Panagiotis Dimopoulos1 and Dimitris Hatzichristou2
(1)
The Christie NHS Foundation Trust, Manchester, UK
(2)
Department of Urology and Center for Sexual and Reproductive Health, Aristotle University of Thessaloniki, Thessaloniki, Greece
Panagiotis Dimopoulos (Corresponding author)
Email: dimopoulospanos@yahoo.gr
Dimitris Hatzichristou
Email: hatzichr@med.auth.gr
20.1 Introduction
Penile cancer is a rare disease. The most common type is squamous cell carcinoma responsible for about 95 % of cases reported. The remaining 5 % have other morphology such as melanoma, basal cell carcinoma, and adenocarcinoma of the penis [1]. There is a wide geographical diversity of the disease. In Western countries, it is quite rare with an annual incidence of less than 1 per 100,000 males. In populations of other countries such as Africa, Asia, and South America, the incidence is higher.
Despite the fact that we lack robust evidence for the etiology of the disease, there are multiple risk factors such as HPV infection, phimosis, chronic penile inflammation, smoking history, low socioeconomic status, high age, and multiple sexual partners [1, 2]. Neonatal circumcision significantly reduces the incidence of penile cancer as seen in countries where it is routinely performed.
The treatment of penile cancer depends on the stage of disease at presentation. At the very early stage of the disease when it still is localized, local treatments may be utilized, such as 5-flurouracil topical cream, laser therapy, and glans resurfacing. The gold standard of treatment remains the surgical excision of the tumor with adequate margin of healthy tissue for oncological control. The surgical strategy depends on the extent and location of the primary tumor and can include local excision, circumcision, partial penectomy and total (radical) penectomy. Additional surgery is required for advanced penile cancer with inguinal lymph node involvement such as inguinal-pelvic lymphadenectomy. In well-selected patients with localized disease, radiotherapy can also be used as organ-preserving treatment for the primary lesion with good local control. Chemotherapy and adjuvant radiation therapy can be used for palliative treatment in extensive disseminated disease.
It is rather obvious that penile cancer has multiple implications for the patient’s life. There are many different factors that play an important role through the patient’s journey with this disease. The presentation and location of penile cancer, the age at presentation, and the diagnosis of a cancer, which is rather aggressive and a potential lethal disease may have devastating effects on overall psychological well-being. Furthermore, the majority of treatments may be disfiguring and this has an impact on patient’s sexuality and sexual function, quality of life, social interactions, self-image, and self-esteem [3].
20.2 Sexual Function and Penile Cancer
Sexual health and function, reflect a complex phenomenon. Men’s sexual function depends on anatomic, neurogenic, vascular, and hormonal integrity, with important additional psychogenic components.
As the penis has a central role in men’s sexual function and expression, any defect of the organ constitutes a pillar for men’s sexuality and intimacy. Penile erectile function depends on multiple components. The corpora cavernosa contain the erectile tissue which in the tumescence phase of erection are filled with blood in response to central efferent stimuli and result to the erect and rigid penis. Sufficient penile length is important for penetrative sex. In addition, the glans of the penis provides sensory input to facilitate erection and enhance pleasure, facilitates intromission due to its cone shape appearance, and in addition serves as a cushion to lessen the impact of the penis on female organs.
From all urologic malignancies, penile cancer is the one that most obviously jeopardizes sexual function as well as body image [4]. In addition to the worries related to any cancer, this particular location and the treatment of this cancer instinctively appear as a severe strike on a man’s sexual capability and sense of masculinity. Hence, some recent studies have focused on penile-preserving techniques and reconstructive surgery to reduce the assumed psychosexual morbidity associated with treatment [5]. The following section addresses the different treatment modalities and the implication to sexual function in males with penile cancer.
20.3 Treatment for Penile Cancer
Surgery for penile cancer is technically uncomplicated. Hospital stays are short, patients usually recover quickly to a good physical health, except perhaps for those who have lymph node involvement and require lymphadenectomy that leads occasionally to significant morbidity. The chances of cure are usually high, particularly for those with early stage disease typically with >80 % of them surviving. As mentioned before, treatments for this disease have long term and often distressing and devastating functional and psychogenic effects to some men. Unfortunately, to date there are not many studies that fully address these effects and most of them are small and of retrospective design [6].
Depending on the stage of the disease as well as the anatomical location of the lesions, different approaches may be considered. The aim is to achieve good oncological local control with maximum preservation of the penis. Physicians should be aware of the current state-of-the-art treatment of penile cancer as well as the consequences of its treatment in men’s sexual life. Knowing the treatment modalities and the prognosis may help them in the development of a management plan for their patients’ sexual problems.
