Michael Geoffrey Kirby1
(1)
The Prostate Centre, 32 Wimpole Street, London, Wig 867, UK
Michael Geoffrey Kirby
Email: kirbym@globalnet.co.uk
26.1 Erectile Dysfunction After Cancer Treatment
Pelvic cancer treatments in men invariably lead to post-treatment erectile dysfunction (ED) and cause much distress for men and partners alike [1, 2]. The term “pelvic cancer treatments” here includes: surgery (radical prostatectomy [RP] for prostate cancer, radical cystectomy [RC] plus urinary diversion for bladder cancer, and surgery for colorectal cancer), radiotherapy (RT) (external beam radiotherapy [EBRT] or brachytherapy [BT]), and androgen deprivation therapy (ADT) (inducing a significant reduction in serum testosterone levels).
A loss of erections following pelvic cancer treatments is not the only sexually related issue. Cavernous tissue damage following RP may result in significant reductions in penile length and circumference. All effects have been shown to occur within the first few months of surgery [1]. Even with the adoption of nerve-sparing procedures, erectile dysfunction (ED) can be a long-term and sometimes permanent complication [1].
Fertility is an issue that should be discussed with fertile couples who may wish more children. Sperm storage is an option in this situation.
RT also impacts on vascular structures; endothelial cell damage and microvessel rupture lead to luminal stenosis and arterial insufficiency over a period of months or years after radiation exposure, mediating the decline observed in erectile function (EF) [2].
ADT blocks interaction between androgens and the prostate by decreasing testosterone production, leading to loss of sexual interest and ED. Indeed, it has been suggested that the testosterone threshold value below which erectile function (EF) is affected is about 10 % of the normal range of testosterone. Below this threshold value, EF is affected in a dose-dependent fashion [2]. After prolonged ADT (>3 months), there is generally a decrease in nocturnal penile tumescence in terms of frequency, degree of rigidity, duration, and volume of erection [2].
Management of ED involves the use of any medication or device to maximize recovery of EF. Treating ED is important for endothelial and smooth muscle protection, neuromodulation, and reduction in corporal fibrosis [1].
The currently available options for ED management include:
· Oral medications (phosphodiesterase type 5 inhibitors [PDE5-Is: sildenafil, vardenafil, or tadalafil])
· Intracorporeal injections (ICI)
· Intraurethral suppository or cream containing alprostadil that dilates the penile blood vessels
· Vacuum erection device (VED)
· Sexual counseling
· Pelvic floor exercises
· Combinations of the above
· Penile implant: malleable or inflatable as last resort
With the increasing number of sexually active patients undergoing treatment for pelvic cancers, and improvements in cancer survival rates, the restoration of sexual function has become increasingly important to men, couples, and clinicians. Reduced sexual interest can result in withdrawal of emotional and physical intimacy and may result in significant patient and partner distress [2].
Compared with postprostatectomy patients, patients treated with radiotherapy (EBRT or BT) may be less motivated initially to start or remain compliant with a sexual rehabilitation regimen, especially as the addition of ADT will normally reduce sexual interest and drive [2]. Furthermore, there is a delayed pattern of ED development/EF recovery (up to 2 years following end of RT and up to 12–18 months after cessation of ADT) [2]. The rationale for EF restoration must be communicated clearly to men (and partners with the man’s consent) with verbal and written information about the immediate and long-term impact of RT/ADT on their sexual lives. The inclusion of partners is important in ED management decisions, wherever possible, because female sexual function can be significantly affected by the partner’s ED. A supportive partner is an essential part of any penile rehabilitation program [2]. This also applies to men having sex with men.
Delayed penile structural changes created by RT necessitate early intervention to try to preserve EF and reduce impact of RT-induced fibrosis. Longer term ADT is associated with worse outcomes, especially regarding loss of sex drive or libido, and the benefits of early sexual rehabilitation interventions may not be immediately apparent to men with low sexual interest or delayed development of ED [2].
A recent review discussed a series of the more neglected sexual side effects of radical prostatectomy, including orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasm-associated pain (OAP), penile shortening (PS), and penile deformity [3]. The review concluded that these side effects seem to reduce over time [3]. Furthermore, daytime incontinence, previous TURP, a lack of nerve sparing, and previous erectile dysfunction were all factors associated with these side effects [3].
