Video: Sexual Dysfunction & Prostate Cancer Surgery | Jesse Mills, MD

2019 PCRI Conference Interviews | Transcription

I’m Dr. Jesse Mills. I'm an Associate Professor of Urology at UCLA and I run the men's clinic at UCLA as well which is both in Santa Monica and in Westwood. So, convenient appointments at either place. 

We discussed all kinds of things sex. So, essentially, your—the sexual medicine is everything from erectile dysfunction to orgasmic dysfunction to leaking uring during ejaculation or orgasm as well as a little bit about testosterone therapy in the unique individuals with prostate cancer and hypogonadism.

Are many of your patients reluctant to talk about sex? Why do you think that is? 

A lot of guys have this barrier to talking about sex with their doctors in general. So we know that men have—about 90% of men and actually women too—want to talk about sexual matters with their physicians, but only about 30% of physicians feel qualified to discuss sex with their patients. So, if you then look at another population of men that are going through a therapy that has a very high risk of sexual dysfunction, it really increases that level of scrutiny from the patient's perspective and as well as the doctor's perspective because the average person that comes into the physician's office after radical prostatectomy to get therapy for sexual dysfunction is not going to get the answers that's he's gonna look for from your average doctor. So the idea is that specialized care is what's going to drive these men and so part of it is frustration on the part of the male because if he goes to a number of physicians and has not the answers that he's seeking, then a lot of guys will just give up. So, the goal for the men's clinic, especially the way that I look at it, is to not only open that access, but break down those barriers and say, "Look, you can tell me anything. I'll give you 100 bucks if you make me blush. I mean it's hard." So, that's what I do and I think that helps guys be able to open up a little bit more and tell me what's really going on. I mean, imagine as a man to go into your physician's office and say, "Not only can I not get erections, but if I can get an erection and I'm having sex, I start leaking urine in the middle of the erection. It's a really difficult thing for a man to come to terms with. 

What preemptive measures should patients take to maximize erectile recovery after treatment? 

So, there's a concept that's starting to float around that I call prehab or prehabilitation prior to prostate cancer surgery mostly, but it works probably for radiation as well though it's not as well studied. The idea is to enfranchise a man into his own care prior to surgery. Have them have the tools and the understanding they need to give them the best outcome sexually after radical prostatectomy. I think the conventional thought is, you're going to go through surgery, we know there's a risk of erectile dysfunction, have the surgery, and let's see what happens. So in other words, sit around and wait, and if it comes back, great! If it doesn't, then we have all kinds of therapies we can do for you. Pills and injections and surgeries. But, what if we're able to change that. What if we're able to say if you take 100 guys and you meet them ahead of surgery and sit them down and say, "Look, here's what you're going to go through during your prostate cancer surgery. Here's what I can do to help you through that, both here in this visit (2 weeks, a month before your surgery) and even a year after your surgery, we're gonna hit certain milestones where you're gonna be taking a medication, you're gonna be exercising, you're gonna be losing weight, staying in great physical shape, and sleeping well, as we talked about. That was my big lesson is "eat, move, sleep," right? We have to do all of those. The discipline that I make my guys go through before I put a penile implant in is the same. They're gonna stop smoking, they're gonna lose weight if they need to, they're gonna make sure their blood pressure is controlled, they're gonna make sure their blood sugars are controlled if they're diabetic. A lot of stuff before they end up in the operating room because I want them to have the best possible surgical outcome and a lot of that is in their hands. 

What do you consider the future of sexual medicine? 

So I think, in general, the future in sexual medicine is coming up with more ways to do less invasive things, right? So, right now we're at this—there's a lot of things out there that we talked about a little bit today (low-intensity shockwave therapy, maybe some kind of stem cell therapy, platelet-rich plasma). All of those things are out there, but none of them have really proven to be more effective. So, potentially more research to know whether or not these are effective or if they're just, you know, a bunch of hogwash. The real future, I think, where the science has to head to is in regenerative medicine, and that's true in anything from orthopedics and joint regeneration. Instead of looking at an organ wearing out and then replacing it, what if we grew a new organ or what if we took that piece of tissue and rejuvenated it somehow and that's where the future is going to be and certainly we're looking at that at UCLA now. We're setting up a tissue engineering lab for penile tissue to see if we can have a guy actually regenerate his own tissue to replace the diseased tissue. So, that's gonna be the exciting thing in the field. It's not new surgeries or it's not new pills, but it's really harnessing the body's ability to regenerate itself.