Male Sexual Health after Transplant

Male Sexual Health after Transplant

Sunday, May 1, 2016

Presenter: Katherine Marchese MSN, ANP-BC, CUNP, CWOCN, Rush University Medical Center

Presentation is 43 minutes long with 10 minutes of Q & A.

Summary: Male sexual dysfunction occurs in almost 50% of bone marrow transplant recipients. It can take many different forms. This presentation discusses the full range of male sexual dysfunctions and the remedies available to treat them.

Highlights:

• The main types of sexual disorder affecting bone marrow transplant recipients are lack of desire, difficulties attaining and maintaining an erection, and orgasm disorders.
• Supportive, open communication between sexual partners is crucially important in resolving sexual dysfunction and restoring enjoyable sex and intimacy after a bone marrow transplant.  Professional help can assist partners in achieving this positive communication.
• There are a variety of treatments for erectile dysfunction including vacuum erection devices, treatment pills, penile injections, other medications, and penile implant.

Key Points:

(05:42): Lack of desire may occur from low testosterone due to chemotherapy or radiation.

(06:44): Orgasm disorders include premature ejaculation or difficulty achieving orgasm.

(08:08): Male fertility may be affected by bone marrow transplant.

(08:42): Radiation can damage the blood vessels of the penis and cause erectile problems.

(13:46): Certain medications may also contribute to erectile problems.

(20:09): Sensate focus or non-sexual touching can promote more open communication.

(22:46): Sexual desire disorders may involve drive or physical components, expectations and wishes, and motivation around intimacy.

(27:20): Low testosterone can be medically treated but it may reduce the body’s own ability to maintain testosterone levels.

(30:46): Erectile dysfunction was originally understood as a psychological problem. More recently, erectile dysfunction is understood more as an organic problem that includes a psychological component.

(39:55):  Premature ejaculation may be prevented by the “stop/start” or squeeze techniques. Other treatments may desensitize sensation and prolong erection.

Transcript of Presentation:

(00:01): [Parameswaran Hari]     Introduction. Good morning. Thank you all for coming. This is the most interesting topic, I guess. Last meeting I did here, there weren't this many people and I can still see people coming in. The topic for this forum is Male Sexual Health after Transplant. I am Parameswaran Hari from the Medical College of Wisconsin and the CIBMTR. I'm the moderator for this meeting.

Our guest speaker is Dr. Katherine Marchese. Dr. Alba could not be here because of the family emergency and Ms. Marchese has very kindly stepped in. She's actually the best person for this. She's a nurse practitioner in urology at Rush University in Chicago and she has more than 20 years of experience in urology. She has several publications and peer-reviewed journals in urology on topics such as erectile dysfunction, testicular abnormalities, and a wide variety of urologic topics. She lectures nationally and internationally on a wide variety of topics. She's the President of the Certification Board For Urologic Nurses and a member of the Society of Urological Nurses. She's also adjunct faculty at the Rush University School of Nursing. So, let's welcome Ms. Marchese.

(01:26): [Katherine Marchese]   Overview of Talk.  So, if you look at your handout, you can tell that I am not Jeff, as he mentioned. It's unfortunate. Jeff is a phenomenal speaker and you would've enjoyed his talk. I hope that I can fill his shoes and give you the same amount of information that you need. So, I was glad to see that there were more people walking in than were walking out. This is a very tough topic to hear about and to communicate with and that's one of the things that we're going to stress in our talk is the importance of being open about it, having good communication, and understanding that it's a couples situation. It's not just the male. We need to bring the female into it also.

So, when we're talking about male sexual dysfunction, we're talking about a special group with patients who have bone marrow transplant. There are more increased complications after bone marrow transplant that can affect the ability to achieve an erection, to have sexual desire, and to have an orgasm. So, some of these complications and I realize that I'm speaking to the choir because of how highly educated you are all in this disease, but because of the chemotherapy and the radiation therapy and then the chronic fatigue that comes from those two issues, you're going to have a lack of sexual desire.

 (02:59): Male sexual dysfunction takes many forms but it can be helped. There is also pain that is experienced if you have that GVHD and it'll be penile pain so actually penetration or sexual touching of the penis could be uncomfortable. There's also a change in your self-image. There's been weight loss. If you're on corticosteroids that causes other facial changes. You feel differently about yourself. You're not the healthy person that you thought you should be. So, how you look at yourself and your quality of life is different.

What we want to say though is that that does not necessarily mean that we can't get you sexually active and return your sexual desire. So, keep open in this entire talk that there are things we can do to help you.

 (03:48): Patients will have patterns of avoidance. They don't put themselves in situations - I always liken it to diabetics. You don't see diabetics hanging out in bakeries. You don't see them hanging out in candy stores, right? Because they know they can't have it. When you know that you have a problem with your erection, you avoid those situations. You don't put yourself in the situation where you might be expected to perform at a level that you're not comfortable with.

