From “The Decision”
The anatomy of the prostate - Water and nerves
Common things occur commonly.
Dramatic and life-threatening complications can occur with any of the forms of treatment for prostate cancer. Although knowledge of all potential problems and their likelihood should be part of your database in making “the decision,” I recommend becoming familiar with the most common risks and side effects of the various treatments and weighing them more heavily in your decision-making process. When you hear hoof beats, think horses, not zebras. If you take all the uncommon, major risks off the table, you are left primarily with the effect the treatment you choose will have on how you void and your sexual function. This particular chapter is a primer on the prostate’s anatomy and how it plays a role in the potential adverse effects of your treatment.
Water – How the anatomy of the prostate relates to voiding.
The prostatic urethra is the star of any prostate movie. Thee must know and understand the prostatic urethra regardless of the treatment chosen.
All treatments for prostate cancer affect the prostatic urethra. Surgical removal of the prostate removes the prostatic urethra and potentially causes activity related urinary incontinence. Radiation inflames the prostatic urethra and causes irritative urinary symptoms of frequency, urgency, getting up at night, and sometimes urgency incontinence. Choose your poison.
When men urinate, the bladder contracts to force urine through the prostate and then out the urethra through the penis. Urine travels through a channel in the prostate called the prostatic urethra. As men age, usually starting around the age of 50, the prostate enlarges due to the male hormone testosterone. As the prostate enlarges, this “pinching in” from the lobes of the prostate narrows the prostatic urethra, making it more difficult to urinate. This difficulty voiding is common in older men, is more commonly associated with benign enlargement rather than cancer, and occurs earlier in some men than others.
The degree to which the prostate affects urinary flow varies as well. Almost all men will have some slowing of their urinary stream at some point in their life, but not all will feel that the severity of a less forceful stream requires treatment. In some men, the slowing progresses to the point that they cannot void at all (urinary retention). There are medicines for this that will either relax the muscles within the prostate to allow for better flow of urine or shrink the prostate to improve urinary flow. All of the treatment options for prostate cancer will affect how you void. It is incumbent upon you to know and anticipate the effects that various treatments will potentially have on how you void.
- If the prostate is removed, then the prostatic urethra is removed. If your prostate is causing obstructive voiding symptoms, then the removal by surgery improves these symptoms. The voiding issues after surgery relate to the potential for incontinence as a result of the absence of the prostate and prostatic urethra.
- If you have radiation and already have obstructive voiding symptoms, these symptoms most probably will worsen. The voiding issues after radiation are caused by the inflammatory response of the prostatic urethra to the radiation. This results in the subsequent irritative or obstructive symptoms that commonly occur.
Nerves – You may have heard the expression, “I got one nerve, and you get on it!” Well there are two nervers on either side of the prostate and all the treatments get on “em.”
The nerves responsible for erections in the male are located alongside the posterior-lateral aspect of the prostate. Surgical removal and radiation can both have a negative effect on these nerves, and hence both treatments can influence the subsequent quality of erections. With surgery, the nerves can be bruised or damaged in removing the prostate, and in the case of radiation, the nerves are damaged by the harmful effect of the radiation itself. Although both forms of therapy can affect the quality of the erection, the forms of treatment affect these nerves differently and in different time frames. For many men, the potential for a change in their ability to have an erection is the most important factor in choosing a treatment. It is very important for each man to first determine how much of a factor preserving erectile quality is for him. The patient then needs to understand specifically how the nerves will be affected by each treatment, keeping in mind his baseline function. The better a man’s health and erectile function is before treatment, the better odds he has of preserving it regardless of the treatment chosen. In the risk-driven section of this book, the relationship between each treatment and its effect on these nerves will be presented in such a fashion as to help you place the “erection issue” in its proper place in the decision-making equation.
- Surgery and radiation both affect the quality of the erection, but do so in different ways and in a different time frame.
- Choosing either treatment modality because you feel one is more certain to preserve your erections is a decision made in error.
- It is common to have the complete return to your baseline sexual function with surgery if the nerves are spared.
- You have a greater chance of complete loss of sexual function with surgery because of the irreparable harm done if both nerves are severed during surgery.
- Radiation will negatively affect your erections to an unknown degree. You will not have a dramatic loss of your erectile quality, but a deleterious effect of the radiation on the nerves may occur over time.