Education After Prostate Cancer

Introduction and Guest Credentials 0:00

Everyone, welcome once again to the Prostate Cancer Summit. I'm your host, Doctor Geo Espinosa. And it is my pleasure to introduce to you my friend and colleague, Doctor Rena Malik, who's a board certified urologist with a talent for dispelling medical misinformation, discussing intimate topics and educating the general public. With over 300 million views and 2 million subscribers, her YouTube channel, Rena Malik, MD, has become a go to destination for frank and evidence based discussions of taboo topics.

Men's health magazine named her as one of the top ten influencers in 2023. Doctor Malik is regularly featured at media outlets including insider, Mental Health, self, Scientific American, bustle, U.S. News, and World Report, and has been a guest on multiple podcasts, including the popular diary of a CEO, Huber and Huberman Lab, of course, and Mel Robbins Podcast. Doctor Rena Malik specializes in sexual medicine and female pelvic medicine and reconstructive surgery. Her practice, Rena Malik, M.D., offers M.D.

focused I'm sorry offers patient focused individualized care in bladder health and sexual dysfunction, hormone management and and the compassionate management of non narcotic pelvic pain. She is located in Beverly Hills in Irvine, California, but sees patients in multiple states California, Florida, Illinois. Lastly, Doctor Rena malik's extraordinary contribution to the realm of urology has earned her the distinguished title of 2023 American Urological Association Young Urologist of the year. With a prolific profile portfolio boasting over 80 reviewed publications.

She continues to contribute to the advancement of innovation in the field of urology. She's an online content editor of the Journal of Urology and Urology Practice journals. You know, Rena, I'm reading this and I'm saying, and I know you have to go to a game with your son. I was like, how does she do it? How does she do it? Thank you so much for being on the on this summit. I think, your input and your expertise will be so valuable for our viewers. I'm happy to be here. And thank you for having me.

It's important. I love the work you do. And everyone just follow Rena Malik everywhere, I think. Where are you? Not I know you're on Twitter, you're on Instagram, you're on YouTube. You're like me and everywhere. I'm not, I'm not on Twitch. I'm not on Twitch, not on Twitter. Yeah. You got to follow her. Her information. And that's one who follows her everywhere is science based and is, it's attractive, it's informative, it's valuable.

Why Sexual Health Matters in Prostate Cancer 3:08

So, please, everyone watching, follow Rena Malik. And maybe you'll, we'll have your Twitter handle and all your handles everywhere. For this summit. Rena, you know, we've had several experts on this summit for, you know, what happens after prostate. I had a patient today. I had two patients today, actually post while one is trying to both actually in this case, they trying to figure out, what's the best prostate cancer treatment for me because I'm very interested in keeping my sexual health. And, it used to be I remember when I first started doing urology over 20 years ago, I was like, don't worry about that.

Worry about, you know, you worry about that later. Don't worry about sexual health, worry about cure and not having prostate cancer. You know, I think that is important for all of us, any health care practitioner, to, to understand and empathize with the patients and kind of listen to what, what matters to them. And I think to overlook sexual health and quality of life is not the right way to go. So what are your views on that? What's your experience on that? And what do you tell your patients? Yeah, I think, you know, first of all, the prostate cancer discussion is very nuanced and it's very specific to your grade, to your desires and goals.

So if sexual function is important to you, you need to bring that up to your doctor. And, you know, I think the beauty of prostate cancer is that it's slow growing. So for the majority of people, you can take your time and get a variety of inputs. You can talk to a radiation doctor, you can talk to a urologist, you can speak to someone maybe doing trial or doing high fu or sort of more, gland, specific things that might preserve sexual function a bit better. And so I think getting taking that time to really get input from all these different doctors, taking into consideration your specific presentation, because prostate cancer can be very slow growing, very benign.

It can be managed with active surveillance even, or it can be very aggressive. And, you know, in those cases sometimes, yes, sometimes we have to say like, look, it's either we do something which could potentially cause erectile dysfunction or you're going to die from your cancer. But that's not always the case. Right. And I think it's really important to realize that that like it's not a diagnosis that you're doomed. Right? It doesn't mean, oh, I have prostate cancer. I'm never going to have an erection again. Oh, I have prostate cancer.

