Dr. Alisha Morgans and Dr. Martin Kathrins discuss the sexual health challenges many men face after prostate cancer treatment and the options available to address them. Dr. Kathrins explains that treatments for erectile dysfunction range from oral medications and penile injections to penile implants, emphasizing that men's sexual health specialists can help patients find the approach that best fits their needs and restore intimacy after treatment.
Dr. Alisha Morgans:
Marty, I wanted to talk with you a little bit about how patients can think through engaging with somebody who works in your field, which is of course urology, but you're specialized in a different area than maybe the doctor that did the surgery for patient's prostate cancer. I guess, first, how would you describe your specialty? If a patient is looking for somebody like you who works on sexual health and incontinence issues, how would they find you?
Dr. Martin Kathrins:
So that's a great question. And I think a lot of patients often think of urologists as the physician that's trying to cure them of their cancer, which is absolutely true. But we're also there for our patients after the cancer therapies. And so a lot of physicians tend to focus on the cancer treatment part, and there are urologists like myself that tend to focus on the aftermath, the survivorship aspects of these things.
And so a lot of larger academic centers have men's health centers, the Brigham and Women's included in that. And there are doctors there that work on all kinds of issues related to urinary problems, sexual health, pain in the pelvis in the general region. Not necessarily focusing on the cancer management itself, but all other aspects of urology. And so really any academic medical center is going to have a provider like myself that's going to be able to see a man after his cancer therapies.
Dr. Alisha Morgans:
That's so helpful because I think it can be really confusing when both of these kinds of doctors are labeled as urologists. People might think, "Well, shouldn't my urologist already be taking care of this?" So it's nice to know that there are specialists in men's health, erectile dysfunction, incontinence. So thank you.
Let's focus first on erectile dysfunction. This is something that, interestingly, I think people focus on a lot going into prostate cancer treatment. Maybe they focus in other areas after they're coming out of it, but it's always an important piece of people's lives. When people come out of prostate cancer treatment or when they're still going through my hormonal therapies, many patients say, "I thought that I just would have to give this piece of my life up. I just wasn't going to have sex or worry about sexual health anymore." Is that true?
Dr. Martin Kathrins:
So it's not true. And so we have a number of treatment options. And I see two kinds of men. I see a man like you just described, that has resigned, in my opinion, not accurately to this sort of future without sexual activity. And then I have another kind of man who maybe has an unrealistic expectation about what his life will be after these kinds of therapies, and that things will be exactly the way they were before. And so I think the truth lies somewhere in the middle. And so even a man being treated with the most aggressive systemic therapies, chemotherapies, hormonal therapies, after either surgery or radiation therapy, when it seems fairly hopeless to the man when he's at home and speaking with his partner, there are options. There are treatment options.
And as I would tell patients, it sort of depends on how aggressive we want to be or we need to be. And a provider like myself, we start at the bottom rung. We try to find a therapy that's least intrusive into his life, least invasive into his life. And we climb that ladder while he's recovering from his treatment therapies, while he's recovering from his cancer therapies. And we can be as aggressive as necessary, all the way up to surgery for some men. But we go low and start and head high, I guess, if necessary, to treat the problem.
Dr. Alisha Morgans:
Well, let's walk through that ladder a little bit, just to give people a sense of what you're thinking about. Where are some of the places where you start?
Dr. Martin Kathrins:
I mean, certainly for sexual health ... And it's a complicated thing, sexual health. And so I think urologists, we tend to focus on erectile function, but there's so much more than that. And I have colleagues that are psychotherapists that work on the relationship aspects of these things. But specifically focusing on erectile function, certainly the easiest thing to do is a pill, an oral therapy. Most men have heard of these drugs, even before their therapies. But because of the way that the nerves are impacted in the pelvis by prostate surgery, by radiation therapy, even a man that was responding to these pills before his surgery, he may very well not be responding to them, especially initially after his prostate is removed.
So when pills are not effective, and that may often be the case, we have other therapies, so-called local therapies. And these involve something called penile injection therapy, which is actually an incredibly old therapy. It predates things like Viagra by almost 20 years. And this is the therapy that we're often employing to be really aggressive with a man, to help him get an erection. And when men hear the phrase penile injection therapy, it's very, very scary. We've taught so many men how to do this over the years. And I would say that the patients tell me the worst part of the whole interaction is driving over to see me, because they're thinking about it and worrying about it. And myself, the nursing staff, physician assistants, we try to demystify this for men. And they can do quite well with this.
All the way up to surgery, which is something like a penile prosthesis, but we would never skip to the front of the class. We want to start with something least invasive. And if that's not effective, go up to something more invasive, and so on and so on until the man's satisfied in his relationship.
Dr. Alisha Morgans:
So that's great. Just to dig in a little bit to the injections, I definitely have patients who are concerned. It is kind of frightening. Thinking about shots of any kind can be scary. But I've also had them come out the other end and say, as you said, "It's actually really not that bad." One thing I want to just get you to expand upon is does he just get a prescription for an injection and just go home and that's it? And does somebody teach him how to do that?
Dr. Martin Kathrins:
Yeah. Absolutely, we teach them. I would tell a man, "I have no expectation that you know what to do with a hypodermic needle." So we start with an assumption that there's no knowledge whatsoever about how to do this. And over the years, and seven years of doing this, I think we've, I would like to think, streamlined the process for the man.
