DR MAGRINAT: I love my urologist — I think he is fantastic; however, maybe he thought that I already knew all I needed to know. He made a couple of comments, but it took me a while to figure out that if I had no seminal vesicles, nothing was going to come out — I was going to have one of these blanks.

The next thing that happens is that you have these little periurethral glands, which do produce some semen. I didn’t understand what was going to happen to me. I think patients have a lot of very specific questions they want answered. For example, they need to know that they can have an orgasm, even if they don’t ejaculate, and that it’s going to be dry, but it may not be dry all the time.

DR ROBERTS: One of the areas that needs to be discussed more thoroughly — I can say this from my own personal experience — is the difference between erectile dysfunction and being castrate.

Tremendous emphasis is placed on the importance of erectile dysfunction, and I think that’s an extremely small part of the side effects of hormonal therapy. We need to discuss what it’s like to be castrate, so our patients have a better understanding of what their life is going to be like.

DR LOVE: What about the dynamics between the patient and spouse: intimacy, touching? Are these the kind of things that we should be discussing with patients? What happens to couples during this period of time?

DR SHUMAN: Although it may not be practical, I think these issues should be discussed with the patient and their significant other before treatment. It becomes more difficult to discuss after treatment when patients are recovering from the surgery or radiation.

Another issue is libido. For men who are chemically castrate for the longterm (more than three months), that’s a huge issue. It becomes even more complicated when you are talking about men in their fifties.

We need to articulate these problems and study how best to address them. I suspect that for most men around the table here, who have been treated — and I was treated 11 years ago — those kinds of discussions were secondary and tertiary in their encounters with their physicians.

RICHARD: Getting back to the twin fears of incontinence and sexual dysfunction, especially for younger patients — in my own case, just shy of 60 — I think some men are avoiding care. Once you have gone through this, you discover who else has the problem. They talk to you, or you hear about them. I know of at least two colleagues with gradually rising PSAs who are avoiding care because they’re afraid of losing sexual function and becoming incontinent.

Many of us have to face the fact that we haven’t been well educated. We’re not knowledgeable in the way we need to be. We didn’t get good sex education in medical school. That probably has been corrected to some extent in the 1980s and 1990s.

You discover the difference between Cialis® (tadalafil), Levitra® (vardenafil hydrochloride) and Viagra® (sildenafil citrate). If patients who haven’t been diagnosed were educated about the disease, we’d see a lot of people coming out of the woodwork for treatment.

DR LANGE: This is a changing scene. Urologists are seeing more and more patients on Viagra, etcetera, not because they have to have it, but because it makes it better. Is that a patient who should undergo sexual nerve-sparing or not? It’s causing havoc with our databases, in terms of trying to figure out what to tell the patient about what to expect.

The other observation I’d like to make is what I call renegotiating the contract. How many of us have seen couples where the man is on Viagra, and the woman says, “Whatever.” These couples first struggle with whether they’re going to regain their potency, then with all the three Viagra-like drugs, then injections, vacuum devices and maybe penile prostheses.

Very often they just say, “Well, heck. We have the grandchildren. What are we doing?” It’s often initiated by the wife, but female sexual dysfunction is another whole category. Preoperative education and postoperative early intervention, before they get exhausted, have not been emphasized enough.

DR DEETHS: Another important issue is incontinence. We’ve made a significant effort to train our nurses to talk to spouses and patients about the various diapers and products that are available on the market, which most men — myself included up to that time — have no idea about.

You’ve got people who come into the office and promote stuff, but many items are available on the market and patients need to be educated about them. Since I experienced the problem firsthand, we’ve trained our office staff to help patients understand what’s available and where to get it.

DR MOUL: I think clinicians probably need to do a better job with education. A lot of resources are available, such as the National Association for Continence (www.nafc.org, 1-800-Bladder). They have an excellent resource guide that lists all the different products that are available.