You know, I have to have surgery or I have to have radiation. I'm no longer going to have an erection. I think there's nuance there. I think that's why it's really important to be at summits like this, where you can get information from experts and, you know, follow people like us on podcast, on social media so that you can learn from the experts. And then you go in with questions or educated. So, you know, like, what is your rate of erectile dysfunction after prostate cancer? What do you do for your patients after you get treated for prostate cancer?

What sort of pathways do you have? You have a doctor who specializes in sexual medicine on your faculty or in your group. That's going to help me through this process because there are certainly ways that we can preserve sexual function, maintain it, do the best we can in getting you erections after you've had surgery or radiation or whatever. For prostate cancer. But sometimes it requires a proactive approach. And so I think really the key is take your time, be informed, ask questions. I mean, I wouldn't say have been off for two years, but like take a few months and really figure out what you want to do and make a decision and stick with it.

And then, you know, as things evolve, just realize, like, things change, things happen. But ultimately, you know, make sure you feel like you're making the best decision for you because the last thing you want to do is rush into something because you're scared of the C-word, and then you are looking back and saying, man, I didn't know life was going to be like this. And, you know, unfortunately, we do hear that, right? Unfortunately, we hear it. We hear where people are like, I wish I hadn't done that.

I wish I had taken a different approach, and who knows if that different approach would have led them to a different outcome. But ultimately they'll never know, right? So I think don't rush into it. Take your time. Get get expert opinion. I love it. Hey, your mic is rubbing up against something. I don't know where your mic is, so maybe you're. Oh, perfect. Perfect. Thank you. Thank you for that. Look, I had a patient today. He. You're going to you're going to. It's going to blow your mind. Two years ago, roughly.

Yeah. Two years ago, he was 40. He was 45. Diagnosed with Gleason, nine, prostate cancer. PSA 68, out of the capsule. Right. Seminal testicle involvement. He does some natural things that then some imaging,

Pre-Treatment Sexual Function Planning 7:54

not a scan or even an MRI indicated according to the reading, the, the, the, the reading from the MRI, that from the imaging that it reduced in size the, the tumor, remember some of the vessel involvement outside of the capsule. He chooses to do high food, right? Which I'm a I'm a fan, right? I'm a fan. But in this particular case, the cat is out of the box. It's not going to work. So he he chose to preserve his quality of life. But here we are a year later and his PSA 30 and, you know, still a problem.

And two things. Number one is he was misinformed. And you know, who's this physician that said, yeah, it's a good idea to do high school in this particular case. Right. Silly. All that to say that you want to try to, while quality of life, sexual sexuality important. Maybe you could do both. I am as a non surgeon. Right. I've never done surgery. I'm impressed with you guys. The urologist, the surgeons who they remove this prostate and within. You know, for most, you know, it takes time for an experience.

And there's a learning curve there. They are good are good to go. I mean they are within a short period of time they return back to their quality of life. Sexuality may take a little bit longer. One of the things, however, is that some of our colleagues talk about 90%, you know, erectile function after Sir Alec. Well, that's that's a little bit of a little bit of exaggeration. So I always say two pieces. Look, knock that down. Whatever they say by 20%. Look, everybody, I want to say that my lifestyle and natural approaches are 80% effective, right?

Is the natural bias, but I think it's very important for the audience to know that, even after a prostate removal, you can retain, particularly if you're good before or if you're if your sexuality is good before you can retain that sexuality. So about about the rates specifically when you look at trials and I think you're right. I mean, when I was trained, I was told 85% will maintain their erectile function after 18 months. In reality, when you look at the studies, it's about 40%, right. So 60% will go on to have it.

And that's when you're looking at men who had erections beforehand. If you had poor erections beforehand, that's even less like type. Two diabetes and all these other things. Right. So it's very specific. But I would say, no, it's not 90% if a surgeon is telling you that like they're not accurate. Right. And and you know, unless they're only doing really small cancers and they're doing nerve sparing every single time and they're doing perfect nerve sparing and like and that's not no no surgeons doing that.

