What is the prostate gland?

The prostate gland is part of the male reproductive system. It is located between the bladder and the rectum, deep in the pelvis. Women do not have a prostate gland. In men, the urethra (the tubular structure through which we urinate) passes through the prostate gland as it carries urine from the bladder toward the penis.

The prostate gland contributes to reproduction by producing some of the fluid in semen, the substance that is emitted from the penis during ejaculation. The purpose of this fluid is to provide nutrition and protection for the sperm and to facilitate movement of the sperm within the vagina after sexual intercourse. The prostate gland is not known to serve any other function besides its role in reproduction. It should be noted that the word "prostate" (pronounced PROS-tate) has only one "r". It is often mispronounced as "pros-trate".

Prostate cancer causes

It is not known exactly what causes prostate cancer, but there is strong evidence that testosterone, the primary male sex hormone, plays an important role. Men with higher testosterone levels appear to be at higher risk of developing prostate cancer. Evidence also exists that eating animal fat increases the risk of being diagnosed with prostate cancer.

Eating a diet low in red meat and other sources of animal fat may lower the risk of prostate cancer but this has not been proven. Men who are obese also appear to have an increased risk of developing and dying from prostate cancer, but it is not clear why. Genetic factors contribute to the development of prostate cancer and men with brothers, fathers, and/or sons with prostate cancer have an increased risk of being diagnosed with the disease themselves.

Who is at risk for prostate cancer?

Research has identified several risk factors for prostate cancer. The clearest risk factors are African ancestry and a family history of prostate cancer. An example is in the United States, black men are 60 percent more likely to be diagnosed with prostate cancer and more than twice as likely to die from the disease. About one in five black men will be diagnosed with prostate cancer and one in 20 will die from the disease.

In other words, about 5 percent of black men die of prostate cancer compared to less than 3 percent of white men. Similarly, a man with a brother or father with prostate cancer is twice as likely to be diagnosed with prostate cancer as a man with no close family history of the disease. The more close blood relative with prostate cancer, the higher a man's risk. This is particularly true if the relatives were diagnosed with prostate cancer before the age of 60.

These are the currently known or suspected risk factors for prostate cancer:

Known Prostate Risk Factors
. Blood relatives with prostate cancer (particularly a father or brother)
. African ancestry (African Americans and black Americans)

Prostate Risk Factors
. Diet high in animal fat, particularly from red meat and dairy products
. Obesity
. High levels of testosterone in the blood

What are the symptoms of prostate cancer?

Prostate cancer does not usually result in symptoms unless it behaves aggressively and spreads around the body. When prostate cancer is still limited to the prostate itself and is thus still potentially curable, it only rarely results in symptoms. Therefore, symptoms are not a reliable way to tell whether or not a man might have prostate cancer.

Nonetheless, the following is a list of prostate cancer symptoms that sometimes result from prostate cancer. It is important to remember that most men with these symptoms do NOT have prostate cancer. In other words, the symptoms below can be caused by prostate cancer but are usually caused by something else.

In particular, the symptoms of frequent urination, difficulty emptying the bladder, slow urine stream and difficulty postponing urination are common symptoms among men over the age of 60 and they usually result from a benign enlargement of the prostate and not from a cancer.

. Frequent urination with small amounts of urine coming out each episode
. Difficulty emptying the bladder
. Slow urine stream
. Difficulty delaying urination; in other words, the need to urinate is usually very urgent and comes on suddenly
. Blood in the semen or urine
. Pain in the pelvis
. Back pain or bone pain
. Unexplained weight loss

How is prostate cancer diagnosed?

Some prostate cancers are discovered as a result of a digital rectal examination, another test that aims to identify early prostate cancers in men without symptoms. The digital rectal examination, or DRE, consists of a health-care provider inserting a gloved finger into the rectum so that the provider can feel the surface of the prostate. If the prostate feels hard or has lumps that can be a sign of cancer and a biopsy is typically recommended. (The word "digital" here refers to the doctor's finger. The Latin word for finger is digitus.)

