant surgery - in which a template is sutured to the perineum to allow the introduction of the transfer tubes bearing the Iridium 192 needles into the prostate - took barely 45 minutes, after which I was wheeled into the recovery room before being taken (2 hrs. later) for a CT scan, then the actual radiation delivery.The whole administration lasted about 20-25 mins. I received a total dose of 1930 cGy (centigray), with bladder-rectal sparing contours - optimized by UCSF's specialized IPSA planning software. The rectal-bladder sparing radiation was at 90 percent of the full dose. The most painful part of it all? Probably when the Foley (catheter) was removed.Following the treatment, I was pretty well prepared for the effects to follow - thanks again to Dr. Mulhall's book. Mulhall, for example, superbly describes how radiation works to effect a cancer treatment (p. 78):"Radiation therapy works by killing cells. It kills not just cancer cells but normal cells. However, those cells that are the most rapidly dividing are the most sensitive to radiation (as is true for chemotherapy). Fortunately, most cancers have cells that are dividing more rapidly than normal cells.Radiation attacks the DNA in our cells. It causes breakages in the DNA, and when this occurs, the cells commit suicide, a process known as apoptosis. Normal cells have better repair machinery to fix some radiation damage while cancer cells do not. As well as killing off the actual prostate cancer cells, radiation causes injury to the blood vessels that supply the cancer."Alas, as Mulhall notes later, these blood vessels- many of them - also supply blood to the erectile tissues. Most shocking to me was to read that erectile success rates are the same for surgery and radiation after 24 months, and while radiation oncologists tend to look at sexual function after 12 months or so, Mulhall indicates it needs to be 3-5 YEARS after (p. 83) . He refers to this as a "glaring deficiency" (ibid.) and adds:"Any study looking at erectile function outcomes should really assess these outcomes at no sooner than 24 months, if not 36 months, after the completion of radiation."Another aspect is "loss of ejaculatory volume". Mulhall again on p. 80:"Radiation therapy results in reduced ejaculate volume as the function of the prostate and the seminal vesicles is to produce ejaculatory fluid, and in most men, will result in loss of ejaculation completely".Reading this is critical because the information helps to allay groundless fears. Thus, in my own experience post-treatment, I found the effects indicated by Dr. Mulhall fit my own situation markedly. The knowledge meant that I didn't become as frustrated as I might have. Since I now understood the physiology better. After one year, of course, efficacy has decreased further because of increase blood vessel damage from the radiation (this increases as time goes on).Another effect, dysorgasmia (i.e. orgasmic pain) As Mulhall observes, p. 113:"This is a peculiar problem which is seen more frequently after surgery than radiation, but is seen in both cases, and believed to be related to spasms of the muscles of the pelvic floor at the time of orgasm. The bladder neck is supposed to close at the time of orgasm, and the belief is that the bladder neck muscle and the muscle surrounding this in the pelvic floor may in some men go into spasm at the time of orgasm with pain referred to the penis, testicles, lower abdomen or rectal area."Mulhall goes on to state the pain "typically lasts from seconds to a minute" but in some men can last for hours after orgasm. In my case, the pain was much like that experienced as the first needle entered for my prostate biopsy back in 2012, with an incinerating pain referred to the whole urethra. That lasted maybe a minute, but the first orgasm after radiation treatment saw the pain lasting up to five minutes afterward, and of such intensity that I nearly passed out. Again, I'd have been shaken to the core had I not been informed in advance of what was going on!Why such harsh results? Never mind the inflammation aspect, i.e. "radiation causes inflammation in the prostate, urethra and bladder" (p. 79), Mulhall also notes (ibid.):"The amount of radiation needed to cause endothelial damage is tiny, ranging from 0.1 to 1 Gy. It is estimated that between 15 to 20 Gy is required to injure large blood vessels (when given in a single dose). This damage to blood vessels is known as endartertitis obliterans and may take up to a decade to manifest itself maximally."The negative indicator here, with which I certainly concur, is that such orgasmic pain can impede a man from any sex activity altogether. This is quite understandable! Why would you want to repeat a pain that is so horrendous via a sex outcome (orgasm) presumed to be pleasurable? The form of rehab or prescription for avoidance of the pain as Mulhall notes, is Flomax (ibid.) However, I wanted to try to avoid the use of drugs entirely so chose what one RN website advocated: a full body massage. This was found to work, thanks to my wife's masseur, a female massage therapist who'd helped other cancer patients. I found that after the 4th or 5th massage, for whatever reasons, the acute pain had subsided.Another aspect to consider: after surgery or high dose radiation it may be exceedingly difficult to gain erections. The danger is that if not attained - and regularly - the blood vessels and tissues can be adversely affected. In this regard, Dr. Mulhalls Chapter 7: 'Penile Rehabilitation and Preservation' comprises a very key chapter in his book.Dr. Mulhall notes (p. 99) the average healthy male gets 3-6 erections every night of his life, during sleep, but after surgery (or high dose radiation)this isn't the case because of "nerve injury".or blood vessel damage (radiation) He goes on to observe that the penile rehabilitation program aims to ensure or at least encourage, men to get at least 2-3 erections per week at a level of at least 6 (e.g. 6/10) on the hardness scale. He emphasizes that neither orgasm or penetration as in intercourse is required, just ensuring the erection, to get blood and O2 into the penis.The aim throughout is to protect the erectile tissues from degeneration. If these PDE5 rehab procedures don't work then more radical methods have to be considered such as: 1) penile injections, 2) intra-urethral suppositories, 3) vacuum devices, or 4) penile implants. None of these is exactly "enjoyable" but the alternative may be quite depressing and also pose latent health risks (i.e. penile tissue rigidity leading to a U-shape)..For example, in terms of (1) Mulhall recommends a 29-gauge needle 1/2" in length for penile injection, and he provides a close-up diagrammatic view of where to inject on p. 145,Fortunately, I have not had to go to such extreme measures, but it's nice to know they are there. It's gratifying, especially, to know this book exists for men who fall victim to prostate cancer which claims frmo 29,000- 31,000 lives a year and annually affects nearly 900,000 men in the case of recommended biopsies.Needless to say this is an indispensable resource, even if a guy doesn't have prostate cancer. The odds are you will get it eventually!(As my urologist informed me, 3 of 5 males over age 65 have it, though it hasn't yet impacted their lives and PSA tests may not have disclosed it.)