(04:17): Because of decreased immunity, I've heard some strange things., Patients worry, "Am I going to pass this on? Can my partner get the same thing that I have because of this?" The partner will say, "Am I going to catch something from him?" The patient then will wonder, "Am I going to pass something on to my partner like - as far as your immunity is lower- am I going to give her a viral infection, him a viral infection?" So, we want to take a look at that.

(04:53): There's other complications that happen with long term therapy and that can be you're at increased risk for hypothyroidism. You're at increase for diabetes as well as cardiovascular diseases. These are some of the common complications that happen with any patient. Take out the bone marrow disease itself. Medications that you use to treat those disease are well known to cause problems with erections.

(05:20): The main types of sexual disorder affecting bone marrow transplant recipients are problems with desire, erection, and orgasm. So, as we're going to talk about sexual dysfunction, we're going to divide it up into three categories, a desire disorder, erectile dysfunction, and orgasm disorders. As a patient who has a bone marrow transplant in your history, you will have all of these. Or you possibly could have all of these, but again, there are things we can do.

(05:42): Lack of desire may occur from low testosterone due to chemotherapy or radiation. So, desire disorder is divided into low libido, which means you don't think about sex. You don't have the desire for sex. Even if you're put in the situation, you may just not really be interested in it. This can be related to something called hypogonadism.

Again, because of the chemotherapy that you had, because of the radiation therapy, there's been changes to the axis where your testosterone level is produced. So, testosterone is a male hormone that increases your desire. It gives you that, like men I say, "Makes me feel like I'm a man." So, it increases your energy. So, when you're low, you can have more fatigue. You can see mood changes, depression, so you can see how that would affect your desire.

(06:32): Erectile dysfunction is defined as the inability to get or to keep an erection hard enough for sex, long enough to satisfy both partners.

(06:44): Orgasm disorders include premature ejaculation or difficulty achieving orgasm. And then we look at orgasm disorders. This can be premature ejaculation. There are a million definitions for premature ejaculation. Basically, some men can have an ejaculation before they even penetrate. Typically, it will refer to having an ejaculation within one minute of penetration, but there's some that can't even hang on for that long.

(07:14): At the opposite extreme, there's difficulty achieving an orgasm and a climax. So, it's important to understand that there's a difference between ejaculation and an orgasm. So, the ejaculation is a physical act of the fluid coming out. Orgasm is that overall good feeling that you get ,usually during the ejaculation.

(07:39): Sexual dysfunction may occur in up to 47% of male bone marrow transplant recipients. So, we find that sexual dysfunction rates can vary anywhere from 29 to 47%. Most commonly men will see problems with erection and ejaculatory issues.

Again, you don't need to know the specifics, but the hormone levels are changed because of the radiation and the chemotherapy. So, your testosterone would be lower, which is going to affect the three categories that we just talked about.

(08:08): Male fertility may also be affected by bone marrow transplant. A thing that I also want to mention is that there is likelihood of change in your fertility. Again, because of the radiation and smaller testicles, damage to their nerves and the blood vessels, you may not be able to produce the same amount of semen, same amount of sperm. So, many times, depending upon the age, we will talk about sperm banking and you can talk to your urologist about where you would go for that.

(08:42): Radiation can damage the blood vessels of the penis and cause erectile problems. So, we know chemotherapy and radiation can affect both the sexual function and the fertility. How does this work? When you get an erection, what happens is the arteries will get larger, more blood will flow down into the penis. The two bodies in the penis are called corporal bodies. Those will fill up with the blood. As that happens, the penis gets longer, thicker, and more firm. Then the pressure of all that blood flow into the penis causes the veins to close down. So, now what you have is the situation where the blood is flowing into the penis and it's staying there, which is the good erection that you want.

(09:25): When you have radiation, you're causing damage to the elasticity of those blood vessels. So, instead of getting wider when you're excited, they may just stay narrow. So, that can affect your ability to have adequate blood flow going down there. Same damage can happen to the veins. Again, remember the veins need to close down to keep your erection. So, if they're scarred and they're not closing down, you're going to get the situation where the blood flows in and the blood flows out and you're not going to get that firm erection that you want.

(10:05): Radiation can also cause damage to the nerves and the nerves are what sends the message to the blood vessels. Okay, time to relax, open up, or time to close down. So, if the nerve impulses aren't the same, you're going to get the same thing, altered blood flow.

(10:25): Men and women differ in their sexual response cycle and time to orgasm. We're going to talk about sexual response cycle. Have you heard of that book Men Are from Mars, Women Are from Venus? All right. This to me is like a perfect section with this.

(10:39): Men have the excitement phase, we have the plateau, you have the orgasm, and then there's the resolution phase. The resolution phase is actually the period of time it takes you from having your orgasm to being able to have another erection and having intercourse again. When you're looking at an 18-year-old male, that's just a couple minutes. You start looking at over 50, you might be talking a couple hours, you might be talking a couple days. But here's where this comes, look at the male [he]can get excited, have the plateau, have the orgasm in 2.8 minutes.

