Video: ED after Surgery, Prostatitis, and Testosterone Replacement | Ask a Prostate Expert

Ask a Prostate Expert | Transcription

Alex: Hi everyone! I'm Alex with the PCRI and we are here for our second episode of Ask a Prostate Oncologist. I'm sitting here with PCRI's Executive Director, Dr. Mark Scholz, and we're excited to be here today. We have new questions every week and so if you would like to have a question covered in the future you can go ahead and comment and ask below in the video and our team will go ahead and add that to our list. 

Our first question is about surgery, and so, basically, we had a caller who wanted to know how long does erectile dysfunction last after surgery?

Dr. Scholz: This is probably the most important question that we face in managing early-stage prostate cancer because the number one side effect is erectile dysfunction. Sadly, even the best surgeons can't guarantee that men will recover after surgery and unfortunately, many men never recover and this is a scary thing and when we're talking about different treatment options for prostate cancer we're obviously putting that as probably the number one thing. 

The number two thing being loss of control of urination. So, to give you some hard statistics, it's dependent on a man's age. So, younger men who are operated on by very skilled surgeons, so if you see someone in their 50s, for example, they can start to recover sexual function and erectile function sometimes within even just a couple of weeks of surgery. But if there's a delay, they shouldn't be intimidated because men can recover as late as six, twelve, even eighteen months after surgery.

Alex: Do you know how often either one would happen? Whether it's…

Dr. Scholz: Yeah, that's the important question. So, let's go back and talk again about the younger, say, under age 60 group and let's assume that everybody's getting the best surgeon (which is a big assumption, and we're not gonna talk about how you pick the best surgeon, that's a whole different question) but assuming you've got an excellent surgeon and you have a man under age 60 whose sexual function is normal prior to the operation (they're not using any Viagra, they're not using any Cialis or Levitra) oftentimes the studies that are done they look at it about a year or a year and a half afterward to judge the percentage of men who recover and if you take the type of relatively young person that I just described with excellent pre-existing function about probably 60-65%, 70% of men will recover what's called a serviceable erection. That just means something firm enough for intercourse. If you adopt a higher standard of recovery and you ask patients and their spouses, "Is it like before?" That's pretty uncommon even in men under age 60. Now, you take the older group, the 65 plus group, the numbers are probably going to be about half that good. It's amazing how much difference 5-10 years makes as people look at the damage that can be done—the permanent damage that can be done—by an operation like this. 

Alex: So, those side effects are obviously pretty devastating, not even just in the short term, but in the long term. So, is there anything a man can do before surgery to help, you know, mitigate these side effects or is it only after surgery that they can do things?

Dr. Scholz: There isn't a whole lot to be done before surgery. It's sort of what do you bring to the table? How good is your health? How good is your function? And that is partly just genetics and it's partly how healthy of a lifestyle that person has been living through the years. So, it's a bit of a crapshoot. It's a lottery-type experience. Some men are going to emerge on the other side very functional and very happy. I'm generally not a very big fan of surgery, but I will say that the men that get to the other side, do recover completely, are in a very good situation because things will remain stable, then, on an ongoing basis thereafter. The problem is the percentage of men that are really happy after surgery is relatively low.

Alex: Okay, so if a man is experiencing erectile dysfunction, I know there are a number of treatments, so what is the order of the treatments you would suggest? Is it pills first? Vacuums? You know, at what point, you know, the varying degrees of...? 

Dr. Scholz: Well, that's a vast subject, but I think it's very important that you've raised this question of what to do, say, right after the operation before recovery occurs. Is there anything that will help in that situation? And the evidence is pretty strong that men who are who doing nothing and just waiting around are not gonna have as good of a recovery or they're not going to recover as frequently as the men that implement some sort of a program and start getting erections again more quickly through artificial means. You mentioned pumps, obviously, the common pills (probably everyone should be taking those), but usually those aren't enough and the next step is to think about giving yourself a shot which many people find to be rather daunting and frightening because it's in a very sensitive area of the body, but the needle is very tiny and the shots are very effective. There have been some nice studies comparing groups of men that don't do shots after surgery with men that do shots right after shots (and I'm not talking about 6 months after surgery, I'm talking, like, 2-4 weeks after surgery) and that the group that does do those shots right away after the operation have better long-term recovery rates. 

