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PROSTATE
PROBLEMS, SPINAL CORD INJURY AND SEX
by
Stanley Ducharme, Ph.D.
With
aging, most men will at some time develop disorders related
to the prostate gland. Typically, these problems are first
seen after age 50 or during the 60s.Unfortunately, having
a spinal cord injury does not eliminate the probability
of developing a prostate problem. Although most of us think
of cancer when we think of prostate trouble, other disorders
related to the prostate are far more common. These may include
prostate enlargement or “ BPH” as well as acute
or chronic infections known as prostatitis. Fortunately,
prostate problems don’t need to mean complicated operations,
embarrassment with urination or the end of sexual functioning.
Today, early diagnosis, new techniques and effective medications
have greatly improved the treatment of prostate disorders.
What
is the prostate and what does it do?
The prostate is a small gland located just below the bladder.
The gland is only found in men. It is shaped like a doughnut
and surrounds the urethra, the tube through which urine
flows. The prostate reaches its adult size by the age of
20 and weighs a little less than one ounce. It is stimulated
to grow during the teenage years by the male sex hormones
which become active during puberty. For reasons that are
not well known, the prostate again begins to grow at about
age 45 or 50 and continues growing throughout the life span
of the man.
The
main purpose of the prostate gland is to produce a fluid
that combines with sperm and other fluids to form semen.
For men with spinal cord injury, this semen may be expelled
from the body during ejaculation or mixed with urine in
the bladder (retrograde ejaculation.) This ability to ejaculate
is unique for each man depending on the level and completeness
of the spinal cord injury. In all men, the prostate gland
responds to the level of sexual arousal in the individual.
As the man becomes aroused, the prostate gland produces
more fluid in preparation for ejaculation. During ejaculation
and intercourse, this semen is the fluid that carries the
sperm into the vagina.
If
there is no ejaculation when the man becomes aroused, the
fluid produced by the prostate will be excreted into the
bladder and expelled during urination. By allowing this
fluid to empty into the bladder, the prostate gland avoids
a condition known as prostate congestion. Although not dangerous,
prostatic congestion can be unpleasant and uncomfortable
if the man has intact or some sparing of sensation.
As
the prostate gland becomes enlarged during the ages beyond
50, it also squeezes the urethra causing both urinary difficulties
and a decrease in ejaculatory fluids. For men with spinal
cord injuries, urinary changes may not be noticeable depending
on the urinary collection techniques and if bladder surgery
was performed. For example, intermittent catherizations
provide a direct route into the bladder so that enlargement
of the prostate will not impair urination as it might in
a man without a disability. In addition, if the man has
had previous surgery on the bladder neck, changes in urine
flow, urgency for urination and difficulty starting or stopping
urination will not be a concern. Since urinary changes are
often the first signs of prostate problems, it may be difficult
for the man with spinal cord injury to recognize early prostate
disease without regular PSA (prostatic specific antigen)
blood tests.
Although
not a lot is known about the prostate gland in men with
spinal cord injury, recent evidence has suggested that PSA
levels may be somewhat more elevated than for men without
injuries. In addition, studies at the University of Miami
have begun to study the seminal fluid produced by the prostate
in men with these injuries. Newer studies are suggesting
that alterations in the semen from the prostate in men with
spinal cord injuries may be responsible for male infertility
in this population. Scientists have discovered biochemical
changes in the seminal plasma of the prostate that seem
to have a direct impact on sperm motility in men with spinal
cord injuries.
Enlargement
of the prostate or BPH
The most frequent cause of prostate trouble is a condition
called BPH. This stands for benign prostatic hyperplasia,
which means noncancerous enlargement of the prostate. BPH
is quite common and by the time men reach their 60s there
is a good chance that most men will experience some prostate
enlargement. BPH is rarely a life threatening disease. It
progresses slowly and potential serious complications can
be anticipated and avoided.
Typically,
doctors suspect BPH by understanding urination patterns,
urine flow and frequency. The symptoms of BPH include some
or all of the following: a need to urinate more often than
usual at night, difficulty in starting your urine stream,
slowness and weakness of your stream, a need to urinate
frequently and with great urgency, dribbling of urine after
urination and passing small amounts of blood in your urine
or ejaculate. Because of neurogenic bladders after spinal
cord injury, many of these symptoms may not be present in
the man with a spinal cord injury.
Without
proper diagnosis and treatment, BPH can lead to acute urinary
retention, urinary tract infections, loss of normal bladder
functioning and eventual kidney damage. From a sexual perspective,
BPH can significantly affect ejaculation and make it difficult
for the ejaculatory fluid to be expelled from the body.
