At our meeting for the start of Spring, Dr Michael Lowy from the Australian Centre for Sexual Health gave an extremely interesting and informative talk on The Effects of Prostate Cancer on Sexual Function. Dr Lowy described himself as a sex health physician with a background also in psychology. He is based at St Luke's Hospital, Potts Point and works in association with the urologist, Dr Philip Stricker.

The male sexual function can be divided into five stages: libido/desire (that is, sexual drive); erectile function/ arousal (the excitement stage); vascular/ genital response; ejaculation/ orgasm; and resolution.There can be a variety of reasons for having sex: for procreation, for love and affection, for pleasure, passion, communication or intimacy, or simply for fun.There are, however, a few myths that need to be dispelled: for example, men always want it and are always ready for it; all physical contact leads to sex; sex equals intercourse; or good sex always ends in orgasm.

Sexual desire can have many sources: dreams and fantasies, self stimulation, initiation of sexual behaviour, general receptivity, genital sensations, and so on. Issues which may interfere with desire may be things like low interest in sex, inhibitions to sexual desire, or desire discrepancy between couples. Other common difficulties that may interfere include: problems in communication between couples, not creating the conditions for good sex, having a limited repertoire, or emotional problems such as anxiety, guilt, anger, or grief.

The process of having an erection passes through several phases: sexual impulse (which has its origins in the brain), passage of this impulse through neuro-transmitters in the brain, the release of nitrate oxide, smooth muscle relaxation, tumescence (swelling), venous occlusion (shutting off of the veins in the penis), rigidity, and erection. The occurrence of erections at night or in the morning are nature's way of keeping the tissue of the penis healthy.

Normal changes occur in men's sexual function with aging, such as: taking longer to achieve an erection, finding it more difficult to sustain the erection (due to venous leakage or anxiety), needing more tactile stimulation, taking longer to reach orgasm, a less intense orgasm, or reduced ejaculation. Also, there may be other medical conditions affecting performance; for example, disfigurement, certain medications, depression, previous sexual functioning, the state of the relationship between the couple, or problems with libido. The paradox of sex is that the harder you try the more difficult it gets! On the other hand, unless you use it you lose it!

There are, of course, similar aging effects on sexual functioning among women. Unfortunately, society has a negative attitude towards open discussion of sexuality in older people; it's one of those things that just isn't talked about. Other issues associated with age and sexual activity are fluctuating desire, the availability of a sexual partner, the presence of medical illnesses, and the rigidity of the sexual script between couples.

In recent years, there has been an increasing interest in men's health at all ages. The particular issue of erectile dysfunction (ED, - the persistent inability to achieve or maintain an erection) is a common but complex condition. It is estimated that, worldwide, more than 100 million men would be affected; in Australia, approximately one million. Of men aged 40, approximately 40% would have erection difficulties; of those aged 50, 50%; at 60 years, 60%; so that among men aged 70, it is estimated that only 30% would be able to have a reasonably firm erection. These statistics are a clear indication that attention to the matter of erectile dysfunction warrants investigation and publicising. 80% of cases of erectile dysfunction (ED) are associated with a particular set of causes: blood problems, heart disease, diabetes, obesity, smoking (here there is a clear association), - all can affect the arteries in the penis.

There are certain factors which increase the risk of ED: with aging, there are hormonal changes, and the chance of chronic illness. Drugs may also be significant in exposing a man to risk: alcohol, tobacco, substance abuse, and some medications. Psychological factors associated with ED include depression, anxiety, previous experiences of having been abused, the feeling of narcissistic wounding, or concerns over sexual orientation. Factors may relate back to childhood experiences, or may arise out of current concerns. This may play out in avoidance of being touched, or a denial of wanting sex.

In dealing with the effects of prostate cancer on sexual function, Dr Lowy pointed out that his concern was not with the tumours themselves, but rather with the treatments. Approximately 30% of men with prostate cancer may experience ED prior to treatment, due to age, medications, smoking and so on. It can also occur as a result of the diagnosis or the prognosis of prostate cancer, of the effect of cancer therapy on your body image, of incontinence, of resulting depression or anxiety or grief over changes in your self image, of fear of disability or death, or it may arise as a result of your partner's coping strategies.

Radical prostatectomy does not lead to any change in hormone production, but it may damage the nerves (despite nerve sparing surgery) or blood vessels. Also, half the length of the spongy tissue which constitutes a man's penis is, in fact, inside the body. Thus, when the prostate gland is removed, this spongy tissue recedes into the space that was occupied by the gland, and the patient may notice an apparent shortening of his penis. Sexual function may recur after surgery, and begin to improve over a period of three to 18 months, but the quality of erections may be reduced. Statistical evidence suggests that 40-70% of prostate cancer patients who have a prostatectomy retain their sexual function. However, during discussion among members of the Group, these figures were thought to be rather overstated. Also, members considered that there was generally inadequate information from urologists on post-operative sexual functioning. Dr Lowy recommended that, after their operation, men should seek advice on restoring their sexual function.

