The sun cast a questionable ray of hope across a wall in Lionel’s foreboding room. It was still decorated with the posters warning the unwary of the various maladies that a urologist and his stockbroker live for.  It had been almost three months since the removal of the catheter and I had an appointment with Lionel to discuss the final steps regarding my return to a normal life.
         

I was shown into his room and told to take a seat. I chose one of the two seats at random, and it did not take long to conclude that the seats were designed by an HMO to promote short visits and higher profits. A little time later, a short but authoritative knock was heard. This was followed by the door swinging open to reveal the puffed smiling cheeks and twinkling brown eyes of the effervescent Lionel.
       

“How is the legend?” he cried while thrusting a hand in my general direction.
    

“You promised to make me a stud again and I have come to take you up on your promise,” I said, shaking his hand.
    

“Let’s not rush things,”  he said. “I think we should wait a few months to give the nerve bundles a chance to heal. They have recently undergone a considerable trauma.  Lets see if time will heal them and make a natural erection possible.”
    

“In the mean time,” said Lionel “there are number of things I can do to help you. At present, there is no pill I can prescribe that will guarantee an erection. However, Pfizer is working on a pill that shows a lot of promise, it should be available early next year.  In the meantime, I’d like us to go through a number of different strategies until we find the one that is right for you.”

 

“What I want you to try first, are an injections of papaverine into the base of the penis.  Its quite easy and not as painful as it sounds.”

 

“You’ve got be out of your tiny urologist mind,” I said  “Its not your penis we’re going to use as a pin cushion,”  I cried.
          

Ignoring my questioning of his sanity, Lionel said,  “Once you get the knack of it, it’s easy and it can be quite effective. It works by sending a similar chemical signal that is produced naturally in the prostate nerve bundles to the penis. This in turn triggers the expansion of the arteries in the penis, allowing blood to enter the penis.”

 

“Sticking a needle into my cock does not sound like a pleasant start to a sensual encounter” I said.  However, I’m willing to give it a try, but if I find that this therapy is not for me, what are my alternatives ?” I asked the great inquisitor.

 

“After the Penile Self injection, we have the Vacuum Pump.  And in a few months time we expect FDA approval of a suppository.  This will work in a similar manner as the Penile Self injection, however, the medication is  inserted into the tip of the penis with a special applicator.  Then we have the new oral drug by Pfizer that should be available early year. If that does not work, we have the Penile Implant again made by Pfizer. I do several of these operations a month, and, I can guarantee you a satisfactory erection with this alternative. Don’t worry, we’re in this together, I’ll get you where you want to be,” said Lionel.

 

Then without further preamble he told me to drop my pants.  ( this is a common request of a urologists). Turning in his swiveled chair, he stretched out a gloved hand and opened a drawer and extracted a small glass vial containing a clear liquid and an hypodermic syringe still warped in its hermetically sealed protective wrapping.

 

There followed a silence between us, as he went through an apparent ritual that had been perfected over years of practice with other victims of this Star Chamber.  The syringe was removed from its wrapping and the protective cap removed from a short thin needle and discarded. The vial held upside down, was lifted slightly in his left hand. With his right hand he pressed the needle into the re-sealable vial cap, and slowly, he withdrew a portion of the clear liquid. The syringe was removed from the vial, and the plunger slowly pressed, allowing a small amount of the liquid to flow from the tip of the needle.  He turned to me smiling, with as much conviction as anyone can while holding an erect and cocked (in more ways than one) instrument of pain.                 

 

“I’m going to start you off with 20 cc of papaverine.  We can increase the dose over time if it is warranted,” said Lionel. Now its important that you make the injection into muscle of your penis.  You do this by making sure the needle is at 90º to the penis and not tangential or to one side,” he said.
    

 With this singular advice, he pointed a finger at the target area of the injection, and without further comment, jabbed the needle into to my flesh. There was a short sharp pain as the needle entered, but no undue sensation after the needle was withdrawn.             
    

“I’m going to leave you for ten minutes to let the medication work.

 

Oh’ yes, one more thing.  You should rub your penis a little to stimulate the chemical reaction.”  With this dismissal, I was left on my own in his small room.

