These last two chapters are probably the most difficult emotionally, to write about. And yet, they are probably the most critical in the minds of most men when they think about the possible long- term effects of prostate cancer. They go to the very heart of a man’s masculinity. After survival, and the meeting of his basic needs, the perpetuation of the human species is the next highest plateau on the Maslow pyramid of human motivations. This is true even after a man is beyond the age, or even the desire, to raise a new family. The sex drive is heavily imprinted into the human psyche.  If in doubt ask Madison Avenue or Hollywood.

After going through this odyssey, another thought occurred to me; prostate cancer is as much a woman’s problem, as breast cancer is a man’s problem. I’m sure a woman who is diagnosed with breast cancer faces many similar fears that a man goes through after he has been told that he has prostate cancer. Both diseases are potentially fatal, and both can have a devastating effect on the perception of ones masculinity or femininity, and both can test the spousal relationship. In both cases, the healthy spouse suddenly has additional responsibilities, such as care-giver, counselor, medical researcher, etc.  

Sarah was always there by my side with a shoulder to cry on and advice when needed.  However, from the beginning I felt that it was important for me to adopt a positive attitude, and in my case, use humor as a means of dealing with the many decisions and ordeals that I would encounter along the way to recovery.  Please give humor a try if you are diagnosed with any kind of life threatening malady.

As most men know, there is often but not always, a problem with having an erection after the treatment for prostate cancer. With radiation therapy, radical prostatectomy, and cryosurgery (the freezing of the prostate), the two bundles of nerves surrounding the prostate that is responsible for transmitting the vital erection signals from the brain can be damaged, or severed altogether.  This can prevent the arteries in the penis from filling the spongy tubes of tissue   ( the corpus cavernosa and corpus spongiosum ) inside the penis with blood, making a natural erection difficult or impossible.

To most men this can be devastating news.  And naturally the doctor is almost always asked a variation of the following question after a patient has been diagnosed with prostate cancer.   

“Once we have cured or controlled the cancer, how is my sex life going to be affected ?”
    

Lionel made me aware of this problem from the very beginning, and further research proved him to be correct.  

“There is no current technology available that can guarantee a cure for prostate cancer and also guarantee an erection after treatment. However there are a number of ways to overcome this problem, and its up to me to make you the stud you were before you came to see me,”  promised Lionel.    

Several months after my surgery, these prophetic words were going through my mind as I sat in my car at a high tech firm’s parking lot in San Jose. I was waiting for a colleague to arrive from Salt Lake City. We had an appointment with the firm’s senior management.  Through the windshield, I saw four lovely young ladies emerge from the front door of the  building to take advantage of the warm weather.  A gentle breeze caused the long black hair to fall over the unadorned face of the woman in front necessitating a slim hand to occasionally move the hair back into place.               

She wore a simple white dress that seemed to make her appear translucent, revealing everything and yet nothing at the same time.  All the ladies looked so exceedingly desirable in their short skirts and high heels.  My mind said so.  My recollection of the past said so.  But physiologically, nothing happened, and I suddenly felt desperately lonely and depressed.  

This had to be one of the lowest points of my recovery so far.  I almost cried.  Its not so much that I would or could  have done anything about the situation, even if I did have a natural physiological response.  I am too married and too old. But I felt cheated, because my freedom of choice had been taken from me.  Now many nations, I thought, had fought wars over the centuries in the name of freedom.  Yet we take freedom for granted until we lose it.  Suddenly, I felt that this was my Dunkirk.  But, who can live too long with the legacy of a great retreat?  
        

At that moment, I decide that I needed to regain my freedom of choice . This was to be the first day of the rest of my life. It was time to roll out the old Spitfires for one more battle, I could smell the Castrol oil as the Rolls Royce engines turned-over in my mind.
 

Most men have little knowledge about the physiological workings of their own reproductive system.  And before they can make an informed  choice of the appropriate treatment, they should have at least a basic understanding of how all this plumbing operates.  What follows, is a brief layman’s primer on the subject.

