'Penile Rehabilitation' After Cryo Surgery - Not Like After Radiation

In a blog post five years ago I cited the work of cancer specialist Dr. John P. Mulhall, and the need for "penile rehabilitation" in prostate cancer patients who've undergone surgery or radiation, e.g.

http://brane-space.blogspot.com/2012/10/penile-rehabilitiation-what-most-docs.html

Mulhall is the author of an academic monograph entitled: "Sexual Function in the Prostate Cancer Patient,"  and also wrote a less technical book for actual prostate cancer patients and their significant others, entitled: "Saving Your Sex Life: A Guide for Men with Prostate Cancer".  In this book, Dr. Mulhall takes the 'bull by the horns' and shows that men who've had prostate cancer treatments - whether radical prostatectomy, radiation or hormone therapy, actually face immense work to overcome the attendant sexual problems.

The incipient damage is called "atrophy" which increases in probability the longer a patient goes without erection,  post-surgery. (p. 98) Atrophy is, in fact (op. cit..):

"a scarring of the erectile tissue, and if the erectile tissue scars, the patient will never get his own erection back and will always struggle with medication".

Dr. Mulhall goes on to note (ibid.) that "the incidence of erectile tissue damage, as measured by the presence of venous leak is very uncommon before the fourth month after surgery. However, at eight months after surgery it "occurs in about 30% of men and at one year 50% of men".  This also occurs or can occur after high dose radiation which I had in September, 2012.

Radiation attacks the DNA in 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."

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."

So, bottom line, I knew going into focal cryosurgery salvage treatment (treatment after initial radiation) the chances were not good to recoup erectile success. What I wasn't prepared for after the cryo is that this would plummet even more than after the high dose radiation (5 year mark). Of course, you are informed that though the targeted cryo can eliminate the localized tumor there is no assurance that adjacent nerve networks can't be damaged. This is because, unlike the tumor, these nerves branch out and aren't so localized.  The risk is also much greater for older patients, i.e. over 65 (I am 71).

On Monday I returned to UC Health in Aurora for the follow up appointment (after the procedure done on June 20th). This was with Dr. Crawford's professional assistant, Kristen -  a 26- year old woman and Columbia University grad. She had me fill out a "sexual and urinary function" form and then went over it with me afterward. The form covered about 15 aspects, i.e. urinary frequency, urgency, erectile quality, maintenance etc. - each on a 0 to 5 scale.  

I also, since I reported urinary frequency beyond the norm, had to submit to a bladder ultra sound in the office, performed by a medical assistant. Kristen noted that if the urinary retention was too high in the bladder (over 100 ml, after urinating) I might have to have a bladder dilation performed. Naturally then, I was relieved the retention volume was barely 30 ml.

In terms of the sexual -erectile aspect, and interestingly connected to the urinary issues as well, Kristen pointed out that both could be improved by taking 5 mg of Viagra or Cialis each day. As also noted by an American Cancer Society website., this is not enough to produce erections but it is sufficient to keep some blood flow going to those tissues which otherwise would receive little or no oxygen.  Thus, she sent in a prescription for our pharmacy.

The ACS site in relating similar information, points out that - typically - erectile quality, if it is to return at all, usually happens after two years. It takes the nerves roughly that long to heal, so we see that cryosurgery, like radical prostatectomy - is not exactly without its issues (including some incontinence).  In the meantime, it is important to be doing the low dose PDE inhibitor .  Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells, which promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this, since else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion the PDE5 enzyme.

In terms of orgasms, Kristen pointed out that these were still possible even without erections.  As noted on a UCLA website:

"An erection is not necessary for orgasm or ejaculation. Even if a man cannot have an erection or can only get or keep a partial erection, with the right sexual stimulation you can experience an orgasm. Your orgasm has little to do with your prostate gland. As long as you have normal skin sensation, you can have an orgasm."

As far as "supplementary aids", Kristen did mention possibly using special vibrators which "we could discuss at a later date", which was fine with me.