Alex: Are there any supplements that you suggest men take that can help with the erectile dysfunction recovery process? Maybe like L-arginine or anything like that?

Dr. Scholz: L-arginine would be a reasonable consideration if someone is severely constrained by cost. That used to be more of an issue when the Viagra and Cialis pills were not available in generic form. So, I don't recommend it much anymore. If you look at alternative things that can help with sexual health in general, we're talking about good diet, don't be overweight, exercise, don't use excess alcohol, all of those things result in better outcomes. 

Alex: Okay. Alright, Dr. Scholz, our next question is regarding prostatitis, and so prostatitis is a massive subject. We get hundreds of questions at PCRI regarding this and so the main question I have is, Does prostatitis cause prostate cancer?

Dr. Scholz: So, that is an interesting question. So, if prostate cancer is caused by prostatitis, at least in some cases, it's a process that's ongoing over many, many years. The research on that question is still out. It is possible that chronic low-grade inflammation in the prostate, what you called "prostatitis," can lead to prostate cancer. We know that prostate is very common; we know that prostatitis is very common, so there is a logical assumption, maybe there's a connection, but proof that is the cause of prostate cancer doesn't exist. 

Alex: So, when it comes to prostatitis, what causes prostatitis itself?

Dr. Scholz: So, the inflammation in the prostate comes to medical attention usually when men have an elevated PSA. It's not typically because someone's feeling badly although some men will talk about some vague discomfort in their pelvic area, maybe a little irritation with urination. We don't understand very well what prostatitis is. It could be—in different cases, it could be different things. For instance, viral infections, autoimmune problems where the immune system is attacking the prostate just as, say, in the case of asthma attacking the lungs, or, you know, inflammatory sinusitis or eczema where people get skin problems when they're nervous. So, that, autoimmune, viral, bacterial infections which can indeed cause symptoms. Sometimes men will have elevated PSAs, urinary symptoms, and then they'll respond to a quinolone antibiotic like ciprofloxacin or Levaquin. The usual policy for treating prostatitis when we discover it is simply to observe it or treat it what we call symptomatically which is giving some Aleve or Advil and just sort of waiting it out. The problem with giving antibiotics is that it may give temporary relief, but it rarely permanently cures it. So the problem comes back and you're determined, you're back on antibiotics again, you're off antibiotics, you're back on antibiotics. 

Alex: I've heard your frustration regarding a lot of people having rising PSA and just trying to test whether it's prostatitis and throw antibiotics at it, so is there a way to determine without throwing antibiotics or do you think that they should just get an imaging scan right away?

Dr. Scholz: So, the diagnosis of prostatitis, like many diagnoses in the field of medicine is called—is mostly through what we call a diagnosis of exclusion. In other words, there's only so many things that raise PSA. You know, is it a bad lab value, is it recent sexual activity, is it an enlarged prostate, is it prostate cancer? So, after you've gone down the long list of things that it could be and they've all been eliminated, it isn't prostate cancer (you mentioned getting a scan, that's a very efficient way to try and rule out prostate cancer), but the diagnosis of exclusion just means that we didn't find anything else, therefore it must be prostatitis. 

When we do a color doppler ultrasound on the prostate, we can see increased blood flow in men that prostatitis, so that's not a for sure sign of prostatitis, but it is an indication and if it's in the context of all that other stuff checking out, then we conclude that it's prostatitis. The last thing that helps us make a diagnosis is the way that PSAs fluctuate up and down when men have prostatitis. With prostate cancer that's uncontrolled or untreated, the PSA will steadily and unremittingly rise over time. With prostatitis, if you check multiple PSA, it will bounce around and up and down and typically PSA levels do not go down with cancer. So, prostatitis, you see a characteristic zig-zag approach, zig-zag type of pattern on a graph of PSAs. 

