Much is written about the side effects of prostate cancer, its treatment, and possible post-operative impotence or erectile dysfunction as they relate to heterosexual men fulfilling the needs of their female partners or to an inability to conceive children. But rarely do we see anything about the emotional and physical needs of gay men who have to deal with impotence after prostate surgery or radiation.
As a urologic oncologist, I have treated many gay men for prostate cancer. Some of them have undergone radical prostatectomy, either laparoscopically or robotically. As a consequence of treatment, a relatively small number of these men will experience postoperative impotence of some degree for up to 18 months or even longer.
As a general rule, gay men are no different from heterosexual men with regard to their desire to get an erection firm enough for penetration. Certainly, in the gay community, infertility is not an issue, except of course if one partner wants his sperm to be used to fertilize an egg carried by a surrogate. In that case, I recommend that arrangements be made to collect, freeze, and store the donor’s sperm in an appropriate sperm bank before treatment commences.
Almost all men are penis-oriented, which means that a man’s personality, behavior and outlook are governed in large part by his image of his penis. This is simply the way nature intended men to be. The biological and emotional signals sent to a man by his penis makes him “penocentric.” Usually, this idea has a pejorative connotation, but I don’t view penocentricity negatively.
In many respects, the penis is the organ of a man’s essence, the axis around which the male body and personality rotate. This is universal, whether he is gay, straight, or bi.
In a man’s psyche, the penis is king, ruling its owner. Sometimes, like a potentate who follows the will of his people, the penis does a man’s bidding. Other times, like a dictator, it commands by its own rules — rules that men cannot always comprehend. As a monarch, the penis acts in unpredictable, enigmatic ways — sometimes despotic, capricious, and selfish and at other times, benevolent, magnanimous, and wise.
Oftentimes, after prostate cancer surgery, no matter how hard a man tries and no matter what help he gets from his partner, “things just aren’t working.” When things are working perfectly, King Penis issues a command and a man has little power to disobey. The penis can turn the mind, emotions and senses into obedient serfs. And if the penis is unresponsive to a command, the results can often be emotionally debilitating, especially in gay men.
In terms of prostate cancer, the good news is that we have made much progress. Previously, most men in the 40- to 60-year age range who were diagnosed with prostate cancer underwent radical surgery, occasionally resulting in profound erectile dysfunction. Over the last decade, however, the urologic community’s approach to the treatment of early-diagnosed, low-grade (defined by a prostate biopsy), and organ-confined prostate cancer has evolved dramatically, particularly in younger patients.
Urologists have become aware that many of these cancers are either slow-growing or non-life-threatening, and these patients are placed in an active surveillance group that does not require radical surgery, if properly monitored. For those few who do require aggressive surgical treatment, the development of the Da Vinci robotic surgical system — a truly revolutionary surgical modality, now routinely used on an outpatient basis with a non-incisional, nerve-sparing, and continence-preserving technique — rarely results in post-operative impotence or incontinence.
One thing does change with this operation, however: The ejaculatory fluid becomes absent. This fluid, produced by the prostate gland, is no longer emitted. Most of the fluid in an ejaculate comes from the prostate and is not sperm, which is produced by the testicles. A small amount of fluid can still come out of the penis after an ejaculation when the prostate has been removed, but this is not ejaculation fluid.
In most cases, post-operative orgasms feel about the same as pre-operative orgasms, with the exception that there is a paucity of fluid emitted.
Gay men in particular must make a giant psychological adjustment. They must accept that being cured of prostate cancer comes with the tradeoff that there will be little, if any, ejaculatory fluid associated with orgasm or that some degree of impotence can be expected.
Very little can be done with regard to the fluid. For restoring potency, though, vasodilating drugs that dramatically increase blood flow to the penis (Viagra, Cialis, Levitra, etc.) are extremely effective. Farther down on the list of remedies is the use of injection therapy, in which a small volume of vasoactive drug is injected into the base of the penis before sexual activity, increasing blood flow and creating an excellent erection in most cases.
Every man, gay, straight, or bi, will be deeply affected by the results of prostatic surgery done for the cure of prostate cancer. The most important advice that a urologist can give to any of these patients is this: “Accept what you must, change what you can, and be intelligent enough to know the difference between the two.” All of life has tradeoffs, and I believe that most men would prefer a long life with a penis not firm enough for penetration to a horrible death from untreated prostate cancer.
For gay men in particular, it is essential to understand that the prostate and the ejaculate it produces are unrelated to libido or desire. Libido is driven by the testosterone produced primarily by the testicles, which are not involved in the surgical or radiation treatment of prostate cancer. In the same way that erectile dysfunction drugs are drugs of performance and not of desire, the loss of one’s prostate is unrelated to libido.
As a last resort for men who find it unacceptable to be unable to get an erection firm enough for penetration, the excellent treatment options include a variety of penile implants (analogous to an implant in a woman’s breast). These implants require a surgical procedure, and most use a pump mechanism to achieve penis firmness. The devices are highly sophisticated and have been in use for many years. They are exceptionally effective in men who are motivated to proceed.
Much of what I have outlined above with regard to the surgical treatment of organ-confined prostate cancer and appropriately aged men also applies if the patient has chosen to have radiation therapy. The effect of sexuality, ejaculation, erections, and impotence apply as well.
If you have been diagnosed with prostate cancer, be sure to discuss all your options with your urologist. With the proper treatment, you can live a long, healthy and satisfying life.
Dudley S. Danoff, M.D., F.A.C.S., is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles. He is the author of “The Ultimate Guide to Male Sexual Health: How to Stay Vital at Any Age.”