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Can Fam Physician. 2005 July 10; 51(7): 977–982. | PMCID: PMC1479526 |
What happened? Sexual consequences of prostate cancer and its treatment Anne Katz, RN, PHD OBJECTIVE To describe the sexual consequences of prostate cancer and its treatments
(prostatectomy, external beam radiation, brachytherapy, androgen deprivation
therapy) and to suggest treatments for sexual side effects of these
therapies. QUALITY OF EVIDENCE Most studies of the sexual consequences of prostate cancer treatments and
studies of therapy for these side effects provide level II evidence. MAIN MESSAGE Diagnosis of prostate cancer in itself can cause sexual dysfunction. All
forms of treatment for this cancer cause serious sexual problems for men.
Treatments for the erectile dysfunction that results have varying success
rates. Prostatectomy has been shown to cause erectile dysfunction in 30% to
98% of men, depending on whether both, one, or neither nerve bundles was
spared. Radiation therapy results in erectile dysfunction in more than 70%
of those treated; brachytherapy produces the least amount of sexual deficit.
Hormone ablation therapy has serious consequences: more than 80% of men
report loss of erections at 1 year after therapy in addition to profound
loss of libido. CONCLUSION Family physicians are ideally placed to provide anticipatory guidance to men
with prostate cancer on the sexual consequences of both the cancer and its
treatments. Family physicians can also assist men and their partners in
managing these sexual side effects. OBJECTIF Décrire les conséquences d’ordre sexuel du cancer de la prostate et de son
traitement (prostatectomie, irradiation externe, curiethérapie, traitement
anti-androgénique) et proposer des traitements des effets secondaires
sexuels causés par ces traitements. QUALITÉ DES PREUVES La plupart des études sur les conséquences sexuelles du traitement du cancer
de la prostate de même que celles qui portent sur le traitement de ces
effets secondaires sont fondées sur des preuves de niveau II. PRINCIPAL MESSAGE Le diagnostic de cancer de la prostate peut à lui seul provoquer une
dysfonction érectile. Toutes les formes de traitement de ce cancer peuvent
entraîner des problèmes sexuels sérieux. Les traitements de cette
dysfonction érectile ont alors des taux de réussite variables. On a démontré
que la prostatectomie entraîne une dysfonction érectile dans 30% à 98% des
cas, selon qu’il y a eu lésion d’un seul, des deux ou d’aucun des faisceaux
nerveux. Le traitement par irradiation entraîne une dysfonction érectile
dans plus de 70% des cas; c’est la curiethérapie qui cause le moins de
déficiences sexuelles. Le traitement anti-androgénique a des conséquences
importantes: plus de 80% des sujets accusent une perte d’érection un an
après le traitement, en plus d’une grave diminution de la libido. CONCLUSION C’est le médecin de famille qui est le mieux placé pour informer le patient
atteint d’un cancer de la prostate des conséquences sexuelles éventuelles de
ce cancer et des traitements associés. Il peut aussi aider le patient et sa
partenaire à traiter les effets secondaires d’ordre sexuel. EDITOR’S KEY POINTS- The diagnosis of prostate cancer alone causes some loss in sexual interest
and function. Prostatectomy causes loss of erectile function in 30% to 98%
of men, depending on their age, their previous functioning, and the degree
of nerve sparing in the operation.
- External radiation causes erectile dysfunction in about 50% of men, while
associated brachytherapy affects about 25%. Hormonal therapy affects both
interest and functioning in 80% to 90% of men.
- Treatment leads to some improvement in 30% to 50% of men. Oral agents improve
erectile dysfunction, depending on the type of treatment. Early treatment
with these agents has led to a greater success rate, with reduced fibrosis.
Mechanical devices have a mixed success rate.
- Family doctors can help their patients undergoing treatment for prostate
cancer with anticipatory and ongoing counseling as well as by facilitating
treatment.
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POINTS DE REPÈRE DU RÉDACTEUR- Le simple diagnostic de cancer de la prostate peut entraîner une baisse
d’intérêt et d’activité sexuels. La prostatectomie entraîne une diminution
de l’activité érectile chez 30% à 98% des hommes selon leur âge, leur niveau
d’activité antérieur et l’importance des atteintes nerveuses durant
l’opération.