You can't cherry pick who comes into your office. And so you got to treat everybody. And so you're not going to have a 90% success rate. That's just not realistic. So what's your process. Do you have a pre treatment process. So let's just keep it simple. And let's just kind of say you know people are still the majority of people with prostate cancer. They're still either getting surgery or radiation or radiation with hormonal deprivation therapy. We know there's focal treatment out there, but people are still doing primarily one of those two options.

Do you have a pre treat pre prostate cancer treatment protocol for men for their sexuality before they get their treatment. You know I think if you're having erections maintain them meaning continue to have erections. Like don't if you need to use a vag or sorry. So then Philadelphia continue using it. If you're not getting great erections prior to then I would probably intervene and say try something. So if you haven't tried medication, try that. Try injection therapy. Try a vacuum erection device, but get something to start getting you good blood flow to the penis.

Now if you're a healthy man, you will be getting nocturnal erections 3 to 5 a night, right? And so that's going to take care of it. You don't need to do anything extra, but if you're like on the borderline you're struggling. You're not getting nighttime erections.

Post-Treatment Rehab: Tadalafil and Vacuum Devices 11:50

I would encourage you to continue to get them so sometimes I'll put people on a daily dose of tadalafil five milligrams every day to sort of help increase blood flow to the penis. Now, if that's not helping them in some way, shape or form, then we move on to those other options. Excellent. So let's say now they had treatment and that this two year mark thing that people talk about, you know, to s a long time. A long time. I'm not sure about that. I think Doctor Mulhall started that. I believe that, you know, he wrote a paper or maybe I'll listen to him.

He said, well, up to two years. It takes, That's a long time. What? After treatment? Again? Not specific. Let's assume if they have surgery, they had at least one nerve spare. If not both. Right. Let's just make that assumption. What's your process to get them? Get them going again? Yeah. I think if they've had any nerve sparing I would start them on tadalafil daily. You know, the data sort of mixed on that, whether that's going to actually do like some sort of rehab or flotation but lots of blood flow.

Right. So the goal is to get blood flow to the penis. And we want to maintain your link. So the other big thing I think people don't talk about after prostate cancer surgery specifically. So you will reduce length. And if you don't maintain that over time, you can get fibrosis and scarring in the penile tissues. And then that can cause shrinkage even more. And so in terms of increasing length, you want to be getting erections to do that. So you can do that with medication. In vacuum erection devices have been shown to be effective in this case.

So using them for five minutes twice a day. So basically getting erections for a total of about five minutes twice a day, can help maintain length after having a prostatectomy. And so those are sort of my go tos. But if those aren't working very quickly, we'll move on to injection therapy because you know, we want again them to be getting erections as soon as possible. And in order to hopefully have them give some of that back, I think the other really important thing, and most cancer patients are sort of on this track, but really like optimizing your health.

And that's before or after. Right. And you talk about this a lot. But like you've got to make sure you're maintaining your body weight. You got to maintain your diet. So you're not eating ultra processed hyper palatable foods. You know, you're trying to get in enough, fruits and vegetables, healthy protein, like all those things are so important. And then getting good exercise. So at least 150 minutes of cardiovascular exercise. I know you've said like 300 before, which is great, but I think at a bare minimum 150 minutes at a bare minimum and had some resistance training, you've got to maintain your body.

And those things are also going to help blood flow. Right. So I think we don't talk about those enough. As urologists. We sort of we're like, we don't have enough time to talk about all that. But that is the pillar that is the foundation of health. So making sure that you're doing those things, your cholesterol is in check. And if it's not treating it, your blood pressure is in check. If it's not treating it, diabetes is in check. And if it's not treating it like all those things need to be optimized.

And so we can talk about all these other things. But those are the pillars. And you've got to do those first. You're preaching to the choir on it too. I mean, I think that, I think to try to skip is is not the best way to go and look, try and mix all these things five minute, first of all, five milligrams with tadalafil. That's all I say. Hours for those that those of you who don't know, it's it's almost like a supplement. I mean, I, I'm a fan. It kind of feeds the, I think is healthy for the, endothelial cells of the arteries.

And, and if you still have a prostate intact, it may have benefits there. I mean, people hear me talk, I love it, I love Bill, and they they. Are you selling out? You are your natural fat, aren't you? I was like, no, no, no, this thing, you know, 20mg now more side effects, right? The higher the dose at five milligrams it's great. And when you joke it, I always joke it should be in the water. I mean, there's data now there. It's it's cardiovascular protective. There's even data on muscular health.