When the lesions are limited to foreskin or shaft without invading the urethra, spongious or cavernous body, wide local excision and/or circumcision are considered to be sufficient enough for achievement of local control. Penile shaft skin lesions may be also excised with direct closure or use of graft in case of large or widespread extension on the penile shaft. This usually has relatively little sexual consequences.
When in those cases the glans is involved, partial glansectomy can be performed with either primary closure or advancement of foreskin flap when circumcision is simultaneously performed. Larger defects might need partial or full-thickness grafting. With co-existing differentiated or undifferentiated PeIN (penile intraepithelial neoplasia, previously named carcinoma in situ), circumcision must be the first initial step.
Laser treatment is another least invasive procedure for penile cancer as a penile-preserving approach. Traditionally, it has been used for the treatment of PeIN, but it is also utilized for treatment of invasive disease in well-selected patients.
When the lesion is located on the glans with involvement of the corpus spongiosum, but not the corpus cavernosum or urethra, a glansectomy may be performed for preservation of penile length. This involves the dissection of the glans from the corpora cavernosa. The exposed corporeal heads may be covered with partial thickness skin graft, quilted to the corporeal tips for prevention of hematoma and better cosmetic result. Instead of a graft the urethral mucosa may be also everted and reconstructed as to cover the corporal heads. Both techniques provide additional sensory input that might improve sexual stimulation and satisfaction in comparison with more mutilating procedures such as penectomy.
More advanced invasive tumors involving the glans, coronal sulcus, or penile shaft are managed with partial amputation of the penis. Care must be taken for the reconstruction of the neo-urethral meatus and reduction of excessive penile skin as these may have some implications in sexual function and overall satisfaction.
Patients with large extensive infiltrating tumors involving the glans, midshaft of penis, or urethra require a total penectomy. Larger lesions can impose removal of scrotum or even testis. Urinary diversion with a perineal urethrostomy is dictated when penile stump does not allow upright micturition [5].
Radiotherapy
For well-selected patients that do not want any surgical intervention, external beam radiation therapy and/or brachytherapy offer another penile-preserving treatment for penile cancer, with surgery reserved as a salvage option upon recurrence after treatment [5].
20.4 Treatment Effects on Sexual Function
The functional results concerning sexual function vary considerably amongst published studies. Less invasive procedures are less debilitating for sexuality by preserving anatomy, sensation, ejaculatory and orgasmic function, with acceptable cosmetic results. And the preserved penile length will make penetrative sex more likely. Additionally, they cause less impact upon the body image, mental health, well-being, and perception of masculinity [3].
Part of the patients report improvement in their sexual activities following treatment with less invasive procedures, especially when, prior to diagnosis and treatment, they suffered from pain, bleeding, and embarrassment and accordingly stayed away from sexual activity.
Following laser therapy as an organ-sparing procedure, sexual function and satisfaction are only marginally affected, although delay in healing after laser treatment means that the patients have to wait 2–3 months before they are able to resume sexual activities.
In a Norwegian study, all patients treated primarily with partial amputation experienced a reduction in sexual ability and sexual enjoyment, and none had normal sexual functioning, while part of them still had normal sexual interest. That was contradicted in a Brazilian study where sexual interest, sexual function, and frequency of sexual intercourse were unchanged or only slightly decreased in more than half of patients treated with partial amputation. This may reflect the cultural variation between the population and the level of education and expectations of patients involved. The percentage of patients undergoing penile-preserving procedures rather than penectomy in Europe is currently 60 % versus 40 % [7] whereas in other countries the proportion is the opposite, probably owing to the different demographics and sociocultural background.
Next to a great impact on sexual functions, partial amputation was also found to cause emotional and mood disorders with 35 % of patients experiencing “problems in social life,” 30 % anxiety and 6 % depression. The feeling of loss of manliness and the inability to penetrate is likely to cause emotional stress, and we can presume that many patients treated by total or partial amputation will experience this in varying degrees [3, 8].
Penile brachytherapy caused also a high percentage of erectile dysfunction. However, the men had less problems with their manliness because they did not experience changes in penile length or penile appearance. This is probably an important determinant of their feeling as a true man. They also observed that communication about sexuality in the couple, importance of sexuality for the partner, partner’s coping with sexual troubles were significantly better in patients than in controls and that patients had more fantasy than controls. No doubt that all these factors enable to minor the impact of treatment on glans sensitivity and erectile function, and strengthen their self-esteem and motivation. The majority of the patients were overall satisfied with their sexual life [9].
