Restorative Sexual Health

Restorative sexual health for men post prostate surgery

Restorative Sexual Health

The Penis Podcast Episode 15  |  Follow on Spotify | Follow on Apple iTunes

DR OATES: Hi everybody, it’s Dr Oates here from CALIBRE Clinic. No Gavin here today, but we do have Melissa Headley Barrett. She’s a registered nurse from the restorative sexual health centre and that’s why she’s going to be talking to us. She’s also co-host of her own podcast called the penis project and actually they’re up for an award with the Australian men’s health forum for best content. And it’s amazing, as far as I know there are two penis podcasts in the world that have penis in the title and they’re both based here in Perth, Australia. Both started last year in 2020. Melissa and the penis project have been very busy at producing lot of content and that’s why they’re up for their award so congratulations!

MELISSA: Thank you very much, I’m actually a sexologist and a nurse practitioner.

DR OATES: So tell us then, what’s a sexologist??

MELISSA: A Sexologist is someone who’s got a post graduate in sexology which I have and I did at Curtin University but I’m also a nurse practitioner. The difference between a registered nurse and nurse practitioner has a master’s degree in diagnose and can write scripts and do pharmacy. A registered nurse can’t diagnose or prescribe do tests, a nurse practitioner can do those things as well.

DR OATES: So is that further development from nursing and that’s something that’s sort of really been developing in the last decade or so hasn’t it?

MELISSA: I was the third nurse practitioner in Australia and I got registered in 2003. Nurse practitioner have been around for a very long time in America and England who have private practices everywhere but I was working as a remote area nurse practitioner until 2011 and then we got Medicare so now we can work in private practices now which is what I do.

DR OATES: Okay. And then you focused on sexology. What is sexology??

MELISSA: So sexology is the study of people’s intimate relationships really and most sexologists are usually psychologists first. So it’s all about mental health and psychology behind sexual relationships which I do also do but I think of myself as a clinical sexologist because I like to delve more into what the medical problem and how to fix it from a medical point of view.

DR OATES: So then do men come and see you when they’re having erectile dysfunction, etc.?

MELISSA: Yeah! A lot of the patients that I see are post prostate cancer. I do a lot of penile rehabilitation. Anyone with any sort of erectile dysfunction I teach injectables, I write prescriptions, and teach people how to use penis pumps for this purpose. I also see a lot of women for their menopausal symptoms such as vaginal atrophy. I also do couples counselling, premature ejaculation, porn addiction, pretty much anything that is a problem to do with a sex life.

DR OATES: Okay, there’s quite a range of things there. What percentage of your work is with erection problems then?

MELISSA: About 75%! That’s why I started the penis project with Jo Milios and I started The Penis Project. She’s a physio therapist with a PhD in men’s health. We work together really closely because with erectile dysfunction in particular, there’s a lot of things that are physio that can do to help and then I’ll do the medical side of it, so together we do a lot of men.

DR OATES: So, a lot of men with erectile dysfunction. Is that because it’s a common problem?

MELISSA: It’s a very common problem! 1 in 3 men over the age of 40 will suffer erectile dysfunction in their life. Over 20000 people a day Google “erectile dysfunction” just in Australia.

DR OATES: So if I had erectile dysfunction, I probably wouldn’t google it every day, so that must mean there’s a lot of different men over the year.

MELISSA: Sorry, I don’t mean that there’s men individually google it every day. Over everyday 20,000 different people in Australia google ‘erectile dysfunction’.

DR OATES: So it’s a lot of men and a lot of Googling. Well it’s funny, because the internet started up for men to be Googling porn and now they’re um.. No I’m sure that wasn’t why they invented the internet. And you said that a lot of the men that you see are concerned with prostate cancer surgery?

MELISSA: Yes, or radiation/chemo/testosterone lowering therapy all those treatments that are for prostate cancers have some effect at some stage of the treatment regime on erectile function or intimacy issues and so a lot of my clients I get from referrals from urologists.

