“They say it is better to be poor and happy than rich and miserable, but how about a compromise like moderately rich and just moody?” – A proposal from the late Princess Diana, trying to strike a fine balance for a win-win situation in life. We all know what happened to the Windsor household when “compromise” is simply not an option when it comes to marriage.

Like many relationships, the win-win situation may just be a Utopia that is simply unattainable in medicine. Every intervention offers benefits and drawbacks. The assessment of the pros and cons is crucial prior to deciding medical choices. Many patients are faced with limited options when accepting therapy, despite the risks outweighing the benefits.

With that in mind, lets look into the dilemma faced by one of the readers who is affected by the side effects of medical therapy, but increasingly cornered to face the inevitability.

Dear Dr G,

I am 52 years old and have a young wife who is 36. We have been married for two years. This is my second marriage. My wife and I enjoy our intimacy tremendously, and this is a very important bond in our relationship.

In the last 12 months, I have been facing problems due to enlarged prostate and this is putting a dent in our sexual relationship.

Since I turned 50 years old, my prostate had become enlarged and I started to have problems such as nighttime urination and urgency.

The urination is also getting difficult to start and the ending is dribbling. I have also faced the problems with erectile dysfunction, but this is resolved with the blue pills.

I have been to the urologists, who said the condition is due to the enlarged prostate, which is non-cancerous. He initially prescribed a medicine that improved the flow, however, this resulted in the drying up of semen with endless frustrations.

The doctor then changed my medications to another one that is supposed to shrink the prostate. This side-effect of decreasing my libido and worsening erectile dysfunction is making it worse than before.

According to the specialist, my prostate symptoms are quite serious and I have to consider the eventuality of an operation. I gather this will also have a permanent irreversible damage to my sex life.

I really hope you can tell me what he said is not true. Surely, in the 21st century of advance medicine, there will be a middle ground when the prostate can be treated and yet the sex life of a man be preserved.

I want my prostate symptoms treated and yet I am not ready to compromise on my sex life. Can you help?

Regards

Husni

Prostate enlargement is a fact of life in most men with advancing age. Recent studies highlighted the correlations between enlarged prostate and worsening sexual functions in men in their 50s and 60s.

It is noted that 30% of men facing Benign Prostatic Hyperplasia (BPH) will encounter compromised sexual function, and around one third of men suffering erectile dysfunction (ED) have concomitant troubling symptoms related to prostate.

Sadly, this is a “chicken and egg” situation, which the causality dilemma will never be resolved. For men facing lower urinary tract symptoms of frequency, urgency, slow flow and dribbling, the first line treatment is a group of medicine called alpha-blockers.

The function of this medicine is to relax the prostate in order to ease the flow of urine.

Most men will experience the relief of the urinary symptoms. Some may even experience improvement in blood pressure. One of the complaints encountered by sufferers is retrograde ejaculation. This is caused by the easing of the prostatic sphincter resulting in the semen going backwards. Yes, going backwards!

Retrograde ejaculation is completely harmless. (Well, the backward drainage of the sperms into the bladder is definitely not going to self-impregnate the men!).  Although such inconvenience may sound trivial to some, the “dry orgasm” may be a grievance to sufferers to quit the medicine.

Another class of drugs for the treatment of BPH is 5 Alpha Reductase Inhibitor. The mechanism of such therapy is the reduction of the active component of testosterone which plays a role to shrink the prostate.

Needless to say, the active component of the prostate also plays a crucial role in generating libido and sustaining erectile rigidity. Therefore, it is not uncommon for men to experience flagging sexual desire and compromised erectile after the initiation of treatment.

Recent scientific research had pointed out that medicines such as the blue pills (PDE5-I) will also have a relaxing effect on the prostate.

Therefore, the long acting subgroup of this medicine is licensed to the treatment of BPH. Many of the medical intervention have temporary effects on men, and with advancing age, the looming surgery may be inevitable!

The operation to correct the obstructive prostate can either be carried out with electric loop (TURP) or laser. The technique is simply coring out a cavity to allow better flow of urine with minimal resistance.

The adverse effect of the operation such as retrograde ejaculation is both undeniable and unavoidable. But the degree of compromise on erectile rigidity is still unclear and hotly debated.

“You can’t have your cake and eat it too” is a popular English figure of speech. I guess once the cake is eaten, it is gone. Sometimes, in life’s choices, we really cannot “have it both ways” or  the “best of both worlds”.

In the treatment for enlarged prostate, it is rarely possible to achieve maximum efficacy of treatment without compromised libido, erectile function or backward shoot of the semen.

Aung San Suu Kyi once said: “If you want to bring an end to long standing conflict, you have to be prepared to compromise.” So Husni, which of the sexual dysfunction are you ready to give up for the treatment of your prostate?

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