How A Urologist Talks To His Patients About ED

This interview, “How A Urologist Talks To His Patients About ED,” is provided by Grand Rounds in Urology’s content partner, Prostatepedia.

Dr. R. James Yu is a urologic oncologist with MarinHealth Urology | A UCSF Health Clinic in Marin County, California.

He spoke with Prostatepedia about how he approaches erectile dysfunction after prostate cancer treatment.

Why did you become a doctor?

Dr. James Yu: My parents always engrained in me the importance of helping others. When I was younger, my mom was also diagnosed with a rare thymus cancer that metastasized to her lung. I got to see first-hand the impact cancer had on someone’s life and on the people around them.

I saw her going through chemotherapy and the recovery from surgery. It created an instinctive affinity and empathy in me towards cancer patients. As a result, going into medicine was an easy decision for me, specifically in the field of urologic oncology. I was specifically drawn to urology because of the relationships that I could develop with the patients, which I don’t feel is a common thing in surgical subspecialties.

Have you had any patients over the years who have stood out in your mind as either changing how you think about your own role or how you view the art of medicine?

Dr. Yu: Definitely, but I think my mom had the biggest impact. That’s because I got to see cancer from the other side of the exam room, from the patient’s perspective. I learned from her the importance of having a team when fighting cancer. Everyone has a role to play: the patient, spouse, kids, church, friends, surgeon, medical oncologist, and radiation oncologist. It’s because of her team that helped her beat that cancer.

I see my role in a few different phases when treating prostate cancer. The first phase is when you initially get diagnosed. Of course, my job is to educate about the disease, the treatment options, and all the pros and cons of each modality; but my other job is to help alleviate the anxiety when hearing the C word in their body. Most patients have already done their preliminary research when they come to see me. Their minds have already naturally jumped to conclusions. That is what I saw my mom go through. Dealing with that emotional side of things is important. Until you’ve done that, patients won’t hear what you’re saying. That is why we spend so much time with patients at that initial consultation.

The second phase is actually doing the technical part of the surgery, which is critically important. It requires a lot of experience and expertise to deliver great results. The last phase is the survivorship. This part of the patient’s journey is often overlooked. Patients are having to continue surveillance for their cancer, and are sometimes dealing with some of the side effects of treatments. They always tell me they are super anxious to see their PSA results. But as time passes, they gain more confidence in their cancer control, and also see their side effects improve or resolve. You start to see the tension melt away in their faces. It really brings me a lot of joy to see my patients go through that growth and evolution.

How do you approach the subject of erectile dysfunction after surgery with your patients? Do you introduce the subject in that initial consult?

Dr. Yu: Sexual health, in general, is a delicate and sensitive topic for many patients and their partners. That’s especially true when discussing the sexual impacts that prostate cancer treatments can have on patients. In some cases, the embarrassment in talking about sexual health can negatively impact the patient’s overall recovery. That’s why communication before and after treatment is so important for erectile function. That communication needs to exist between the patient and his doctor AND the patient and his partner. My advice to patients is to not assume the other party knows what you are thinking, or that you know what they are thinking. Only talking about these issues can make things better.

Of course, urologists also know that there’s a natural barrier to talking about these topics. As a result, we give patients a questionnaire that prompts us to start the conversation. These questions usually ask about your sexual activity, confidence level, libido, need for medication, and if other medical problems exist that might impact erectile function. This helps to establish a baseline, which impacts treatment results. I also am very proactive in discussing the potential effects of erectile and ejaculatory dysfunction after prostate cancer treatments in our initial discussions. However, despite these tools, and the doctor asking specific questions, it still requires the patient to engage and answer openly and honestly.

You’re saying that some people are reluctant to talk about it no matter how much you press?

Dr. Yu: Sometimes. But everyone processes things differently and on different timelines. Sometimes, we just need to circle back at a later time to address this issue.

What kinds of questions do you suggest men ask their urologists about ED before they have surgery?

Dr. Yu: First, I believe it is up to the surgeon to bring up the specific risks to erectile function related to any prostate cancer treatment. That’s part of informed consent. From the patient’s standpoint, the main questions I would be asking include, “What is your plan for me before, during, and after surgery to optimize my erectile function recovery?” Related to that is, “Do you recommend a specific regimen for penile rehabilitation protocol? Also ask about specific erectile function recovery rates after surgery specifically for that surgeon. But having a specific plan for what’s going to happen after surgery helps alleviate some of the anxiety related to that potential side effect.

I also think the patient should ask themselves and their partner, some questions: “What is the level of intimacy that we have right now? What do we want it to be in the future?” A change in the way couples are intimate can definitely affect a relationship. I recommend that patients bring their partners into the appointment to not only serve as another set of ears, but also to participate in discussions about issues like this.