The session lasted about an hour, including the ultrasound, and the takeaway I came away with was that I was certain most men didn't have clue one what they were sacrificing when they opted to have prostate cancer treatments of any kind.  It also helped me understand the many thousands of men who refused to have any treatments, opting to do "watchful waiting" instead. (Alas, as Dr. Crawford had told me in our November meeting, that wasn't an option for me given the Prolaris score)

The tragedy is that this cancer can wreak so much havoc especially on younger males, some in their early 40s, who've reported serious marital problems, e.g. on the 'Team Inspire' group.   Once you're in your 70s this isn't so much of an issue, but still you don't want to see certain organs just waste away....so you kind of do whatever the dr. (or his P.A.) suggests.

My primary hope is that the physical (also mental - see my post on memory loss) sacrifices are worth it and this is the final end of this damned cancer. Kristen said I need to get a first PSA test done early next week and then another in three months. I hope that all future PSA test results are as close to 0.0 as possible!

When I jokingly told Kristen: "No more biopsies!"  She laughed and said "We'll see."

Mail Brane: Readers Seeking Answers to Questions

Q. I hope you can help! My husband, age 38, had  been diagnosed 2 years ago with aggressive prostate cancer (classified adenocarcinoma with stage T2(c) in biopsy) and had to have the radical prostatectomy or so he was told. The urologist told him he would need to begin penile rehabilitation as soon as the Foley catheter was removed but he refused. He said the pain was still too unbearable after the surgery and couldn't bear any erections from Viagra or whatever. To make a long story short his initial resistance to penile rehab - such as you described in your October 14 blog last year- became hardened. Gradually, he became incapable of getting any erections and his penis deformed. Much like you described. What can be done? Anything? - Barbara B., Orlando FL

A. At this stage it's doubtful since if the therapy isn't done soon after surgery and erections are allowed to lapse as you described, the tissue damage - due to lack of consistent blood flow - becomes permanent. There may be some surgery that can correct the deformation (I presume you mean the U-shape that Dr. John Mulhall describes in his book that I referenced in that Oct. blog) but the urologist would have to weigh in on that. This, of course, is a cautionary tale that those who have radical prostate surgery need to follow this  with penile rehab as soon as possible, though yes, there may be some residual pain. Your question also seems to imply that a radiation therapy treatment might have been better, but generally at the stage you described (T2c) it isn't an option.  Also, remember the effects of radiation increase over time, as tissues become hardened by the delayed radiation impact. This is also why it's essential to remain sexually active, whatever mechanism is employed.

Q. I was disheartened to read in your July 24 post that Colorado Springs had opted out of the marijuana retail business! Don't they know how much money they are losing? Are there any counties in the state that plan to implement the retail businesses? How many have opted out so far? - Clint, Pompano Beach FL

A. At last count some 57 communities in the state had opted out, but 21 remain in play -seeking rational ways to implement legal guidelines for MJ retail stores. Among those latter are Denver, and Aurora, CO. Almost to a tee, the opt- outs are in conservative counties, though they seem to forget they are flouting the voters' will by their opt out (and in many of those counties, Amendment 64 passed!)  I believe they might well pay at the polls next time any of the respective city council members come up for re-election. It never pays to piss off the voters! The mistake was probably making any "opt out" part of Amendment 64 in the first place. It gave too facile a way to deal with the nettlesome problem of how to regulate, where the controls would be and the level of taxation. It was a cheap way out, a cop out. So, I guess cities like Colorado Springs will have to keep on getting revenue from other sources, say like becoming or staying top national speed traps.

Q. Thanks for your post on being child free! (Aug. 18th). My husband and I were delighted to read and now feel much better about our childless choice. But how do you deal with nosey people that persistently inquire why we're childless? It really bugs me! - Delores, Sioux City, IA

A. Tell them: "Mind your own business, please!  Haven't you enough to do with your own time as opposed to meddling in others' lives".

Q. I've been wanting to join Mensa for a long time, but none of my past standardized tests (SAT in 1995, GRE in 2002) have been found acceptable. I dread taking the actual Mensa test because I hear it's a lot harder. Is this true? What can I expect? - Ricardo, Mt. Shasta, CA

A. It's not that big a deal. Below is an image from the U.S. Mensa site showing some of those taking a recent test.

The Mensa Admission Test takes two hours to complete and includes two tests featuring questions involving logic and deductive reasoning. If you score at or above the 98th percentile on either of the two tests, you'll qualify and be invited to join Mensa. Score below....well I understand there is a 5% society (The International High IQ Society) that accepts entrants at the 95th percentile level.