- L’irradiation externe entraîne une dysfonction érectile dans environ 50% des
cas tandis que la curiethérapie affecte environ 25% des sujets.
L’hormonothérapie réduit l’intérêt ainsi que l’activité chez 80% à 90% des
sujets.
- Le traitement amène une certaine amélioration chez 30% à 50% des hommes. Les
agents oraux peuvent améliorer la dysfonction érectile selon le type de
traitement. Leur utilisation précoce s’accompagne d’un meilleur taux de
succès, avec moins de fibrose. Les appareils mécaniques ont un taux de
succès mitigé.
- Le médecin de famille peut aider le patient traité pour le cancer de la
prostate par des conseils avant et pendant le traitement et en facilitant le
traitement.
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Prostate cancer is the most frequently diagnosed cancer (excluding nonmelanoma skin
cancer) in Canadian men. In 2003, an estimated 18  800 men in Canada 1 were diagnosed with this disease; most of them will survive to
live productive lives. One of the consequences of prostate cancer treatment is the sexual dysfunction that
frequently affects quality of life for these men and their partners. This paper
describes the sexual consequences of prostate cancer and its treatments (prostatectomy,
external beam radiation, brachytherapy, androgen deprivation therapy) that family
physicians will see as they provide care to men with prostate cancer. This paper also
suggests treatments for sexual side effects. Articles in the literature describe the causes of sexual dysfunction following
diagnosis of prostate cancer and the various treatments offered to men.
English-language journals indexed in MEDLINE and PubMed were searched for relevant
articles using the MeSH headings prostate cancer, prostatectomy, radiation therapy,
brachytherapy, sexuality, and erectile dysfunction (ED). References in several
articles were reviewed for potentially relevant articles not identified through
database searches. Articles cited include review articles and randomized trials (13%
of all studies), prospective and retrospective cohort or case-control studies,
observational studies, and case series (86% of all studies). Effect of cancer diagnosis on sexual functioning Erectile functioning declines with age, and many men experience erections that are
less firm, last a shorter time, are less frequent, or require greater physical
stimulation beginning in their 40s. 2 A
diagnosis of prostate cancer can have serious emotional effects. Before treatment is
even started, some men experience sexual dysfunction related to the diagnosis
itself. In one study, 20% of men noted decreased sexual activity after the
diagnosis, 15% noted decreased interest in sexual activity, 12% noted decreased
pleasure, and 10% experienced erectile difficulty (level II evidence). 3Some men experience ejaculatory dysfunction after surgery or radiation therapy. The
lack of fluid leads to what is referred to as “dry ejaculation.” While the other
sensations of orgasm might be present, the lack of ejaculatory fluid can alter the
sensation in the penis itself, and this sometimes causes distress. Guidance in
anticipating this phenomenon can alleviate some of this distress. Erectile dysfunction has far-reaching effects that extend beyond the bedroom and into
everyday life. For many men, the ability to perform sexually is closely linked with
masculinity. Any threat to sexual potency can affect more global aspects of quality
of life, including self-confidence and self-esteem (level II evidence). 4,5Some men choose treatment based on its side effect profile. In a survey of 262 men,
24.8% chose treatment based on possible side effects, and ED was named as an
important consideration for those choosing brachytherapy or radical prostatectomy
(level II evidence). 6Erectile dysfunction after prostatectomy Incidence of ED following prostatectomy varies. Schover et al 7 suggest that only 20% of men will have erections sufficient
for penetration after prostatectomy (level II evidence). An important variable to
consider is the type of surgery: non–nerve-sparing prostatectomy causes
the greatest amount of ED and bilateral nerve-sparing surgery the least. Stanford et
al 8 found that 59.9% of men had ED 18
months after surgery. Prevalence decreased according to type of surgery
(non–nerve-sparing prostatectomy 65.6%, unilateral nerve-sparing
prostatectomy 58.6%, and bilateral nerve-sparing prostatectomy 56%) (level II
evidence). Better sexual health outcomes were found to be related to younger age,
nerve-sparing technique, smaller prostate size, and higher educational and income
level. Other researchers found that erectile functioning improved as time passed,
with progress seen more than 1 year after surgery (level II evidence). 9Erectile dysfunction after radiation therapy Initially, there are few sexual side effects for men who choose radiation therapy,
but erectile functioning declines starting at 12 months and levels off at 24 months.