The goal of EF management strategies in men undergoing cancer treatment is restoration or maintenance of assisted and nonassisted EF and prevention of treatment-induced structural changes in the penis. Male sexual rehabilitation is presented in this section, and EF restoration strategies following cancer treatment are briefly discussed.
26.2 Assessment
Table 26.1 outlines predictive factors associated with post cancer treatment ED. Baseline EF is an important predictor of post-treatment EF [1]. It is therefore important to manage patient and partner expectations by assessing EF before cancer treatment.
Table 26.1
Factors associated with erectile function after cancer treatment [1, 2]
|
Patient and partner age – older age is associated with ED |
|
Pretreatment EF (including preoperative use of PDE5-I) – better pretreatment sexual function is associated with better outcomes |
|
Comorbidity status at the time of surgery (fewer comorbidities are associated with lower risk of ED) |
|
Current medications |
|
Sparing Surgical technique (plan for NS surgical technique (unilateral/bilateral or not) |
|
Prostate-specific antigen level (lower levels at baseline associated with better outcomes) |
|
Lower cancer grade/risk category associated with better outcomes |
|
Lower body mass index is associated with better EF |
|
Testosterone levels – normal levels at pretreatment are important for recovery of EF |
|
Metabolic status |
|
General lifestyle factors, e.g., smoking, obesity, exercise, etc. |
Generally, discussions of psychosexual concerns tend to be marginalized in medical consultations, and there are limited opportunities for couples to discuss the impact of treatment on sexual functioning [1]. Patients with partners who are involved in their treatment plans tend to maintain sexual motivation [1, 2, 5] and have demonstrated improvements in measures of sexual function and quality of life [1, 2, 5]. Satisfactory preoperative female partner sexual function has been shown to correlate with greater patient compliance with the EF rehabilitation program [1]. Patients should therefore be encouraged to take their partners of either sex to appointments in the ED clinic, and sexual health assessment for partners is also advisable.
Baseline assessments of EF before initiation of treatment for pelvic cancers should involve [1, 2]:
· Discussion of ED and its management options with patient, as well as assessment of current sexual function
· Assessment of comorbidities, current medications, current medical history, previous medical surgical, and medication history
· Review of general lifestyle factors, e.g., smoking, obesity, exercise, metabolic status, e.g., men of healthy weight (lower body mass index)
· The wish for more children; discuss sperm storage if necessary
· Assessment of psychological factors (sexual self-esteem/confidence), relationship issues, and any issues of a social context that impact on sexuality or that are affected by the sexual dysfunction, e.g., reduced penile size, loss of ejaculation, etc.
· IIEF/SHIM/verbal assessment
· Discussions about the partners’ sexual function, because partners may require intervention, e.g., vaginal estrogen/lubricants, etc., if they are to support rehabilitation efforts of the patient
The International Consensus of Sexual Medicine (ICSM 2001) recommends that clinicians discuss ED prevalence rates, the pathophysiology of ED, the predictors of EF recovery, and sexual rehabilitation, and its potential benefits should be discussed with patients [6]. Once ED management is initiated, reassessment should occur regularly (at least every 3 months).
26.3 Management Strategies
26.3.1 Initiation of an ED Rehabilitation Program
Earlier ED management (immediately or within 6 months post cancer treatment) is associated with improved outcomes, namely [1, 2]:
· Minimization of the severity/duration of ED
· Improvement of cavernosal oxygenation
· Endothelial protection
· Prevention/minimization of cavernosal structure changes
· Maintaining sexual practice and intimate casualness
26.3.2 ED Management Algorithm After Cancer Treatment
A typical management algorithm employed in clinical practice for ED post-treatment for cancer is shown in Fig. 26.1.
Fig. 26.1
(a) Managing ED post surgery. (b) Managing ED post-RT/ADT
26.3.3 Duration of Treatment
The duration of any management strategy depends on the underlying cause of ED and the specific pelvic cancer treatment used. An individualized management approach in this patient population is very important. The decision to stop ED treatment must also be individualized, as strict time limits are considered inappropriate [2].
26.4 Testosterone Deficiency
A longer duration of ADT results in a decreased likelihood of testosterone level recovery [2]. Testosterone deficiency can also be a late side effect of radiation therapy [2]. Most men recover testosterone levels after long-term ADT or RT to some extent, depending on their age, but recovery of “normal” testosterone levels is slow, and few recover potency and sexual desire [2]. Lower levels of testosterone have been associated with the development of ED [2]. However, the testosterone threshold value below which desire is affected remains poorly defined [2]. Therefore, it is advisable to check baseline testosterone levels at the assessment stage to consider initiating psychological counseling and/or PDE5-Is before cancer treatment.