And like there's a lot of Jim Burrows using it to help optimize gym performance. And you know, I think there's so much benefit to it. And the side effects are very it's very well tolerate the low dose. And so I'm like people are willing to take a supplement. They should be willing to take a low dose. And I agree I think it's similar in the way like it's just optimizing your health. I know. And they kind of freak out because always isn't that a drug is in a pharmaceutical that I, I've been in and you know, this I've been in in conventional settings for over 20 years.

Columbia now NYU. And I've learned more about conventional, the natural natural is what I do. But the conventional side I've learned more. And rather than initially, of course, I was like, well, no, this is bad. I don't know what is good. We all have problems in medicine. We know the problems. We know that there's overtreatment, we know that blah, blah, blah, what's good and long. Like, for example, I knew that fluoroquinolones were not great for microbiome. I'm talking 20 years ago, an Achilles Achilles tendon tear for people using it for prostate as an example.

Not a huge, huge fan of five alpha reductase inhibitors, for example. Never been I am a fan of things like, you know, like, tadalafil for example, for me. Right. So it's like what really works with minimal side effects tadalafil five milligrams, then and then and as best as I know, Bayer is not sponsoring this summit. No, no. And you can get it so cheap. And this is not sponsored either, but I love sharing this information.

Penile Length Preservation and Traction Therapy 17:28

Cost plus the drugs. Mark Cuban pharmacy you can get it shipped to your house for $12 for 90 pills. Go online. We have transparent pricing. And I just think it is amazing, right. Like people. Oh, it's too expensive. Like, no, no, no, you just haven't looked at this option like affordable. Supplements behind me are even more expensive than that. So you know that. Yeah. That's wonderful. Thank you for sharing that. What's the Mark Cuban's, pharmacy is is called what again? Cost, for government plus drugs.

But honestly, if you Google Mark Cuban pharmacy it's going to come up. Yeah. I think they're very good for sure. All right. So. Pino left. You mentioned that they lose their, their size. It's about two centimeters or so. That's not insignificant for a lot of men, if not physically. Psychologically, what's out there to keep their size decent or to what they had before treatment. What's out there? Yeah. So there's not a lot of trials in terms of penile length, right. Specifically length the one there are trials, as I mentioned earlier, on vacuum erection devices and the use of them in maintaining length.

So basically what a vacuum erection device is. It's a cylinder you put your penis in. It has a vacuum. That creates a negative pressure and it forces your body to have an erection if it pulls blood into the penis. So it makes it bigger. So essentially, you turn it on, you get an erection, and then you do it until it's, you know, very full, and then you turn it off and turn on again. And you do that for a total of five minutes so that you're kind of getting an erection. You don't want to be uncomfortable, but you don't want to, you know, you want to make sure you're getting a good firm erection and then you're done.

And you don't have to do it for 20, 30, 40 minutes. I mean, like, because we're trying to essentially mimic sexual activity, right? And the average time for a man to ejaculate is about 5 to 6 minutes worldwide. Now, some people are longer, some people are shorter, but you're doing five minutes twice a day. That's probably sufficient. And and that's what the trials really looked at. So I would say that is, you know, one really pretty cost effective way you can get these pumps online for, you know, pretty affordable $100 or so, up to 400, depending on what you're looking for.

But they are really a great option. Now, in terms of other things, there's no really great surgical options that I would recommend at this time, just given that there's no real high volume surgeons doing them. And so if I recommend you to do any surgery, you should always go to someone who's doing a lot of them. Right. And so, I would say that, yes, there are these things that I have been written about and may increase length, but they all have risks. And the risks can be pretty high, you know, like 70% for some of these surgeries.

So, in those terms, I really don't generally recommend surgeries for increasing length in terms of, other things, you know, there are traction devices. So there's also been a study on one of these traction devices, Restor X, which was actually founded by urologists. And, they've actually shown that using this device, they have a protocol on their website. Using it consistently after prostatectomy does cause an increase in penile length. So the two things I would say to you don't have to use that particular traction device. You can use any traction device.