The impact of total penectomy or partial penectomy with a remaining buried penile stump is most pronounced. These men usually have their libido and sexual desire intact but the majority cannot achieve orgasm causing frustration. For others although the nature of orgasm was different it still gave a degree of relief and pleasure. In general the degree of sexual competence and the ability to achieve orgasm causes problems and is related to the extent of surgery [10]. The importance of the ability to have penetrative, ejaculatory sex was apparent as was the view that this was the only legitimate form of male sexual activity according to this study.
20.5 Dealing with the Disturbances
Penile reconstruction is an increasing social demand after total penectomy procedures. The length and girth of the residual stump will dictate the methods available for subsequent reconstruction. In patients with no evidence of cancer recurrence, total phallic reconstruction can be considered to improve body image and psychosexual identity, especially in younger men. Reports on total phallic reconstruction after penectomy for cancer are rare and this surgery has had a high complication rate, specifically related to urethroplasty. Nevertheless, global satisfaction with the neophallus is found to be high [5].
To our knowledge and experience, very few patients seek this form of surgery especially in the immediate postoperative period. In addition, this type of operation is quite demanding and requires a multidisciplinary surgical approach. Currently, the morbidity is still significant. There are only few centers worldwide with sufficient expertise in this type of surgery.
Usually treatments tend to focus only on restoring erectile function and on penetration rather than improving overall sexual satisfaction. Sexuality is a complicated process, and in some circumstances alternative ways can restore the overall sexual satisfaction of a man or a couple even after total penectomy.
Such an alternative way could potentially be with the use of sex toys such as a strap-on dildo. That obviously can have mechanical advantages. A proper strap-on dildo closely matches the natural size, shape, stiffness, and angle of a man’s erect penis, allowing him to make natural hip thrusts. These movements and the association with full body sensation, intimacy with the partner and simultaneous genital stimulation, can play a pivotal role in reestablishing orgasmic sexuality despite the fact that the dildo cannot be felt by the patient. There is still limited research and solid evidence in exploring this sort of sexual practices. Both orgasm and sexual satisfaction have been achieved even in the absence of erections using such sex toys [11]. In this report, a completely impotent man following treatment for his prostate cancer was able to achieve sexual satisfaction for himself and his partner using a strap-on dildo. The neurobiological explanation is called “multisensory integration.”
Even after penectomy there are still sensitive areas around the scrotum, testicles, and perianal area that can give intense erotic stimulation and the ability to achieve orgasm. Other alternative ways include massaging of the abovementioned areas, the use of vibrator or oral sex stimulation. The most important determining factors remain openness within the couple and the sharing of feelings. Changing the view of how sexuality could be expressed and experimentation are keys for achieving a fulfilling sex life.
20.6 Penile Cancer and Sexuality: What the Health Care Professional Should Keep in Mind
As previously stated, sexuality in penile cancer sufferers depends on many factors. Age at diagnosis, baseline sexual function prior to diagnosis, choice of treatment modality, psychological and mental well-being following treatment, relationship status, body image, and perception of masculinity will all influence quality of life. Many complexities are encountered along the patient’s journey with this disease and ongoing support is important. The journey often starts with misdiagnosis because of lack of awareness of penile cancer by both patients and medical staff. After cancer diagnosis, shock, disbelief, and fear of death are common responses, with “having cancer” as the most dominant aspect and not the site of the disease. When diagnosed there will be rapid treatment which will be reassuring but also frightening. For many, both the physical and the psychological implications are secondary, as the need to deal with the cancer is imperative. At this stage, implications of treatment must be clearly addressed and understood by patients and their partners and expectations balanced. After surgery, the consequences for urinary and sexual functioning and the reality of a changed life become apparent. Three main themes emerge with masculinity as the common concept. Appearance, urinary and sexual functions, roles, and self-image are all affected by surgery and this requires a renegotiation of the concept of masculinity. In a structured interview study, the idealized masculine image of the assertive, potent, stoic male in control of his life overlaid the narratives in terms of how the men saw themselves before surgery and how they coped with postoperative challenges. For some men, facing their diagnosis honestly demonstrates bravery and control. For others, being tied to ideas of the legitimacy of penetrative sex was disabling as it damaged and prevented the sustainment and development of potentially supportive relationships [10].