Other men may have prostate cancer discovered unexpectedly if they undergo a surgical procedure to remove part of the prostate. This type of procedure is performed if the prostate grows too big and compresses the urethra. The problem in this situation is that the prostate can block the flow of urine and make it very difficult to empty the bladder.

While most prostate cancers are discovered as a result of blood tests or a rectal examination in men who have no symptoms of prostate cancer, there are some men whose cancers are only discovered as a result of symptoms of the disease. When evaluating a man suspected of having prostate cancer, a doctor will perform an examination and order tests to help determine whether a cancer is present. Tests may include:

Physical Examination
The first step in evaluating a man suspected of having prostate cancer is to examine the prostate by performing a digital rectal examination. This allows the doctor to feel whether the prostate is hardened and whether or not there are lumps on the surface.
Blood tests - The blood is tested for prostate specific antigen, also known as PSA. If the PSA level is high, that can be a sign that prostate cancer is present. The PSA test is used to estimate how likely it is that a man has prostate cancer.

Ultrasound
This is a test that uses high-frequency sound waves that are transmitted through body tissues. The sound waves bounce off the tissue and return to the ultrasound probe and these returning sound waves (referred to as echoes) vary according to the type of tissue that the sound waves strike. The echoes are recorded and translated into video or photographic images that are displayed on a monitor. Ultrasound machines are not very useful for detecting prostate cancer. Rather, they are used to show the doctor exactly where the prostate is located so that when a biopsy is performed, the doctor can be sure that the biopsy needle is going into the correct location.

Biopsy
A biopsy is how the actual diagnosis of prostate cancer is made. The biopsy involves inserting a small medical instrument called an ultrasound probe into the rectum so that the doctor can see the prostate on an ultrasound machine (see preceding description of ultrasound). Six to 12 tiny pieces of tissue are then taken from the prostate by passing a needle through the wall of the rectum into the prostate. These pieces of tissue are then sent to a laboratory to be examined under a microscope. If prostate cancer is seen under the microscope, then the man has prostate cancer.

Computed tomography (CT or CAT) Scan
This is a special X-ray that uses a computer to create a series of images, or pictures, of the inside of the body. CT scans are not usually ordered in men with prostate cancer unless the cancer has already spread or if there is a high risk that the cancer may have spread or if the scans are needed to help plan treatment.

Bone Scan
A bone scan is a test in which a small amount of radioactive material is injected into the bloodstream. The injected material is formulated so that it goes to the bone. The material accumulates in areas of diseased or injured bone, such as at sites of fractures, infection and tumors. A sensor scans the person being tested after the radioactive material is injected and measures the amount of radioactivity in the bones. Because the injected material accumulates at sites where there is cancer in the bone, more radioactivity is present at these spots and the sensor detects these "hot spots". A bone scan thus allows the doctor to look for cancer growing in any of the bones in the body. Bone scans should only be ordered if the patient is known to have cancer that has spread outside the prostate, if the patient has a cancer with a high risk of having spread, or if the patient is having bone pain or other evidence of cancer in the bones.

If a prostate cancer is found

If a prostate cancer is found, the doctor needs to know the stage of the cancer. In other words, he or she needs to know how far the cancer has spread and how much it has grown. Fortunately, most prostate cancers have not spread at the time they are diagnosed and the cancer is confined within the prostate gland.

In order to predict how likely it is that a man's prostate cancer may have spread, the health-care provider usually looks at some combination of the following variables: how high the PSA was before the biopsy (the biopsy itself irritates the prostate so the PSA will be artificially elevated for a month or longer after the biopsy), what the prostate felt like on digital rectal examination before the biopsy, what the Gleason Score of the cancer is, and how much cancer was found by the biopsy.

In addition to considering how high the PSA is, some doctors also consider whether or not the PSA was rising over time and, if so, how quickly. Any of the following factors indicates a higher risk that the cancer has already spread: a high PSA, a high Gleason Score, or a cancer that can be felt to have grown outside the prostate on the digital rectal examination. In addition, men whose biopsies show a larger amount of cancer have a higher risk of having their cancers spread.