But yeah, I mean, there's a session where he's going to sit down with a urology clinician, either myself or a physician assistant, to explain verbally what is about to happen and what this therapy involves, the benefits, which are obvious to most patients, and some of the fairly minor risks, actually. We have written material that gets handed out so the man can go home. And I would tell him, "If you forget everything I'm saying to you today, we made up all this written literature, so you can go back and read it and reinforce it." I would encourage him to bring a partner. I would say the minority of my patients do bring a partner, but I think it's helpful.
And then the actual process itself. I mean, the logistics of having to do this has to be explained in detail. We have to demonstrate how to do it, how to get the drug into the needle, how to instill the medication safely, what to watch for, how to bring the drug up.
And I follow patients as closely as possible. We have a patient portal where patients can message me. And I would tell a man as he's leaving my office, maybe I'm going to be seeing him again in a month or two, I say, "The worst thing is you waiting two or three months to ask me any questions." That to me is kind of like a failure. So I want to hear from that man. I want him to tell me how he's doing because I would tell him I can make a lot of recommendations without having a formal visit with just some typed information. So I have patients message me all the time with, "Hey Doc, I'm doing this. Maybe it's not working perfectly." And I can respond back.
And I have a lot of patients, if they need to stay on something like penile injection therapy, as you observed, I see him once a year, maybe he gets a refill and he's doing well. I mean, that's a win sort of thing, when he's doing well.
Dr. Alisha Morgans:
Yeah. Well, good. And now let's just talk a little bit more about the prosthesis. I was actually really surprised. I saw one of these at a ... It was at a meeting, and they had example stuff. And urologists love to bring toys to these meetings, which is different than medical oncology. When we're going to have a bunch of pills on a table, it's not as much fun. So I saw this thing, and I actually got to pick it up and try to figure out what it was like. It reminded me of a breast implant, almost. The feeling was sort of silicone. This was years ago. So perhaps they may be higher tech now. But it was really interesting. I just wonder, can you explain, are there different sizes? What does it seem like, and are there things that are hanging out of you? Is everything inside? How does it work?
Dr. Martin Kathrins:
Those are all great and frankly common questions, I think, for patients to ask. So I'm a big believer in this surgery. I do a lot of this in my surgical practice. I'm also a very firm believer that you arrive at surgery. You don't want to hasten to it. And despite the fact that I'm a very big believer in this and I know that the majority of my patients are going to do well, because it's surgery, I kind of treat it as the court of last resort. I don't say that as it should be something that's actively avoided, but it's not something that I would push a man on.
That being said, so these devices are ... They've been around for a long time. The concept of a penile prosthesis, many decades. They've evolved over the years. And there are, generally speaking, two types of prosthesis. There's what's called an inflatable penile prosthesis. And so this is a totally self-contained implant. Everything is on the inside of his body. And this is operated with a small pump that's actually in the man's scrotum, that when he wants to have an erection, he activates it. It's actually saline. It's like salt water. It goes into the penis, makes it hard, he can have sex. And then there's a relatively straightforward deactivation mechanism.
And I would say that the best part about this is a man can be spontaneous again, because I think one of the big victims of these other medical therapies is spontaneity. You have to sort of plan around when do you take the medications. That's not really the case with the surgery. And it's a bit more of a natural experience, the inflatable prosthesis.
There are non-inflatable prostheses which are always firm. They can be essentially bent up and bent down. These are simpler, technologically. I think if you showed an engineer the variety of models, he or she would probably choose the non-inflatable one because it's so simple. And satisfaction rates are pretty similar, maybe a bit higher with the inflatable device because it's a bit more of a natural feel.
But it's my job to sit down with a man and tell him what these devices are, and more importantly than that, what they're not, what they can't do, because I think a satisfied patient after this kind of surgery is a man that has what he thinks he was going to get. And so it's my job to do that. Sometimes difficult counseling to help patients understand what it is.
But yeah, it's all internalized. The inflatable devices, they don't last forever, just like any other mechanical thing, but a good number of years. And I do a lot of revisions for men, removing it, replacing it with a new device. And it's an incredibly rewarding aspect in my practice, to help a couple come together again and feel whole again, so to speak. And so he can start to feel like he's in his own skin again, kind of like the way he was before some of these therapies.
Dr. Alisha Morgans:
How long do they last? How often do you-
Dr. Martin Kathrins:
So there's an average, which is always ... A population-level average for an individual patient's always tough. But eight, nine, 10 years is pretty average. I think I did a revision on a guy, he'd had it in for 24 years. It just broke. That was an outlier. In a blue moon, do we see something that needs the revision sooner than that, if it loses its fluid, but that's kind of an average.
Dr. Alisha Morgans:
Okay. Well, thank you for going through that. Go for it.
Dr. Martin Kathrins:
So for erectile function, a lot of men are going to suffer from this, at least for a period of time after prostate cancer therapies. But there are providers like myself that are both able and, probably more importantly, willing and interested to help you, to hear about your problem, to listen to your problem. And we don't want to match the solution to the patient. We want to hear about what the actual issue is and be patient with him.