But that one, you know, is the one that did the study. And so they did see an increase in penile link. So those are the two sort of minimally invasive. I mean they're not invasive at all really. But they are like something you have to do. You have to be consistent with, to sort of maintain penile length. And, and so let's just say so that tri mix does work. It works sometimes too. Well where, they develop, priapism. Which is, an erection that doesn't go down within a period of time. And then you have to go to the emergency room.

We've spoken about that a little bit in the summit with Doctor Dubin and a few others. Some people, once they get over the psychological fact that they have to inject their penis is like, oh, wow, this thing actually works. Anything you can add on as it relates to,

Injection Therapy and Penile Implants 21:38

the injections, the medications that are used, getting the right dosage. What's your experience with it? Yeah, I think that, in fact, there's been some surveys that have looked at using it, and a lot of times people are using it incorrectly, like they might not inject far enough because they're so scared, right, that they're like they're injecting just a little bit and they're not getting deep into the tissue enough. And, and so these little errors, because you're nervous can actually make it less likely to work.

And then you're like, oh, it's not working. Right. And I think with everything like, yes, this is going to give you an erection, but if you're anxious enough it will make it more difficult. So, you know, you got to sort of work on stress reduction and, and and it's really hard. Right. Like I'm not saying it's easy. Injecting your genitalia is not like something you think about. And are like, yeah, let's do it. You know, so I tell people like, look, I've had people where I will inject them in the office as a test of they'll look at me and have a good one, you know what I mean? Like, I didn't even I barely felt it. Right.

So I think it's really realizing, like, this is a tiny, tiny baby needle. You're injecting a medication that's going to give, give you an erection. And so just doing that and sort of allowing it to, you know, allowing it to work and like sometimes maybe it is like incorporating your partner in the discussion or it's really quick, you run the bathroom, we do it, you come back out. No one has to know. Or if you want to make it sort of part of your foreplay, you can but ultimately, I think really the thing is, like, if it doesn't work, just don't do another one the same day.

Wait at least 24 hours and you can go up a little bit on the dose, about five units. Now, you don't want to go, 5 or 10 years at the most. You don't want to be increasing your dose too much because that will lead to then priapism. But generally speaking it works in about 80% of people and there's so many doses. So I tell patients the first day I think we're going to start on this dose. This is the starting dose. Now there are multiple other doses and formulations we can try. So don't feel discouraged.

We can also do the injections with an oral medication or with a gel or with a vacuum or actual device. You can you can do multiple different things together to get the result you're looking for. And so don't give up. And it is very frustrating, is very exhausting. But at some point, if you are at the point where you've really I always tell people, try it at least try it, give it a good college, try. If you're at the point where you've tried and you're like, I just don't want to try anymore, that's a great time to talk to your doctor about a penile implant.

Because that may be a really good option. It takes that stress away from like, am I going to get an erection to, you know, I am going to get an erection. I have complete control of that, after the surgery. And so while it won't give you the same, you know, feeling as a natural erection in terms of, like, exactly the same, but you will still feel aroused, it will still get somewhat engorged. You will still be able to have orgasms. It will still feel good for you and your partner. So those are sort of like the way I think about it is try don't don't get defeated.

There's so many options of increases dosing, increasing the individual dose and the formulation. And then at some point, if it's really not working, you can either add other things or go on to an implant. So let's talk about implants. Look, I there again, you know, I certainly not one that I want to sign up for unless I absolutely, I absolutely needed or, you know, I'm in a situation where I have no other choice. But it is a surgical procedure. There again, the satisfactory rate seems pretty high to me.

So I've taken out all my biases there. I'm like, well, I see what I see. Guys are happy. Talk a little bit about that. And maybe you can expand on, what you do as it relates to. So let's say a guy has both urinary incontinence and sexual dysfunction. Do you kind of do both? I know that one of the companies kind of have equipment for both. Do you do that and your thoughts on that? Yes. So to answer your first question, success rates are quoted as above 90%. Now is that accurate? I don't know. Right.

