Tamer Aliskan1, Bahadir Ermec1, Samed Verep1 and Ates Kadioglu1
(1)
Section of Andrology, Department of Urology, Istanbul Faculty of Medicine, University of Istanbul, Istanbul, Turkey
Ates Kadioglu
Email: kadiogluates@ttmail.com
19.1 Introduction
Testicular tumors (TCs) account for 1–1.5 % of tumors in men and 5 % of all urologic tumors. Every year there are 3–10 new cases per 100,000 men in Western countries [1]. Of all cancer types, TC is one of the easiest to cure effectively. Histologically, testicular tumors are divided in germ cell tumors (95 %) and non-germ cell tumors (5 %) [1]. The mean 5-year survival rate including advanced stage ranges between 71 and 99 % [2]. These tumors appear most frequently in the third decade of life for non-seminoma and fourth decade of life for seminoma, which is the period in which men tend to be sexually rather active. Compared with the general male population, men who undergo treatment for testicular tumors are at a greater risk of having various sexual problems [3, 4].
19.2 Incidence of Sexual Dysfunctions
Patients diagnosed with a testicular tumor experience have different sexual problems depending on the treatment strategy (orchiectomy, radiotherapy, chemotherapy or post-chemotherapy retroperitoneal lymph node dissection (RPLND)). A meta-analysis with nearly 2800 patients reported a 20 % decrease in sexual desire, 12 % erectile dysfunction, 44 % ejaculation disorder, and 19 % sexual dissatisfaction as a result of the treatment [5]. Ejaculation disorder was mostly related to surgical procedures of the retroperitoneal area. There was also a relationship between erectile dysfunction and radiotherapy, but it has been reported that this type of erectile dysfunction is infrequently seen. Other sexual problems were not affected by treatment methods. On the other hand, psychological factors play a crucial role in decrease of desire, orgasm consistency, sexual activity, and satisfaction. Sexual dissatisfaction was found to be relatively low compared with the other sexual disturbances. Follow-up of long-term testicular cancer survivors showed changes in body image in 17 % of the patients, which revealed that sexual dysfunction was related to all the aforementioned parameters. However, recently it was reported that testis prosthesis after orchiectomy improves quality of life [6]. When treatment methods were compared, only ejaculatory dysfunction was related to RPLND [3].
Erectile dysfunction post-TC could be classified as either organic or psychogenic (although the causes usually interact in some way). Organic ED can be vasculogenic, which is caused by the adverse effects of radiotherapy; neurogenic, due to a chemotherapy-associated neuropathy; and hormonal, as a chemotherapy-associated Leydig cell dysfunction. Psychogenic ED is related with body image, loss of masculinity, low libido, decrease in sexual activity frequency, less sexual satisfaction, and sexual performance anxiety related with changes post-orchiectomy [3]. Other studies report that the ED frequency in men treated for testicular cancer ranges between 12 % and 40 % [7]. In their recent study, Tal et al. evaluated patients who had presented with a testicular tumor and undergone different treatments such as orchiectomy, radiotherapy, chemotherapy, and RPLND and reported having ED 12 months after treatment. They conclude that ED post-TC treatment was psychogenic-based, rather than organic [7].
19.3 Pathophysiology of Sexual Function
19.3.1 Orchiectomy
Despite the fact that orchiectomy is the least invasive treatment option in testicular cancer, it was found that 22.5 % of patients had at least one type of sexual dysfunction after unilateral orchiectomy [8]. Evaluations during follow-up show that in unilateral orchiectomy hormonal values stay at a normal level and the hypothalamus-pituitary-gonadal axis is functioning properly.
Sexual disturbances after unilateral orchiectomy are mainly caused by psychogenic factors [9]. The loss of a testicle due to cancer has considerable impact on the sexual life and overall quality of life because it is felt to be a threat to masculinity by many patients [3]. That loss is associated with feelings of uneasiness or shame about impaired body appearance in one quarter of the patients. The satisfaction rate in patients who get a testicular prosthesis after orchiectomy is quite high [6].
19.3.2 Radiotherapy
Tinkler et al. [10] examined the effects of radiation therapy on sexuality in patients with seminomas. Compared with the control group, there were decreases in sexual desire, erectile function, orgasm consistency, and ejaculate volume. The study showed significant differences in sexual intercourse frequency, interest in sexual intercourse, and the ability to keep an erection. There was also a significant difference in the volume of semen between patients aged under and over 35 years, in favor of the younger patients. These findings demonstrate that patients of older age experience worse adverse effects after treatment. Interestingly, there were no differences found in ejaculation and sexual satisfaction. The authors of another study reported a 22 % decrease in both sexual desire and sexual activity post-radiotherapy but there was no relation with low testosterone levels [8].