If you'd like a practice test (always a good idea) you can also get an idea if you're Mensa level by taking the home test, e.g. https://www.us.mensa.org/join/mht/

A more dated (1989) example which doesn't cost anything to see or assess can be found at this link:
http://articles.chicagotribune.com/1989-01-04/entertainment/8902220824_1_typists-chickens-eggs

Another shorter version with "Mensa-style" questions and answers:
http://www.agincourtpractice.co.uk/resources/mensa.htm

Q. I get a real kick out of your loopy brother (Mike) who thinks he's a Confederate raider or something. On clicking at the entry link to his blog on your August 8 post I see he always tries to appear this homespun dude with this "My friends" stuff. Who's he trying to fool? He's not friends with anyone! You just have to read his crappy blogs to see how disturbed he is. Any take on if and when he might change his blog again to be more tolerant? Also, what is this guy's damage? Was he dropped on his head as a kid?, Murray T., Norman, Oklahoma

A. I do agree that his 'my friends' intros are a bit over played. He likes to portray himself as this down home, relaxed type of southern dude but his own words and hateful content betray him. He's a raging maniac underneath the soft soap veneer, calling people "apes" (mainly blacks), "libtards", "c*nts" or worse.  As for being dropped on his head, no. But maybe in one too many fights where he took as many blows to the head as he delivered. We know, from looking at the NFL football head injuries that have come to the fore (e.g. Junior Seau), that repeated blows can have deleterious effects on the brain. This can lead to erratic behavior.  As for changing again, I could care less if he does or doesn't. It's his choice to make, and he has to deal with who and what he is. As an aside, it's really goofy and misplaced how he often makes lame invocations of our dad, when dad detested everything about Mike's hateful blog when he was alive.

Q. You mentioned doing a blog post soon on JFK and how he challenged the national security state. When can we expect it? Desmond, Portland, OR

A. That post is still in the process of preparation, as I'm juggling that with completing a book, that's due to launch in about 4 weeks, maybe sooner. The title is 'Beyond Atheism, Beyond God'  (to be published by iUniverse) and will be my final entry in my atheist series, showing how a rational atheism can lead to a Materialist conception of Being. Meanwhile, I am also trying to re-organize a science fiction novel on the Kennedy assassination, entitled, The Lancer Expedition. If all goes well it should be out by Nov. 1st, but hopefully sooner!

Q. When can we expect more interviews with your delightful sister-in-law Krimhilde? (Aug. 12 post) She has me considering joining Eckankar. - Molly D., London, UK

A. The next interview will probably be when I see Krimhilde again, perhaps next Spring. Will keep readers posted!

Mail Call Brane(Pt. II)

Continuation of questions from Brane Space readers:

Q. I am a young, married woman of 28, whose husband of 34 recently had treatment for aggressive prostate cancer. This included a radical prostatectomy followed by hormone therapy using a combination of luteinizing-hormone releasing hormone LHRH or  Leuprolide (marketed as Lupron) and a non-steroidal anti-androgen (Bicalutamide). The problem is that though this treatment ended six months ago (the doctors took him off the hormones since) he has no interest in sex at all! Worse, he’s still bothered by the way the hormones caused his breasts to enlarge so is very body conscious. We have tried everything including massage therapy and even trying to use mutual masturbation, but nothing works! Even watching porn videos doesn’t have any effect! Do you have any suggestions, as I noticed you wrote a number of blogs on your own treatment as well as ‘penile rehabilitation’. – Alissa J., Roanoke, VA

 

A. One of the awful aspects brought out in your question is the way prostate cancer is striking at younger and younger males. To this day, the base causes are still being explored, but my theory is that at least half the new and more aggressive cases can be traced to carcinogenic chemicals, toxins in the environment.

Anyway, as I noted in the blog you referenced (Oct. 14, last year) the real need for the penile rehab is on account of  post-op scarring of the erectile tissue, which - if it progresses too far- will prevent the patient from ever getting his own erections back and lead to an endless struggle with medication. This was according to Dr. John P. Mulhall ('Saving Your Sex Life: A Guide for Men with Prostate Cancer') Dr. Mulhall is the Director of the Sexual & Reproductive Medicine Urology Service based at the Memorial Sloan- Kettering Cancer Center.