Alex: So, is the PSA also pretty consistent of not going down when you have an enlarged prostate like BPH?

Dr. Scholz: Yes, without treatment, typically you'll see steady maybe slightly increasing PSAs over time as the gland gets bigger and bigger. 

Alex: Now, it's possible to have prostatitis and prostate cancer at the same time, correct?

Dr. Scholz: It is and it's also possible to have a big prostate at the same time, and this is the problem with the PSA test where people want to try and extract too much information from it. One savvy patient once said look at the PSA like a check engine light on the dashboard of your car because you have to go further and find out well what's causing the light to be abnormal or what is causing the PSA to be high. It doesn't necessarily equate with cancer or a big gland or prostatitis because it could be a combination of the three. 

Alex: Right. So, if a patient does have prostatitis and prostate cancer at the same time, do you treat one or the other first or will some of the treatments for the prostate cancer help with the prostatitis?

Dr. Scholz: Yes, typically, as I said before, we don't attack prostatitis directly, but it is true that things like hormonal therapy, even radiation treatment, of course, surgery where the whole prostate gland is removed, those will all "control prostatitis," and one medicine that's popular for large prostates, Proscar (another name is Avodart), these mild hormone-blocking agents which shrink the prostate down can also reduce inflammation at the same time and quell prostatitis. I'm not recommending them specifically for that purpose because they have some other side effects, particularly an impact on libido that's pretty unattractive.

Alex: So, another question that we have received is, "Can an MRI miss prostate cancer?"

Dr. Scholz: That's a very good question because we've been suggesting that people can substitute MRIs for random biopsies which is a super attract proposition. Random biopsies, they jab needles in your rectum and they can infections and other complications. So, how safe is it to do an MRI instead of a biopsy? Or, as some people have suggested, maybe you should do both? After all, this is cancer. We don't wanna have even a 1% chance of missing cancer. At least, that's the way the argument goes. 

Alex: When you say, "we've been suggesting," not the PCRI in that circumstance, right?

Dr. Scholz: Well, in my own medical practice we've aggressively been recommending a substitution of high quality MRIs for random biopsies and the basis of that is that the MRIs, in comparative studies with biopsies, have been shown to be more accurate. Neither one is perfect. So the answer to your question is that the MRI can miss significant cancers. That is a possibility. It appears that the cancers that could be missed, and this may occur in 15% of MRIs, are relatively small and small prostate cancers, even the ones that are high grade, may not be that dangerous. So, how do we cover ourselves for the possibility that something is missed? The answer is, repeat the MRI annually and make sure that something small that may have been missed on a previous MRI that is consequential gets picked up at the next year. And, with other cancers, waiting a year to diagnosis prostate cancer would be a scary proposition. By then, maybe the cancer would have spread and the situation would be hopeless. But we know that prostate cancer has been radically overtreated over the last 30 years where prostate cancer compared to other cancers is relatively low-key and slow-growing and doesn't spread very quickly. So, a delay in one year is very very unlikely to translate into some situation that was curable and then became incurable. But, what does that very very unlikely mean? Is that less than 1%? I think so. That's my opinion. I think it's less than 1%, and if all prostate cancers that weren't caught were immediately deadly, like say pancreas cancer or lung cancer, then we might not even be comfortable with missing that 1% of people, you know, that does their MRI annually and even with a year delay they get into trouble. But we're talking about, you know, tens, hundreds of thousands of men going through biopsies, unnecessary treatment, possibly for maybe one in a thousand that would benefit by doing a biopsy instead of an MRI.

Alex: In regard to an MRI missing prostate cancer, how important is the magnet in that situation? So we have 1.5 magnets, we have 3T magnets, we have 5T magnets that are now coming which we'll talk about in a minute, but, you know, what do you suggest? 