(11:19): Now we're going to take a look at the female component. It's going to take us an average of 13 minutes. We're not like that. Men can see something. Immediately, they get excited and they achieve their erection. Women, everything has to be right for us. You can't be picking a fight with me and then two minutes later think that hey, yeah, I'm ready for sex. So, it takes more stimulation. We need increased blood flow down to our genital organs too, and we need to be engaged and it takes us longer.

(11:51): So, when you are taking a look at some sexual difficulties and some sexual problems in your relationships, remember this key point. I teach men about erectile dysfunction probably most of my day, and this is one of the things that men are constantly surprised at. It takes a woman that long. No wonder. So, keep this for everybody, keep this in mind.

(12:20): Genital arousal for men may become more difficult with age. So, what is genital arousal? It starts with stimulation. So, this can be thinking something, seeing something, touching something, or actually smelling something. Sexual thoughts start up in the brain. They pass down our nerve pathway and they go down into the penis. It's got to happen. We talk about like an erection. When you were 18, it was easy. You didn't even have to think about it. But now all the ducks have to be in the row. You have to have the hormone levels right. You have to have the nerves right. You have to have the blood flow right, and you have to be psychologically ready for it. Any one of those situations can cause a problem with your ability to get an erection.

(13:13): There are some things that we can do that can improve our blood flow. Stay young, stay 18. Perfect. You don't have to worry about it. As we age, we have changes in our system. We get cardiovascular disease, we get diabetes, we get obesity. All these affect every male with his erectile potential. The less exercise you have, the less blood flow, the less those arteries and nerves learn that they have to be able to open and close.

(13:46): Certain medications may also contribute to erectile problems. And then we talked about the medical conditions. So, it's important to also know that it's not just the hypertension, it's not just the diabetes or the obesity. It's the medications also that you take to treat those conditions. So, there's over 200 medications that you are innocently taking to manage your blood pressure, manage your weight, manage your cardiovascular diseases. The biggest thing that you can do is try to control those medical conditions so that you don't have the complications from that disease and you don't need to be on that medication.

(14:24): When we talk about communication and sex, it's everywhere. You can see it on TV. Now, you see the Viagra commercials. You see couples walking around holding their hands, but I cannot tell you how many patients that I know are uncomfortable talking to their partner about it. Your partner doesn't know there's a problem getting an erection. But if you take the time to communicate with that person, that is the best thing that you can do.

(15:08): Good, open communication between sexual partners is critical to resolving sexual dysfunction. Let's talk about when a good time to start this communication. Do you think it's in the bedroom after you've just failed to perform like you want? Probably not a good time, right? Because you're a little upset about it. Your partner may be feeling bad because she thinks she puts you in a situation that you're not able to handle. So, you want to take a moment of time, set up a time, turn off the TV, turn off those ridiculous cell phones that ring at the most inappropriate times. Just take the two of you. If you want to have a glass of wine to feel more comfortable, do that.

(15:45): Don't be afraid to share anything. If you think that I'm afraid to talk to my partner about this because it might hurt her feelings, believe me, the women that I see that come in with their husbands, they know something is wrong, but whose fault it is, it's theirs. Because they start to think he's not attracted back to me anymore. I've put on weight. I'm not as young as I used to be. He works with this 19-year-old girl that looks terrific. Why would he be excited about me? I've got stretch marks. I'm heavier. I don't dress as cool as they are. So, you need to remember that that's why I keep stressing. It's a couples things. You have a problem but she's with you in that problem.

(16:37): Women often value intimacy over penile size, shape, or hardness. So, there's a misperception about what men think women want with sex versus what they really want. So, the question is length. Is that important? What's the most important thing for women and sexuality? It's that intimacy. The intimacy that doesn't necessarily have anything to do with the size of the penis, the length of the penis, the hardness of the penis. It has to do with that hugging, holding, kissing, that intimate look across the table or across the room. That's what really women love to have as part of their sexual encounter. But if you don't communicate that, if you don't feel comfortable talking to them about that, we're going to miss that whole component of sexuality and intimacy.

(17:31): Performance anxiety in men can be a major barrier to good communication. What are some obstacles to communication? Number one, fear of not being able to perform well. As I mentioned, when you were 18, it didn't even matter. You just got an erection right away. You were able to maintain it and everything was perfect. It doesn't work like that the older we get and we have all these comorbid conditions. So, when we talk comorbid, that just means any medical condition that can affect. So, that could be diabetes, heart disease, obesity. So, the male thinks about that, but guess what? So does the woman. So, she's like, "I'm not going to try anything today because I don't want to make him feel bad if he doesn't think that he'll be able to perform."

(18:18): I have a patient that I'm seeing right now and he never lets his partner initiate sexual activity because he can tell when he's going to be acceptable. So, if he gets the feeling that she's interested, he will pop like a Viagra. But if he doesn't get that feeling right away, he turns her down. So, that's a huge thing in a relationship. Men are sensitive about their sexuality, so are we. So, if I approach someone and then he's not interested, we're hurt and then we're going to avoid it the next time. So, we want to make sure we don't allow that to separate us.