With radiation therapy, blood vessel damage is slow. Effects begin to be noticed about six months into treatment. As with prostatectomy, ejaculation is dry. Hormone therapy may have psychological as well as physical effects, which lead to loss of desire and ED.

Treatment for prostate cancer in a man may influence the nature of marital relations. The effects on your partner may lead to her experiencing emotional problems relating to uncertainty and grief. She may be encountering her own problems associated with menopause and aging. Inhibitors of sexual function may be due to physical, psychological, relationship, or situational causes. The partner with the higher interest in sexual activity may need to compromise. Treatments for sexual relation difficulties may be in the form of coming to accept the presence of a difficulty, more partner participation, or a recognition of the acceptability of 'outercourse' as an alternative to intercourse, - that is, that penetration is not necessary to sexual gratification. This is sometimes referred to as 'soft intercourse'. Outercourse may be satisfying with a semi-rigid erection and gratification may be achieved through 'frottage',- the rubbing of the penis. A range of other courses of action may include counselling, oral sex, penile injection or penile implant, or the use of a vacuum device.

In cases of ED, there are a variety of drug treatments, of which probably the most well known is Viagra. This comes in three dose sizes of 25, 50 and 100 milligrams, and can be taken up to one hour before sex is planned. Sometimes it may be more useful if taken last thing at night for effect first thing in the morning. However, Viagra has no effect on desire; to be effective, it needs stimulation, and the nerves need to be working. It has certain side effects, such as hot flushes, which increase with the size of the dose. It should not be used with alcohol, and it also clashes with nitrate which is taken for angina.

New drugs are frequently appearing, the latest of which, Uprima, is due to be distributed in January. This is dissolved under the tongue; it has moderate side effects. Some other drugs, such as Muse, are disappearing from the scene. Probably the most satisfactory treatment for ED is penile injection, though some men find it difficult to cope with the use of a needle. There may be certain problems associated with frequent injections into the same spot, such as hardening of the area or a slight bending in the penis at erection; or priapism, which is a prolonged and often painful erection resulting from long use or from overdosing the drug.

Vacuum devices are reliable, but are tending to lose popularity. They are simply operated, and may have some use for stretching a shortened penis. It is necessary to remove the elastic band which holds the blood in the penis after half an hour.

In conclusion, Dr Lowy raised the question: in the case of ED, should the ability to have an erection be recreated at any cost? He suggested that successful treatment was measured by restoring performance that was satisfying to both partners. Perhaps men have a fantasy model of the perfect erection, but one wants to avoid phallocentrism, that is, focusing one's whole attention on one's penis. Certain problems may be associated with sexual rehabilitation after treatment for prostate cancer: hospital staff attitudes(due to lack of training or lack of confidence); a man's special needs (being young or single or gay); or whether one has had a good sexual history. The Centre reported that there is some treatment dropout, due to such reasons as lack of efficacy of treatment, or successful resort to outercourse. Guidelines for rehabilitation include going gently, being prepared to use a lubricant, and talking to one's partner.

Very many thanks to those who helped get the first 'Awareness Arousing' activity off the ground. The ICN Plant Market, 20 Macpherson Street, Warriewood proved genial hosts for our Sausage Sizzle on Saturday, 21 September, with thanks also to Van's Bakery, Dee Why for their donation of buns, and to Sydney Meat Supplies at Brookvale for the donation of sausages. Pamphlets on prostate cancer were distributed there and at the Save Our Hospitals Rally at Brookvale Oval on Sunday, 22 September by kind permission of the Rally organisers.

On the Home page there is an offer of a free video on ED. I have ordered a copy of this for our Group's library. You are also asked to complete a brief personal, anonymous survey, but this is not a condition for receiving the video. There are five items on the main menu: i) Information Fact Sheets, with eight links; ii) Heath Professionals Directory, which offers help for a range of services; iii) Friends of Impotency Australia, with four links; iv) Newsletters, with two so far published. (Again, I had difficulty accessing these on my iMac.); and v) Useful Links, with seven links and the Helpline phone number: (02) 9280 0084 There is also a button on the Home page: Men's Heath Tune-up, with 12 links and an offer for downloading a Men's Health screen saver. Altogether, this is a useful and informative site on men's health issues.

ii) November Meeting (6.30pm, Tues., 5 November): Treatment Side effects - Incontinence and Soiling. The speaker will be Ms Judy Tarlington, Special Registered Nurse, Mona Vale Hospital. All friends, partners, carers, family are welcome at all our meetings. (Refreshments served.)

Program Co-ordinator Dr Peter Moore Northern Beaches Palliative Care 9997 3555	Group Leader John Conroy 9918 9358 conroyjs@bigpond.com
NSW Cancer Council Cancer Support Helpline 13 11 20	Prostate Cancer Foundation of Australia 1800 220 099