26.5 Rehabilitation Algorithm
The erectile rehabilitation algorithm for patients post cancer treatment is summarized in Fig. 26.1. In general, after surgery, the first-line treatment consists of early use of PDE5-Is (daily +/− on demand) +/− VED, followed by the addition of intraurethral suppositories/ICI and implant if these strategies fail. It is also possible to initiate PDE5-I before surgery (if preexisting problems have been identified at presurgical assessment) or at catheter removal to improve outcomes (provided the patient is in agreement to do so). However, for nonnerve-sparing surgical procedures, PDE5-I drugs are not generally useful. For such patients, VED is generally the treatment of choice +/− ICI/intraurethral alprostadil and sexual counseling [1].
Early use of VED following RP also facilitates early sexual intercourse, early patient/spousal sexual satisfaction, and maintenance of penile length/girth, and, potentially, an earlier return of natural erections [1].
The RT or ADT patients should initially be prescribed PDE5-Is (generic sildenafil is the most cost-effective), with/without VED, to be used twice a week at a dose that gives them a penetration hardness erection. On the remaining five nights, they are advised to use sildenafil 25 mg when going to bed at night. Daily tadalafil which has a longer half-life is an evidence-based alternative [2]. For the ADT patients, psychosexual therapy and counseling should be considered as first-line options before initiation of PDE5-Is.
Intracavernosal injections are the second-line therapy recommended for RT/ADT patients [2]. ICI are usually more effective than PDE5-Is in men receiving ADT [1, 7]. ICI injections are recommended up to three times per week, while taking low-dose PDE5-I on the days that the patients do not inject [7]. Patients are advised that using ICI with a PDE5-I may increase the likelihood of priapism.
Psychological and sexual therapy and counseling emerges as an important adjunct to any rehabilitation program and treatment of postoperative ED [1, 2]. Use of psychosexual therapy/pelvic floor exercises with the treatments depends on patient preference.
Table 26.2 provides rehabilitation recommendations for the management of erectile dysfunction after cancer treatment.
Table 26.2
Rehabilitation recommendations
|
Postsurgery |
Post-ADT or RT (including brachytherapy) |
|
Pretreatment |
|
|
Involve the man and his partner in discussions about erectile function rehabilitation before and after treatment |
|
|
Assess pretreatment EF |
|
|
Assess comorbidities and current medications which can impact EF Assess biomedical components, including the disease, treatment, current medications, current medical history, previous medical and surgical history, and ED medication history Assess baseline testosterone levels Assess psychological factors, relationship status, and any social factors that could impact EF |
|
|
Initiation of rehabilitation program |
|
|
Initiate early – within 1 month of surgery or within 3–6 months of RT/ADT (can initiate presurgery if EF issues identified at baseline assessment) Early high-dose PDE5-I may preserve the smooth muscle content within the corpora cavernosa VED is a useful adjunct to medication and facilitates early sexual activity where drugs alone are not effective |
|
|
Management options |
|
|
Consider first-line treatment with combination therapy Consider daily PDE5-I therapy in patients with nerve-sparing surgery, especially during initial (early) management (although level 1 evidence is lacking for superiority of on-demand vs. daily treatment) For nonnerve-sparing procedures, VED is generally the treatment of choice +/− ICI or intraurethral alprostadil |
Encourage adoption of exercise program and lifestyle changes. Consider first-line treatment with low-dose PDE5-I daily (with higher doses given, on demand × 1 per week minimum if required) Combination therapy may be needed for some patients (generally PDE5-I + VED) Use the most effective PDE5-I at optimal dose level on at least eight occasions before switching to drug/management strategy Add VED to PDE5-I monotherapy as a second-line option |
|
Add intraurethral alprostadil/ICI followed by discussion of penile implants if these initial treatment strategies fail |
Add intraurethral alprostadil/ICI followed by implants if initial treatment strategies fail |
|
Psychosexual treatment |
|
|
Recommend psychosexual therapy or psychological counseling for patient and partner pre- and post-treatment: Psychosexual therapy and counseling contribute to better biomedical treatment efficacy, patient acceptance, and compliance Encourage partner support of rehabilitation program through ongoing psychosexual therapy and counseling for the couple, and unless contraindicated, include partners in all decision-making processes Psychosexual therapy and psychological counseling are a useful adjunct to ED rehabilitation treatments Psychosexual therapy, especially for patients on ADT with persistent low desire + individual/couple distress Counseling to assist couples in adjusting to permanent changes in sexual function |