(19:05): Professional help is available to encourage more open communication between sexual partners. Lack of comfort talking about sex historically, it'd be really interesting in this room to ask you, we won't, "How many of you talk about your sexual activity?" How many of you are comfortable saying, "This is what I like. I like this when you touch me here. I don't like it when you do that. I know you think I like that, but it doesn't make me feel good"?

(19:32): I wonder how many of you know the non-sexual parts of your partner's body. If you touch them behind the ear, sometimes that can be very, very exciting to a partner. The more that you talk about, the easier it gets. You should always know that there's professional help. You can go to nurse practitioners, you can go to physicians, you can go to psychologists, marriage counselors. There's so many people out there. I just caution though, just make sure you go to someone that has been dealing with this for a long time.

(20:09): Sensate focus or non-sexual touching can promote more open communication. One of the things that we use in my practice is something called sensate focus. This is a phenomenal program for patients who are just in the beginning stages of talking, because what we do is we take away your fear of not being able to perform. So, the first two weeks, we tell you, you are not allowed to have sex, but what you are allowed to do is to explore the non-sexual parts of your body. So, you should touch her behind the ear, rub her arms, give her back rubs.

(20:42): We talk about sexy surprises, like surprise your wife by maybe even just having her come home and you have dinner or you have the dishes done. That could be a very nice surprise. Anybody who wants to sign up, I'll take them. All right. So, we just want to make sure you understand there is so much more to communication.

(21:06): Several therapies and treatments are available for male sexual dysfunction. So, just therapies in general for sexual dysfunction. I'll go through each one of these individually. Counseling, behavioral therapy, and I mentioned this before, maximizing your health with diet and exercise.

(21:20): Exercise is always good. If you have a testosterone level that's low, it's known that the more physical exercise you do, you can help that. Okay, weightlifting, vigorous walking.

(21:34): There's vacuum devices. There's the common magic blue pill, which I want to talk about because it's not all that magic and there's surgery. Now, the understanding with the surgery is that once we go down that road, we can't go back. So, I always like to make sure that patients are aware that that is our last option.

(21:55): Most over-the-counter treatments are ineffective and some can be dangerous. There's a huge market out there for over-the-counter treatments. Patients will come and they'll say, "Listen, I found this in my men's health magazine, can I take this?" And we'll look at it and we're like, "Definitely not." First of all, you're wasting a lot of money. There haven't been that many herbs that are actually proven to work. There's always a psychological component. When you take something, you're thinking it's going to work. We call it the placebo effect. You take it for a while and that you think it's working, but perhaps it's not. But some of them are actually dangerous. Some of them can be blood thinners. If you already are having compromised hemoglobin and hematocrits and platelets, you don't necessarily want to just automatically put yourself on any over-the-counter medications. So, avoid that.

(22:46): Sexual desire disorders may involve drive or physical components, expectations and wishes, and motivation around intimacy. Okay, so desire disorders. This is what makes us move towards sexual encounters and actually move back from them. Okay? So, we talk about it in three different ways. There's the drive. That's the physical components. That's what we talked about before, the seeing, the touching, and the smelling. Okay? Then we have our expectations and wishes. One patient might wish that his partner is just very aggressive and comes on and understands exactly what this person wants. The other one is, "Hey, I want to be wooed. I want you to come at me softly and gently and let's have longer foreplay than 30 seconds." Okay? It's your beliefs, it's your values. There's a lot of cultural issues that we need to take into consideration.

(23:38): There are women that are uncomfortable because of their cultural beliefs or their cultural values in taking off their clothes in front of a man. So, their husbands may never have seen them nude or never have seen them in the light. We need to understand that and we need to build that in and we have to make sure that we bring that into what we are talking about when we're suggesting sexual encounters.

(24:05): Sexuality and intimacy involve more than penetrative sex. So, then there's the motivation. How is your individual relationship? You have to know that sexuality, sexual intercourse is the basis of an intimate relationship. If you don't have that, if you take that out, you're no different than your neighbors who are just friends. We have to understand that sexuality and intimacy do not necessarily mean penetrative sex. Women love to be held. They love to be touched, have their back rubbed, have you do a foot rub. That can be just as sexually intimate and sexually satisfying as penetrative sex. So, be open for those things.

(24:53): Remember that this is an important relationship issue. We want to keep that intimacy in your relationship. So, it's about pleasure. Pleasure could be having a back rub, having my feet rubbed. There's many different ways to do this. So, don't limit yourself. Don't close your mind off. If I can't have penetrative sex with my partner, I will never satisfy my partner. That is not so. The excitement comes from that anticipation and from the mystery of where that intimacy is going to lead us today. So, again, that's where that sexy surprises come in. That's where you do something unexpectedly for your partner, something they didn't even think about. Always remember intimacy is connecting to your other person.

(25:44): Sexual desire may be rekindled by focusing on anticipation, mystery, and “sexy surprises.” So, how can we reclaim the desire? There are some non-hormonal approaches that we always try to do first, okay? Anticipation, mystery, worthiness, a little card that you drop off or sending flowers to your wife at work, just a little vase. Don't send the big thing. That could be embarrassing, but they love that because it shows that you were thinking of them. Take all the guilt, all the blame, and all the pressure. They always joke about the Catholic guilt that sexuality was always like, "You're not supposed to enjoy it, you're just supposed to do it to have children." There's other culture relationships that feel the same way.

