Anejaculation is the norm after radiation therapy to the prostate


There is a widespread misunderstanding that radiation therapy as a treatment for localized prostate cancer will allow the patient to have or recover normal ejaculatory function after treatment. Let us be very clear that this is not usually the case at all.

A new study by Sullivan et al. has helped to confirm the accuracy of this statement.

Within the Sexual and Reproductive Medicine Program, which is part of the Urology Service at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York of the sexual health evaluation for post-RT patients, men are routinely evaluated after their treatment for localized prostate cancer and are provided with information regarding their ejaculatory function and orgasm.

Sullivan et al. carried out an analysis of their database in which they excluded all men with a prior history of radical prostatectomy, cryotherapy, focal therapies, and androgen deprivation therapy (ADT). In other words, they isolated the patients who were treated with some forms of radiation therapy.

Here are the results of their analysis:

  • The basic data included 364 consecutive patients.
    • 252/364 patients (69.2 percent) had been treated with external beam radiation therapy (EBRT)
    • 112/264 patients 30.8 percent) had received brachytherapy (BT).
  • The average (mean) age of the patients was 64 ± 11 years (range, 42 to 78 years).
  • The mean follow-up after RT was 6 ± 4.5 years.
  • The mean prostate size at time of radiation therapy was 42 ± 21 g.
  • 262/364 patients (72 percent) had lost the ability to ejaculate in an antegrade fashion after prostate radiation therapy by the time of their last visit to the sexual and reproductive medicine clinic.
    • 16 percent had experienced anejaculation at 1 year post-therapy.
    • 69 percent had experienced anejaculation at 2 years post-therapy.
    • 89 percent had experienced anejaculation at 3 years post-therapy.
  • For men completing at least two International Index of Erectile Function (IIEF) questionnaires, orgasm domain scores (which range from 0 to 10) decreased dramatically over the follow-up period.
    • At < 12 months post-therapy, the orgasm domain score averaged  7.4.
    • At 13 to 24 months post-therapy it averaged 5.4.
    • At 25 to 36 months post-therapy it averaged 3.2.
    • At >36 months post-therapy it averaged 2.8.
  • Factors predictive of anejaculatory status included older age, concomittant ADT, radiotherapy dose > 100 Gy, and smaller prostates at the time of radiation therapy.

Sullivan et al. conclude that “The vast majority of men after prostate [radiation therapy] will experience anejaculation and should be counseled accordingly prior to undergoing therapy.”

Many patients are apparently under the impression that radiation therapy only affects the cancerous cells in their prostates and that the normal (“healthy”) cells will be unaffected by radiation therapy. This is simply not the case.

Radiation of the prostate is designed to kill all cells in the gland if at all possible. It therefore has the same effect on the functioning of the prostate as radical surgery because (to all intents and purposes) there should be no living prostate tissue a year after the radiation is complete. The reason that there almost always is a small amount of living prostate tissue is that the radiation commonly does not, in fact, kill all of the normal prostate cells, which is also why PSA levels do rise slightly after first-line radiation therapy and don’t drop to undetectable levels. However, the amount of living prostate tissue that remains is normally far too small to permit normal ejaculatory function and normal orgasmic function.

24 Responses

  1. My urologist did no pre-radiation warning of side effects. What are the chances of a successful law suit?

  2. Robert:

    That is a legal question that you would need to take up with a specialist in medical malpractice law. We really can’t offer you any guidance on this question.

  3. It is not true that radiation is designed to kill all the cells of the prostate. Healthy cells are able, within hours, to repair the double-strand breaks caused by radiation, whereas cancerous cells cannot. However, radiation does impair the ability of healthy glandular cells to produce glandular secretions. For example, salivary glands typically lose the ability to produce saliva after irradiation for head and neck cancers. There are a variety of histopathological effects that may occur because of radiation on healthy prostate tissue, including cellular changes, inflammation, glandular atrophy and hyperplasia; however, necrosis does not occur.