Some recommend that men seek out a sexual medicine expert before surgery. Do you think that’s warranted? Or would you only recommend that once a man is already having problems?

Dr. Yu: That is always an option. I don’t usually send patients to sexual medicine experts because I’m comfortable having that open discussion with them.

Is there anything men can do before surgery to prevent potential erectile dysfunction after treatment?

Dr. Yu: There aren’t really any studies that show specifically treating men before surgery with a drug regimen actually improves erectile function after surgery. However, there are many strategies to optimize their overall health which will improve their chances—like eating a healthier diet, losing weight if you’re overweight, and improving your exercise tolerance. Quitting smoking is important because that also impacts vascular disease. Lower your stress levels. Drink less alcohol. Manage the things we know directly impact erectile function like diabetes, cardiovascular disease, and hypertension.

Doing these things are not only good for erectile function, but also good for overall longevity. I tell patients that a cancer diagnosis is oftentimes a wakeup call, and they should take this opportunity to adopt healthier lifestyles.

Are there any ED treatments that are more effective than others after surgery? 

Dr. Yu: I don’t think one ED treatment is more effective than another after surgery. However, doing something is better than doing nothing. Also, the sooner you do it, the better, in order to reduce the risk of poor oxygenation, fibrosis and scarring in the penile tissue. It’s very much a “use it or lose it” mentality. I recommend whichever treatment best enables the patient to resume sexual activity quickly after treatment.

Most men start with medications, because that is the easiest to administer. Published studies don’t show a difference between taking it daily versus on demand, although both regimens are most effective when used consistently in the first year. Some men also use a vacuum erection device (VED) to help them have penetrative intercourse sooner after surgery. VEDs have also been shown to reduce penile length loss after surgery, So again, doing something is better than doing nothing. I tend to recommend a daily regimen post-operatively in combination with vacuum device therapy. Every patient has a different mentality about how aggressive they want to be with their rehab. Some couples are not active at all, so they only do on-demand therapy. Others stick with medications, VED, and some of the other treatments out there in combination. These include intra-urethral alprostadil, or intracavernosal injection therapy with either Caverject or Bimix or Trimix.

Then, of course, if all those fail, you can always consider a penile implant. We usually wait for one to two years before talking about the penile implant, just because the expectation is that we will see patients continue to improve for the first one to two years. Nerves don’t regenerate that quickly. Doing something as permanent as a penile implant that quickly after the surgery is usually discouraged.

Are these treatments covered by insurance?

Dr. Yu: It depends on the insurance. The costs of medications was definitely more prohibitive three to five years ago, but many of these medications are now offered as a generic. This makes it more affordable for patients to pursue even if their insurance does not cover it. The VED and injections usually are not covered as well, so patients pay out of pocket for those regimens. A surgical approach like the penile implant is usually covered by insurance.

There has been a lot of recent publicity for low intensity penile shock wave therapy in patients with de novo erectile dysfunction. This treatment has not been studied in patients with ED after prostate cancer surgery so we don’t know its applicability, safety or effectiveness.

Is that painful?

Dr. Yu: Usually not. A numbing medicine is applied to the penis before the shockwave treatments are given.

Do you have any advice for men who are either worried about ED before surgery yet or who are already struggling with ED after treatment?

Dr. Yu: One thing to keep in mind is to look at the big picture and maintain perspective. We need to really consider the prostate cancer first. The reality is that sometimes we need to be aggressive with our treatments for prostate cancer in order to preserve your life. That may come at the risk to certain functions. In other cases, we can offer active surveillance of prostate cancer because we don’t want to risk impacting erectile function while treating an insignificant cancer. Treatment needs to be individualized to the patient.

For patients who have some baseline erectile dysfunction, there is definitely the risk of persistent or worsened erectile function after surgery or radiation. The good news about erectile function is that even if there is poor recovery, there are still many ways for patients get their sexual function back. It may require some inconvenience, but that’s something that the urologist on your team can help you with. Having a proper expectation going into treatment and recovery helps: understand that recovery takes 12 to 24 months in some cases. And that recovery process can be frustrating because things do not feel natural at first. That’s why it is important to keep the lines of communication open. This is not something that is easily tackled alone. Seek help, even though it is such an intimate topic.

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About R. James Yu, MD

R. James Yu, MD,  is a Urology Specialist with MarinHealth Urology, a UCSF Health Clinic. Dr. Yu received his medical degree from Keck School of Medicine at the University of Southern California, and completed his residency and internship at Stanford University Hospital. He specializes in minimally invasive and robotic surgery, as well as urologic oncology. He is a member of the American Urological Association and the Endourological Association. He was recognized as a Top Doctor by Marin Magazine from 2016 to 2018.