Most men have a very low risk of the cancer having spread and for these men, staging studies such as bone scans and CT scans are not recommended unless the CT scan is needed to assist with treatment planning. On the other hand, men with higher-risk disease who have an intermediate or high risk of having cancer detected on these tests are usually advised to undergo a bone scan and a CT scan of the abdomen and pelvis in order to determine whether metastases can be seen.

Unfortunately, even if the tests are normal, that is not a guarantee that the cancer has not spread. Sometimes metastases are too small to be found but grow larger later on.

Staging prostate cancer

In staging prostate cancer, the major distinction is between cancers that have spread versus those limited to the prostate. This distinguishes cancers that are likely to be curable from those that are most often incurable. There are, however, four stages of prostate cancer and these are subdivided further.

Stage I
Low-grade cancer is discovered unexpectedly as a result of a surgical procedure on the prostate. The cancer must constitute less than 5 percent of the tissue examined.

Stage II
Cancer is confined within the prostate and does not meet the criteria of stage I.

Stage III
The cancer extends outside the prostate into adjacent tissue or into the seminal vesicles but not into other organs.

Stage IV
Any of the following qualifies as stage IV:

. Invasion of the cancer from the prostate into adjacent organs such as the rectum, the bladder or the pelvic muscles
. Spread of the cancer to lymph nodes in the pelvis
. Spread of the cancer to distant sites in the body

In general, stages I, II and III are treated as potentially curable cancers, although the likelihood of cure is greater for stage I than for stage II and is greater for stage II than for stage III. In other words, the higher the stage, the less likely it is that the man will be cured of prostate cancer. Stage IV cancers are almost never cured if the cancer has spread to the bones or other distant sites, but stage IV patients whose cancer has spread only to lymph nodes in the pelvis can in some instances be cured with aggressive treatment, although the success rate is low.

Treatment for prostate cancer include:

Observation
Radiation Therapy
Hormonal Therapy
Chemotherapy
Laparoscopic Radical Prostatectomy
Open Radical Prostatectomy
Interstitial Brachytherapy (Seed Implantation)
Cryotherapy
Clinical Trials

Observation

Although observation is not a treatment for prostate cancer, some prostate cancers do not require treatment. For men with low-risk cancers, observation may be recommended as one option for management.

Radiation Therapy

Radiation therapy is a treatment for prostate cancer that uses radiation to kill cancer cells and it can be administered in one of two ways. One approach uses radiation that is generated by a machine outside the body and is then directed through the skin into the pelvis toward the prostate. This is called external beam radiation. Alternatively, radioactive seeds can be implanted into the prostate.

This treatment for prostate cancer is called brachytherapy. In addition to being used to try to cure prostate cancers that are confined to the prostate or pelvis, radiation therapy is also sometimes used to reduce pain from prostate cancer that has spread to the bones or other areas. Radiation is also often used in those rare cases when prostate cancer has spread to the brain because chemotherapy is not very effective in treating tumours in the brain.

Like surgery, radiation therapy to the prostate can result in erectile dysfunction and urinary incontinence. Radiation as a treatment for prostate cancer can also cause bleeding from the rectum and frequent or painful bowel movements.

Hormonal Therapy

Hormonal therapy comes in several different forms, but in general, the purpose of hormonal therapy is to prevent testosterone (the male sex hormone) from stimulating the cancer to grow. The oldest version of hormonal therapy involves lowering the amount of testosterone in the blood either by surgically removing the testicles or by administering medications that shut down the production of testosterone. Other forms of hormonal therapy interfere with the ability of testosterone to stimulate cancer growth.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy for prostate cancer is administered to the body directly into the bloodstream through a small, soft tube called an intravenous (or IV) line or catheter, which is inserted into a vein. Chemotherapy is called a systemic treatment because the drug enters the bloodstream; travels through the body, and can kill cancer cells wherever they may be (except the brain). Chemotherapy does not cure prostate cancer, but it can bring the disease under control for a period of time.

Laparoscopic Radical Prostatectomy

This minimally invasive procedure, pioneered at the GIH Clinics', removes the prostate gland and typically allows qualifying prostate cancer patients. Unlike a conventional prostatectomy, laparoscopic surgery requires only five buttonhole incisions. Through these incisions, a surgeon uses a laparoscope-a tiny camera-and surgical instruments to conduct the operation and remove the prostate.