DR OATES: Okay if I was a guy having problems from prostate cancer, and there are options open to me with either surgery or radiation, is there much of a difference in erectile function after successful treatment?

MELISSA: It’s just different in when it occurs. Men who have surgery will be impotent, so they’ll have erectile dysfunction most of the time (immediately post-surgery) and then quite often with the changes in surgery that it’ll get better over time. So things will improve with penile rehabilitation. Guys who have radiation usually don’t have immediate effects with their erectile problems but over time – things get worse. But there’s treatments in both of those instances, and people can be sexually functioning again, so erectile dysfunction is not a reason I think to choose your treatment. I think it’s about what the best type of treatment for your kind of cancer and just know that there’s help available and in both of those cases WE definitely deal with the problem and find a solution.

DR OATES: So if a man’s had surgery for their prostate cancer and it’s been successful and from my understanding it’s relatively successful as far as surgery and cure goes, so I wake up and I’m going to be impotent. Maybe the next day I’m not willing to jump right back into the saddle so to speak, so at some point when we’re ready to have sex gain, what am I going to do?

MELISSA: So ideally, someone like myself pre surgery, would talk to you about what your options are post, and if you had any erectile issues before, we would sort of put you on penis boot camp (I like to call it) where we help you get it exercising and use it more, since penis is made out of muscle and we need to get it exercising

DR OATES: People always say there’s no muscle in your penis?

MELISSA: Yes they do! They also say there’s no bone in your boner, but there’s actually muscle in there, just no bone.

DR OATES: I’m a doctor and I’m learning all this news

MELISSA: I’m sure you know that!

DR OATES: So there’s smooth muscle in your penis.

MELISSA: Yes. So when you’re a young guy, you’re getting 20-30 erections a week whilst just sleeping, that’s your body’s way of taking things to the gym. So it’s going up and down while you’re asleep, I always say that, for women it’s like you’re spooning and you’re getting poked in the back and it’s really annoying well that’s how you male partner’s keeping his penis healthy.

DR OATES: Okay. That’s just natural when you’re young, you wake up in the morning and he’s already awake before you. So when you’re getting older that’s sort of starting to reduce anyway, but post prostate surgery, that’s going to be gone all together. So we’re going to be able to exercise our penis before surgery. Okay, what are these penis exercises?

MELISSA: So pelvic floor exercises that you do with the physio, and also if they have really poor penile function beforehand and I put them on a medication, and the reason that would be is if they had some nerve function of their own, they’ll end up getting more nocturnal erections (which is like taking penis to the gym). So the way I always think of it, you go to the gym and you’re working out your biceps (lifting weights), so you’re exercising, the muscle pumps up when it’s exercised obviously. When you stop exercising you get muscle wasting and it would shrink again. That’s what happens when you’re not exercising regularly.

DR OATES: So that’s like the long lasting version of Viagra, which most men would’ve heard of.

MELISSA: That’s right. And it lasts in their system for about 36 hours, so we get people to take a small daily dose which pumps extra blood into the penis shaft, gets it having a little more exercise during the evening and then we continue people on that post surgery and also get them using a penis pump which is like lifting weights with your penis.

DR OATES: Okay, I’m going to come into the penis pump in just a sec, so with the pelvic floor exercises, isn’t that what women do to strengthen their pelvic floor to stop incontinence when they’re laughing or jogging, etc.?

MELISSA: So most men don’t even know they have a pelvic floor but we’re exactly the same down there and their pelvic floor muscles are very important because post prostate surgery, they actually assist with incontinence the same as it does with women after we’ve had babies, and they get a bit loose, we need to keep them tight and get them exercising again. But also they pump extra blood when you do your pelvic floor exercises into the muscles and tissue of the penis. So that is giving more oxygen and better blood flow to the penis to ensure in keeping it healthy. The other amazing thing about those is, the stronger your pelvic floor the more intense your orgasms are. So I think if they taught all teenagers that they’d have better orgasms if they have strong pelvic floors, then they’d probably be doing them a lot earlier in life.