  4. Dear Allen:

    I am not sure whether you are a radiation oncologist or other scientist. While it certainly true that healthy cells can repair breaks in the DNA introduced by radiation, my understanding is that one of the reasons that radiation therapy for prostate cancer is given over many doses and many weeks because one is commonly so uncertain about exactly which cells are actually cancerous in the prostate that is is essential to try to induce necrosis in the entire organ.

    In certain types of radiation therapy (such as combined brachytherapy + EBRT), the specialists who deliver this type of radiation actually set out to drop a patient’s PSA down to undetectable levels, just as a surgeon would be removal of the prostate. That wouldn’t be happening if the normal prostate cells were surviving the treatment. If radiation therapy is not inducing necrosis of healthy cells, then why is anejaculation such a problem after radiation therapy, surely this should recover over time as opposed to getting steadily worse as healthy cells die off?

  5. The reason that standard fractionation protocols exist is because of the 4 Rs: repair of DNA damage, redistribution of cells in the cell cycle, repopulation, and reoxygenation of hypoxic tumor areas. This has to do with cancerous cells only. The radiation causes many double-strand breaks in the DNA of all cells, mostly by inserting hydroxyl radicals (and other reactive oxygen species) into the DNA. Cancer cells lack the machinery for repairing that. Healthy cells will either repair themselves, of, if they cannot, will undergo apoptosis (programmed cell death).

    Cancer cells are more susceptible to be killed when they are actively dividing. They may go into a hybernation-like phase after DNA injury occurs. Then, when they try to divide, sometimes years later, the DNA damage catches up to them, and they die when they unsuccessfully replicate. Healthy cells repair during their resting phase within a few hours. Repopulation is especially troublesome in very actively growing cancers, like head and neck cancers, where the cancer grows faster than the radiation can kill them, so they have to be irradiated very frequently — sometimes several times a day. Because oxygenation is essential to generate those cancer-killing hydroxyl radicals, tumors can survive in hypoxic areas. With repeated treatment, layers of hypoxia are stripped away until the entire tumor is susceptible to oxygenation and consequent destruction.

    Some types of cancers are better killed by slow steady bombardment, and IMRT protocols (40 fractions @ 2 Gy) were developed assuming that was the case for prostate cancer too. Then with the remarkable success of HDR brachytherapy in the 1990s, that assumption was called into question. Prostate cancer is relatively unusual in that it is better killed (and healthy tissue better spared) by fewer more intense treatments. This parameter is called the alpha-beta ratio of the tissue, which is now thought to be very low, about 1.5 Gy, for prostate cancer cells. This means there is a multiplier effect, so that using a high dose, few treatment protocol (hypofractionation) the net cancer cell kill can be greater than standard IMRT while using less than half the total dose. This led to the development of SBRT treatment protocols, like CyberKnife (5 fractions @ 7.25 Gy).

    (BTW- I believe the only reason SBRT has not completely replaced IMRT for primary PC treatment is economic — radiation oncologists make twice as much from IMRT, and the capital outlay is huge. Once a low alpha-beta ratio is admitted, there’s no justification for the IMRT protocol.)

    With radiation, including brachytherapy + EBRT, it is never the goal for the PSA to become undetectable. There will always be enough PSA-producing cells to secrete measurable, albeit low, amounts of PSA into the serum.

    The functional result in terms of ejaculation is the same whether the prostate is irradiated or removed because the induced histopathological effects of radiation appear to be permanent, sadly. The prostate doesn’t become necrotic — even years later it can be biopsied and healthy tissue examined. However, the semen-producing glands do dry up and atrophy. It is true that eventually salivary glands generally recover at least some function a long time after radiation. Other gland types do not recover at all. Perhaps someday there will be a genetic switch to turn the function back on.

    I was a medical researcher long ago, as you surmised.

  6. So here we have it. …

    90% of patients undergoing radiation therapy are unable to ejaculate at 3 years post-treatment.

    Some urologists and presumably some radiation oncologists are telling their patients that no side effects can occur from radiation therapy.

    Some patients believe they can be exposed to radiation intended to destroy cancer cells in their body yet spare them any possible side effects.