 

I looked at the shafts of light spreading through the Venetian blind. It was almost as bright before, yet the angle across  the wall was lower the shadows more stark. This seemed to be a perfect metaphor of my current feelings.  Lionel came back fifteen minutes later ( I’m convinced he has a clock that is set by the Dow Jones Industrial Average he is never on time).  He examine his handiwork, there was definitely a change. There was an appearance of an erection.  Not as firm as I had remembered, but certainly an improvement over my recent memory.  
    

“I suggest you should try this yourself during the next few weeks. And why don’t you increase the dose to 35 cc and lets get together again in four weeks time,” said the good doctor.
    

Rummaging through his drawer, he found two more vials of papaverine and a handful of syringes that he gave to me.

 

“ And here’s a prescription for additional medication and syringes. The medication may not be covered by your insurance, but the syringes will be,” he said, while writing in a pad in that secret code known only to doctors, pharmacists, and spies.

 

Over the next several weeks, I tried out papaverine, but I never felt comfortable with the self injection. Consequently, we would more often than not, postpone lovemaking. Clearly there had to be a better alternative. So I made an appointment to see the Grand Inquisitor once more.    

 

“Well, how did it go?” asked Lionel. I told him of my fear and hesitation about using the needle.

 

“It’s not for everyone,” he conceded. “There are many men who have used the Penile Self-injection method for years quite successfully with no side effects. Then there is the squeamish like you,” he said with a smile.

 

“Now we’ll have to go to phase two. The vacuum pump.”

 

I had seen this device before but I had never held one in my hand.  It consisted of four basic parts; a large plastic cylinder, a hand operated pumps, a special rubber ring and a lubricant.  As was the custom with my “friend Lionel,” after a short get reacquainted chat,  I was asked to drop my trousers on the pretext that he could demonstrate how this apparatus worked.    

 

First the large plastic cylinder was connected to the pump, and a rubber ring  selected from various sizes on hand was placed around the opposite end of the cylinder to the pump. Lubrication was then applied to the penis and the end of the cylinder next to the ring.  The cylinder was then placed over the penis and the pump was activated by squeezing the handle. A vacuum around the penis was created, allowing blood under normal body pressure to flow into the penis resulting in an erection. The lubrication on the penis reduced the friction as it expanded and the lubrication on the end of the cylinder provided a seal against the skin. Finally, when an erection is maximized, the ring is  pushed off the end of the cylinder onto the base of the penis, restricting the back-flow of blood, thus maintaining an erection.  An erection will last until the ring is removed (up to 30 minutes later).  I tried the procedure several times so that I could get the hang of it.

 

“Why don’t you try the pump at home for a few weeks and then lets test your PSA while we are at it, ”  suggested Lionel. In an effort to impress upon me the importance of his advice, he marched me to the front desk and asked Diane to print the necessary forms and labels for the test, and set a time for our next appointment.

The vacuum system with all its paraphernalia, came in a small plastic carrying case for storage and travel. Over the next few weeks I tried the pump. It produced a fairly good erection, the only discomfort was the removal of the rubber ring after intercourse. This required some delicate handling. Efficient for what it was designed for, it made love making anything but a spontaneous event, and I was eager to try any new alternatives.  On my next visit I told Lionel about my experiences with the pump.

 

“I think its time for you to try the new suppository; Muse. It has a medication in an applicator that is inserted into the tip of the penis. It can be used twice a day. You apply it 5 to 10 minutes before sex and an erection can last up to an hour,” Lionel informed me.

 

He then reached for his trusty pad and began to write a prescription in that secret medical code of his.

 

“By the way, your PSA results came in at 0.06. That’s almost too low to measure, your keeping my batting average high,” he said with a smile.

 

With this sporting metaphor, I was once more let out into the wide world to seek the next round of my medical odyssey. I found it at my neighborhood pharmacy. Muse was not covered by my insurance. Be that as it may, can you put a price on upward mobility?  When I got home I read the instructions.

 

“When not in use keep this medication in a cool place,” and this is how Muse coexisted with the broccoli, beans and carrots in my fridge.