|
|
Reassessment |
|
|
Once ED management is initiated, reassess at regular intervals post-treatment, preferably every 3 months |
|
|
Treatment duration |
|
|
Try each strategy on at least eight occasions before switching to another strategy, unless the patient experiences adverse events warranting an early switch Individualize duration of treatment for each patient as strict limits are inappropriate in clinical practice The duration of any treatment can range from 3 months until the patient no longer needs the treatment |
|
Adapted from Kirby et al. and White et al. [1, 2]
26.6 Concluding Remarks
Men undergoing pelvic cancer treatments are at increased risk for ED. Erectile function after treatment depends on several factors that must be taken into account for adequate patient stratification and therapy. There are several options for managing ED post cancer treatment. The treatment duration may range from 3 months to as long as it is needed by the patient, with regular reviews. Longer delay of the start of rehabilitation for ED is associated with poorer outcomes for EF. Early ED rehabilitation can facilitate early sexual intercourse, improve sexual satisfaction, and potentially an earlier return of natural/unassisted erections sufficient for vaginal penetration.
In this chapter, we have discussed a comprehensive ED management algorithm to promote assisted or unassisted EF support for men experiencing ED associated with cancer treatments. Some men achieve assisted erections with PDE5-I use, while others benefit more from a combined ED management approach incorporating conservative approaches such as psychosexual counseling and exercise programs with biomedical interventions and other erectile aids.
In addition to managing a patient’s ED, it is imperative that the patient understands the rationale for proactive EF restoration strategies and that their expectations are managed.
26.7 Check List: Important Matters to Discuss with Patients and Partners
Adapted from: Prostate cancer and your sex life. Prostate Cancer UK. January 2015 [8]
Sex is an important part of life. Dealing with a diagnosis of prostate cancer and living with the side effects of treatment can have an impact on your sex life. Many men with prostate cancer struggle with changes to their sex lives, and relationships are some of the biggest issues they have to deal with.
Having treatment for prostate cancer can affect:
· How you feel about yourself sexually
· Your desire for sex (libido)
· Ability to get an erection (erectile function)
· Ejaculation and have an orgasm
· Satisfaction with sex
· Fertility
· How your body looks
· Relationships
Many men with prostate cancer will have sexual problems before treatment. It is normal for our sex lives to change as we get older, and problems with erections are more common in older men, and treatment for cancer compounds this problem. But that does not mean there is nothing you can do about them.
26.7.1 Practical Advice After Surgery
· It is safe for you to have nighttime erections and masturbate when you feel like it after surgery.
· With keyhole surgery, you can have sex when you feel like it once your catheter is removed.
· After open surgery, wait until the wound has healed, and it feels comfortable before you try having sex.
· Erection problems vary depending on whether the surgeon can save the nerves that control erections.
· Erections can gradually improve, but not all men get their erections back.
· Your penis may become slightly shorter.
· You won’t produce any semen but can still orgasm.
· You won’t be able to father a child naturally (infertility).
26.7.2 Practical Advice After Radiotherapy Treatment
· It is safe for you to have sex or masturbate as soon as you feel like it.
· You may need to use contraception for at least 1 year after treatment.
· If you are gay or bisexual and receive anal sex, wait until any bowel problems or sensitivity in this area has gone.
· Erection problems can gradually develop after treatment.
· You may find ejaculation uncomfortable.
· You may produce less or no semen but can still orgasm.
· You may have fertility problems.
26.7.3 Practical Advice After Seed Brachytherapy
· Wait at least 1 week before you try having sex or masturbating.
· It is rare for seeds to come out in your semen, but use a condom during sex the first five or six times after treatment.
· If you are gay or bisexual and receive anal sex, wait until any bowel problems or sensitivity in this area has gone. There is a risk in the first few months that your partner might be exposed to some radiation during sex.
· Erection problems can develop some time after treatment.
· You may produce less semen but can still orgasm.