Turner et al 10 found that 36% of men whose
erectile function was adequate before treatment had ED at 12 months, and this
percentage increased to 59% at 24 months (level II evidence). Radiation therapy often causes bladder and bowel problems, which can also affect
sexual functioning. Men with bowel dysfunction report decreases in sexual intimacy,
marital affection, and masculine self-esteem (level II evidence). 11 In another study, 12 10% of men reported urinary incontinence associated with
arousal and attempted intercourse (level II evidence). Brachytherapy, the implantation of radioactive seeds into the prostate, is believed
to limit damage to adjacent tissues while maximizing radiation to the prostate gland
itself. While the mechanism of brachytherapy-induced ED is not well understood, it
is likely that a variety of factors affects potency including damage to nerves and
blood supply, trauma to tissues, and psychogenic components. 13 In a review of studies of potency following brachytherapy,
Merrick and colleagues 14 (level I evidence)
cite potency of 94% at 2 years. 15,16 Factors affecting potency include premorbid
erectile function, age, supplemental external beam radiation, or androgen ablation
therapy. 17A meta-analysis of 54 studies where the pretreatment functioning of subjects was
known suggests that maintenance of erectile function varies widely (level I
evidence) ( Table 1). 18 | Table 1Probability of erectile function |
Erectile dysfunction related to androgen deprivation therapy Androgen deprivation therapy is often suggested for elderly men for whom surgery
poses an additional risk, as a way to shrink the tumour before radiation therapy, or
for men who do not respond to other forms of treatment. The sexual consequences are
global: loss of interest in sex as well as ED. Men report substantial problems with
altered body image and self-concept, which often has a direct and devastating effect
on intimate relationships and social functioning (level II evidence). 19,20
Most often, men report a global loss of masculinity that affects family, social, and
work relationships (level II evidence). 21Among men with some sexual interest at baseline, 54% reported no interest at 1 year.
Among men with erections at baseline, 80% had ED after 1 year (level II
evidence). 22 Reduced energy and concern
with urinary symptoms also affect sexual function (level II evidence). 23 In another study, 91% of men were found to
have ED after androgen deprivation therapy (level II evidence). 24Treatment of surgery-related ED Despite the somewhat dismal projections for erectile function following
prostatectomy, several treatments for ED have had some success among men with
prostate cancer. Schover and colleagues 25
found that 38% of men reported that pharmaceutical treatment of ED was somewhat
helpful and that those who tried more than one type of treatment were more likely to
eventually have success (level II evidence). Prevention of fibrosis is the first step. Experts suggest that men should attempt to
return to sexual functioning within 2 months of surgery (level III evidence). 26 Regular use of either oral or intracorporeal
treatment is believed to have an important psychological function in that visible
proof of penile tumescence will prevent a dysfunctional sexual dynamic in couples.
