The Province

Couples must rethink sexuality

Loss or reduction in sex drive can almost be as troubling as cancer itself

- LARRY PYNN GERRY KAHRMANN/PNG

At 78, Karl Eibenstein­er doesn’t see women the way he used to.

The Kerrisdale divorcee is being treated with enzalutami­de for an aggressive prostate cancer that has spread dangerousl­y beyond the prostate and into his bones. The drug suppresses the production of the testostero­ne upon which the cancer feeds, but also robs him of his sex drive, leaving him only with memories.

Pharmaceut­ical crutches such as Viagra don’t help. “Not only does the dick not get hard, but the traffic between the ears dies,” Eibenstein­er reflects. “Before, you’d look at a pretty woman, but all of a sudden it doesn’t do anything for you. It doesn’t give you any desire. It’s dead. It kills the thought of sex.”

Eibenstein­er has female friends, including for intellectu­al conversati­ons, but has no interest in sleeping with them.

“Oh, well, once upon a time.” For men battling prostate cancer, the loss or diminishme­nt of one’s sex drive can almost be as troubling as the cancer itself. For much of their lives, sex helped to define who they are, and now they must soldier forward not knowing when or how it might return.

In White Rock, Peter Burnstad still has sexual thoughts at age 87, despite having both his prostate and bladder removed.

“I’m not trying to be active again or anything,” he said.

“But when you have your libido, you feel so good. That’s what I’m driving at now.

“If I can get feeling the way I used to feel, then it makes life that much more richer.

“It’s an important part of our life.” Nikita Ivanov is a nurse practition­er with B.C. Cancer who advises men on androgen replacemen­t therapy, or hormone therapy, which kills the sex drive. Some men in the late stages of their cancer choose to reject the therapy because of the side effects.

“Sex is so important they are willing to forgo the treatment and put themselves at risk for severe complicati­ons,” he said. “Never assume if you have an elderly gentleman in front of you that sex is not important.”

The Vancouver Prostate Centre offers a free prostate cancer supportive care program, with education for men dealing with their cancer.

Sexual health clinicians Christine Zarowski and Monica Tancon teach “sexual rehabilita­tion,” pointing out that prostate cancer is a “couples’ disease” and that, while partners may have been content for decades having sex the same way, those days are gone.

The reaction to the loss of sexuality can be akin to mourning. What a couple had is gone, and they must now redefine their sexuality, a process that can take years, with varying outcomes.

Said Zarowski: “A patient came to me and said, ‘This experience has given me a licence to be intimate with myself.’ I thought that was very powerful because a lot of times we don’t give ourselves permission to explore different desires or different ways of being sexual.”

Knowing which path is best for a specific couple is not easy.

“This is a time of challenges, both physical and emotional,” Zarowski said. “It’s scary out there — lots of places where you can get informatio­n, but sometimes it’s hard to know which informatio­n is accurate.”

Dr. Larry Goldenberg, a Vancouver urologist surgeon, wrote the best-selling book The Intelligen­t Patient Guide to Prostate Cancer with co-authors radiation oncologist Dr. Tom Pickles and medical oncologist Dr. Kim Chi. It is now in its fourth printing.

Goldenberg writes that whether a man chooses surgery or brachyther­apy radiation, the sexual outcomes are not ideal. “Often, the erection may be more difficult to attain, softer, and quicker to fade.”

Sexual function may return gradually after prostate surgery, even as long as 24 to 48 months later. With radiation, men usually maintain function early on but may suffer a gradual loss without recovery.

Men who have their prostate removed can no longer ejaculate, though they can still have orgasms, and in about 20 per cent of cases find their orgasms more pleasurabl­e, Zarowski said.

Outcomes can vary depending on the man’s age, other health issues, including medication­s that can affect libido, and the surgeon’s ability to spare nerves around the prostate during surgery.

In general, removal of the prostate results in immediate incontinen­ce and erectile issues, but these can improve over time. In comparison, the impact of brachyther­apy kicks in later as the radiation begins to affect tissue, nerves and blood cells. Brachyther­apy also results in an urgency to go to the bathroom,

but that fades over time.

No two men are alike in their journey with prostate cancer.

“Some men on androgen replacemen­t therapy say, ‘You know what, I find it kind of refreshing not being distracted by sexual thoughts,’” Zarowski said. “Some will get into new domains of creativity.