Open Radical Prostatectomy

A surgical treatment for prostate cancer, the radical retropubic prostatectomy procedure removes the entire prostate with an incision in the lower abdomen. Since the prostate wraps around the urethra, once it is removed the surgeon must reconnect the bladder with the urethra.

Interstitial Brachytherapy (Seed Implantation)

Interstitial Brachytherapy is another form of radiation therapy. A radiation oncologist and urologist implant radioactive pellets or "seeds" into the prostate, and the pellets radiate the prostate and surrounding tissue over time. The GIH Clinic has pioneered the intensity-modulated radiotherapy (IMRT), which has shortened the duration of treatment by several weeks.

Cryotherapy

Four to eight small needle-shaped probes can be inserted into the prostate in order to freeze the gland to temperatures lethal to a prostate cancer. This minimally invasive, incision-free procedure is performed either as an outpatient or one-night hospital admission. Temperature monitoring probes allow GIH Clinic urologists to cure prostate cancer with minimal trauma and without radiation. Patients recover in a matter of days and usually experience minimal after effects.

The different types of treatment apply to the different stages and types of prostate cancer as follows:

. Stage I: Observation, or Surgery (removal of the prostate), or Radiation therapy
. Stage II: Observation, or Surgery, or Radiation therapy
. Stage III: Radiation therapy with or without hormonal therapy, or Surgery in select cases only
. Stage IV: Hormonal therapy, or Radiation therapy with hormonal therapy in select cases only

Clinical Trials

A clinical trial is a research program conducted with patients to evaluate a new medical treatment plan, drug or device. There are many clinical trials for prostate cancer because it is a common disease that kills many men.

Clinical trials of new treatments for prostate cancer are ongoing for men with all different stages of the disease except that there are few trials for men with stage I disease because such men rarely require treatment.

What is the prognosis for people with prostate cancer?

The prognosis for most people with prostate cancer is outstanding. For every 1,000 men diagnosed with prostate cancer, only two on average die of the disease within five years of their diagnosis.
However, the prognosis gets worse as the cancer spreads. Men with stage I disease thus have a much better prognosis than men with stage III disease, and most men with stage IV disease die from it.

Can prostate cancer be prevented?

Prostate cancer cannot generally be prevented. It is believed that men may be able to reduce their risk of prostate cancer by eating a diet that includes (1) a lot of vegetables and (2) very little red meat or other sources of animal fat. Vegetables that may help lower cancer risk include cooked tomatoes (as in tomato sauce) and cruciferous vegetables (such as broccoli, cauliflower, cabbage, kale and Brussels sprouts).

However, it has not been proven that men can alter their cancer risk by altering their diet. Research studies are trying to determine whether certain medications, vitamins or minerals can reduce the risk of prostate cancer, but the results of these studies are not yet available.

The Bottom Line

For a small number of patients, screening offers a chance to catch aggressive cancers before it's too late. Therefore, for some men, the PSA screening test can be a life saver. At the same time, PSA screening subjects thousands of men every year to needless biopsies and other medical procedures that carry the risk of bleeding and infection and cause unnecessary anxiety. Further, screening leads to treatment of a lot of cancers that aren't life threatening. In addition, the treatments can cause impotence and incontinence and seriously erode a man's quality of life.

The issues surrounding PSA testing are conflicting and confusing. Only after the outcomes of ongoing trials are published will the role of PSA testing be further clarified. Until such time, you and your doctor must work together to make an informed decision on PSA testing. You and your doctor will review the pros and cons of the PSA screening test, your own risk factors for prostate disease, and your comfort level regarding cancer risk versus worries about treatment side effects. If you do choose to have the PSA screening test, make sure you have it along with the digital rectal exam. Having both screening tests is the most likely way not to miss a cancer.

Surgery

Complete removal of the prostate is one of the most common treatments for prostate cancer. Today, most of the procedures are done in ways that attempt to spare the nerves controlling your bladder and erections. These nerve-sparing surgeries reduce, but do not eliminate, the risk of incontinence and impotence.

