Dr. Zach Klaassen:
Hi, my name is Dr. Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. We're filming today for Cancer Patient Voices, and I'm delighted to be joined by my good friend and colleague, Dr. Sherita King, who's a urologist and specializing in sexual medicine.
Dr. Sherita King:
Yeah. Thank you for having me.
Dr. Zach Klaassen:
So I know my job is to basically take prostates out and create all sorts of problems with sexual function, urinary continence, and basically try to get a cure from prostate cancer. But as you and I have worked together over the last several years, this is the prostate cancer journey, and it includes prostate cancer survivorship. And thankfully, I have used my partner, and I'm delighted to explain to our viewers and to the patients out there sort of what that journey entails from the time that I call you up on the phone and say, "Mr. So-and-So's coming to see you. We took his prostate out. He's 55 years old. He's got a loving wife. He's sexually active before treatment, and he wants to see you." So what's that sort of first conversation that you have with Mr. Smith?
Dr. Sherita King:
It depends. We also have patients that we share that I actually see pre-op too.
Dr. Zach Klaassen:
That's right.
Dr. Sherita King:
So it just depends on where I'm catching them in that spectrum. But the first thing I want them to know is that even though you're experiencing this now, I can get you back to the function. It just depends on how far you're willing to go and how far your health will allow us to go. So we start off by figuring out exactly what their function is. I have a real candid conversation with them, just to discuss exactly how much function do they have. I have some creative ways we... And we use analogies to different fruits and vegetables to try to figure out exactly where they're on that scale, because that will really change the way that we're going to treat them.
The other thing that we want to do is if they're not ready to start intercourse, we start a penile rehab program. And with that, what I like to do is make sure that they have a vacuum erection device, and that'll help encourage blood flow to the penis while it's recovering. I call them penis pushups. I say, "You take your heart to the gym after a cardiac surgery. You go to cardiac rehab. After prostate surgery, we're going to penile rehab."
Dr. Zach Klaassen:
That's right.
Dr. Sherita King:
So we have them place the vacuum on, and they're going to inflate it multiple times throughout the day. And again, what this does is it kind of simulates the spontaneous morning erections that they used to get.
Dr. Zach Klaassen:
Right.
Dr. Sherita King:
There is an evolutionary reason for that, not just for you to wake up happy. So what we're trying to do is make sure that they're getting good blood flow to the penis as everything is healing, because there are some damages that can occur with surgery or even radiation.
Dr. Zach Klaassen:
Sure.
Dr. Sherita King:
And then based off of all of that and how they're progressing, we can progress through the different treatment options that we have.
Dr. Zach Klaassen:
Excellent. So one of the tools that I use when I'm counseling men about treatment, and especially young men that I think are candidates for surgery, is I want you to understand the side effects, but I don't want you to be so scared of the side effects that you're not going to go and get the treatment that you probably need. So how do you sort of... If you see these patients pre-op, how do you take that conversation in terms of, "Dr. Klaassen said this, but here's how we're going to help you with that"?
Dr. Sherita King:
Yeah. I just let them know that there's hope out there. There are different things that we can try that will actually help them get their function back. So that can range from just taking pills, up to having injections, all the way to surgery to do corrective treatment. And I just let them... give them the hope, because once you give them that hope, then they feel empowered that they can make this decision about their prostate cancer.
Dr. Zach Klaassen:
And not be scared of the treatment, but knowing that there's hope after the procedure.
Dr. Sherita King:
Absolutely. Absolutely. I think that's the biggest message that we have in prostate cancer survivorship.
Dr. Zach Klaassen:
Sure. And I think one of the sort of corollaries to that is men that have incontinence or leak urine after surgery, it can be very debilitating. It can be very disconcerting, to the point where they may not want to leave the house. So I know you do a lot of work with incontinence, so sort of speak to that aspect of the survivorship as well.
Dr. Sherita King:
So as far as incontinence goes, the way that we work this is we start them off with Kegel exercises. I try to do that pre-op if I catch them.
Dr. Zach Klaassen:
Just tell our viewers what Kegel exercises are.
Dr. Sherita King:
So Kegel exercises is a exercise... So imagine you were trying to hold in urine, right? Or say you're on a big date and you don't want to pass gas. Those muscles that you're squeezing to hold that in-
Dr. Zach Klaassen:
That's right.
Dr. Sherita King:
... those are the muscles that you squeeze for a Kegel. And you'll squeeze them, hold them for a couple of counts, and then relax. And then you do that multiple times throughout the day. You do different series of reps throughout the day to try to regain some of your pelvic-floor musculature. Now, that's just the beginning. After surgery, I try to get them into our pelvic-floor physical therapist. This is something that I learned when I was in fellowship to really try to incorporate. And what they do is like Kegels on steroids. That's what I tell patients. So they're able to take them from just doing these simple tightening and relaxation of the pelvic floor to having biofeedback. So things that they can actually get measurements and know how well they're doing. And they have a whole host of other exercises that they can teach the patient to try to help with their incontinence.
And what all this is doing is trying to build up the pelvic-floor musculature so they're able to control when urine is going to leak. So I'll tell patients, "If you're going to go bend over and pick up something and you know that's one of your triggers to leak, do a Kegel. Do those exercises at that point. Or if you're about to sneeze, do a Kegel." And those things kind of empower men at the beginning.
Dr. Zach Klaassen:
And you're retraining the body to do that.
Dr. Sherita King:
Yeah, retraining, yeah, exactly.