“Others feel lost. They don’t know themselves anymore.”

Men may be surprised to know that they needn’t have an erection in order to achieve an orgasm. “They’re completely different,” Tancon said. “We’re talking about sensory nerves versus motor nerves.”

Partners need to rethink their sexuality, Zarowski said, putting less emphasis on the act of intercours­e and more on the full range of emotions affecting intimacy, including physical, intellectu­al and emotional aspects. “This is something that’s very personal, very intimate. A lot of times, couples don’t even talk about sex amongst themselves.”

For some couples, prostate cancer may have arrived late in their life, and they’re OK with giving up sex.

“We had a good sex life, very active,” said one woman, who asked not to be identified because of the personal nature of the subject. “But now we’re in our 80s. That makes a difference. We’ve been married for more than 60 years. We’re pretty comfortabl­e with each other.”

The sheer stress of having cancer

can also affect one’s desire to have sex. Other couples very much want sex to remain part of their relationsh­ip. “When we think about sexuality, it spans through a lifetime,” Zarowski said. “Some people think there’s a cutoff, 65 years and that’s it.”

Some seniors may even buy into the idea that they shouldn’t have sex.

Said Tancon: “You may have heard myths that sexual aids are perverted, that sex is for young people, that good sex requires orgasms, that sex should be spontaneou­s with no talking and no planning.

“We laugh about that one. What other things do you do in your life that don’t take planning?”

Men who take the educationa­l course receive a “use it or lose it” ultimatum. Like any other body part, the penis can atrophy if the man does not continue to exercise

it — either through sex or regular methods of stimulatio­n.

“When a man is sleeping, he might have three to six erections per night,” Zarowski said. “They help to keep the tissue inside the penis healthy. Through prostate cancer treatments, that biological mechanism is taken away.

“That’s why men need physiother­apy for the penis, a minimum three times per week.”

In some cases, regular low doses of Cialis can help in maintainin­g the structure of the penis.

A vacuum erection device, or penis pump, can also help keep the penis exercised, and address the problem of shortening of the penis, which is common after treatment for prostate cancer and erodes a man’s sense of masculinit­y.

Other options to help men overcome the sexual side effects of prostate cancer treatment include intracaver­nosal injections — self-administer­ed into one of two tubes known as the corpus cavernosum that run alongside the shaft of the penis. The drug is very effective at achieving an erection and is often covered by extended health benefit programs.

“I know it’s hard for men to think about doing an injection in their penis,” Tancon said. “I get it. I do. But it’s a small needle, and it shouldn’t be painful if it’s done properly.”

Vibrators are not just for women, and can be used to help stimulate blood flow in a man’s penis, along with a soap massage in the shower, even if it doesn’t result in an erection.

Intraureth­ral gels can also assist men in getting an erection. Penal implants do the same, but are often seen as a last option.

Silicone constricto­r or tension bands — often sold as “cock rings” in sex shops — placed at the base of the penis can help to maintain an erection. “I’ve had some men tell me they borrowed their partner’s hair band,” Zarowski said.

To which Tancon added: “You can do that. But don’t return it.”

Both clinicians are also available for one-on-one appointmen­ts, with referrals from a family doctor.

Contact pcscprogra­m.ca for more on the Vancouver Prostate Centre’s free prostate cancer supportive care program

“I’ve had some men tell me they borrowed their partner’s hair band.”

— Christine Zarowski, clinician

 ??  ?? Sexual health clinicians Christine Zarowski, left, and Monica Tancon of Vancouver Prostate Centre point out that prostate cancer is a “couples’ disease.”
Sexual health clinicians Christine Zarowski, left, and Monica Tancon of Vancouver Prostate Centre point out that prostate cancer is a “couples’ disease.”
 ??  ?? Kurt Eibenstein­er, 78, is undergoing treatment for prostate cancer, which has spread throughout much of his body. The drug that he’s taking suppresses the production of the testostero­ne upon which the cancer feeds, but also robs him of his sex drive.
Kurt Eibenstein­er, 78, is undergoing treatment for prostate cancer, which has spread throughout much of his body. The drug that he’s taking suppresses the production of the testostero­ne upon which the cancer feeds, but also robs him of his sex drive.

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