DR OATES: Yeah. I don’t know if teenage boys need encouragement in getting more orgasms. So to really get a feel for how to do these exercises they come in and see someone like yourself who’s able to train in these exercises?

MELISSA: They need to see a physio who specialises in pelvic floor. I don’t teach pelvic floor, so someone like Jo Milios, there’s a lot of male speciality pelvic floor, pelvic health and all sorts of physio therapists that specialise in that area.

DR OATES: And is it a bit like when women kegeling?

MELISSA: Yes, exactly the same. The other way the guy can tell whether they’re doing their pelvic floors directly is if they’re standing in front of the mirror and they wave their penis at the mirror, they’re using the right muscles like that.

DR OATES: Guys often sort of bring that up with me when they say there’s no muscle in their penis but also “oh but I can make it move” and obviously that’s a muscle doing it. Waving your penis at the mirror is good pelvic floor exercise is good for erectile function and strengthen your orgasms. So how many time a day do I have to wave my penis in front of the mirror? Do you do sets of ten or something..?

MELISSA: I’d have to remember how Jo’s regime goes, it’s basically the quick and long acting pelvic floor exercises, she teaches them in a certain way when she uses an ultrasound and pops it on their bellies so they can see their pelvic floor moving, but I think to get the exact regime, you have to go to Prost for the exact regime and all the exercises.

DR OATES: I think we’ll get Jo to talk more about the exercise because I think with exercises and intense orgasms, I’m sure guys are going to be more interested in that. And then you also mentioned penis pumps like in the Mike Myers movie, Austin Powers??

MELISSA: I’ve got one here, do you want me to show you?

DR OATES: Okay! You show yours and I’ll show you mine! There’s something special about this but we’re not ready to tell everyone about it just yet. I’ll tell you why I have a penis pump in my office another day. So, what does a penis pump do?

MELISSA: So there’s a lot of dodgy websites out there telling you penis pumps will make your penis bigger, and that’s not true. So in the regime I teach, you pump it up, hold it for one minute erect in the tube and release. Do that 3 times in a row at least every second day (preferably daily) what that will do is you’ll get extra blood flow and stretch the smooth muscle in the penis and it’ll prevent any atrophy which is penile shrinkage, and keeps everything flowing.

DR OATES: So my understanding is that after prostrate surgery, if they don’t have an erection for however long it takes for that regrowth of the nerves, whether it’s sort of for that 1 or 2 years maybe. But when they get their erections back, then they’ll find that they’ll have lost length. And that’s because they haven’t been stretching out that’s smooth muscle maybe it’s that fibrous coat around the erectile tissue that’s sort of contracting down. So it’s a use it or lose it sort of thing.

MELISSA: Yeah! It’s the same with all of our body. It’s a common thing that I say is that God must be a man, because the penis and the clitoris are the only parts of the body that you don’t have to consciously have to exercise until something goes wrong.

DR OATES: And such as, somebody doing surgery and damaging your nerves.


DR OATES: So, they use the pump, stretch it out, use the medication and that prevents them from losing that length and hopefully at some period after surgery, it’s the nerves that are re-growing and reconnecting and they’ll be able to get their erections again

MELISSA: That’s right. Using a penis pump and then taking the Tadalafil I was talking about doesn’t make your nerves heal any quicker. What it does is it keeps the penis healthy while we’re waiting for the nerve to heal. They take up to 2 years, and I have seen peoples nerves getting better after that time but the most common time is between 12 and 24 months that it takes for them to heal. So what we need to do is keep the penis tissue healthy while we’re waiting for those to wake up. It doesn’t mean you have to wait two years to wait to have intercourse again, in that time, I’ll teach them how to use injectable therapies, or a pump with a cock ring so that they can have intercourse again.

DR OATES: Okay so with the injectable therapies, they inject the medication deep into that erectile tissue causing it to become engorged and then it stays for a period of time long enough so that they can have intercourse.