He notes that "the incidence of erectile tissue damage, as measured by the presence of venous leak is very uncommon before the fourth month after surgery". However, at eight months after surgery it  "occurs in about 30% of men and at one year 50% of men". This is why it's essential, if men care at all about their future sex lives, they do everything possible to ensure erections of some mode (they are graded on a scale of 1-10 for hardness) occur before the 4th month after radical surgery. Why do erections need to occur? Because the absence of blood, and hence oxygen getting into the penis, leads to ongoing and progressive atrophy and tissue scarring. Mulhall invokes the "use it lose it" saying here. In some cases, indeed, prolonged disuse engenders organs which are badly misshapen (bent as in a U-shape) and essentially unusable because of unequal scarring in different tissues.

His aim in penile rehabilitation is for the patient to chemically-manually induce at least 2-3 erections per week as soon as possible after the surgery (this would be especially needed if HT was to be started after recovery).  In Mulhall's penile rehab program, the pre-op use of PDE5 inhibitors (such as Viagra)  is implemented up to two weeks before surgery. Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells, which promotes relaxation of smooth muscles and erection. (PDE5 blocks release of cyclic GMP, so PDE 5 inhibitors block the action of the cyclic GMP- blocking PDE5's.)

Now, the question is whether your husband was put on such a pre-op therapy. If not, as Mulhall points out, then it would be much more difficult to get success later. Post-surgery, the patient gets a prescription for a PDE5 inhibitor the day the Foley catheter is removed. He is then told to take a full dose of Viagra (100 mg) or Levitra (20 mg) once per week with adequate accompanying stimulation to attain at least a 6 scale out of 10 erection. On the other 6 nights he's told to take a low dose pill (50 mg Viagra or 10 mg Levitra) before going to bed.  Again, if none of this was done, the difficulties would be much much greater in gaining any success. The problems would be magnified if hormone therapy was delivered soon after.

There are, of course, other alternatives as I noted in the blog, including using vacuum pumps as well as the drugs Bimix or Trimix with a 29-gauge needle 1/2" in length for penile injection (as recommended by Dr. Mulhall). There is also the option of having a penile implant, but this also requires surgery.

In any case, the best option is discuss these with a urologist and see what strategy might work at this phase. By all means, explore every possibility since losing one's sex life so early cannot be any fun!

Q. if the Shroud of Turin is separately re-tested and found to be genuine, and more evidence also comes forth to show it really was Jesus, would that make you give up atheism? – Brenda K., Scarsborough, NY

A. Not at all. Merely because the Shroud is proven to be historically accurate, doesn’t prove the additional hypothesis that Yeshua was a God-man. As I noted in my blog on the Mithra-Mithras God-man mythology:
http://brane-space.blogspot.com/2012/12/more-on-mithraic-god-man-mythooogy.html


Mithraism provides the template from which Christianity adopted all its savior myths, including being born of a virgin, rising from the dead, etc. Heck, the Christians even copied Mithras' birth date on Dec. 25th.

J.M. Robertson, author of Pagan Christs, observes (op. cit.)


The celebration of the Mithraic mysteries, of the burial and resurrection of the Lord, the Mediator and Savior, the sacrament of bread and water...all these were in practice long before the first Christian Gospel of a Lord who was buried in a rock tomb


Robertson (op. cit., p. 121) also cites other common symbols that the Christians appropriated from Mithraic traditions, including the Agnus Dei, or "Lamb of God". As he notes:


"The Christian assimilation of Mithraism is still more clearly seen in the familiar Christian symbol in which Christ is represented as a lamb, carrying by one forefoot a cross."

What about the way in which Christians have consistently copied images of Mithras and used them for Jesus? Robertson again (op. cit.) supplies an answer (p. 124):


"The Christian imitation, took place, be it observed, because the features imitated were found by experience to be religiously attractive."

It’s clear from this that the Mithras mythology sticks in the craw of many biblical literalists and even orthodox Christian non-literalists, since their dependency on the notion of one unique "Savior" exposes their egocentric certainty they alone possess the truth. But they are deluded. They merely possess an ancient God-man myth stolen from earlier sources.