The impact of penile cancer is rarely felt in relation to a single facet of a man’s life. Men reported that it affects sexual, physical, and psychological well-being, in varying degrees influencing each other, indicating the complexity of men’s pre- and post-surgery care, and highlighting the need of a holistic approach to the individual patient. Men treated for penile cancer will experience changes in their sexual function, ability to engage in regular sexual intercourse, and achieving sexual satisfaction. When surgery is more radical, it obviously will have greater impact on such a sexual impairment; however, there are conflicting evidences on the impact on men’s mental health and well-being [3, 8], apparently caused by differences on the methods used, education level, and cultural diversity, and also on diversity of male experiences within a given culture.
Men with penile cancer are more likely to focus on immediate treatment and defer the implications of their treatment. When guiding the decision-making process, health care professionals play an important role. Accuracy of information before treatment and the subsequent expectations of patients can influence the management of the disease [8]. This may reflect why some men react with shock to see the results of surgery. Before treatment, the patient should be aware of the implications of treatment and manage expectations about his recovery and the impact on his broader life in a realistic and holistic manner.
Age at diagnosis is an important factor with older men, stating that treatment would have greater impact should they have been diagnosed on a younger age. In addition, life’s experiences have been referenced as helping some men cope with the impact of treatment [10, 12].
20.7 Partner Consequences
Coping with cancer, its treatment and recovery are dyadic processes within a relationship. The acceptance and support of wives and partners was found to be an important and integral part of coping with the impact of surgery and regaining quality of life in the majority of the studies. Men in such relationships showed stronger resilience and significant less feelings of emasculation. The characteristics of these relationships were openness and acceptance and carried a degree of experimentation in sexual activities that lead to improved sexual satisfaction. This reassurance provided from intimate partners helped strengthen their relationship. On contrary, patients with no partners were prone to feelings of ridicule and rejection concerns that were overcome by avoiding new relationship. Providing such support undoubtedly places great stresses upon intimate partners meaning that they may also require help to manage the impact of penile cancer surgery on themselves and relationship [12]. In a prospective study aimed to describe the dyadic aspects of sexual well-being and life satisfaction, sexual dysfunctions were common found among men, especially decreased sexual interest and dyspareunia. At follow-up, increased sexual function was found, with the exception of erectile function and women’s orgasm, although a rather high proportion was unhappy about being sexually inactive [12].
Glans preservation plays possibly the most important role, as it effectively preserves the functional anatomy and cosmetic appearance of the glans and the penis. After glans-preserving surgery, patients performed better sexually and were satisfied with their appearance than men who underwent partial amputation. Sexual partners had also much higher appearance satisfaction and intercourse acceptability after glans-preserving surgery than after partial amputation [13]. This was supported by another study where penile-sparing surgery showed better sexual performance, and also better life interference and urinary function.
20.8 Management Recommendations: Conclusion
The challenges after penile cancer are diverse and complex. Both surgical expertise as well as ongoing support following treatment are required with an eye for individualization according to the patient needs and expectations, and for sensitive and appropriate counseling. With a rare disease, such as penile cancer, specialist teams must guide and deliver treatment. Multidisciplinary teams that deal with this disease in high volume centers is imperative to be able to develop and maintain the necessary expertise. A team includes urologic surgeons, clinical oncologists, histopathologists, palliative care specialists, plastic surgeons, radiologists, nurse specialists, and psychologist with specialization in sexual behavior and cancer.
Recently, in United Kingdom, health service changes recommended that penile cancer patients should be managed in such specialist supranetwork multidisciplinary teams (Sn-MDTs). They should see at least 25 new patients annually (covering a population of at least four million) with both the treatment and postoperative care restricted to such units. By creating a network of centers with specialized and geographically centralized services for a rare disease, a critical mass of experience and resources can be developed, with standardized care pathways and consistent protocol-driven level of service. And finally evidence on optimal treatment of penile cancer with improved maintenance of urologic function and patients’ quality of life. In this structured setting, patients will benefit from psychosexual guidance services with highly trained professionals that will help them and their partners cope with the implications of the disease and treatment. Furthermore, practitioners should not only provide information on appropriate services but also sensitively challenge the reluctance to attend these services.
Carer groups, charities, or friends with experience of similar issues can provide emotional and practical support throughout the patient’s journey. Patients have a lack of formal and informal support networks with direct or indirect experience with penile cancer, its treatment, and long-term effects. Even those lucky enough to have a specialist penile cancer team will find a lack of experience among associated health professionals and services, such as with a community continence nurse or primary care practice. That asks for good-quality information via mass media, such as the Internet. Patient’s Experience of Penile Cancer study (PEPC) will create a penile cancer module [6]. Patients are interviewed to form a module on the site that has audio and video clips on the topics that emerged from the interviews.
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