MELISSA: So anywhere between 45 minutes to an hour does the erection stay, guys love injectables. They hate the idea of it, but once they realise that there’s no pain (which no one ever believes me until they do the first one). There’s actually no pain receptors in the corpus cavernosum, which is where the injection goes, so you can feel it on the skin but nothing else. So it actually feels painful I’m told because I don’t have a penis. The feeling is similar to when diabetics put a needle in their finger to check their blood sugar level (which a lot more than the pain you feel in the penis!) The great thing about, erections goes down for most guys after they’ve had an orgasm but using injections, they don’t. So multi-orgasmic for the first time.

DR OATES: In fact I was told that the secret of porn stars, the reason they’re able to go on and on, is just movie editing and the orgasm that is shown way at the end has actually taken place right at the start. Then they’ve had the injection and then can just keep on going. So when you’ve seen someone in porn who’s had sex for hours at a time, it’s all fake. But you too can have that!

MELISSA: I see a lot of guys coming in thinking they have premature ejaculation and they actually don’t because they’ve watched porn and everyone’s got it up forever but really, anything under 2 minutes is considered premature ejaculation and the average time is actually 5 minutes.

DR OATES: You go on for 5 minutes you’re doing a good job!

MELISSA: You’re doing amazing! So it’s not uncommon. I think there’s just an unrealistic explanation out there.

DR OATES: Mkay. You also mentioned with the pump about using a cock ring, so that’s not just for kinky guys, what does that really do?

MELISSA: So the idea of the cock ring is that you would pump the penis up and the cock ring goes on the base and so it’s like an elastic band around the base of the penis and it holds the blood in there. The only negative about the cock ring is that they hinge at the base. Normally the penis goes hard at the bit that you can see and it’s like an iceberg all the way back inside your body. So when you put a cock ring on, you’re strangling it at the base. So you end up with a hinging point. It’s still very usable, the sensation is still the same, but you can’t leave a cock ring on longer than 30 minutes as you aren’t getting any fresh blood flow into the penis.

DR OATES: So will it be like a lambs tail and drop off?

MELISSA: Yes, exactly.

DR OATES: That’s not so good. So we’ve been talking about guys and how long they’re going to manage erection problem after prostate surgery and we’re hoping that sometime between 12 and 24 months, the function is going to come back. Do you have any sort of statistic on what percentage of guys have their erection function return?

MELISSA: So the research is that there are so many articles and the research varies between 30 and 70%, the research is also quite old (from when the research is done and when it comes out). There’s a 5 year latency period in that but definitely since I’ve been doing this work (about 5.5 years now), but now I’ve seen a dramatic improvement in guys getting their erections back so it used to be, I’ve never saw anyone before a year getting their erection back but now it’s not uncommon to see guys getting their erections back even at 6 -12 months and occasionally even earlier. Just because surgery has gotten so much better and also we do penile rehab and we’re actively helping people get things back again and keeping things healthy, so there is a big difference in the outcome now.

DR OATES: So potentially, if they’re doing that penile rehab even before they’ve had surgery and they start it soon as they can after surgery the potentially it’s leading to an early recovery of that erectile function.

MELISSA: That’s right.

DR OATES: What about robots doing prostate surgery?

MELISSA: They do and the fantastic thing about robots is that they are much less invasive. They have 6 little stab wounds on their belly and the robot arms go in and they have much smaller blades than a big scalpel blade. So, less damage with a robot. So the outcomes from a cancer perspective are the same, whether or not it’s open surgery or robotic surgery. But, the outcomes from the incontinence and erection point of view, I think they get these things back quicker there’s not much invasive things going on.

DR OATES: Okay, sounds like there’s some good things there on the surgical front, hopefully increasing early return or return of function but then there are still some guys who don’t get that spontaneous erection back again.