First and foremost, we should try to understand the various functions that the prostate plays in our everyday lives.

The Prostate.
    
This thing we call a prostate, despite all the problems it can cause many men and the revenue potential it has for medical plumbers, is a remarkably small capsule.  About the size of a walnut, it acts very much like Grand Central Station, with multiple functions that have to be orchestrated in the correct time sequence.  
    

The prostate is not a single gland, but a collection of glands surrounded by a single capsule. This capsule has a dual role; the regulation of the liquid waste from the bladder to the outside world, and  the production of the essential fluids for the reproductive system. The prostate is situated just below the bladder, the organ that collects urine.  

There are two valves, or as doctors call them sphincters, (circular muscles); an internal sphincter in the bladder, and an external sphincter below the prostate. By working in unison, these two sets of muscles are responsible for preventing urine leakage before voiding. They also regulate the emission of semen during an orgasm.  

If the external sphincter becomes damaged during surgery or radiation, it can lead to urinary incontinence.  But with improved surgical techniques, this is not the problem it was several years ago.  Although most patients will encounter some degree of incontinence that might last a few days, as in my case, or several months in some other men, most men will regain control of their bladder eventually .   
    

The other major function of the prostate is it’s role in the reproductive system. The prostate produces the vast majority of the fluid that makes up semen, including enzymes that nourish the sperm cells produced by the testicles, and other compounds that protect the cells from bacteria.    
    

At the moment of climax, the internal sphincter closes, and the external sphincter relaxes. Semen, entering the urethra under high pressure is prevented from entering the bladder thus, separating the urine from the semen. The semen has only one place to go, and is forced out through the penis under high pressure.

The Sexual Response.

Most of us are fortunate to be born with five senses. Each sense on its own, or in combination with the others can arouse sexual desire.  A sound, a touch, a certain smell or taste, or a visual excitement will produce tiny chemical and electrical reactions in “Sex Central,” the hypothalamus, a gland deep inside the brain.

Both men and women have the same four cycles during the sexual response. They are:

Desire: This is an interest in sex at that particular time, or a feeling of attraction to a person.
Excitement: This is the phase when you feel aroused and excited. This state is brought on through external stimuli orchestrated by “Sex Central” and exhibits the following physical responses:
        •    An increase in blood pressure.
        •    Increased flow of blood to the genital area resulting with an erection in a man.
        •    Heavy breathing and an increase in the heart and pulse rate.
Orgasm: This is the sexual climax.  The nervous system sends waves of heightened pleasure throughout the body, particularly round the genital area. In men, there is a contraction of muscles around the prostate resulting in the ejaculation of semen.
Resolution:  This is a return of the body to its steady state.  Blood drains from
the penis which becomes flaccid once more.   

The hypothalamus, in combination with the smaller pituitary gland at the base of the brain is responsible for regulating the male hormones that effect the development of the sexual organs and sexual behavior.   

Testosterone is the primary male hormone.  When the body is low in
testosterone, the pituitary gland sends a message through the bloodstream to activate the testicles to speed up the production process.
 

When a man is sexually aroused or “turned on”, small electrical impulses are sent from the sensory receptor in the hypothalamus. They travel through a maze of nerves in the spinal cord to the nerves in the pelvic region, and too those all important pair of nerve bundles along either side of the prostate.

Arteries carrying blood into the penis receive these signals and expand, allowing blood to surge at high speed into the spongy tissue of the penis. The veins in the penis which normally drain blood from the area become constricted by this sudden expansion,  thus slowing the drainage of blood from the penis.  The result is an increase in blood pressure in the penis and a firm erection.  

It is when these nerves bundles and blood vessels become damaged through the treatment for prostate cancer that erectile dysfunction can occur.  One important fact that should be stressed at this point is that.  The only nerves affected by these prostate cancer procedures are the nerves associated with producing an erection.  The nerves that produce pleasure when touched, and an orgasm when stimulated, are generally not affected.  This means that if a man can achieve an erection through one of the several alternatives which we will discuss next, he should be able to  lead a normal and healthy sex life.