(26:25): You know what? We are one man, one woman. We're two men, we're two women. Whatever we choose to make our sexual experience, that's what we should go with. We shouldn't have guilt. It shouldn't be like we only have sex in the bedroom with the door closed and nothing going on. You should be able to do what is comfortable for you. That's sexy surprises. That's enjoying the off moment. If your partner can't get an erection, don't blame him. Believe me, I've never met a man that purposely does not want to get an erection. Never in my life. We don't need to make him feel worse because he's not getting one. What we need to do is help him feel better about himself because that's going to make your relationship better.

(27:14): We want to make sure that we develop our own desires, okay?

(27:20): Low testosterone can be medically treated but it may reduce the body’s own ability to maintain testosterone levels. Understand that that will be different. There's hypogonadism. So, this is where, for one reason or another, your testosterone level is low. There are certain symptoms that we will use to decide if we're going to treat you. Low sex drive, change in your spontaneous erections, decrease energy or mood, poor concentration or memory loss. You're going to notice that your arms and your muscles aren't as thick. Your legs may not be as strong. You may develop body fat. So, what men will do is they'll get a tire around their waist. The problem with that is that your testosterone then converts to estrogen, which gives you the bigger belly. Okay?

(28:04): All right. So, we can treat you with testosterone, but the problem with that is if we do treat you and you're on it for six months to a year, we can't take you off of it. You've only got a certain amount of time where we can play around with it and then it can alter your ability to produce testosterone on your own. There are a lot of side effects for it. Too much to go into in a talk like this because I want to spend a little bit more time on some treatment options for you. Again, so since we're mostly talking about males, I will tell you that we do have some women that we use it off label.

(28:43): Testosterone treatment should be avoided by those with certain medical conditions like breast or prostate cancer, untreated sleep apnea, and uncontrolled heart failure. So, if you have recent breast or prostate cancer, we don't recommend it. If your hemoglobin level is high, we don't recommend it. If you have sleep apnea that is not treated, again, not recommended. If you have uncontrolled heart failure, we don't want to do it because of how it can change your fluid levels. Also, if you have uncontrolled heart failure, having sex is maybe not a good thing for you because your heart rate goes from zero to 60 in a second. So, your heart might not be strong enough for you to physically have sexual intercourse.

(29:18): The other thing is if you are young and you're trying to father a child, what the testosterone is going to do is stop your own production of testosterone and that's going to affect your ability for sperm production. So, hypogonadism can be treated with injections once a week, twice a week, twice a month.

(29:40): There are non-genital patches. You can put it on your arms, on your shoulders, on your buttocks. There's a patch that goes and sticks on the inside of the gums. They now have a nasal spray. They've got pellets that you get injected into the buttocks and they work for 12 weeks. So, we have lots of treatments, lots of different options.

(30:01): Erectile dysfunction is the inability to obtain and maintain an erection that is sufficient for sexual satisfaction. So, now we're going to the sexual class, the erectile dysfunction, which is our second classification. Again, this is the inability to obtain and maintain an erection that is sufficient for successful sexual satisfaction. I always put that clause in there because I want you to understand that what might be good for you may not be good for you. I have patients that if they have intercourse for five minutes, they're satisfied. I have patients that want to have penetrated sex for 40 minutes. So, if I try to say, "Well, you've got it for five minutes, that's good." They're not having successful sexual satisfaction.

(30:46): Erectile dysfunction was originally understood as a psychological problem. When I started working with ED back in the late '80s, everybody assumed that if you had problems with erections, it was a psychogenic problem, that there was something wrong psychologically with you. Either you didn't find your partner stimulating, you didn't have a partner, or that there was something wrong with you. So, it was 90% psychogenic and it was only 10% organic. Luckily, when I started in this field, I worked with a man that believed that those were the exact opposite.

(31:22): More recently, erectile dysfunction is understood more as an organic problem that includes a psychological component. Sure enough, over time, we now know that almost 90% of men's problems with erections are organic in some cause. However, there is always that psychological component. If you know you're not going to get a good erection, you're going to veer away from that. So, when we're working with men and we're giving them treatment options, we like them to also be aware that, "Yeah, we have to work on that also. We have to give you the confidence to know that you can put yourself forward like that." Probably the one take home message that I want today is that it's treatable. I want the two of you to be walking off into the sunset, okay? Holding hands. All right.

(32:06): Vacuum erection devices are one treatment option for erectile dysfunction. We're going to spend a little time going over the different treatment options that we have. We define them as first line, second line, third line. We're just going to mix them all up though. So, the first one is the vacuum erection device. This is a cylinder that you put over the penis before it's erect. There's a little pump mechanism there, and what that's going to do is that's going to pull the blood down into the penis and produce a very, very firm erection and that it's going to actually be longer and thicker than your normal erection.