MELISSA: That’s right. There are and that’s definitely a risk and in that instance there’s no time limit to how long you can use injectables for or, what I find is most guys who’ve used injectables in the last couple of years go “it works well but it’s a little bit of a passion killer when I know I’m going to get lucky and get up and use it. So I might decide to go off and have a penile implant put in, which is amazing surgery that lasts for about 10 years (in comes with a little pump in your testicles and pump it when you want to use it). Guys often expect the contraption to be on the outside, to anyone listening, it’s completely contained inside the body, it can’t be seen at all and they work really well. I always encourage guys who are sexually active and don’t like this and of interruption to have to go up and draw up a needle to definitely go and speak to someone about penile implants.

DR OATES: So that’s a very simplistic, long sort of skinny balloon that’s inserted inside the penis sort of in that area where the erectile tissue is (the corpus cavernosum) and it’s got a tube that goes down into a reservoir in the testicle and they basically… so is it like a third testicle in there???

MELISSA: It’s really small, about 2 cms across in diameter and it’s a little circle. It’s just got like a valve on it, you pump it and the water goes from the reservoir into the two cylinders that go on each side inside the shaft of the penis, the water goes in and the penis goes up and after using it, you push the button and you release the water, back in and it and your penis goes back down.

DR OATES: So once you pump it, it’s up as long as you want it to be?

MELISSA: Yup, you can have it up as long as you want.

DR OATES: I can remember, a long time ago, there was also a flexi rod type ones as well. Are they still around?

MELISSA: Yeah, they’re called malleable implants. The main reason guys would choose those is because some men when they get a lot of penile atrophy or shrinkage, then it’s difficult to get their penis out in front. And then when they want to go to the toilet they can’t stand up to pass urine, so they have to sit down and those malleable ones, you can use them for intercourse but you they’re not as good as the pump up ones, but they’re fantastic for keeping the penis in front, outside the body so you can stand up to pass urine.

DR OATES: So you can be a shower instead of a grower?

MELISSA: Yeah. What about with a pump, ca you leave it a little pumped up?

MELISSA: With the pump ones, you do sort of end up with a very slight erection or a bit of a turgidity.

DR OATES: I guess that’s sort of a one way surgery, there’s no going back from that.

MESLISSA: I tell guys to wait 2 years post-surgery to see whether r not they’ve got some natural erection back, unless of course they’ve had non nerves bearing surgery. If the cancer has gone into the nerves, and the surgeon says “sorry mate, we couldn’t save any of them”. If you know there’s no hope then you may as well go straight for the implant I you’re thinking of it because you’re not going to get your erections on your own anyway.

DR OATES: Then get it all out of the way in one go?

MELISSA: Most guys I know who’ve had a penile implant feel completely sorry for themselves for about 2 weeks and then they love afterwards. So to have prostate and that all at once would be a quite an uncomfortable situation.

DR OATES: Well maybe it gives you something to look forward to, and what about the size? Can you go extra-large?

MELISSA: No, unfortunately it has to because you’d end up with pressure areas at the end of the penis from the little plastic things so you got to be careful that the size is right.

DR OATES: “But I was naturally 8 inches long before, I promise!”

MELISSA: People tell us whatever they want but we actually examine the area to see how much tissue is there so,

DR OATES: So there’s no fooling you. So you said an alternate treatment for you prostate cancer is to have radiation and you said immediately after your function is okay but something happens to the nerves??

MELISSA: I think of it as a slow burn. And the radiation treatments are getting better as well because they do things like putting gold seeds where the actual tumours are, so they try really hard not to burn the nerves and just to get to the cancer. It really just depends on where the cancer is and if you do have changes down the track, then it’s not immediate because radiation works slowly over time and so you might have good erectile function over 6-12 months after the radiation bit then get erectile dysfunction after that. I think there a little bit of a misdemeanour out there that if you have radiation, you don’t get erectile dysfunction, well, you often do. It’s just later rather than immediately. As I said earlier, the treatment should be chosen on the best cancer outcome and then we’ll deal with the side effects.

DR OATES: And the way you manage the problems is basically the same either way.