· You may have fertility problems.
· Your penis may become shorter, and, if you are on hormone therapy, your testicles may get smaller.
· You may produce less semen and have less intense orgasms.
· You can’t pass on cancer to your partner through sex.
· Having sex will not affect your prostate cancer or the success of your treatment.
· Having sex has no effect on the chances of your cancer coming back.
· It’s safe to have erections when you have a catheter in.
26.7.4 Top Tips for Keeping Your Sex Life Going
· It can be difficult to talk about sex, but talk to your doctor or nurse about your worries.
· Some of the treatments for erection problems can seem artificial, and you may feel like you lose the moment. With a little understanding and patience, you can overcome some of the embarrassments and difficulties. Some couples even use the vacuum pumps or cream or pellets, as part of their foreplay.
· Encourage your partner to come to appointments with you. Try to use treatments with your partner in the room as it may be helpful if they know how they work. Sex therapy may help you work through changes to your sex life.
· Keeping a healthy weight and being physically active can help with erection problems.
· Physical activity can help you to get back to sexual activity. It can also improve your energy levels, lift your mood, and help with some of the side effects of treatment, such as fatigue.
· If you do not feel interested in sex, then let your partner know. If possible, explain why and how you feel – as your partner may feel rejected. Try and talk about other ways you can be intimate together, whether sexually or not, kissing and cuddling are very helpful.
· Encouraging blood flow to the penis after surgery may improve erections and prevent your penis becoming smaller. In particular, using a vacuum pump with or without PDE5 tablets may help maintain your penis size and improve erections.
· If you have had surgery, you might leak a small amount of urine when you orgasm. This is called climacturia. Although it could be a shock at first, urine is germ-free and safe. If it bothers you, you could try:
· Urinating before you have sex
· Wearing a condom
· Having sex in the shower
· Having sex on a towel, or keeping towels or tissues nearby
· Using a tight constriction band round the base of the penis (especially relevant when urine is lost during oral sex)
· Sex and masturbation may be an important part of your life and a way to be close to your partner. Masturbation and sex may be a way of having fun, relaxing, coping with difficult times, or boosting self-esteem and happiness.
· There are ways to tackle these issues and find solutions that work for you. Even though your sex life is unlikely to be the same as it was before cancer, you do not have to give up on having pleasure, closeness, or fun together. It can help to be realistic but flexible in your approach to sex. Try sex toys and visual stimulation. You may not find a quick fix, but keeping some kind of physical closeness alive, in whatever ways possible, can protect or even improve your relationship.
· Make opportunities to be together in a room that is warm and comfortable, and take some time to be physically close. Try some mutual massage sessions. You could start with massage that avoids the sexual parts of the body and then add some genital touching later or at another time. Take things slowly, and later add in a session when you spend more time touching each other’s genitals – which may lead to orgasm. If men relax and use all the senses, they can have an orgasm with a soft (flaccid) penis.
References
1.
Kirby MG, White ID, Butcher J, et al. Development of UK recommendations on treatment for post-surgical erectile dysfunction. Int J Clin Pract. 2014;68:590–608.CrossRefPubMed
2.
White ID, Wilson J, Aslet P, et al. Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer. Int J Clin Pract. 2015;69:106–23.CrossRefPubMed
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Frey AU, Sonksen J, Fode M. Neglected side effects after radical prostatectomy: a systematic review. J Sex Med. 2014;11:374–85.CrossRefPubMed
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Mulhall JP, Parker M, Waters BW, et al. The timing of penile rehabilitation after bilateral nerve-sparing radical prostatectomy affects the recovery of erectile function. BJU Int. 2010;105:37–41.CrossRefPubMed
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Campbell SE, Glazener CM, Hunter KF, et al. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2012 Jan 18;1:CD001843.
6.
Hackett G, Kell P, Ralph D, et al. British Society for Sexual Medicine guidelines on the management of erectile dysfunction. J Sex Med. 2008;5:1841–65.
7.
Stember DS, Mulhall JP. The concept of erectile function preservation (penile rehabilitation) in the patient after brachytherapy for prostate cancer. Brachytherapy. 2012;11:87–96.CrossRefPubMed
8.
Prostate Cancer UK. Prostate cancer and your sex life. Jan 2015. https://prostatecanceruk.org/prostate-information/our-publications/publications/prostate-cancer-and-your-sex-life.