Dr. Scholz: The use of new technology to substitute for old technology, you know, it's always fraught with some danger that well maybe it won't pan out like we hope and, you know, are we taking chances with people's lives? So, I always advise not only that people use a 3-Tesla magnet—I'm not aware of where we can get 5-Tesla at this point—but 3-Tesla magnets are important. To me, they're a sign that that particular facility has made a commitment to doing quality scans. You can scan with a 1.5-Tesla magnet, but you don't get quite the same image quality. More importantly, is who's reading it? One well-known expert said that it takes a thousand practice reads of an MRI of the prostate before you're competent to be reading out and telling people whether or not they have cancer or not. So, you have to go to a high volume center with a good reputation if you're thinking of substituting an MRI for a standard random biopsy.

Alex: Okay, so I know that I mentioned 5T magnets, so I believe that USC bought a magnet and they're doing some research with it, but you haven't heard of any other facilities that are currently using it?

Dr. Scholz: No, it is, of course, the next horizon is to get even more powerful magnets and further improve the image quality. That's not something that we're pursuing. We would just love it if people would get good quality 3T MRIs and consider substituting the MRIs for the old random biopsies where people get stuck a dozen times.

Alex: Alright, so the next question I would like to cover is in regard to testosterone. So we get a lot of questions about testosterone too. As we know with hormone therapy, testosterone levels get down, men have to deal with all sorts of side effects and hot flashes, and possible breast growth, and the concept of going off of hormone therapy and then taking testosterone shots, you know, they want to know, "Can I get my energy back? Can I get my muscle back?" And so, how often do you prescribe testosterone in regard to...

Dr. Scholz: More frequently than you might think for someone that only takes care of prostate cancer and the reason is is that testosterone blockade with something like Lupron sometimes causes lingering low testosterone even when you don't need the treatment any longer. And this occurs because elderly men, their testicular function just doesn't recover very well sometimes. So, that is one risk of Lupron and Lupron related drugs is that men will have persistent low testosterone levels even when the treatment has been stopped. So, some people, of course, are nervous about the idea of giving testosterone to someone that has a history of prostate cancer, but...

Alex: Well, can it make it come back?

Dr. Scholz: Testosterone won't make the man produce testosterone, but testosterone would be a substitute for testicular testosterone, so that idea of allowing testosterone to come back or giving testosterone, say in a cream or a shot, in my mind is the same thing. So, the same men that you would be comfortable stopping their Lupron would be the same men who, if they have low testosterone, you'd be comfortable giving testosterone to, and, of course, it has to be monitored. Testosterone has a risk apart from any prostate cancer-related questions of creating cardiovascular problems and especially if the red blood cell counts go too high. It can predispose men to heart attacks and strokes. Very serious stuff.

Alex: What's the percentage likelihood of that?

Dr. Scholz: Well, I think it's almost zero if the red cell counts are monitored closely and men's red counts are kept below a hematocrit less than 50%. I think it's perfectly safe, but if men aren't monitored and they're red counts are allowed to rise too high then it's not a high risk, but any risk of an unnecessary heart attack or a stroke is unacceptable.

Alex: So, with the testosterone coming back, a lot of people fear that the testosterone injections themselves could cause prostate cancer. Can you speak to that?

Dr. Scholz: Yeah, so the whole theory of testosterone causing prostate cancer is based on this idea that if you take testosterone away cancer recedes. So, the logical conclusion is if you give testosterone, the cancer grows. The example I've tried to use, I don't know how well it works, is that we need oxygen to live, but if we breathe more oxygen, we don't grow bigger, and so, the idea of allowing testosterone to be present doesn't cause prostate cancer. The removal does cause a reversal of prostate cancer. So, like any powerful tool, testosterone or any other, there has to be judicious consideration as to the pros and cons for every individual, but the idea of men having to be on low testosterone forever for every prostate cancer sounds patently ridiculous because we know so many prostate cancers really aren't that dangerous.

Alex: Right, so besides red blood cell count monitoring, what other things should men be aware of if they're going to do testosterone injection therapy?