(32:41): Now, unfortunately, when you slip that off, that erection's going to immediately go down. So, there has to be rings that you put around the base of the penis. So, the ring is actually held down at the bottom. When you've used the device and it's firm enough to penetrate, with your fingers, you slide that off and it clamps onto your penis. Now those rings have to be very tight, right, because we have to close down all the blood vessels, all the arteries, and all the veins. So, it takes a while to get used to this. This is not something that you could go pick up and be ready to use the next day. I always tell the patients, "Get it, practice it by yourself. Don't have your wife or your partner sitting there waiting for you." Honey, where are you?

(33:28): All right. The other thing that happens with this is it takes the moment away. So, usually, what will happen for it to be successful, the partner will go off and he will produce the erection that he wants and then he comes back. What's important for the partner to realize and for the patient, this is when foreplay begins. So, women feel less connected with this. So, it takes a lot of education, a lot of working with the partner to make sure that they understand that this is like a means to an end. Foreplay and sexual stimulation are still there. It just comes after the erection develops. The nice thing about this, you can use it as often as you want. You could use it 10 times in a day if you want, but you just can only leave that ring on for 30 minutes and then you need to take it off, give yourself a break, and put it on again if you want.

(34:22): Pills like Viagra are another treatment option for erectile dysfunction. So, when we're talking about the treatment pills, this is the magic, the Viagra magic pill. All these pills have to be taken with stimulation so you can't pop the pill and 40 minutes later say it's not working. What happened? It's not going to work unless you have stimulation with it. It's easy, it's discrete. Some of these medications can cause some achiness in their joints. It can cause nasal congestion. It can cause flushing. A lot of times wives are a little worried after someone's taking their Viagra pill for the first time because their face is flushing. Then they think they're having a heart attack or something.

(35:01): You remember when Viagra first came out, there was all that hullabaloo about people were having heart attacks associated with Viagra. It wasn't because of the medical components of the Viagra. It's because now men who were not healthy enough to have intercourse could like men with heart failure or high blood pressure. All of a sudden, we were giving them a pill that they could have sex with and their heart really wasn't strong enough for it.

(35:28): A MUSE pellet is another option but it has some drawbacks. Next option is MUSE. This is a tiny little pellet, about smaller than a grain of rice that you urinate first. You slip this little device into the urethra, which is where your urine comes out and you deposit that pellet. Then you wrap your hand around the head of the penis and hold it there and it's in a wax matrix so it melts. What this does is it's going to increase the blood flow down to the penis and produce a good erection.

(35:57): I always tell patients they have to have it done first time in the clinic because one of the side effects that can be pretty severe is super low hypotension to the point where they can't even sit up or they're just going to pass out. So, I always make sure that they do it here. It doesn't work 100% of the time, somewhere between 30 and 40% of the men. It is expensive. The way that we're going in healthcare nowadays, most insurance companies are not covering the cost of these. So, if you look at a $50 treatment option that's not going to work, you may not want to waste your money on it.

(36:36): Penile injections can be quite an effective treatments for erectile dysfunction. Then we have penile injections and the comment I get with this, you're going to do what and where? Come on,  Come on. So, your penis has two corporal bodies that connect. So, we will place an injection into the side of the penis, not on the top, not on the bottom. We deliver this medication that produces a phenomenal erection and we try to calculate a dose that's going to allow you to have intercourse for the length of time that you want, 5 minutes, 40 minutes, whatever. What's super nice about this is that the partner really feels like she is part of producing this erection. Why? Injection's given, this erection develops over 10 minutes. How long does it take a woman to reach her orgasmic level? Thirteen minutes. The odds are coming together. It's a good thing and you don't need to have a ring around the base of the penis.

(37:33): So, what are some of the cons? Biggest con is getting over that initial I am going to put a needle where. All right, I tell patients, "Do you get the flu shots?" I got some head shaking going on over here. All right. You have a flu shot. How painful is that flu shot? Not bad. Most of you must agree with that. It doesn't really hurt that much and it's a quick sting and then it's over. Same thing with this, same nerves, same needle, same amount of pain. The plus though is that we're going to give you an erection that is going to allow you to have sexual intercourse and be comfortable with it.

(38:16): Medications for erectile dysfunction may also be considered. There are a couple of different medications that are used. I know here in Jeff's talk, he talked about them being expensive. That is the injection that is prostaglandin and that can be pretty expensive. In my facility, we use a lot of the Trimix, which is a combination of three different medications and that ends up being a lot less expensive.

(38:40): A surgical penile implant is a more drastic solution for erectile dysfunction and is permanent. So, our last treatment is surgery, and this is a penile implant. So, we have the two rods in the penis. We have a pump down in the scrotum and we have a reservoir placed in your abdomen. All of this is done without scarring that you're going to see. Okay, so it's done down in this scrotal area. Sometimes there'll be a small abdominal incision, but what this does is this allows you to have intercourse whenever you want and for however long you want. However, it's permanent. So, once we do this, there's no going back.

