In my work at a busy prostate cancer clinic, I discuss all available treatment options with men who are experiencing erectile problems after surgery or radiation therapy. The discussion proceeds in an orderly fashion, with the oral agents described first, then the penile pump, the alprostadil pellet, penile self-injection, and lastly the penile implant, since this the order in which most men try these interventions. The oral agents help about half of the time, dependent on degree of nerve-sparing during radical prostatectomy as well as pre-treatment erectile function and age. If those fail, some men are interested in the penile pump; however, I do share with them that I have not found that to be successful with most patients. Many patients, and in particular their partners, are not satisfied with it due to the mechanical nature of the device and the degree to which is interrupts the flow of the sexual encounter. The alprostadil pellets are expensive and many men experience a burning sensation in the urethra and attrition is high. Penile implants tend to be a measure of last resort, involving major surgery that many men are reluctant to undergo.
When I talk to them about penile self-injection, many men cross their legs in an automatic reflex. They are often horrified at the idea of doing this, even though it is a technique that is easy to master and has good results, even years after treatment and an extended period of profound erectile dysfunction. It can take multiple appointments and increasing desperation before they are ready to try this, and I understand why this is for many a challenging idea. I agreed reluctantly to do the test doses for these men. I used to refer them to one of my urologist colleagues when they agreed to try this technique because it felt a little uncomfortable for me to see them in counseling and then to see their naked genitals. But the wait to see the urologist for this was usually months long and they often did not receive comprehensive education about how to draw up the medication and the technique of injecting themselves. I would see men who had given up on the intervention because they were not sure how to do it, or were anxious that they would harm themselves, or who tried it once and gave up when the result was less than optimal. So I had a little talk with myself and decided that I needed to get over myself and start doing the teaching and the test dose.
Recently I was stopped by a patient as I walked past the examination rooms in the clinic.
“Dr. Katz, can I talk to you for a minute?”
I stopped, my mind trying really hard to recall his name and what, if anything, I had managed to help him with.
“I want you to know that those injections have made such a difference in my life,” he said, his icy blue eyes filling with tears. “I don’t think you know how bad I was feeling about myself as a man,” he continued, “and it might seem silly, but being able to, you know…. Well, I feel like myself again,”
He had his hand on my shoulder as he talked, and the grip of his hand was strong.
“I do know how important it is,” I said, “but it takes a lot of courage to get over the fear and to finally agree to it.”
“Exactly!” he replied, the tears now gone and replaced by a twinkle in his eyes. “I have told so many men at the support group about what a difference that little needle has made—but so many of them just can’t seem to get over themselves.”
We talked for a few more minutes and then he shook my hand and thanked me again.
I walked back to my office with a big grin on my face and a bounce in my step. Almost every week I see approximately one patient for a test dose. They always bring their partner/spouse with them and I demonstrate the procedure on a rubber model penis that I have for this purpose. Then I leave the room to gather my supplies and when I come back, they are seated sideways on the examination table with a draw sheet over their lap. I show them how to draw up the medication, how to check the dose, and then I do the injection. It’s over in about 30 seconds and then I leave the room for 20 minutes. I tell them that I don’t need to see the results because the look on their face will tell me if it worked or not. A couple of men have tried to fool me by putting on a sad face when I come back to check on them, but after about 5 seconds they burst into laughter and tell me that they were only teasing, the results were akin to when they were 20 years old. It is immensely gratifying to me to see their joy—and I’m pretty sure that it is for them too.
I had to get over myself—my reluctance was mostly about personal discomfort—and focus on the needs of the patients who desperately wanted this part of their lives back. And my patients in turn had to get over themselves and their valid fear of sticking a needle into a very sensitive part of their anatomy. This mutual getting over ourselves has been a happy outcome for all of us.