More to the point, Oxford Scholar Geza Vermes in The Authentic Gospel of Jesus, dismisses the notion that Christ himself believed himself to be special or a God. Vermes points out any such belief on Christ's part would have been interpreted as self-idolatry. He never ever referred to himself as "Son of God" only as "Son of Man", nor did he dictate any belief be accorded him. All such references were fraudulent later additions.
Given all of this, if the Shroud is proven to be historically valid, all I’d be prepared to admit is that a man actually lived at the time indicated and this may well have been Yeshua.

But he wasn’t a special divine creation!

Q. Your blog on the next stock market crash (March 19) really has me worried with my 401k and all. From my reading, it seems like almost a 63% chance we will have a major correction and maybe as much as 90%. Couple of questions: 1) How long would it take to make up losses if there was a big crash or correction? And 2) What other places can a person put his money to get anything?- Regis M., Seattle, WA

A. The math for recouping major losses after stock market corrections is pretty straightforward. For example, a stock – or mutual fund- that drops in share price from, say $20 to $10 has suffered a 50% loss. But for that $10 stock or fund share price to return to $20 it must gain 100%, or double. This may take not just two or three years, but more than TWENTY! In some cases it may NEVER return!


Many cheerleaders, as well as innocent lay folk, do not know that if a share of anything goes down by 20%, it requires an advance of 25% to get back just to the breakeven point. If the value of a share drops 40 percent (as has occurred with some recent mutual fund hits since 1999), you need a 66.7 % advance to break even. If the share drops 50% - as already noted- a 100% gain must be registered to return to ‘break-even’ (i.e. you’re not losing more than what you already paid).

Let’s assume then that this current bubble bursts in October, and there are 50% losses across the board, ‘blood in the streets’ as it were. Let’s say in the wake, with the arrival of austerity budgets and consumer retrenchment, the new increases are more on the order of 1%- 1.5% a year. (More realistic returns as predicted for example, by William Wolman and Anne Colamosca in their book The Great 401k Hoax, 2002)

Then you could be looking at about a thirty year time horizon to just get to the break event point. But in that thirty years inflation will likely have risen at least 2% per year, so in many ways you are in even worse shape and more so- because you’re likely at an older age when employers cease being interested.

The best advice one can give, then, is simply not to chase yield. If you are looking for a safe investment, always be wary of anything promising more than 4-5% in our current Fed cheap money environment.

My personal wake up call appeared in The Wall Street Journal, from Nov. 27, 2003, page D1,

'A Harsh Truth: Most of Your Investments Won't Make Money- Even in the Long Term'.

 
The piece showed that when stock or mutual fund investors actually include fees, commissions, taxes, expenses etc. they essentially don’t “make” any money at all. They’d be better off just staying with totally safe investments. The piece showed that when stock or mutual fund investors actually include fees, commissions, taxes, expenses etc. they essentially don’t “make” any money at all. They’d be better off just staying with totally safe investments.


People need to know the basic Wall Street pyramid game has never changed in over 70 years and is elementary to grasp. Pundits, wags and paid whores hype the various stocks, funds or instigate a "buzz" about them - to get suckers to buy in.

The increasing buy in inflates the price-to -earnings ratio (P-E ratio) and produces a bubble of high profits. The "Big boys" (large, institutional investors) get tipped 1-2 days in advance and cash out, leaving the little guys to sink. If they're lucky they may earn a few bucks. Not much.

The thievery works eventually because most manjacks are conditioned to "buy and hold" rather than fold when the share price dives below a certain threshold. (Which ought to be the tip off). Thus, there are always ample marks left at the end game to be properly fleeced. Amazingly, they're always ready to play the game again, and pile their newly saved up money in.