 

The next weekend I tried to use Muse, but I could never pluck up the courage to insert the applicator into my urethra.  It was like the penile self injection. I could not overcome the act of self induced pain prior to a natural and wonderful experience.  So I went back to the pump.

 

March 28th, 1998 was a Saturday, and as was my custom, I started the day with tea, toast and the San Jose Mercury News.  On its front page, I read  the following: “First pill for treating impotence is approved.”  The article went on to say in part,  “Viagra is taken by mouth, about an hour before intercourse, and does not directly cause penile erections; rather, it affects the response to sexual stimulation.

 

Essentially, the new drug enhances the smooth-muscle relaxant effects of nitric oxide, a chemical that is normally released in response to sexual stimulation; this smooth-muscle relaxant allows increased blood flow into certain areas of the penis, leading to an erection.”    

 

“This new therapy increases the range of options available for men with this problem” said (and I kid you not, this is absolutely true) Janet Woodcock, director of the FDA’s center for drug evaluation and research.  And they say the federal bureaucracy has no sense of humor. Where is Jay Leno when you really need him?

 

With such a signature endorsement, who would not want to try it ?  Several weeks after reading the article, I made an appointment with John  Quick to talk about the various remedies available for my high cholesterol count. At our meeting, we agreed on a cause of treatment.  I then told him about my various impotence therapy experiments, and I asked him for a trial prescription of Viagra.  After some discussion about the pros and cons of the drug, he gave me one prescription for my cholesterol problem and a second for Viagra.  

 

“Now its important, that before you go on this soiree with Viagra, you should read this fact sheet written by our Urology Department,” said John, placing the scroll in my hand and closing my fingers around it. The information contained said in part…”Take one tablet by mouth one hour before you plan to be sexual. Do not expect results much before that, though it  

is certainly OK to be intimate while waiting.  The drug is active for several hours after you take it, so no need to say “On your mark, ready GO!” as the countdown gets to one hour. But if you take the pill and three hours later you’re still in front of the TV set watching Flipper reruns, don’t expect much.

 

Viagra will not cause an erection on its own. It will not work unless all the factors are present that normally get you aroused and in the mood….. Whatever, don’t just sit there and watch it grow, because it may not unless there is sex on your mind and some form of physical stimulation. “Fantasy and friction” as the sex therapists say.”     
    

The information sheet went on to say “The success rate for Viagra is about 80% overall, though men who have had a total removal of the prostate gland for prostate cancer do not do as well, about 45%.”
    

I tried Viagra several times over the next few weeks, but with no success.  I guess I was in the lower half of the 45 percentile. I had one last step to go, a final operation, I phoned Lionel.
    

“ Get your scalpel out, I think we have to make an appointment for an implant. But before we do that, I would like to talk to someone  who has gone down the same road that I am going down now.”   Lionel thought for a moment, then he gave me the name of a patient and his phone number. He added that this patient had already agreed to be a reference for this type of procedure.

 

A couple of days later I phoned the number I was given. A contralto voice answered the phone.  My first thought was, I hope that this vocal range was not the result of the operation, I liked being a bass.  After further inquires, the voice turned out to be the wife of my soon to be soul mate.  I told her who I was and why I was calling.  

 

“O you must be one of Lionel’s elite patients”, she said with a sense of humor in her voice (I liked her already).  And since I had her on the end of the line, I took advantage of the situation.

 

“If you don’t mind while I have you on the phone, I have to ask you, how do you feel about the results of your husbands prophesies operation ?”

 

“I have no complaints, it’s been wonderful. But I think you should talk to my husband about it,” she said in a more subdued voice, now realizing I suppose, that she was talking to a complete stranger about a very intimate subject.

 

“Let me call him,” she said.  After a few moments pause, a baritone voice challenged me on the phone. I introduced myself and told him,
    

“ Lionel Foster gave me your name and number. I’m contemplating having a penal implant procedure after prostate surgery, and Lionel suggested that I should give you a call and ask you about your experiences after having the procedure.”
    

“I have nothing but good things to say about it,” he replied.    

