I wasn’t sure what his response would be to my suggestion, but I thought it was worth talking about.

I have had numerous conversations with this man over the past 2 years. The first time I met him was about 2 weeks after his diagnosis of prostate cancer. He came to the appointment with his wife and they were both shell shocked and unsure what the diagnosis meant and what they were going to do about treatment. Over two appointments he came to the decision to have surgery, an appropriate choice as he was diagnosed with unfavorable intermediate-risk cancer. The surgery went well, and he recovered quickly and went back to his usual life—but not without the expected challenges of incontinence and sexual problems.

He saw the pelvic floor physiotherapist both before and after the surgery and by 3 months after surgery was mostly continent other than when he laughed, coughed, or sneezed. I saw him on multiple occasions about the sexual issues he was experiencing. The oral agents didn’t help him achieve erections and while I encouraged him to have patience, he was increasingly frustrated. By the 1-year anniversary of his surgery he was ready to try penile self-injections. We laughed when he told me that he was used to injecting their diabetic cat so this would not be a problem, but on the day that he came in for a test dose, he was not laughing.

I didn’t hear from him for about a year after that other than when he needed me to organize a refill of his prescription. Our phone calls were brief, and he assured me that he was doing well.

Then, a week ago, he left a message for me to call him urgently. I arranged for a video appointment for the next day and was curious about the need for urgency. I checked his chart before our appointment and there seemed to be nothing untoward. His PSA remained undetectable and he reported no problems at his last visit with the surgeon.

Our appointment started with the usual questions about how we were both coping with the COVID-19 restrictions. He didn’t look like his usual self; he would usually laugh and joke with me but this time it was different. It took just one question for the flood gates to open.

He hated having to inject himself to have an erection. Their sex life was nothing like it was before and he was too young to have to deal with this. He wanted things to be the way they were before. He was sad and mad and why did this happen to him?

My answer was brief and phrased as a question.

“Have you mourned what you have lost?”

Wittman and colleagues describe the process of grief and mourning what has been lost after treatment for prostate cancer.¹ This incorporates acknowledging the loss, experiencing the emotions related to this, creating a perspective of what sexual functioning used to be like, and then finally starting to create a new view of sexuality based on the reality of what one is able to do.

I described the process and the rationale for actively mourning the loss of the spontaneity, confidence, and reliability of his erections in the past. And I encouraged him to talk to his wife about this because the partner too must mourn what used to be in order to move forward into a new way of being sexual as a couple. He nodded as I talked and expressed his interest in at least trying what I had suggested. Our video appointment came to an end but before we signed off, I arranged for a follow-up call 2 weeks later.

He cancelled that appointment and didn’t respond to my voice message suggesting another date and time for us to meet. After repeated calls to him and some back and forth we arranged another video call. He looked a bit depressed and I asked my usual questions about how he was feeling and what had happened over the past weeks since we had last met. His response was as I anticipated; he was stuck with not knowing how to do what I had suggested. How did one mourn something like this? What did he have to do? Could I describe the actual steps that he had to take? I smiled as he talked. Here was a man who wanted directions, unlike the common myth that men never ask for them!

I took a deep breath, not sure what his reaction was going to be to what I was going to say next.

“How about you write a letter to your penis?”

The expression on his face made me want to smile but I kept control of myself.

“Let me explain,” I continued. “This is something that has been helpful to other people who have experienced a loss of something fundamental to their self-image and, in your case, your masculinity.”

“Okay, I’m listening…”

I explained more about why and how to do this. I told him that there were no rules, that he should write from his heart and not censor himself. And most importantly, I told him that no one will see the letter and that even he didn’t need to read it again. He could burn or bury it, shred it or store it in a secret place that only he knew about. The sole purpose of writing the letter to this part of him that had changed in so many ways was the first step in his coming to terms with his loss and grief.

We have an appointment at the end of this month. I wonder what he will report…

Reference

1. Wittmann D, Foley S, Balon R. A biophysical approach to sexual recovery after prostate cancer surgery: the role of grief and mourning. J Sex Marital Ther. 2011;37:130-44.