In rare cases it may cause erection problems but this tends
to be unlikely. Interest in sex can be affected if the man
experiences problems with ejaculation and erection or if
he is uncomfortable due to urinary tract infections.
Over
the last decade, medications have replaced surgery as the
primary treatments for BPH. Some of these medications include:
Hytrin, Flomax and Proscar. These tend to either relax the
smooth muscles of the prostate and bladder neck or reduce
the size of the prostate itself. Some medications such as
Proscar can affect sexual abilities and have been shown
to reduce ejaculatory force, impair erections and decrease
sex drive. Usually, these side effects will disappear when
the medication has been finished. As a side note, women
who have the potential for pregnancy should not handle crushed
Proscar since it can be absorbed through the skin and has
been shown to cause certain types of birth defects.
Some
men with spinal cord injuries have had surgical procedures
known as transurethral resections (TUR). This procedure
is also used for the surgical treatment of BPH. In this
procedure, a surgical instrument is inserted in the urinary
passageway and some of the enlarged prostate is cut to widen
the passage in which you urinate. It is the simplest operation
and leaves no scar. Unfortunately however, this procedure
can seriously affect the man’s ability to get an erection.
Many doctors will attempt to preserve sexual abilities after
TUR but sexual difficulties are very prevalent even in these
cases.
Prostatitis
Prostate infections can be acute or chronic and are called
prostatitis. In men with sensation, prostatitis can cause
back pain, pain in the rectal area and burning with urination.
Treatment of this problem is usually done with antibiotics
but warm baths and muscle relaxants have also been found
to be beneficial. Although prostatitis doesn’t typically
affect sexual functioning, some men report painful ejaculations
due to painful spasms of the prostate muscle at the time
of ejaculation.
Another
form of this disorder is called congestive prostatitis.
Although the exact cause is generally unknown, some doctors
feel that constant vibration or irritation can be a factor.
Truck drivers and motorcycle riders, for example, often
develop this uncomfortable condition.
Prostate
cancer
Cancer of the prostate is the most common malignancy of
men in the United States. There are three major goals for
treating men with prostate cancer. Obviously, the most important
is to eliminate all malignant cells. The second goal is
to maintain as much urinary control as possible. The third
is to try to preserve erectile ability. Because one of the
potential side effects of treatment for prostate cancer
is erectile problems, an increasing number of men and their
partners are affected by sexual changes.
The
two standard treatments to address prostate cancer are removal
of the prostate gland (radical prostatectomy) and radiation
therapy done either by an external machine or from implanting
radioactive seeds. Both surgery and radiation treatment
carry the risk of erection problems. Prior to 1982, loss
of erections was inevitable in all men who had their prostate
removed. In that year however, a new procedure was developed
at Johns Hopkins University in Baltimore. This procedure,
called a nerve sparing radical prostatectomy, attempts to
preserve the nerves that are connected to the erection tissue.
Even with this surgery however, erection problems are very
common.
The
best predictor of whether erection problems will occur after
surgery is the quality of the erections before surgery.
Cigarette smoking, alcohol use, cholesterol levels, medications,
diabetes and the spinal cord injury itself will all determine
how much sexual functioning is preserved after treatment
for prostate cancer. Typically, it can take at least several
months to determine whether sexual functioning will return
after surgery or radiation. During this time, maintaining
ongoing contact with your urologist is a good idea in order
to explore treatment options and their effectiveness.
Many
of the treatments for erection problems after spinal cord
injury are also commonly used in men who have had radiation
treatment or prostate removal. These include the use of
penile injections, vacuum devices and oral medications such
as viagra. Most of these treatments tend to be well received
although currently there is little available data on the
effectiveness of viagra after prostate cancer. Even if viagra
was helpful after spinal cord injury, the same dosage may
not be as effective after prostate treatment. However, if
you have partial erections after surgery, viagra alone may
restore your abilities without further treatment.
Typically,
when sexual functioning is regarded as important, men will
begin to address erection issues within one to three months
after surgery. Often the use of erection treatment within
a few months after surgery will ultimately help a better
return of sexual functioning in the months or years that
follow. This is probably due to the increase in oxygen to
the penis that occurs during frequent erections.
In
conclusion, prostate problems are very likely in many men
after age 50. Regular check-ups, blood tests and prostate
examinations need to be conducted on an ongoing basis. Today
however, prostate problems have received considerable attention
by the medical establishment and many new procedures and
medications have emerged in the last several years. Although
many prostate problems can affect sexual abilities, there
are effective treatments which can restore potency. Today,
prostate problems no longer need to signify a loss of sexual
functioning.
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