 

“Regardless of the circumstances, I can always have an erection and it will last as long as I want it too. And the sensation of making love and reaching a  climax is the same as before the operation.”  

 

We talked for quite a while about the operation and its results. He warned me that I would probably have a lot of pain during the week after the operation.  It should take about five weeks in all before  you will be ready to start your field trials. I thanked my new friend.  I told him that I would talk to my wife and Lionel one more time.  But after our talk, I felt good about having the operation.
    

A week later, Sarah, Lionel, and I were bent over Lionel’s plastic table. The good doctor had a working model of this uplifting device.
    

“It consists of two cylinders, implanted in the corporal bodies of the penis using a penoscrotal approach, with a single pump placed in the scrotum,” he said, hence the sub-title to this chapter “The case of the third ball.”  

 

“The device is made of silicone elastomers and stainless steel components. The fluid in the device is isotonic saline. When the pump is squeezed, fluid flows from the reservoir into the implant, causing an erection.  When you want to bring the penis back to its natural state, you bend the penis down and hold it in that position for about 16 seconds,” said Lionel.
    

“This inflatable implant provides the most natural erection of any of the other devices available today,” he said while toying with the device in his slim brown hands. For a while, we talked about the pros and cons of the procedure.

 

“If you decide to have this operation,” said Lionel,  “you will have to limit your love maki.. ( at this point I kicked his foot under the table. He quickly got my drift. ) I mean, you should have sex frequently. This is most important.”
Finally all eyes turned to me for a decision.  Being the magnanimous type,  I asked Sarah what I should do. She replied, that it was up to me to make the decision and she would support me either way.
    

“Ok Lionel what do we have to do next?”
    

“ I will have to write a letter to your insurance company. I’ll tell them that you have had a radical prostatectomy, and that we have tried all the normal methods of achieving an erection. And, that I feel that a Penile Implant is the only alternative for you.”
    

Several days later, Lionel wrote and mailed a letter to my insurance company, leaving us all to wait for a response from those people who control a good deal of our medical destiny, the bureaucrats that divides doctor from patient. In today’s parlance their called actuaries and lawyers,  several years ago they were known as odds makers or bookies. They can calculate the return on investment for other people’s medical care in a nanosecond.

 

I was fortunate, four weeks later I got a phone call from the clinic saying that the procedure had been approved, and would I call Dr. Foster’s office to set a date for the procedure. I called Lionel and we decided on the fifth of August, about two weeks away.

 

The evening before the procedure, I suddenly thought of a question that I had not put to Lionel, so I phoned him at home.  After several rings the doctor answered the phone.

 

In an effort to get the upper hand I chastised him for answering the phone. “You’ve got an important day tomorrow, what are you doing answering the phone? You should be getting your sleep,” I said.
“Never mind, I have a more important question for you. This is our last chance to get things right. As you know, all men are not built the same, and we have not yet talked about how you go about sizing the device.  I don’t need to know the technical details. Suffice to say, that after you measure me, if you decide on a size 5, I want a size 10,” I said.

 

“Length is not the most important factor with most women Howard. It is the girth they look for. Don’t worry I will look after you,” said my soul mate. (In Thickness as in Health I seemed to hear him say about our marriage vows).

 

The next day Sarah and I drove to the address we were given in San Jose. It was a small grey complex close to the O’Connor Hospital.  We parked the car and walked the few steps towards my next medical adventure.  Upon our arrival we were met by a middle age lady who demanded to know who I was, and who was the woman with me ?  After explaining that I was here for an operation, and that the lady with me was my wife, I was asked to provide further paper and plastic proof of my bonafides.  

 

Eventually, I must have past muster, since, I was led into a small room by a young nurse named Lisa, who had a wonderful Alabama accent and a great sense of humor.  Unabashed, she asked me to get undressed and change into the regulation hospital gown.