Q. I found your blogs on exegesis and the Shroud so powerful and convincing that they have me thinking of becoming an atheist or at least agnostic. Meanwhile, out of curiosity, I checked your fundie brother’s blog (through the portal you gave in the Amazing Race blog) and see he’s bitching about ‘NBs’ having the chronology of the resurrection events all wrong. Is there any more you can add to what you already showed to bolsters arguments for the Fundies getting it wrong?- Carol, Los Angeles, CA

 

1. There is a lot more that can be added, but we can always be sure of one thing: People (fundies) like my bro will always worm their way out and find more rationalizations, excuses and nonsense. For example, any proper Materialist or physicalist could ask why reports of supernatural beings vanishing, talking and materializing out of thin air, along with long-dead corpses coming back to life, and people levitating should be given serious consideration at all. At face value, this is the stuff of psychosis and in any other setting the propounders would be locked up and the key thrown away!

In this light it’s really funny that traditionalist Christians (including Protestants and Catholics) seem to have no trouble applying healthy skepticism to the miracles of Islam, or to the claims of Eckists, like my sister-in –law. But if they do that they have an obligation to scrutinize their own supernatural stories.. Why should Christians treat their own outrageous claims any differently? This is one of the things I detest almost as much as nationalism, the religious exceptionalism!

But again, we go back to the numerous contradictions in quadriform gospel accounts which the rational person is obligated to see as the first indicator that they don’t add up. Let’s list some:

Who was at the tomb when the women arrived?

• Matthew: One angel (28:2-7)

• Mark: One young man (16:5)

• Luke: Two men (24:4)


Where were the "messengers" situated?


• Matthew: Angel sitting on the stone (28:2)

• Mark: Young man sitting inside, on the right (16:5)

• Luke: Two men standing inside (24:4)

• John: Two angels sitting on each end of the bed (20:12)


• John: Two angels (20:12)

When Mary returned from the tomb, did she know Jesus had been resurrected?

• Matthew: Yes (28:7-8)
• Mark: Yes (16:10,11)

• Luke: Yes (24:6-9,23)

• John: No (20:2)

 

When did Mary first see Jesus?

    • Matthew: Before she returned to the disciples (28:9)

• Mark: Before she returned to the disciples (16:9,10)

• John: After she returned to the disciples (20:2,14)

 

Could Jesus be touched after the resurrection?

  • Matthew: Yes (28:9)

• John: No (20:17), Yes (20:27)

 

After the women, to whom did Jesus first appear?

    • Matthew: Eleven disciples (28:16)

• Mark: Two disciples in the country, later to eleven (16:12,14)

• Luke: Two disciples in Emmaus, later to eleven (24:13,36)

• John: Ten disciples (Judas and Thomas were absent) (20:19, 24)

• Paul: First to Cephas (Peter), then to the twelve. (Twelve? Judas was dead). (I Corinthians

 

Where did Jesus first appear to the disciples?

  • Matthew: On a mountain in Galilee (60-100 miles away) (28:16-17)

• Mark: To two in the country, to eleven "as they sat at meat" (16:12,14)

• Luke: In Emmaus (about seven miles away) at evening, to the rest in a room in Jerusalem later that night. (24:31, 36)

• John: In a room, at evening (20:19)

 

Did Jesus stay on earth for a while?

  • Mark: No (16:19) Compare 16:14 with John 20:19 to show that this was all done on Sunday

• Luke: No (24:50-52) It all happened on Sunday

• John: Yes, at least eight days (20:26, 21:1-22)

• Acts: Yes, at least forty days (1:3)

 

Where did the ascension take place?

  • Matthew: No ascension. Book ends on mountain in Galilee

• Mark: In or near Jerusalem, after supper (16:19)

• Luke: In Bethany, very close to Jerusalem, after supper (24:50-51)

• John: No ascension

• Paul: No ascension

• Acts: Ascended from Mount of Olives (1:9-12)

There are so many contradictions, that in the end NONE of the claims can be trusted. SO they amount to exactly what Rev. Thos. Bokenkotter has said they are: PR efforts to try to convert unbelievers.

Oh, the fundies will always try to rationalize a way out, but the problem is that this only works for irrational, ignorant or stupid people - who refuse to consult the sources themselves! Far from trying to "take anyone's faith away" we skeptics are trying to show that these ancient books written by semi-literate nomads, are the last place one ought to invest faith!

