Crooked Erections Occur in One in Six Men after Prostate Surgery

BY MARK SCHOLZ, MD

The American Urology Association meeting is the biggest meeting of urologists in the world.  The program is structured around the exposition of several thousand scientific presentations, preliminary reports called “abstracts.”  While reviewing this year’s abstracts, one in particular, written by Dr. John Mulhall from Memorial Sloan Kettering in New York, caught my eye.  Dr. Mulhall, as many of you know, is the world’s leading expert on male sexual dysfunction occurring after treatment for prostate cancer.  He has written several books on this topic and will be a featured speaker at the Prostate Cancer Research Institute’s patient education conference this September.

In Dr. Mulhall’s study, there were 276 men who underwent surgery for localized prostate cancer and were evaluated for the development of a crooked erection (Peyronie’s disease) within 3 years after undergoing the operation. The mean age of the men in the study was 56.  Dr. Mulhall found that 17.4% of the men developed a crooked erection an average of 12 months after surgery, a more than tripling of the risk of Peyronie’s disease compared to the rate in the general population rate which is only 5%.

As described in Wikipedia, “Peyronie’s disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis affecting an estimated 5% of men in the general population. Specifically, scar tissue forms a sheath of tissue surrounding the corpora cavernosa causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening. A variety of treatments have been used, but none have been especially effective.”

In his abstract, Dr. Mulhall stated that there has only been one previous report indicating that prostate surgery leads to an increased risk of Peyronie’s.  How is it possible that such a frequent and devastating development could have been overlooked by the urologic medical community for so long? Nerve-sparing radical prostatectomy has been performed in several million men over the last 30 years.

I can only think of two possible explanations.  One is that urologists simply don’t talk to their patients and they have been totally unaware of the frequent occurrence of Peyronie’s.  The other is that the urologists are indeed aware of this devastating side effect but have failed to report it. This would be consistent with the failure of urologists to report another shocking side effect—ejaculating urine—that Dr. Mulhall and a few other experts have reported occurring 20% of the time in men who have prostate surgery.  “Climacturia,” as Dr. Mulhall has termed this unfortunate side effect has also only recently come to medical attention.

If the surgical treatment of prostate cancer was the only way to improve longevity, dreadful side effects like these might be considered acceptable.  However, in this day and age, multiple other options such as radiation, seed implants, focal therapy and even simple monitoring with active surveillance, are all considered mainstream.  Even so, over 75,000 men continue to undergo radical prostatectomy every year.

Studies show that 80% of the time, when trying to decide on treatment, men ultimately decide to follow their doctor’s recommendation. That doctor, in the world of prostate cancer, is almost always a surgeon.  Urologists are the designated hitters who perform the random needle biopsies that lead to a diagnosis of prostate cancer. As a result, urologists are positioned as the ‘first physicians in line” to advise a newly-diagnosed patient when cancer is detected.  The urologist makes the initial phone call when a biopsy shows cancer and naturally assumes the primary role in guiding that man in the management of his cancer.