MELISSA: It is, just keep exercising it (use it or lose it) the treatment for erectile dysfunction are exactly the same.

DR OATES: And having radiation knowing that can damage tissues, that doesn’t sort of predispose against you having an implant say if you wanted to have that in the future?

MELISSA: No! Not at all because any of the tissue that’s not in the penis tissue that’s in the bed of where the prostate was, so there’s no problem with having a penile implant after having radiation at all.

DR OATES: It’s two different ways, one is you lose it straight away and you get your erectile function back and the other is you keep your erectile function and then worry that you’re going to lose it.

MELISSA: that’s right. Most men’s erectile function is going to go on a downward slope just like the rest of our body. So was it going to happen to you anyway, or is it the radiation, yeah.

DR OATES: Sounds like there’s a lot you’ve got to work on there.

MELISSA: I always think with prostate cancer there’s 3 outcomes you want. First, get rid of the cancer! Second, you don’t want to wear nappies for the rest of your life So that’s really important, third one is you want to be able to have an intimate life so I think whether that’s spontaneous or not there’s (obviously if you get it back to spontaneous, that’s great) but if you don’t there’s ways of dealing with it. I see a lot of guys getting depressing thinking that’s the end of the road for them but it isn’t, there’s a lot of things we can do to help.

DR OATES: And that’s exactly why the restorative sexual health clinic exists! But you mentioned nappies then, that’s another side effect of the surgery, does it also happen with radiation that you can become incontinent with urine?

MELISSA: Yes, but, same again, the incontinence of urine with surgery straightaway usually and then guys do pelvic floor exercises and that gets better over time, most men are dry in six weeks nowadays with surgery. Six months at the outsight, and if you’re not dry again then there are surgeries to fix that but not very often do people need that anymore. So with radiation it’s the same, they are usually very incontinent at the beginning but then over time, they may develop some bladder or bowel issues, which aren’t as common with radiation.

DR OATES: Serious stuff treating cancer isn’t it? Well it’s good to know that you’re there and able to help. We’ll have to get Jo on another podcast, and get her to talk more about all these exercises as I’m sure that my listeners will be interested in exercises that help their erectile function and make their orgasms more intense. And maybe, if you do your exercises you’re going to prevent having erectile dysfunction in the future. One in three…

MELISSA: One other thing I think people need to know is you don’t need to have an erection to have an orgasm, and it’s hard to get your head around it – to associate orgasms and erection together for men. But they can have an orgasm with a flaccid penis if they stimulate it. And it’s quite reassuring for guys because “oh well not everything’s broken” and a lot of couples are happy having outer course until they realise they can both have an orgasm and it’s all about the erection!

DR OATES: Okay! So outer course as opposed to intercourse, so that’s a term then. So you can have a prolonged erection without an orgasm or an orgasm without an erection! Thank you so much for taking the time to have a conversation with us, good luck with the penis project and Australia Men’s health forum for best content, I would advise any guys who have interest in penises and penis function to check out the penis project?

MELISSA: We’re up to 40 this week!

DR OATES: Wow, so you’re much harder working on it than I am, no wonder you’re getting the awards!

MELISSA: It’s interesting, we’ve had a lot of guys requesting to be on the podcast, wanting to be on and share their stories. Also our episode with you “can my penis be made bigger” is our second top downloaded as you would expect.

DR OATES: Well, guys are interested in penises and guys are interested in size, it’s just a fact. But there’s no point in having if you don’t have function. So, Jo, a physio therapist who’s an expert in penis exercises for rehabilitation and a sexologist and a nurse practitioner, sounds like a perfect-

MELISSA: One of my patients calls me the erection fairy, so I’m kind of going with that

DR OATES: Thank you so much Melissa Headley, the erection fairy!

You can find the link to the restorative sexual health here as well as Melissa and Jo’s podcast, The Penis Project, here.

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The Penis Podcast Episode 15  |  Follow on Spotify | Follow on Apple iTunes