Risks:
Most men lose control of their ability to urinate after surgery, and the problem could last for months. While most men gradually improve, about 10 percent will leak urine after coughing or other stressors. One percent or less will have a more severe long-term problem that can be fixed by the placement of an artificial sphincter. Despite the reduced risk of impotence with nerve-sparing surgery, many men will lose some degree of sexual functioning. Estimates of the number of men with impotence are wide ranging - from 20 to 70 percent - with this range being complicated by the number of men with possible pre-existing sexual dysfunction and the reported stage of cancer.

Benefits:
Prostate cancer surgery often provides peace of mind because it removes the cancer. Men whose cancer has not spread beyond the prostate have a 90 percent chance of surviving and being cancer free 10 years after surgery.

Radiation Therapy

Radiation is about as effective as surgery to prevent cancer from spreading over a 10-year period. There are two types of radiation therapy - external beam radiation and brachytherapy.

External Beam Radiation:
This form of radiation therapy uses powerful x-rays to attack the cancer. Body scans and computer technology are used to pinpoint the exact location of the cancer to which the radiation beam is applied. Treatments take only about 15 minutes but are time-consuming in that you will likely need to go to the hospital daily for about two months of treatments.

External Beam Therapy Risks:
Urinary problems (burning and increased frequency) commonly occur during treatment (but there is less risk of permanent urinary problems compared with surgery). Diarrhoea, bleeding from the rectum, painful or difficult bowel movements, fatigue, and loss of appetite are other problems that are seen that tend to be temporary and subside over several months. Compared with surgery, the rate of impotence may rise to the same level as surgery after five years post treatment (about half of all patients report impotence).

External Beam Therapy Benefits:
The benefits of this focused-beam therapy are that it minimizes damage to nearby tissue and structures. Also, treatment is not painful and less debilitating compared with surgery. Beam therapy can be used to treat cancers that have spread into the pelvis and cannot be surgically removed and can help reduce pain and shrink tumours in advanced disease that can't be cured. Compared with surgery, incontinence is a less common occurrence. More research is needed to confirm the external beam radiation's potential benefit and place in prostate cancer therapy.

Brachytherapy: this form of radiation therapy, radioactive pellets - each the size of a grain of rice -- are implanted into the prostate. The number of pellets implanted (up to 200) depends on the size and location of the cancer. This therapy may work best in small- to medium-sized cancers and may not be a good option for men with larger tumours, more aggressive forms of prostate cancer, or cancer that has spread just outside the prostate. The implant procedure takes about 1 hour and is done on an outpatient basis. Although the pellets deliver a higher dose of radiation than the external beam procedure, the radiation travels only a few millimetres and therefore is unlikely to extend beyond the prostate.

Brachytherapy risks:
Even though radiation does not travel far with this form of therapy, because of the prostate's proximity to the urethra, brachytherapy may cause more urinary problems (and more severe problems) than external beam therapy. Some patients need a catheter at times to help them urinate while the radiation remains most active - usually about six months, although it may take up to a year for the radiation to be fully depleted. Also, despite a low risk, because pregnant women and small children are more susceptible to the effects of radiation, patients undergoing brachytherapy are advised to stay at least six feet away from these types of individuals for the first few months of therapy.

Brachytherapy benefits:
Compared with beam therapy, brachytherapy may be associated with fewer rectal symptoms and a lower incidence of impotence (only reported by 30 to 50 percent of brachytherapy patients versus 50 percent of beam-treated patients).

Overall/additional risks of radiation therapy:
Urinary problems (burning and increased frequency) and bowel problems (diarrhoea, bleeding from the rectum, painful or difficult bowel movements) are more common with radiation treatment compared with surgery. Incontinence is less common with radiation than with surgery. The urinary and bowel problems can last for months before gradually subsiding. Radiation therapy may cause impotence in up to 50 percent of patients.

Overall/additional benefits of radiation therapy:
Because there is no surgery or anaesthesia involved, radiation treatment is associated with a lower risk of death and other serious complications compared with surgery. Radiation therapy can be less painful and easier to recover from than surgery. Radiation therapy can be used to treat cancers that have spread into the pelvic cavity and can be used to help shrink tumours and reduce pain in advanced disease. Compared with surgery, there is less of a risk of permanent urinary problems; however, with certain types of radiation therapy, there is a higher risk of permanent bowel problems.

