Lower Risk of Erectile Dysfunction and Incontinence
Is HIFU for Me?
Erectile dysfunction is a condition that occurs in many men with aging. The cause of ED includes decreased testosterone, decrease in blood supply to the penis which goes along with high BP, peripheral vascular disease, and heart disease. These diseases also cause decreased blood flow to other organs and patients are at risk of stroke, heart attack, and ischemia of the lower extremities causing leg pain.
Surgery and other treatments for prostate disease such as radical prostectomy, radiation, laser surgery, and trans-urethral resection can all cause a decrease in blood supply and nerve supply that is required for maintaining erectile function.
Any treatment for prostate disease is associated with a certain degree of risk of erectile dysfunction. Just as in incontinence, the degree of erectile dysfunction depends on the preexisting status of erectile dysfunction, the extent of cancer, the type of procedure that is performed, and other contributing factors.
For the erectile function to occur normally, apart from the arteries and veins being normal, the nerves also have to be functional. The nerves of erectile function travel from the lower portion of the spinal column and exit from the sacral bone on the inside of the pelvis and travel along the sides of the lower portion of the bladder and prostate.
The surgeon who is able to preserve these nerves during surgery does so because he is experienced in nerve sparing surgery and also because the cancer is small enough and does not involve the edges of the prostate, prostatic capsule, and nerves.
Blood vessels and nerves for erectile dysfunction travel close to the prostate. Both of these will be spared during HIFU treatment in patients where the cancer is not too close to the vessels and nerves. An experienced HIFU physician can vary the ultrasound lesions during HIFU such that he can treat the edges of the prostate without damaging the nerves of erection and blood vessels that are next to it. The nerves and blood vessels are important to be preserved for erectile function.
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Evaluation and Treatment of Erectile Dysfunction
In patients with ED after prostate procedures, the physician will obtain a copy of their history and perform a physical. Questions will include whether the patient has had tried to have sex, whether there is partial erections, and questions about other diseases, general health status, and medications. The time after surgery is also taken into consideration.
A penile Doppler may be used to determine if patients have good blood flow to the penis. If there is poor blood flow, treatments will include injections of medications such as prostaglandin to improve blood flow and use of vacuum devices. If there is scar tissue that can be felt as a cord in the penile tissue then addition treatments may be required such as injections of medications into the scar tissue.
Patients who have erectile function may also have hypogonadism where there is a decrease in levels of testosterone. This is evaluated by a blood test and can be corrected by use of testosterone supplements.
After HIFU, patients may need to be on a course of medications such as Viagra or Cialis. Improvement of blood flow to penis may also be improved by injections of prostaglandin or Trimix. Some patients would prefer not to inject the penis and may consider use of erectile pump. These details can be obtained by calling us or consulting your local Urologist.
Testosterone supplements should be used with caution after prostate cancer treatment. Most Urologists would not recommend testosterone supplements until 5 or more years after the disease is considered cured. If at that time the PSA is very low and has been consistently low, cautious use of testosterone may be considered.
The recommendation for use of testosterone after prostate cancer treatment should be considered cautiously and varies between urologists. You will have to discuss it with your local Urologist. If you are considering testosterone supplements after a HIFU procedure or other prostate cancer treatment, you should be carefully followed with a PSA blood test every 3-4 months to make sure that the PSA is not rising and if there is a rise in PSA, the testosterone supplements should be promptly stopped.
With regards to HIFU, incontinence is a rare problem. Because HIFU does not cut tissues, incontinence occurs in a very small number of patients unless both sides have to be treated and the cancer is in the apex and extending to the muscles that control continence.
There are several causes of incontinence. One example is the incontinence caused by the extent of cancer. This is because cancer involves the muscles that prevent leakage, damage to these muscles by surgery, radiation, or other procedures. Incontinence caused by cancer extending to the muscles occurs because large cancers can invade the anterior fibro muscular zone and/or the apex of the prostate where the external sphincter is located and will have more incontinence as these areas need to be removed to cure the cancer.
Extensive cancers may also involve pelvic muscles and blood vessels and in the process of securing these blood vessels and removing the large cancer, injury may occur to nerves and blood vessels of the penis and muscles controlling continence which results in scar tissue and decrease of blood and nerve supply which results in a higher chance of incontinence.
It has been found that physician experience and the hospital center’s experience have a bearing on patients’ continence. Physicians who have done several hundred surgeries in centers that do these surgeries often have less incontinence than in centers where the physician has less experience and where less surgeries are performed.
The technique of surgery also has some bearing on incontinence and surgeries that use robotic techniques and laparoscopic techniques in certain centers may obtain better results than older forms of surgery although this is controversial.
Studies have shown that the single most variable affecting recovery of continence is the volume and grade of cancer at the time of surgery.
Treatment of Incontinence
Initial treatments for incontinence would include rehabilitative exercises and exercises to improve muscle tone. This can be done by biofeedback or patient performed Kegel exercises.
If these rehabilitative exercises do not cure the incontinence, a variety of medications may be used. There are two classes of medications. One set would relax the bladder muscles, thereby allowing the bladder to accumulate more urine and reduce incontinence. These are called anticholinergic agents. Anticholinergic agents are of two types: those that are specific to the bladder and those that are non-specific. These anticholinergic agents mostly relax the bladder so that the patient has less leakage but they don’t necessarily treat the sphincter muscle.
Next, there are the minimally invasive treatments. These include injections into the bladder, such as collagen, coaptite, or Macroplastique into the urethra mucosa.
The next procedure that is possible is the male sling.
The last and most invasive and effective treatment for significant incontinence is the artificial urinary sphincter, which has been used effectively for many years.
Incontinence after HIFU
Incontinence after HIFU is reported to be less common when compared to traditional treatments such as surgery and radiation. However, as mentioned in the earlier paragraph, this depends on the location and extent of cancer. Patients who have cancer located in the apex of the prostate are more likely to get incontinence. Studies have shown that if the apex is involved with cancer and not treated, then cancer will recur. If the cancer is treated at the apex, then incontinence is a distinct possibility.
Patients who only have cancer on one side have good chances of not having incontinence if the apex on one side is free of cancer and can be preserved. This will depend on the treating surgeon and the volume of cancer