Dr. Scholz: Well, I think the only other comment I would make is that—kind of like PSA—people tend to focus too much on the number. "Is my testosterone 200 or 400 or 600," and that has some relevance just like PSA has some relevance, but what's more important—the reason why we give the testosterone—is how people feel. Do you have more energy? Do you have a stronger libido? Do you concentrate better? Are your emotions more stable? Is it easier to build muscle? You'd say the answer would always be yes, yes, yes, yes with testosterone, but it's not always the case. Some people, the testosterone seems to have a magical flourishing effect and in other people, you give them testosterone and they really can't detect much difference. If you look at it the other way, I've had men that have gone on testosterone withdrawal treatment with Lupron and don't feel anything. No reduction in libido, no loss of energy. So, people are wired differently, and it's important to individualize and talk to each patient, "Is this stuff really benefiting you or are we just treating a number?"

Alex: Right, right. So, it's really really important for patients to discuss what they're experiencing on these treatments with their doctor and like force him to take a little more time with them because I don't think many doctors spend a lot of time with patients when they're coming in and out and giving Lupron shots, so I think that patients should really learn that they need to fight for that time.

Dr. Scholz: Yeah, I think with the way modern medicine is going with so much new knowledge, no doctor is keeping up on all of it. Everybody needs to educate themselves if they want to take advantage of all these new discoveries.

I'd like to make one other comment about testosterone as we've, through the years, we've given testosterone, taken it away, given it back, and men's sexual interest and libido goes up and down and up and down, and of course, sexual activity is a partnership thing and a lot of our patients have postmenopausal spouses who prior to menopause had normal estrogen levels and also small amounts of testosterone coming from their ovaries which often disappears when women go through menopause and they're kind of like, "Eh, sexual activity. Ho-hum." And so, you know, happy relationships are based on two people with either both have low libidos or both have normal libidos, but when you have one other the other there's a problem and so when we restore testosterone to patients that have previously been on Lupron, for example, we'll talk to them and ask them are their spouses interested in you getting your libido back or are they dreading this proposition and have they considered something called bioidentical hormones.

Bioidentical hormones mean giving the spouse—it can be men too, but I'm talking about women in this situation—small amounts of testosterone, small amounts of estrogen to help restore the premenopausal interest in romantic activity. And this, you know, has been also surrounded with some controversy because of concerns about breast cancer and whatnot. So there are calculated risks with every type of activity, but this blanket statement that you should always do this or never do that, that never works out.

Alex: Yeah, that's actually really interesting because I recently was talking about bioidentical hormones with a wife of a patient and she had read this article about—actually, Oprah wrote it—and she was talking about the importance of bioidentical hormones and how she got her energy back and her libido back and everything. I don't—it was interesting because the patient's wife looked at me and said, "Well when he talked me into this, raising my libido wasn't my biggest motivation." So what other benefits would women experience besides that?

Dr. Scholz: Well, behind closed doors—I shouldn't reveal this—I'm always joking with these patients of mine when talking about potentially broaching the subject with their wives is that people that have low libido don't really care about having a low libido, it's sort of an abstraction. So, to sell the concept the other salutary aspects of testosterone are pretty exciting: Weight loss, increased energy, better concentration, more stable emotions, and I'd say restoration of energy is a big one. Everyone in this busy lifestyle seems to be fighting to find the energy to get through the day, and so, yeah, people get involved and they experience those benefits and then as an aside their libido can come back as well.

Alex: Well, I think that's a great sell, especially the energy part is really exciting.

Go ahead and subscribe to our Youtube channel, the subscribe button is right here on the bottom right of this video, and give us a thumbs up if you like the content. One of the big things that PCRI is super passionate about is we want to answer your questions. So, go ahead and leave your questions that you would like Dr. Scholz to answer in future videos in the comments below and you guys can go ahead and have conversations if there's more information, you're like, "Oh I like this person's questions. We should add this." And we're gonna go ahead and our team is gonna read through that and you'll see it in future videos. And, we're here, we're excited, and we love you at PCRI, and we hope you have a great week.