Watchful Waiting

Watchful waiting, now more commonly called "active surveillance," requires no treatment for a discovered prostate cancer until your doctor detects signs that the cancer is growing more aggressively. This option is reserved for patients who have a cancer that is confined to the prostate gland and have a cancer that is defined as low to medium in aggressiveness. It is most often offered as an option to older men who are in poor health because it avoids the risks and side effects of treatment. Most of these men will die of some other cause before the cancer would become a problem. Active surveillance can be an option for younger men who want to avoid the side effects of treatment or postpone it as long as possible. The debate on the risk associated with this approach in younger men is ongoing.

Risks:
There is a chance that the slow-growing cancer could suddenly speed up in growth and you could be caught with a cancer that spread beyond its original site or is no longer curable. Waiting until you are older for treatment is riskier, increases the chance of side effects, and lengthens the recovery period. Also, you have to be willing to return to your doctor's office more frequently for blood tests, rectal exams, and biopsies to check on your disease. Worry about having a cancer and knowing that it isn't being treated may become emotionally overwhelming.

Benefits:
The risk of impotence and incontinence associated with treatment is avoided. There is a good chance that you may never develop symptoms or require treatment. Even if the cancer grows, most prostate cancers grow very slowly. You may benefit from newer treatments that may be developed while your cancer is under surveillance. Research has shown that at least for the first eight years, the life expectancy of men who choose this option appears to be no different than those who choose to treat their cancer aggressively.

Hormone Therapy

Hormone therapies can't kill prostate cancer but can be given alone or in combination with other forms of treatment in the hopes of improving the quality of life or extending survival. Research on the value and effects of hormonal therapies is ongoing. The most common form of hormone therapy is drug therapy. Drugs such as leuprolide (Lupron, Eligard, Viadur) and goserelin (Zoladex) block the effect of testosterone, the male sex hormone. By blocking testosterone, the rate of growth of the cancer is slowed. Another class of drugs, the antiandrogens flutamide (Eulexin), bicalutamide (Casodex) and nilutamide (Nilandron), work by preventing your body - and thus the cancer cells -- from using testosterone.

Risks:
Hormone therapies are associated with many side effects including lowered libido, impotence, hot flashes, weight gain, breast tenderness and enlargement, loss of muscle and bone mass, nausea, diarrhoea, fatigue, and liver damage. While it's possible that hormones may delay death, they cannot prevent it. Eventually, advanced prostate cancer becomes resistant to hormone therapy and it no longer works.

Benefits:
Hormone therapy can shrink tumours, thus reducing your symptoms and pain and possibly extending your life.

New Treatments

Newer approaches to treating prostate cancer continue to emerge. Among the newer developments:

. Docetaxel (Taxotere), a drug previously approved to treat breast cancer, has now been approved to treat advanced prostate cancer. Studies are underway to determine if the drug is beneficial in earlier stages of the cancer and in combination with other treatment strategies.
. Cryosurgery (using liquid nitrogen to freeze and kill cancer cells) is being studied. While it seems to reduce urinary problems caused by surgery, it is associated with a high rate of impotence (as much as 80 percent).
. Minimally invasive laparoscopic surgery to remove the prostate is under development. Early research show this approach to cause less pain and result in shorter recovery times than traditional surgery, an equivalent amount of side effects, but possibly a higher risk of cancer recurrence.
. Vaccines - using the body's own immune system to kill off cancer cells - and angiogenesis inhibitors - drugs that work by cutting off the blood supply to cancer tumours in the hopes of starving them - are other areas of ongoing research.

This document presents an overview of possible treatments for prostate cancer. The details of different surgical approaches were not discussed nor were the different types of radiation therapies (for example, high-dose versus conventional beam radiation therapy and radioactive seed implants), and combinations of different treatment approaches. The field of knowledge regarding prostate cancer treatments is growing and changing all the time. Similar to breast cancer in women, the results of new studies can be confusing and even conflicting with the "current standard of care," raising even more questions. It is wise to seek out hospitals and doctors who have a lot of experience with prostate cancer care. In addition, do your own research and bring your questions and concerns to your doctors. Together, you can make the best, well-informed decision for your personal situation.