This dynamic often occurs when intercourse is impossible after surgery, and a
pattern of avoidance begins, with the man withdrawing sexually and his partner
reluctant to discuss the issue for fear of upsetting him further. He interprets this
as lack of interest, which exacerbates his feelings of inadequacy, and the couple
settle into a non-sexual relationship (level III evidence). 27Sildenafil is somewhat useful for treating surgery-related ED; however, age and type
of surgery (nerve-sparing vs non–nerve-sparing) are important. Zagaja et
al 28 reported an overall positive
response rate to sildenafil of 29%, yet men younger than 55 years who had bilateral
nerve-sparing surgery had an 80% success rate compared with only 33% of men older
than 66 years who had bilateral nerve-sparing surgery. Men in all age groups who had
non–nerve-sparing surgery had no response (level II evidence). 27 Similar results were found in a California
study (level II evidence). 29 Three years
after beginning therapy with sildenafil, 71% of the sample was still responding to
the drug (level II evidence). 30Another study of 21 men found that 71% of those participating had a positive response
to sildenafil at approximately 24 months after surgery. Most of these men (81%) had
no erectile problems before their surgery; however, 80% of the sample could achieve
an erection only with the 100-mg dose (level II evidence). 31 Positive results have been reported with the newer
phosphodiesterase inhibitors; vardenafil was shown to be effective in promoting
erections among 71.1% of men taking 20 mg and 59.7% of men taking 10 mg of the drug
after bilateral nerve-sparing prostatectomy (level I evidence). 32 Tadalafil differs from sildenafil and vardenafil chemically
but works similarly; however, it has a longer half-life than the other two and can
be taken with food. These oral agents might not be tolerated by patients, and there are reports in the
literature of serious side effects. The primary concern with these drugs relates to
cardiovascular events, most commonly hypotension. A contraindication to use of these
drugs is the use of nitrates. 33 Other side
effects include headache, flushing, dyspepsia, rhinitis, nausea, visual disturbance,
and back pain (level I evidence). 34Other erectile aids have been shown to be effective in surgery-related ED. In one
study, the 32% of participants who used erectile aids (vacuum devices,
intracorporeal injections of alprostadil, or penile implants) were satisfied with
the modality chosen (level II evidence). 35
Vacuum devices can cause bruising and trauma to the penis, however, and partners
have complained that the penis feels cold. Use of intraurethral alprostadil also
causes pain for about half the men who use this therapy. Surgical implants are
highly effective but are expensive and invasive. 36 A small prospective study has shown intracorporeal injection of
alprostadil, starting at 1 month after surgery and given three times a week, to
increase the recovery rate of spontaneous erections (level II evidence). 37Treatment of ED related to radiation therapy Lack of erectile activity after therapy might cause chronic hypoxia in the corporal
smooth muscle of the penis with a subsequent loss of elasticity and distensibility,
which could lead to venous leak. 38 This
fibrosis is also believed to cause penile shortening, observed in 68% of men after
surgery (level II evidence). 39 Using oral
therapy, such as sildenafil, to promote erections, with or without sexual activity,
on a regular basis is suggested to preserve or improve erectile functioning (level
III evidence). 40 Fifty-five percent of men
taking sildenafil 39 months after treatment with external beam radiation were able
to have sexual intercourse (level I evidence). 40Sexuality is a complex phenomenon that encompasses identity, body image, intimate
relationships, sexual activity, and communication. All these come into play as men
confront sexual problems related to the cancer itself and the treatments they have
had. Many men regard ED as “their” problem and attempt to solve it alone with the
use of medication or an erectile aid. The reality is that intercourse is a couples
issue, and successful treatment requires the input and cooperation of the man’s
sexual partner. Some women in this age group have their own sexual problems related
to menopause and could in fact welcome the cessation of coital activities caused by
ED. 7For those couples who are not interested in pharmacologic or mechanical solutions,
couples counseling with an emphasis on communication skills, bibliotherapy, and
sensate focus exercises is helpful in teaching alternatives to coital activity and
helping to maintain intimacy in the face of sexual problems that are not amenable to
treatment. The full range of counseling interventions is beyond the scope of this
paper; however, Schover’s book can help physicians and patients. 41 Referral to a sex therapist or support group
can be beneficial as an adjunct to pharmacotherapy or when alternative coping skills
are needed. Family physicians provide care to men with prostate cancer and their partners in all
phases of the disease and should be able to anticipate adverse affects of the
disease and treatments. Knowledge of the various treatments for ED is important to
ongoing care of this population. | Levels of evidence Level I: At least one properly conducted randomized controlled trial, systematic
review, or meta-analysis Level II: Other comparison trials, non-randomized, cohort, case-control, or
epidemiologic studies, and preferably more than one study Level III: Expert opinion or consensus statements |
| • | Dr Katz is an Adjunct Professor at the University of Manitoba and the
Clinical Nurse Specialist in the Manitoba Prostate Centre at CancerCare
Manitoba. |
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related ED