(39:17): I tell people it's like taking a loaf of fresh bread. If you have a loaf of fresh bread and you sit on it, when you get off of that loaf of bread, it's not going to pop back up. So, when we're putting the implant in, what we're doing is we're pushing your normal tissue off to the side and we're filling that space. So, if we would take it out, it's not going to go back to its normal. It's going to be scarred down. Some insurances do cover this, and this can end up being expensive too. This is about $25,000, but it does work well.

(39:55):  Premature ejaculation may be prevented by the “stop/start” or squeeze techniques. All right. So, ejaculation and orgasm problems. We can have premature ejaculation. That means that you have a hard time controlling your climax. Some techniques that we can use are distraction, changing your position, the stop/start, which basically your partner will say to you, "Okay, hold on a second, it's too close now." You'll actually stop and you'll wait a couple minutes.

(40:18): There is a squeeze technique where your partner will reach down and squeeze the penis and close off the ejaculatory duct in the urethra. Sometimes if you have a climax prior to sexual penetration, that will slow down that ability. But then we're taking into consideration what's that resolution period. If you have an orgasm and then you take four or five hours before you're ready again, that's probably not giving you a good system.

(40:49): Other treatments may desensitize sensation and prolong erection. You can use multiple condoms because that's going to decrease your sensation. There's a new spray out. It's called Promescent. You spray the gland of the penis and you spray the top part of the shaft. Again, it's like a numbing sensation, so it cuts down on the sensation and allows you to maintain that erection a little bit longer.

(41:10): You can use creams. There are medications that we use, antidepressants like Elavil in low doses. There are some patients who will be on a low dose every day, and there are some patients that just need to take it two or three hours before the expected event.

(41:30): Summary of presentation.  So, final slide. What are my key points?

Sexual dysfunction is common in men after transplant. It's also common in men who haven't had a transplant. So, you're not isolated, you're not in that little group.

Any man that has a lot of co-morbid conditions also is going to have problems.

Men over the age of 50 have a higher level of problems with erections.

(41:57): We need to understand that there are treatment options. Sexual and intimacy issues can be addressed successfully, going back to the idea that everyone doesn't have to have the firm erection to have sexual and intimate relations.

(42:13): Communication with your partner is crucial for enjoyable sex and intimacy. Communication can be critical. We got to remember this person that you're having sex with, that's probably your best friend. Probably the person who knows you the best. Don't be afraid to talk about it. Choose the right moment though. Okay?

(42:30): So, it's possible to have enjoyable sex and intimacy after cancer treatments. If you can't do it without help, we'll be here to help you.

(42:43): This is a list of some of the resources that you can use and you can always talk to any of your healthcare providers too. Are there any questions? Anything I can answer for you? Yes.

Question and Answer Session

 (42:56): [Speaker 3]   Now, you stated about the testosterone. Do they not use that long-term anymore?

 (43:03): [Katherine Marchese] No, we do, but that list of conditions that I listed that you have to have, you have to have two or three of those in order to make it worthwhile.

 (43:11): [Speaker 3] So if he wants to father a child, do they stop the testosterone to do that?

 (43:16): [Katherine Marchese] We do.

 (43:16): [Speaker 3:] Okay. All right.

 (43:18): [Katherine Marchese] We'll get him off of that. We might put them on Clomid for a while and bring the counts back up and then take them off of that and see where we are.

(43:26): [Speaker 3] Okay, thank you.

 (43:30): [Katherine Marchese] Any other questions?

 (43:34): [Speaker 4] Okay, I have a question. Okay. Do we find that some of these medications like Viagra and Cialis are therapeutic and have some healing effect?

(43:53): [Katherine Marchese] Healing effects? So are you asking me does it cure erectile dysfunction?

(43:58): [Speaker 4] Improve. Is there anything like that?

 (44:01): [Katherine Marchese] So, one of the things that's interesting is they now have Cialis five milligram dose where you take every day. This is a great therapy for people who have a fairly large psychogenic because it takes that anxiety away. I will also say that I have anecdotal cases where patients started using oral agents, Viagra, Cialis, any of them. Their erections started improving on their own. Is it because that all of a sudden, once the penis is able to get stretched out, it broke up some of that scar tissue? We don't have any actual data that says long term, it will help, but we have anecdotal studies.

(44:46): The same thing with the penile injections and the vacuum device. I do a lot with radical prostatectomy patients with prostate cancer, and we have a penile rehabilitation program that we use very vigorously. Starting within two weeks after their surgery, we put them on oral agents every day and we put them on the vacuum device and we encourage them to have sex as often as we can, because we've found that the less damage that we allow to occur, talking about nerves, we want to do everything we can to prevent that tissue atrophy and to prevent that nerve damage. So, stimulation helps for that. I think there was in the back. Okay.

(45:38): [Speaker 5] I have a different problem than you described here. When I have an orgasm now, I don't really ejaculate. It's more of a feeling than a physical experience.

(45:50 ): [Katherine Marchese] So, you don't have the physical release of the fluid.

(45:53): [Speaker 5] Right, it drips out basically.