What Most Docs Won't Tell You: Effects Of Prostate Cancer Radiation Treatment

In Dr. John P. Mulhall's less technical monograph (op. cit., Part 1), in Chapter Five: "Prostate Radiation and Sexual Function", a wide array of information is presented along with summaries of erectile dysfunction for different treatment modalities, and we also see or understand why a dearth of longitudinal (over decades) studies exist in respect of radiation treatments for prostate cancer. As an early stage survivor who has received this treatment I will also share my experience.


Here's the key for seeing why such studies are sparse: Most men don't want to provide feedback on their sexual activity or sex lives, after such treatments. They feel, for whatever reason, this is no one else's business - but fail to understand that without feedback and information which can be integrated into analyses to grasp effects, they are doing an injustice to other men - who may also have to face such treatments. (In this respect, let me add that I recently completed a UCSF patient form in the aftermath of treatment, and will also be filling Dr. Hsu in on the after effects in an email -or phone consult next week.)

When I first began my search for treatment options, after learning I had stage T1c prostate cancer, I was dismayed by the dearth of solid, consistent information on the after -effects, and especially as they might impact sexual function. What I eventually decided is that there's no central core of agreement on the effects because the data are too sparse. This was confirmed for me as I read Mulhall's Chapter Five.

Let's cut to the chase: Mulhall superbly describes first 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."

On reading this my own erectile success in the wake of my treatment (on Sept. 25th) was put into harsh perspective and my hubris vastly tempered. Indeed, within 3 days of the treatment I'd been able to get and hold an 8-9 pt. erection, and in doing so believed I'd "conquered the world". How foolish! On reading Mulhall's chapter, I am now left to wait and see what progressive deterioration awaits, and in fact, what assorted methods of "penile rehabilitation" I will be left to take, unless I want to just let everything atrophy.

But I get ahead of myself a bit. Another aspect is "loss of ejaculatory volume". Mulhall 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".

In my case, this has not yet transpired . I was first able to attempt an ejaculation two weeks and two days after my treatment, and following two successive massages from a trained massage therapist, who I will call 'Mrs. D'. This was mainly to try to eliminate a persistent painful kink-knot under the back left shoulder blade - caused by being in an uncomfortable position in the Treatment Room for nearly 4 hrs. She worked intensely on that area - and associated neck 'scalenes'- and also gave a whole body massage. Within a day of this the burning urination I'd been experiencing ceased. Causal connection? Maybe, maybe not. In any case, I felt confident enough to attempt an ejaculation but hadn't yet read Mulhall's warning about another unwelcome side effect, dysorgasmia (orgasmic pain, p. 113). As Mulhall observes:

"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 July, with an incinerating pain referred to the whole urethra. That lasted maybe a minute, but this first orgasm after radiation treatment saw the pain lasting up to five minutes afterward. It was so bad I almost felt I'd pass out, maybe 9.5 on a ten scale. Meanwhile, only bloody fluid was produced as ejaculate.

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 is Flomax (ibid.) So I will have to monitor and see if the pain subsides - if I ever attempt another orgasm! - or if not, obtain some Flomax!

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."

Great! Recall my single dose for the whole prostate volume was 1930 cGy or 19.3 Gy, or near the top of  the dose threshold to injure large blood vessels. In addition, I received 18.5 Gy for the urethra, rectum --- which means blood vessels in those areas will also likely be affected in ten years at the "maximal level" - whatever that means. (Mulhall suggests loss of any erectile capacity unless his "penile rehabilitation" methods are employed.)

But, suffice it to say, by age 76 I do not believe I will be getting any full surgery done for getting an implant in place, or injecting myself with a 29-gauge needle. Hopefully, as in all cases of aging, I learn to let go gracefully and just be thankful for the splendor of nature and being able to partake of it.

"Penile Rehabilitation": What Most Docs Won't Tell You After Prostate Cancer Treatment (1)

Readers who may have read the republished comment of an RN  ('Prostate Cancer Corruption') in my blog from last Sunday, will have perked up to the key point that getting enough information before a prostate cancer procedure can be tricky. In many cases, urologists tend not to give men the full lowdown of what lies in wait, including mortality rates as high as 1 in 100 for radical prostatectomy - many deaths coming as a result of post-op infections, including from accumulation in the abdominal cavity of a lymphatic fluid called "lymphocele" - whereby tubes must be inserted in the patient's abdomen to secure drainage.

