Читать книгу Saving Your Sex Life: A Guide for Men With Prostate Cancer - John P. Mulhall - Страница 22

I have outlined the mechanisms by which erections occur in the first chapter of this book, but to recap, blood flows into the penis under the stimulation of a chemical known as nitric oxide. Nitric oxide comes predominantly from the erection nerves and results in relaxation of the erectile tissue, which is combined smooth muscle and endothelium. Blood flows into the penis, the penis enlarges, the valve mechanism closes and erection occurs. Therefore, erection nerves, erection tissue and a properly functioning valve mechanism are critical to the generation of a good erection. The penis is kept flaccid during non-aroused states, and after orgasm it returns to flaccidity by the action of adrenaline. The erection nerves supply adrenaline, which is the most potent anti-erection chemical that exists. It is not unusual for a prostate cancer patient soon after diagnosis to experience fear, anger, stress, frustration, thus leading his life in a state of high adrenaline. In the bedroom, adrenaline is the enemy of good erections, and in this high-stressed state, it is very common for men to notice significant reduction in their erection hardness during sexual relations.

As previously stated, the confidence that a man has in his erectile ability is critical to his erectile function. Clinical experience has shown me that as men, we often believe that we are only as good as our last erection, and if our last erection is not good, the majority of men will walk into the bedroom on the next occasion remembering the failed attempt and being worried about the next attempt.This lack of confidence leads to high levels of adrenaline in the penis.This restricts blood flow into the penis,opens up the valve mechanism, and a man has difficulty getting an erection or just gets a short-lived erection (often this erection comes and goes during the sexual event). As many men take several months to make a final decision regarding treatment, they may experience several months of poor erections.

What is interesting about erectile dysfunction is that the longer it goes on, the greater the degree of distress, the greater the adrenaline level and the lower the confidence a man has in his erection. The typical male response to such a scenario is avoidance behavior, which often appears the same to a partner as a reduced libido. Men hate to fail, especially in the bedroom, and when a man lacks confidence in his ability to get and keep an erection, he will avoid any possible sexual encounter. Not only will he avoid sex, but he will also avoid any physical intimacy, such as kissing and cuddling and sometimes even hand-holding.The reason for this is simple. It is essentially ingrained in our male biology that such activities as adults often lead to a sexual scenario. Given the low level of confidence in such men, they are concerned that such activity will lead to sex, and they will be frustrated and embarrassed, and their partners will be upset. Thus, it is common in my practice to see couples after surgery where the partner complains about the absence of any physical attention by the other partners.

Adrenaline can also cause premature ejaculation. Secondary premature ejaculation is a condition where men acquire rapid ejaculation at some point later in life when they previously experienced normal ejaculation. One of the most common reasons for this in my practice is the presence of erectile dysfunction. Practically two-thirds of the patients in my practice who have lost erection sustaining capability have developed decreased ejaculation time. Once the erectile dysfunction is adequately treated, the majority of men will improve, if not completely correct, their ejaculatory function.

CASE HISTORY 1

Impact of Diagnosis of Prostate Cancer on Sexual Function

Brian is a 55–year-old man who is married to Joan, his 40–year-old wife. Brian is generally healthy, although he has mild high blood pressure for which he uses a medication. He has been having his PSA level checked annually for the past five years, and this has always been normal. His prostate exams have also been normal, but this year his family doctor found a nodule on the right side of his prostate. He was referred to his local urologist, who did prostate biopsies and found a small area of cancer within one of the cores. He had been trying to make up his mind whether he should proceed with watchful waiting, radical prostatectomy, or radiation therapy. He comes to see me saying that, over the course of the last month since the diagnosis of prostate cancer, his erections are worse. Prior to his diagnosis of prostate cancer, he says his erection hardness was a 10/10 and currently it is 6–7/10, just about good enough for penetration. He has also noticed that he has had a significant reduction in his sex drive. Hormone blood tests and a duplex Doppler ultrasound of his penis are both normal, suggesting that his erectile problems are psychologically based. He was prescribed Viagra and responded beautifully to this. Brian eventually chooses to undergo radical prostatectomy surgery.

This case history illustrates the negative impact of any stressor, including a new diagnosis of prostate cancer, on a man’s erectile function. Adrenaline, which is generated under stress, during anxiety or in association with frustration, has a potent negative impact on erectile function. The penile ultrasound demonstrate normal blood flow confirms the diagnosis of psychologically based erection problems. This case also illustrates the negative impact of erection problems on a man’s libido; roughly two-thirds of men having erection problems will have loss of libido also. His normal testosterone blood test confirms that there is no hormonal cause for his low sex drive.

Some men may experience the exact opposite problem, retarded orgasm, where they have difficulty reaching orgasm or find it impossible. Any distraction during sex, for example, worrying about the ability to get or keep an erection, may actually reduce or decrease the ability to obtain an orgasm. I see men who routinely spend more than 30–60 minutes thrusting away in an effort to achieve an orgasm and fail. Some of these men achieve an orgasm only with masturbation, which suggests that the cause is likely psychological in nature. For the post-menopausal woman, who has vaginal lubrication problems even when using an external lubricant, 30 minutes of penetration will often result in vaginal pain during or after sex.

A diagnosis of any kind of cancer is not good for the sexual function of men or women, and you should not be alarmed if you experience some erectile problems after your diagnosis of prostate cancer. A supportive partner will go a long way toward helping this. The last thing a man with erectile dysfunction needs is increased pressure or resentment from his partner, as this will just increase the adrenaline level during sexual encounters. My recommendation to you is that should you be experiencing weakening of your erections after your prostate cancer diagnosis even prior to your treatment, you speak to your physician. Your doctor may consider starting a medication to boost your erection hardness as soon as possible. This may be combined with a suggestion that you speak with a psychologist. Initiating treatment early will “stop the rot” and may limit the severity of the decrease in erectile dysfunction. Interestingly, about 15% of my patients who have pure psychogenic erectile dysfunction (normal blood flow, normal hormone levels) do not respond to Viagra-like drugs. This is a testament to how important adrenaline is in turning off erections. When it is present at high enough levels, it will result in inhibition of the effect of these medications.