Dr. Zach Klaassen:
So a man's gone through the surgery. He's seen you. He's, let's say, 6, 12, 18 months out. He still is not happy with his sexual function or maybe he has incontinence. Take us through some of the, I guess I'll say, more advanced treatments or even additional operations that can help with these side effects.
Dr. Sherita King:
Okay. So I'll start with erectile dysfunction. So with erectile dysfunction, the way I look at it, there's three treatments that I typically use for our patients. We have pills, and that can range from-
Dr. Zach Klaassen:
Cialis, Viagra.
Dr. Sherita King:
Yeah, Cialis, Viagra, Levitra, Stendra. Those are all the ones that are pretty much on the market. If those don't work, then the next step is injection therapy. Here at our institution, we have the benefit of having a penile Doppler. So we will send them for a penile Doppler. That is their gateway into injection. So that way they can-
Dr. Zach Klaassen:
That's an ultrasound of the penis, correct?
Dr. Sherita King:
Yes. That's an ultrasound of the penis. So they'll go down to radiology. They'll get an injection on the side of their penis, and then that will let us know what kind of function they'll have. And then on top of that, what the ultrasound is telling me, how well is the blood flowing into the penis and if they're able to trap it, because those are the two things that have to happen in order to get a sustainable erection.
Dr. Zach Klaassen:
Right.
Dr. Sherita King:
And then based off of that, I can decide, "Yes, Mr. X, you can definitely do injections at home. This will be sustainable." And we'll teach them how to do it properly and safely. If they do not get a good response to the injection and they have poor arterial inflow, so the blood coming into the penis is slow, or if they're not able to trap it, and that's what we call a venous leak, then we start talking about surgical intervention. So that would be the penile prosthesis. So when you're looking at the penile prosthesis, there's a couple different ones that are out there on the market. You have a semi-rigid or a malleable one. I tell patients it's like a pipe cleaner. So when they want to have intercourse, they bend it up. When they don't want to, they bend it back down.
But some men want something that's a little bit more physiologic, that's more like their natural erection. So that's when we start talking about the inflatable. So with the inflatable, you have two cylinders. They sit in the corpora cavernosa, which is the erectile chambers within the penis. And then you have, depending if it's a two piece or a three piece... For a two piece, you just have a pump with that. With a three piece, we add a reservoir. And that reservoir sits up in the abdomen, and it holds all the fluid for that implant.
Dr. Zach Klaassen:
I see.
Dr. Sherita King:
So when they want to have intercourse, they pump the device. It pulls the fluid from the reservoir, puts it into the penis, and they're able to get a sustainable erection.
Dr. Zach Klaassen:
I see. So basically, it starts out... So you sort of ramp yourself up based on the patient's goals, and you get to as far as you want. So basically, if there's a man out there that wants to be as aggressive as possible, you can give them an erection after surgery. It may be with the inflatable penile prosthesis, but it is possible.
Dr. Sherita King:
Yes, absolutely.
Dr. Zach Klaassen:
Awesome. So tell us a little more about some of the more advanced procedures or interventions for people that are really miserable with incontinence.
Dr. Sherita King:
Okay. So for incontinence, we have two different treatment options there for men. You have a sling, and then you also have an artificial urinary sphincter. So the sling is definitely the least invasive of the two. It's just a piece of mesh that we implant into the perineum. So that's the area between the scrotum and the anus where the urethra starts to dive into the pelvis. So once we get to that area, we put a piece of mesh there, and it's going to elevate the urethra back into the pelvis. And then one of them even has compression of the urethra a little bit. So what those two things do is it's increasing the resistance of the urethra. So when they do the cough or sneeze or bend over, then they don't have the leakage.
Dr. Zach Klaassen:
Right.
Dr. Sherita King:
With the artificial sphincter, it's a little bit more involved. With this one, we have to dissect all the way around the urethra, and we place a cuff. That cuff stays closed at baseline.
Dr. Zach Klaassen:
Right.
Dr. Sherita King:
Okay? So when they want to go to the bathroom, they have to squeeze a pump that's going to push the fluid that's in that cuff up to a balloon that's in their abdomen. And then the good thing about the AUS, or artificial sphincter, is that you don't have to pump it to reactivate it. It's an automatic thing because that balloon is under pressure. It pushes that fluid back down within 90 seconds. So they have about 90 seconds to be able to urinate. So it just depends on how severe their leakage is.
Dr. Zach Klaassen:
I see.
Dr. Sherita King:
So if they have mild to moderate, then we do the sling. If they have moderate to severe, then we can do the artificial sphincter.
Dr. Zach Klaassen:
I see. So basically, to sort of summarize, I take the prostate out. These patients come see you either before or afterwards. And there'll be a period of recovery time. Everybody has to heal. So at some point as they go down their patient journey, whether it's several months, several years, or even further out, you've got phenomenal options to basically get them to the point where they're dry, they're not leaking urine, and they have the sexual function they desire.
Dr. Sherita King:
Exactly. Exactly.
Dr. Zach Klaassen:
Fantastic.
Dr. Sherita King:
Whatever they want to do, we can get them there.
Dr. Zach Klaassen:
I think that's the important message, is that the side effects will be there. Everybody's going to have a different journey and a different experience after surgery or radiation. But having the ability to visit with somebody like yourself to discuss those things and have those treatment options explained and potentially intervened on is fantastic. I'd like to thank Dr. Sherita King for her time today. We had a great conversation, and thank you for your attention.
Dr. Sherita King:
Thank you.