19.3.3 Chemotherapy
Chemotherapy toxicity depends on the drug type and dose of the drug. Various dysfunctions are related to the cumulative doses of the treatment. Adjuvant chemotherapy involves bleomycin, etoposide, cisplatin (BEP) or bleomicin, vinblastin, cisplatin (PVB) protocols. The treatment usually does not cause major or permanent sexual dysfunction disorders [11]. Compared to orchiectomy patients, more chemotherapy patients had low libido, decreased sexual arousal, erection and ejaculation disorders, and decreases in orgasm consistency [12].
19.3.4 RPLND
Retroperitoneal lymph node dissection (RPLND) is performed in cases of testicular tumor with involvement of the retroperitoneal lymph nodes. Ejaculation disorders, both retrograde ejaculation and anejaculation, are a common result of RPLND. Modern nerve-sparing techniques try to diminish the damage to the lumbar splanchnic and hypogastric plexus nerve injuries, but antegrade ejaculation is reached only in approximately 80 % of the RPLND cases [13, 14].
19.3.5 Diagnosis
In patients with sexual dysfunctions after treatment for TC, different evaluation tools should be applied according to the complaints of the patient or the couple.
A patient with an ED problem is primarily assessed using the International Index for Erectile Function (IIEF) questionnaire. Laboratory tests should be performed on total testosterone, LH, and FSH to evaluate the endocrine system. Additionally, a nocturnal penile tumescence and rigidity (NPTR) test could be conducted over at least two nights. For functional rigidity, an erection should be at least 60 % rigid and should be maintained for more than 10 min [15]. The intracavernous injection test gives information about the condition of the penile circulation. A positive test should provide a rigid erection after the injection that should last for at least 30 min [15]. A positive test shows that the penile vascular system is adequate and will respond to intracavernosal injection therapy. Values for peak systolic blood flow >30 cm/s and end-diastolic velocity <5 cm/s in duplex Doppler ultrasonography are considered to be normal [15].
Semen analysis is required for patients with fertility issues. When, in the absence of ejaculate, retrograde ejaculation is expected, a post-orgasm urine sample is centrifuged and investigated for the presence of sperm.
19.3.6 Psychological Issues
One should keep in mind that the disease and its treatment have also psychological implications, such as anxiety over a failure to satisfy one’s partner or inhibitions towards one’s partner, which may determine sexual functioning, along with physical conditions. Notably, when changes in sexual functioning occur immediately after diagnosis at the beginning of treatment and after treatment, this further confirms the importance of mental factors.
Marital status (single or committed) has also influence on sexual dysfunctions. The men who were single at the time of diagnosis reported more sexual problems than those in permanent relationships. Committed partners at the time of diagnosis experienced increased intimacy in their relationships, likely to act as a buffer protecting them against adverse emotions and consequences of the disease. Singles were deprived of that protective mechanism. Moreover, they could feel more afraid of infertility. The fear of infertility negatively affects sexual functioning and raises concerns over future intimate relations. It is also worth noting that singles have fewer sexual intercourse with more partners, hence different aspects of their sexuality are more difficult to evaluate. The lack or lower frequency of sexual activity may lead to reduced performance and artifacts. Symptoms of clinical depression after chemotherapy were substantially more often observed in singles than committed partners. Depressive symptoms were related to erectile disorders, lower sexual satisfaction, and overall deterioration of sexual functioning 3 months after orchiectomy. One year after testicle removal, depressive symptoms did not show any predictive value for sexual dysfunctions. Thus, they can be claimed to represent a risk factor only within several months following diagnosis [2, 3].
19.3.7 Treatment
The treatment of sexual dysfunction should include an integrated approach where all biological (see above) and psychological factors are taken into account.
Aspects like fear, depression, diminished body image (among others due to orchiectomy) should be addressed.
All patients undergoing surgery for testis cancer should be informed about the availability of a testicular implant. More than one quarter of all testis cancer patients wish to receive a prosthesis to replace the excised testicle [6]. In case of ED, psychotherapy could be applied in combination with PDE-5i use when needed.
Anejaculation is another effect experienced after RPLND, and Wayland Hsiao et al. [16] used pseudoephedrine at a dosage of 60 mg four times a day for 2 days for the initial treatment in their study. Electroejaculation (EEJ) was performed for fertility, when poor results were encountered after the medical treatment. Testicular sperm extraction (TESE) is a second option in the event that sperm are not acquired with EEJ.
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