Dr. Mulhall is the world's leading expert in sexual medicine, as it relates to preserving male functions after radical prostatectemy (prostate removal for cancer). After my prostate removal in August 2013, I did a massive amount of online research regarding how best to get back to normal after the surgery, which will take 12 to 24 months. Prostate removal, universally results in the inability to achieve erection, due to nerve damage (even when the nerves are totally spared). It takes the nerves as much as 12 to 24 months to come back to life, in order to trigger normal sexual function, even though you have full sensitivity to touch, without any lapse, immediately after the surgery.An unforeseen problem arises for those who do not engage in penile rehabilitation, during this critical 12 to 24 month period of nerve healing. If erections are not instigated through intervention (as described in Dr. Mulhall's book...daily use of low dose Viagra or Cialis, or trimix injections), on a regular basis, starting about 6 weeks after surgery, then the cavernosa muscles in the penis, which the blood flows into, in order to "inflate" can be become damaged through lack of oxygen that accompanies engorgement from blood flow. Collagen deposits will form in the spongy tissue of this muscle and cause atrophy, over a period of time. Then when the nerves do come back to life, they are ineffective in causing an erection because the erection muscle has been damaged through inactivity.The only reason I knew about this critical post operative requirement is because I went to Houston to have my prostate removed, by one of the foremost surgeons in that situation. Dr. Brian Miles has performed over 5,000 of these surgeries over the past 20 years and he told me that it was critical to follow this protocol to keep myself in the best possible condition for the return of the nerve function. I discovered that every male has 2-3 nocturnal erections every night in their sleep. We may not be aware of them, but it is the male body's normal way of keeping that muscle oxygenated, which was a complete surprise to me. Clinical sleep studies measured a large number of test subjects, to discover this universal pattern. So Dr. Miles advised that stimulating at least one to two erections per week with the help of Viagra or Cialis and in conjunction with your partners help, if possible, is critical to maintaining the health of the membranes. Subsequent research on my part, led me to Dr. Mulhall, who lectures to Urologist symposiums throughout the country (some of which can be seen on Youtube, under a keyword search of his name). I discovered that he had written this in depth book on the subject and purchased it to educate myself even further. There are no gimmicks here. This is a true medical professional, writing on a very critical subject, with the sole purpose of allowing yourself to get back to normal with the highest potential degree of success. The book covers every possible aspect of explaining how we function "down there", and what leads to erections, along with in depth education on the structure of the membranes and tissues which are affected and what they will respond to, in order to overcome erectile dysfunction.AN ABSOLUTE MUST READ FOR EVERY MAN THAT GOES THROUGH PROSTATE REMOVAL.12/5/14 UPDATE. I am happy to report that, approximately 9 to 10 months after the surgery, my system started to awaken without the use of Viagra or Cialis and am delighted that one year after the surgery (following the book's advice) that I am totally back to normal and able to maintain full erections, as I had before the surgery. Thank you Dr. Mulhall and my surgeon in Houston, who brought this critical post op regimen to my attention.

If one suffers from prostate cancer one of the greatest fears is complete loss of erectile function. I found this book helped me put things into perspective. There were a number of procedures from injections, drugs, inflaters and penile prosthesis explained and I tried three out of the four. Following the radical prostatectomy, where all erectile nerves were cut because the cancer had escaped the capsule and grown over the nerve fibres, I did not realise I would miss sex so much. All treating doctors told me nerves do not grow back although one reference did indicate it was possible. I think the best advice I gleaned from a range of references including this one was the need to maintain stimulation, also known as "forget everything your mother told you". With regular stimulation during showering and at other times, slowly, the function has returned. So four years post operation with the use of Cialis and occasionally without, erectile function is adequate for sex. The lesson from all the readings is simple "never give up" Incidently Ciallis and other similar drugs, according to the European registration data, are excreted via faeces so drink lots of water after taking them. I usually have two glasses before retiring for the evening. I found the book very useful as an information source. One reference in the book to orgasm said it was a problem in about 25% of those who had had the operation. I found that to be the case until things firmed up. Good luck it can be a long, frustrating and hard road. PG

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