Each year in Australia, 10, 000 men are diagnosed with prostate cancer, and 2500 men die from the disease. Since screening and early intervention began, mortality from prostate cancer has dropped 25 per cent. Treatment options for localised prostate cancer include watchful waiting, external beam radiotherap y, iodine seed brachyt herapy, high dose rate brachytherapy and radical prostatectomy. When practised by experienced clinicians, brachytherapy and radical prostatectomy are low-morbidity procedures with excellent outcomes in a large number of cases. Nevertheless sexual dysfunction can occur after both procedures.

Erectile dysfunction is very common in the community. It frequently occurs in men aged from the mid-forties onwards. Although a common problem, it is not often spoken about – with many couples suffering as a result. Erectile dysfunction should be viewed as any other medical complaint. It is a problem that needs to be discussed frankly with a man and his partner. Quality medical advice should be sought and appropriate treatment options explained. The Massachusetts Male Aging Study, a large population-based study in the US, demonstrated that softening erections in the general population were a significant predictor of an adverse cardiovascular event within a five-year period. The study showed that rates of heart attack and stroke were increased for such men if critical lifestyle issues were not addressed. These lifestyle factors included smoking, obesity, diet, cholesterol, blood sugar control and blood pressure. Regular exercise was also found to be very important. Lifestyle modifications are as important to men treated for prostate cancer as they are for men in the population at large.

At the interview when I first inform a man and his partner that the prostatic biopsies are positive for cancer, a long and in-depth discussion follows, covering myriad seemingly confusing concepts. It is necessary to discuss in detail the management options. Issues relating to the Gleason Grade and clinical stage of the prostate cancer need also to be explained.

A realistic assessment of life expectancy, factoring in the patient’s age and any coexisting medical disease, needs to be taken into account when considering the best management option for an individual. The chance of long-term cure is discussed with patients in detail, and concepts such as margin positivity after surgery and rising prostate specific antigen (PSA) after radiotherapy or brachytherapy need to be explained frankly. What naturally follows is a detailed discussion about the potential side-effects of treatments, including radiation damage to adjacent organs, urinary incontinence and finally erectile dysfunction or impotence. It is very important that the first post-biopsy interview is an overview only and not a decision- making interview. The man and his partner should always be invited back within a week to review the information, ask questions and clarify concepts. It is natural for a couple to be involved in intense information seeking behaviour involving family, friends and online sources. While some couples handle the intense education process well, others suffer rapidly from information overload leading to a sense of confusion and despair. Patients and their partners frequently say to me during this time that erectile dysfunction is the least of their concerns. Wives frequently state in a loving and supportive way: “As long as I have my husband, doctor, I am not worried about sex.” While this is a true, heartfelt reaction to the diagnosis of cancer, chronic erectile dysfunction frequently becomes the couple’s main concern following treatment, especially when the treatment, by all indications, has been successful from the point of view of treating the prostate cancer. It is critically important that the potential for erectile dysfunction is introduced early in counselling, to reassure the couple that sexual rehabilitation will be offered at the appropriate time.

During this pre-treatment stage – a time of great emotional and psychological vulnerability – it is critically important that the man and his partner are given accurate, realistic information regarding the likelihood of sideeffects resulting from prostate cancer treatments. There has been an increasing tendency in the US, and latterly in Australia, for doctors to indulge in medical marketing based on their self-assessed ability to preserve erectile function after cancer treatments. Unfortunately a ‘successful’ erection, as assessed by a medical survey, does not always equate to a useable erection on a day-to-day basis. Medical practitioners have an obligation at this stage of the counselling process to give the man and his wife the unembellished facts. The radical prostatectomy patient is, on average, in his early sixties. A significant prop ortion of these men will already have noticed declining erectile function based on age and other cardiovascular adverse risk factors, as outlined above. These men need to be informed frankly that bilateral nerve-sparing radical prostatectomy surgery will not preserve or improve post-operative erectile function. The best candidates for successful nerve sparing radical prostatectomy are younger, potent men who do not have coexisting vascular risk factors. A realistic estimation of success with respect to erectile preservation is in the order of 50-75 per cent. Conservative estimates are appropriate, so as not to magnify the sense of loss by unrealistic and unfulfilled expectations. Surgical ego and pride must give way to the patient’s desire and need for realistic accurate information. Technical innovations must be appraised critically and explained realistically to patients. I believe the use of the new CaverMap machine, which maps the presence of the erectile nerves, is mainly as an aid for teaching junior surgeons the technique of anatomical radical prostatectomy. I do not feel that it improves the nerve-sparing results of an experienced, competent urological surgeon who is practised and trained in the technique of neurovascular preservation. While much has been lately made of the technique of sural nerve grafting, I, like many urological surgeons, remain sceptical of the value of this technique, and am awaiting the presentation of a peerreviewed randomised trial before enthusiastically advocating its use for our patients. It is very important that both urologists and patients are not seduced by an inappropriate ‘technology push’.

Most men are continent and ready to return to mainstream living four to six weeks after successful radical prostatectomy. They are once again ready to be physically and sexually active. Hopefully their PSA level will have returned at less than 0.1 ng/mL, as this portends a good long-term prognosis. After successful nerve - sparing surgery, spontaneous erections may start to occur from six months post-operatively, though they can take up to three years to return. It is essential to commence sexual rehabilitation as early as possible after radical prostatect omy, four to six weeks postoperatively being ideal. It is now well recognised that after bilateral nerve-sparing radical prostatectomy, the early administration of intrapenile injection therapy hastens the return of spontaneous erections in men whose nerves have been successfully spared. It is therefore important that men are carefully and thoroughly counselled in the correct use of penile injection therapy and encouraged to commence its administration. Early introduction of penile injection therapy is important in facilitating the return of sexual function and critically in enabling a couple to maintain their sexual relationship and personal intimacy. It is important for a couple to regain physical intimacy as soon as possible after treatment in order to prevent turning off and turning away from each other within the relationship.

