Ten years ago, I first met this patient, newly diagnosed with intermediate-risk prostate cancer. As I walked into the examination room I was struck by the juxtaposition of his wife, crumpled in a chair and weeping silently, with the patient himself, pacing the 12’-by-4’ room with a look of either anger or frustration. This difference in response between the man and his spouse is not unusual; what was unusual was that he seemed to lack the usual shock that I anticipate seeing in the wake of those three words, “you have cancer,” recently delivered by the physician. What I thought was anger or frustration was in reality both, and over the following years I witnessed variations on this theme under many different circumstances.
To condense his story, he had a radical prostatectomy shortly after we first met and experienced a biochemical recurrence within months of the surgery; he had salvage radiation therapy with an initial good response, however, recently his PSA has begun to increase. But that is not the reason for this reflection. Like many men with this kind of history, he experienced profound erectile dysfunction after the surgery and has never regained any function. He tried PDE5-inhibitors early on with no success and eventually and reluctantly agreed to try intracavernosal injections. I lost touch with him for a couple of years after that; I assumed he was doing well because I had not heard from him, despite his regular attendance at our clinic for follow-up visits with the radiation oncologist.
Three years ago, he contacted me again, this time in extreme distress. His wife had left him, suddenly and—in his opinion—without cause, and he wanted to start dating again. There was no time to waste, he told me, he needed to get the “erection thing” sorted out so that he had something to offer the women he anticipated dating. I saw him the next day and we reviewed his options for achieving erections. I talked about the stress of being sexual with a new partner and how performance anxiety could counteract the benefits of the novelty of being with someone new. He denied that this could possibly be of any importance and he was quite sure that everything would work out.
The best laid plans, as they say…
He met a number of women online and went on dates with a few of them. Most of those dates didn’t turn into second dates. In part, he was still looking for his wife in the faces and personalities of women who were not her. And he was not what some of them were looking for either. Was he too old, too set in his ways, or too desperate for something that he couldn’t describe? Dating in the 21st century when you are mostly a 20th century person is difficult.
He finally met someone, 15 years younger than him, whom he fell for, hook, line, and sinker, and head over heels as well. He came to see me shortly after they met because they had tried to be sexual and… he could not achieve anything even approximating an erection. He was frustrated and angry (again) and he needed to fix this, now!
We reviewed the technique of the penile injection and he seemed to be doing it right. But as I explained, not for the first time, the penis is connected to the head and to the heart, and its response is not purely mechanical or chemical.
Six weeks later, he called me, once again devastated. The woman was not answering his many calls, texts, and voice messages. He was even more committed to finding a way to get his penis to cooperate, because in his mind, this was the deal-breaker in the last relationship. Once again I saw him, reviewed his technique, and asked him what he thought had gone wrong.
“I was desperate,” he said. “I wanted—no, I needed that relationship to work because I can’t bear to be alone.”
Finally, a breakthrough. He had connected to his head and his heart.
Two weeks ago, he came to see me. I could see the difference in him as he sat in the waiting room. His step was lighter and his face brighter. On talking to him, his heart was happier too. He had met someone else, a woman closer to his age, who was also divorced. He had taken it slower this time and not jumped straight into a sexual relationship. They were working things out that way; she was helping him with the injections and they were working for him, at least most of the time.
And when they didn’t, then they talked and had a glass of wine. It’s good for the heart, wine is.