 (45:55): [Katherine Marchese] So, this is an area that is very disconcerting to men and a lot of men will actually avoid intercourse if they can't have an ejaculation. Sometimes it's the medications that you're on. There are certain meds, Flomax, Rapaflo, those type of medications to help you urinate better that have that problem. That's their side effect.

(46:17): [Speaker 5] That's what I suspect. Yeah, I'm on Tamsulosin because when I started having chemo, I had a lot of problem peeing. Okay.

 (46:24): [Katherine Marchese] So, what you can do is you can switch off of Tamsulosin and consider Rapaflo or one of the other meds. There's like four or five different medications that you can try switching to and that may make a difference.

(46:39): [Speaker 5] Okay, thank you.

(46:42): [Speaker 6] I started testosterone replacement about a year ago or a little more maybe. I think I heard you say that if I were to go off of it now or reduce the amount, my body won't at this point.

(46:54): [Katherine Marchese] Right, your body probably won't start producing it.

(46:59): [Speaker 6] Okay. I just want to speak to my experience in general, maybe see the other men in this room have had this experience, but I asked my Kaiser oncologist who was more of a generalist about what's going on with my libido. This was a year after two transplants and a year of maintenance therapy before I really noticed this, but he's like, "Well, ask your estro GP about that." So I asked my transplant doctor who's through Colorado Blood Cancer Institute and a very well respected oncologist.

(47:37): Right away, he told me, "Well, of course," but my frustration is nobody warns you. I don't know if other men in the room have had that frustration, but it just seems like and I know the medical community doesn't always look at the entire person, but nobody warns you that this is going to happen. Be careful because your T levels might start dropping.

(48:03): [Katherine Marchese] I think that that's one of the best things about venues similar to this, is that we need to get this out to the patients that are experienced. We need to share this more with bone marrow patients as well as the physicians who are treating these patients. Sometimes you get so focused on treating the current medical problem that the side conditions are not the key. Your oncologist was busy focusing on getting you healthy, helping you over this. That was something that's collateral damage, but it's things we can do something about.

(48:42):[Speaker 6] Okay, thank you.

(48:50): [Speaker 7] My husband has had chemotherapy and he has neuropathy pretty bad in his feet and ankles. The doctors were wondering if you had neuropathy in the penis also, because he's got absolutely no response whatsoever. This is almost three years past the date. Does that happen?

(49:12): [Katherine Marchese] It does. When you have neuropathy, you just think generally about the fact that neuropathy means that there's damage to the nerves. All right. It's not just going to choose one little nerve here. It's not going to choose one little nerve. You're going to have neuropathy affecting the entire system. So, yes, they can. Typically, you'll see that your ejaculation doesn't feel the same. They're not able to get the same rigidity. Even when they get a rigidity, they will talk about it not feeling the same. They don't have the same sensations.

(49:47): [Speaker 7] He has nothing. No sensation, nothing. Is there a chance that that'll come back?

(49:53): [Katherine Marchese] How far out is he?

(49:54): [Speaker 7] Three years. Almost three years.

(49:56): [Katherine Marchese] So in order to prepare for this talk, I did some reading on bone marrow transplant and side effects of ED and all of that. They do say that changes can occur after three years. So, there's a possibility. The thing is, is he doing anything now to achieve an erection?

(50:15:): [Speaker 7] No. Well, he just talked to his doctor and he's getting a pump next week.

(50:19): [Katherine Marchese] Okay. I think that, as I mentioned before, getting the skin and the tissue stretched out is going to actually increase some of the nerve endings and get the blood flow going. Hopefully, that will help.

(50:34): [Speaker 7] Okay. Thank you.

(50:48): [Speaker 8] One of my questions when I had a stem cell and a bone marrow transplant and after I had this transplant, maybe about a year and a half in, then all of a sudden, everything just started working again and it started working great. Then probably after about three or four months, then it started. It didn't work. Things still work, but they didn't work like it did before. So it's almost like that you're wondering, "Wow, what happened?" So what I'm trying to find out is this, what do I do now and is it best to see someone before you start rather than to try to do all of these remedies yourself?

(51:51): [Katherine Marchese] So there's not too many home remedies that work.

(51:55): [Speaker 8] I mean, not home remedies, but I'm saying, you see stuff on the TV. Is it better to talk to someone?

(52:04): [Katherine Marchese] I would definitely talk to a healthcare professional. I have a lot of patients that have spent so much money on TV commercials and pills that they purchased online because of a journal article or something and Men's Health or something like that. You need to sit down with a professional. We can do a simple test. We can actually evaluate your ability to get a firm erection using ultrasound and then injecting the penis with this medication. We can tell you if it's a blood flow problem or if it's a nerve problem.

(52:39): [Speaker 8] Okay. Then can I find out afterwards how do you go about doing that or what?

(52:46): [Katherine Marchese] Sure.

(52:47): [Speaker 8] Okay. Thank you.

(52:48): [Katherine Marches]: Closing. Yeah. Any other questions? Well, thank you for your attention today, and hopefully, we've answered some questions. Check with your urologist, your counselors, whoever you need to become sexually active to the best of your ability. Thank you.