Penile injection therapy has been the mainstay of management of erectile dysfunction for 20 years. Two types of preparation are available: the commercially available Caverject, which is a freeze-dried form of pure prostaglandin PGE-1 alpha; the second form of injection therapy is commonly known as Bimix or Trimix. The latter products are mixed by a compounding pharmacist and contain varying levels of prostaglandin, papaverine and phentolamine. The Bimix preparation excludes papaverine, which is thought to be more likely to result in corporeal fibrosis. The Bimix and Trimix preparations a re more convenient for the patient as they come in a 12 mL multi-use vial. They do not require freezing and 0.3 mL, 0.5 mL and 1.0 mL insulin syringes are used with or without spring-loader injectors. It is essential that the patient and his partner are instructed in the proper use of penile injection therapy. It is important that the injection occurs at either the 10 or two o’clock position along either side of the penile shaft. The injection must be well back from the glans penis (the glans does not interconnect with corporeal bodies and therefore the injection would be ineffective). It is important that the injection proceeds to the full depth of the needle in order that the medication is delivered well into the erectile space. The patient is instructed to hold firm finger and thumb pressure over the injection site and then to vigorously massage the penis for five minutes. A solid erection is generally achieved within this time frame. The complications of injection therapy include priapism and penile fibrosis, the latter of which may result in chordee or a bent erection. Should a man experience a rigid erection lasting beyond four hours, medical attention should be sought. The initial treatment is to aspirate blood from the engorged corporeal bodies. Should this not prove effective, injection of vasoconstrictors may be required. The patient should be examined at least every six months for evidence of penile scarring. This is evident as a firm plaque within the corporeal bodies. Penile injection therapy should begin one month after bilateral nerve-sparing radical prostatect omy. It should continue until spontaneous erectile activity has occurred or until the patient responds to phosphodiesterase type 5 (PDE5) inhibitors. Many men use penile injection therapy indefinitely. The advantages are that it is generally effective, can be used five minutes before intercourse and is cheaper than oral medications.

Three oral agents are available: sildenafil, tadalafil and vardenafil. These are all PDE5 inhibitors, which inhibit the phosphodiesterase enzyme in the erectile tissue that is responsible for clearing cyclic guanosine monophosphate (GMP), a potent vasodilator of cavernosal tissue. PDE5 inhibitors work only in the presence of intact cavernosal nerves as the cyclic GMP pathway is mediated by the non-adrenergic, non-choline rgic nitric oxide mediated pathway. Following nerve-sparing radical prostatectomy, these compounds should be introduced at six months post-operatively. Even with nerve-sparing surgery, neuropraxia occurs. This can take from six to 36 months to recover. The patient should t h e re f o re use penile injection therapy for four to six months and then trial oral medications. Should the oral medication not work, penile injection therapy should be continued. PDE5 inhibitors are safe compounds providing they are not taken with nitrate medications commonly used for the management of ischaemic heart disease. Profound hypotension may follow use in combination with nitrate medication. Side-effects are predictable in terms of these products’ known action of increasing blood flow. A ruddy facial complexion and a mild vascular headache commonly occur, but they generally decrease in intensity the more the medications are used. Other side-effects include mild dyspepsia and occasionally myalgia.

Penile prosthetic surgery has been the mainstay of erectile dysfunction therapy for the past 30 years. The best prosthesis is the three-part inflatable model that comprises a reservoir of n o rmal saline that is placed retro-pubically, inflatable cylinders within the erectile bodies, and an inflate-deflate mechanism within the scrotal pouch. The patient is operated on under either a general or a spinal anaesthetic and is generally discharged within 24 hours of surgery. A settling-in period of four to six weeks is necessary and thereafter the device is ready to use. When a man wants to make love to his partner, he feels for the inflate mechanism within the scrotum, and a well-maintained rigid erection will be produced within 20 seconds. After love-making, the deflate mechanism is pressed and the penis once again becomes flaccid as the fluid is transferred from the penis into the retro-pubic reservoir. Constant refinements have occurred with penile prostheses. The latest include frictionless multi-layered coats, which are anticipated to increase the life of the device beyond 15 years. The prosthetic equipment is now impregnated with a multid rug antibiotic system that elutes post-operatively.

It is anticipated that prosthetic infection rates will fall to one per cent. Diabetic men are suitable for penile prosthetics if their HBA1C is between 6.5 and 7.5 per cent. Couples choose to undergo penile prosthetic surgery for two main reasons. The first is that love-making once again becomes spontaneous and therefore romantic. Secondly there is no performance anxiety with respect to initiation and maintenance of the erection. By removing the problems of lack of spontaneity and performance anxiety couples can once again have relaxed and romantic sex together. A man should be considered for penile prosthetic implantation if he was impotent pre-operatively or if he has undergone a non-nerve-sparing radical prostatectomy or a nerve-sparing radical prostatectomy that has not been successful. It is important that couples are counselled about penile prosthetics, and not left untreated should they not respond to penile injectable or oral medications. Similarly, men who have suffered erectile dysfunction as a result of radical radiotherapy of any form to the prostate should also be considered for penile prosthetic surgery.