 

We were soon joined by a tall athletic young man who entered my field of vision. He introduced himself as Dr. Richard Kataz, he was to be my anesthesiologist for the day.  After the normal pleasantries about the weather and other vital issues of the day, the doctor started to take command of my left hand.  A needle was inserted into the back of the hand and was firmly taped into place. The tube leading from the needle was connected to a plastic bag suspended from a stainless steel carrier.
Dr. Kataz turned the valve at the base of the bag clockwise and smiled at me. Slowly, all sense of reality and the heavy burden of life’s responsibilities  started to slip away.  But before I could fall through the rabbit hole and meet Alice in Wonderland, I remembered I had one last instruction for Lionel.

 

Quickly I thrust my hand under my pillow and retrieved the label complete with rubber band that I had prepared the day before.

 

It said, “Dear Lionel, I hope this procedure is easy for you, and hard for me !!  PS. Does it have a parts and labor warranty ?”

 

I attached the said label onto the normal part of my body that Lionel  was accustom to see.  Later, I was to find out that this Inflatable Penile Prosthesis, as it is officially known, does have a warranty. And to ensure that it is a Pfizer product, and that it has been implanted correctly, a Pfizer rep. was in the operating room to observe my favorite urologist at work.

 

After the operation, Lionel told me of the conversation he had, with the Pfizer representative. When it became time to measure me for the implant,
(I was playing croquet with the King and Alice at the time,) Lionel made his calculations and said,

 

“I think we’ll add an extra 2.5 cm. to these calculations.”

 

A gasp was heard from the Pfizer rep. “But why?” she asked.

 

“Someone special,” replied Lionel with brevity.
I awoke several hours later, with no mallet in hand. I guess the King or Alice must have taken it away from me. I felt some pain where you would expect after such an operation. I pushed my hands into my groin area only to find my penis encased in  bandages.

 

“It’s all over now, come on, I’ll help you get up,” said Lisa, in her hauntingly southern accent.  She put her arm around my shoulders and lifted me into a sitting position with my feet resting on the ground. I looked around the so called real world for the first time in several hours. I felt the world of Lewis Carroll was so much better.  

 

Sarah had overheard the conservation between the nurse and myself and came to my bedside. “How are you doing love ?” she asked.

 

“Uncomfortable, actually I feel like hell” I said through clench teeth.  At this point Lionel came into the room.

 

“Every thing went fine,” he said while smiling and putting an arm around me. “ You’ll  probably have some pain over the next several days. It looks like you have some now.” His eyes looked into mine for confirmation. He seemed to find it, since he went on to say.

 

“I’ll give you a shot before you go and write you a prescription for some medication, just take one pill as needed.”    

 

Over the next week and a half, I had a lot of pain. I was taking pills on a regular basis.  However, when you come to think about it, it’s not really so surprising that I should have had so much pain. An operation had just been performed on the most sensitive part of a man’s body, then this same organ had been asked to heal itself with an implant that was 2.5cm larger than it had been designed for.

 

Gradually, the pain became more tolerable and about two weeks after the operation, the pain gradually diminished. It was 32 days after the operation when we decided to conduct our first field trials.  The results are classified. However, I can say that everyone concerned was satisfied.

 

It has now been over three years since my prostate cancer diagnosis and the original operation. My quarterly PSA tests have been all been negative. My singular advice to all men in their mid forties and above is to have a regular physical exam that includes a digital rectal exam and a PSA test. It can save your life.  If the tests indicate positive for cancer, don’t despair.  Find yourself a good urologist, assume a positive attitude, and get your family and friends to be your pillar of strength. Prostate cancer can be beaten if it is found in time, and life can go on, and don’t forget to smile.

 

Incidentally, Lionel has recently left the San Jose Medical Group to start his own practice in down town San Jose. I am pleased to report that his new office is devoid of those intimidating posters and is quite comfortable for a medical office.

The reason for writing this anecdote of my experiences was two fold.  First as a catharsis for myself and to bring some closure to this episode of my life, and secondly, when Lionel Foster knew  what I was doing he encouraged me to continue.  He thought that it had an important message for men and those who love them who might find themselves diagnosed with a similar affliction.   Hopefully between us we have shown with this story, that even under adversity some fun can be had,  just as long as you have a positive attitude.  In the next chapter, Lionel Foster talks about prostate cancer from the doctor’s point of view.