But given 99 of every 100 guys survive the radical prostatectomy, the next most abundant concern remains quality of life issues. Here, as I noted, the full info tends not to be conveyed, i.e. in terms of incontinence (50% of men have some form, that never abates) and sexual function.  I elaborated a lot pertaining to the latter in my blog last week, but more needs to be said.  Especially after my own experience in the wake of my own treatment (more on that in Pt. 2). Let me say in light of this is that any sex activity after a prostate cancer treatment is not going to be "uneventful" or normal. But let me go to the main issues.

Dr. John P. Mulhall, author of an academic monograph entitled: "Sexual Function in the Prostate Cancer Patient,"  also wrote a less technical book for actual prostate cancer patients and their significant others, entitled: "Saving Your Sex Life: A Guide for Men with Prostate Cancer".  (Note: Dr. Mulhall is the Director of the Sexual & Reproductive Medicine Urology Service based at the Memorial Sloan- Kettering Cancer Center.)

In this book, Dr. Mulhall takes the 'bull by the horns' and shows what men who've had prostate cancer treatments - whether radical prostatectomy, radiation or hormone therapy, actually face and the work they will have to do in order to overcome the attendant sexual problems. Let me say he pulls no punches. And, if any men are faced with the disease - which kills 30,000 a year-  I strongly recommend they get hold of the book.

Let's first cover those who face surgery or who have opted for the radical surgery. Let's understand that in this surgery the entire prostate gland is removed along with some ancillary erectile tissue, nerves as well as the urethra being severed in 2 places (the urethra passes through the prostate). Thus, in the course of the surgery the base of the bladder has to be resected to the remaining part of the urethra that was excised from the prostate base.  Given all this 'interference' it's no surprise that sexual functions, erectile capability etc. are disturbed.

Apart from incontinence, the greatest risk that surgical patients face post-op is loss of erectile ability.The incipient damage is called "atrophy" which increases in probability the longer a patient goes without erection post-surgery. (p. 98) Atrophy is, in fact (ibid.):

"a scarring of the erectile tissue, and if the erectile tissue scars, the patient will never get his own erection back and will always struggle with medication".

Dr. Mulhall goes on to note (ibid.) that "the incidence of erectile tissue damage, as measured by the presence of venous leak is very uncommon before the fourth month after surgery. However, at eight months after surgery it "occurs in about 30% of men and at one year 50% of men".

This is why it's essential, if men care at all about their future sex lives, they do everything possible to ensure erections of some mode (they are graded on a scale of 1-10 for hardness) occur before the 4th month after radical surgery. Why do erections need to occur? Because the absence of blood, and hence oxygen getting into the penis, leads to ongoing and progressive atrophy and tissue scarring. Mulhall invokes the "use it lose it" saying here.

In this regard, he observes that a concerted effort at  "penile rehabilitation" is needed to help keep the erectile tissue healthy and "waiting for the nerves to recover from the trauma of surgery". In this regard, his 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 this isn't the case because of "nerve injury". 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.

In the structure of the penile rehab program, the pre-op use of PDE5 inhibitors is implemented up to two weeks before surgery. Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells, which promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this, since else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion the PDE5 enzyme.


Mulhall notes that the pre-op use of PDE5 inhibitors is a novel concept called "endothelial preconditioning, whereby the endothelium (the lining of the erection spaces) is in some way protected by pre-treatment. Typically, the patient then gets a prescription for a PDE5 inhibitor the day the Foley catheter is removed.  He is then "told to take a full dose of Viagra (100 mg) or Levitra (20 mg) once per week with adequate accompanying stimulation to attain at least a 6/10 erection. On the other 6 nights he's told to take a low dose pill (50 mg Viagra or 10 mg Levitra) before going to bed.

The aim throughout is to protect the erectile tissues from degeneration. If these 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.

For example, 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, noting the '10 o'clock'  position based on a frontal cross-section view.  He notes (ibid.): "You need to inject only one side of the penis to get an erection of the whole penis". The primary danger or side effect is possible priapism. The medications he recommends for injection are Trimix or Bimix. (The posture and positioning for injection is depicted on p. 142.)

Part 2: What the radiation treatment patient can expect.