Drug Therapy

Three oral drugs have been used in patients who have had radical prostatectomy for prostate cancer. These three drugs are Viagra, Levitra, and Cialis. While success rates with these drugs have varied, patients who have achieved the most benefit are those who have had bilateral nerve-sparing radical prostatectomy. Up to 70 percent of these patients may respond to one or more of these three drugs (response to each individual drug may from person to person). Success is less likely in patients who have had only a single nerve spared, and is very unlikely in patients who have had no nerves spared during surgery. Success rates with oral therapy are also higher in younger patients and are probably better in patients who do not have other risk factors for erectile dysfunction, such as cigarette smoking, hypertension, high cholesterol, and coronary artery disease.

When oral medications are unsuccessful, the following devices and alternative medication delivery routes are other options.

Vacuum Constriction Devices

Vacuum constriction devices consist of an acrylic cylinder that is placed over the penis. A lubricant is used to create a good seal between the body and the cylinder and a pump mechanism is used to create a vacuum inside the cylinder, which allows a patient to achieve an adequate erection. If an adequate erection is achieved, a band or ring is then placed over the base of the penis (the part of the penis closest to the body), which is used to help maintain the erection. Although some men find these devices helpful for achieving intercourse, many men find the band at the base to be uncomfortable or find the device to be somewhat cumbersome. These detractions tend to limit the number of men who choose this therapy following radical prostatectomy.

Intracevernous or penile injections

Penile injections are probably the most widely used non-surgical method when oral therapy fails to produce an adequate response and, in particular, are the most widely used medical treatment option amongst patients who have had a radical prostatectomy. This method will work in patients regardless of their nerve-sparing status. Penile injections are successful in approximately 80 percent of patients who try it. The patients do need to inject each time they want to have sex and the drug is injected directly into the erection tissue. With proper technique, the injections themselves are not painful. However, after radical prostatectomy, the most commonly used medication for injection, alprostadil, results in an erection that is painful in a significant number of men. Complications of injection therapy include a prolonged erection (which would require injecting additional medication into the penis to make it flaccid or soft again) and the possibility of scar tissue (which could result in curvature of the penis). Drug-induced prolonged erections are rare, fortunately. Scar tissue development seems to be related to both the frequency of injections and duration of use of this therapy. Although this is a successful therapy, there is a significant dropout rate over time.

Intraurethral therapy

This therapy involves using an applicator to place a suppository or pellet into the urethra (or tube that carries the urine). The small applicator is placed into the tip of the urethra through the opening at the end of the penis. The insertion is usually not uncomfortable. The medication contained in the pellet is the same as that used in penile injection therapies but contains 50 to 100 times more medication. This is because the medication has to be absorbed by the urethra and travel into the erection chamber.

While this medication can, at times, produce an adequate erection, in most men, the erection produced is generally felt to be unsatisfactory. In addition, the higher amount of medication that needs to be inserted and absorbed causes considerable discomfort in many men, particularly after radical prostatectomy. This alternative, therefore, is not an attractive option for most men who are post-prostatectomy. Sometimes intraurethral therapy is combined with oral medication when either one of these therapies fails as single therapy. However, relatively few men respond to this combination, and the combination is quite expensive.

Penile implants or prostheses

Clinical studies have demonstrated a high degree of patient satisfaction with penile prostheses. Patients who have had bilateral or unilateral nerve-sparing surgery are usually counselled to wait a year to see how their recovery progresses. Sometimes the degree of recovery combined with a non-surgical alternative can achieve a satisfactory response and reduce the need or desire for surgery.

Patients in whom non-surgical therapies fail or who find other options unacceptable, even if they do get a response, may be candidates for a penile prosthesis. Problems that can occur with prosthetic devices include infections (in which case the device needs to be removed and a new one inserted) or device malfunction (which also results in the need to remove the device and consider inserting a new device).