Because you'll do a surgery. You'll see somebody a couple times, particularly after penile implant, and they're on their way. They may not come back to you if they have a dissatisfied result. Right. So I don't know how accurate, but I would say satisfaction rates are very, very high, right? If you're counseled correctly and you know what you're getting and you're happy with what you're getting and you've done your research and, I think people are very happy. I think the time when people are not happy is when their expectations are they're going to get a longer growth of your penis than they already have, and they don't get it.

And so, you know, there are limitations to what we can do with it. It's not going to make you longer. It's not going to make you growth here, but it will give you an erection when you want it. At any point in time. You can have erections. They can last as long as you want. Not a problem. So I think that is a really great thing, but I just think that, you know, a lot of times people oversell like it's this great, amazing, wonderful thing. It is it is a great, amazing, wonderful thing when you know what you're getting.

Right. In terms of the incontinence. So, the surgery that's most often offered is an artificial urinary sphincter, which is a surgery where we put a cuff around the tube or the urethra that is closed so that when you leak, it doesn't come out. And then when you need to pee, you push a little pump in the scrotum and it opens, and then you can pee and it prevents you from leaking. Now, I think the I think it's a great operation. It's transformative. My happiest patients are the ones who get near us, because when you're leaking and you go from leaking to not leaking, that is like life changing.

So I highly recommend it. There are other options like slings as well, for less, severe incontinence or mild incontinence, which also work quite well. And I would say these are great options. And I think that if you are, you know, if you've tried all the conservative things like Kegel exercises and you've waited a sufficient amount of time for healing to occur, which is usually at least a year to two to some 18 months,

Urinary Incontinence Surgery and Closing Remarks 27:28

then it's very reasonable to talk about getting one of these operations because we don't have any medications or things that are really going to stop that leakage unless the leakage is I got to go, got to go. Can't make it. That's a different type of leakage. But leakage that occurs after prostatectomy is most often I cough, I leak, I sneeze, I leak, I bend over, I leak, I walk, I leak. And so that is what that surgical operation is for. If you have, radiation then you may have some of that other type of leakage.

And so that's a different pathway. And there are medications available for that. But I think it's a great operation. I think of course everything has risks. And sometimes you're not 100% dry afterwards, but you're going to notice a significant difference after that operation. And so, I think it's something worth considering talking to your doctor about and getting a full discussion about the risks and benefits. All right. So is it possible to get a twofer? Yes. So some people yes, yes, it is possible to do both at the same time.

I generally don't like that because I think, I like to just make sure that especially with penile implants, that we're doing the fastest operation possible so that we're limiting infection risk. But there are many doctors who do both at the same time. And if that's your preference, I mean, it works fine. We've shown in the literature that it doesn't cause or increase infection risk. I think it's just my own bias that I do that I don't do them at the same time. But yes, you can do. It separately to two separate surgeries.

Yes, yes. That's amazing. I think that we cover a great deal, you know, not quite a masterclass but a nice overview of the full spectrum after prostate cancer treatment. Doctor Rena Malik, any final words and all your handles and where can people find you. Yes. Well I would say if you are struggling with prostate cancer, we are here for you. We care about you. We want you to have the best outcome possible. Please find, surgeon, urologist, radiation oncologist, whoever it is that you feel like gets you.

And that really understands what matters to you. And we will support you along the way with your issues with erections or the issue of leakage. If those happen, we are there for you. In terms of where you can find me, but my most my largest platform is YouTube. Rena Malik, MD. I make videos all the time, so check me out there. You can probably put my name in any topic in urology and you'll find the video about it. And if it's not there, make a comment in one of my videos that I'll probably make it at some point.

You can find me on any platform that you're on. Really. Rena Malik, M.D., anywhere. And, and if you want to get some more information, you can sign up for my newsletter, which is on my website, or see me as a patient. I see patients in Beverly Hills and Irvine, California, in person. And then virtually. I have licenses in eight states in the United States. Or I can see you for an educational visit where we just discuss a topic that you may have questions about, that you can then take back to your doctor.

Lovely doctor, Rena Malik. Thank you so much, Rena, for being on. Yep. Bye bye. Thank you everyone for watching this. Yet another amazing, nice and brief nice overview on well, you know, what happens after prostate cancer treatment from a from the perspective of sexual health. So thank you for coming on. Thank you for viewing. We have more coming so stay tuned. Much love. This is Doctor Geo Espinosa signing off.