    I guess we still have much work to do.

  7. I am not disagreeing with you but at least some radiation oncologists (e.g., Critz et al) who have been avid appliers (rightly or wrongly) of the combination of brachytherapy + EBRT would appear to do so since they argue vehemently that their data show that they can reduce PSA levels post-treatment to stable nadir levels of < 0.1 ng/ml, i.e., comparable to the undetectable levels seen in men treated surgically.

    This would seem to be a somewhat academic discussion, in any case, if what you are saying is that some healthy cells remain after therapy (which I have never disagreed with) but that to all intents and purposes the prostate is non-functional from an ejaculatory point of view after radiation therapy — which was the point of the original commentary.

  8. The dialogue between Allen and Sitemaster is indeed an intriguing one, and I hope Allen returns to respond. My limited understanding is that complete “necrosis” does not occur, lest the gland truly die and degrade in situ, promoting possibly life-threatening infection. Hence, my view is closer to Allen’s. In fact, many men undergoing RT are “cured” whilst maintaining a PSA level between 0.50 and 1.0 (or even higher), suggesting live glandular tissue remaining post-therapy.

  9. Dear Dr. Kelly:

    I’d be very surprised if any urologists or radiation oncologists were actively telling their patients that “no side effects can occur from radiation therapy.”

    Rather, I suspect what is happening here is the sin of omission, such that at least some doctors are failing explicitly to educate their patients about the wide range of complications and side effects associated with radiation therapy. My bet would be that if one read carefully through the treatment agreement that most of those patients signed prior to initiation of therapy, it would actually include a detailed listing of the known complications and side effects of radiation therapy … but that’s not the same as making sure that one’s patients actually understand what they have been asked to sign.

  10. Does lack of ejaculation ruin sex?

    Are there supplements that can be taken to protect non-cancerous cells?

  11. Doug:

    Re your first question. If your interest and pleasure in sex is primarily focused on your own ability to ejaculate, then yes, lack of the capacity to ejaculate will profoundly impact your attitude to sex. However, a lot of men think rather differently about what is important to them in their sex lives.

    Re your second question, I am not aware of any supplements that have ever been proven to have such effects … but all sorts of supplement manufacturers are well known to make all sorts of claims.

  12. >>>
    Does lack of ejaculation ruin sex?
    <<<

    "Orgasm" and "ejaculation" are two different things. After my prostatectomy, ejaculation, and erections, were gone. But orgasmic capability remained (and remains) intact.

    So lack of ejaculation changes sex, but it doesn't necessarily ruin sex.

    Charles

  13. Discussion between Allen and Sitemaster

    Thank you both for going over some key issues. (Allen, I’m delighted to see you posting here. I’m trying to maintain some internet activity but have been really short of time over the past year.)

    Having had to look at radiation carefully over the past year, in preparation for my currently ongoing course of TomoTherapy (21 sessions down out of 39), all that Allen has stated is credible to me, and I also appreciate Sitemaster’s comments that put the end results in a practical perspective.

    I’ll add some additional thoughts separately.

  14. MSKCC’s COMMENTS/RESEARCH REGARDING ORGASM DECLINE

    Dr. John Mulhall, the world-class expert at MSKCC in sexual aspects of prostate cancer treatment, is the senior author of this study. I’ve had the good fortune to hear him present at least twice at one of the annual conferences on prostate cancer that take place in the LA area in September. I’m glad the MSKCC group has presented findings about radiation and sexual consequences.

    The research about ejaculation is credible to me, but I have doubts about the orgasm research, doubts not because of the quality of the research, but because of possible – I think likely – confounding factors.

    The results reported by Sitemaster were that

    For men completing at least two International Index of Erectile Function (IIEF) questionnaires, orgasm domain scores (which range from 0 to 10) decreased dramatically over the follow-up period.

    At 36 months post-therapy it averaged 2.8.

    Here are a few points that seem relevant to me.

    First, the group of men in the research were a fairly typical group of prostate cancer patients who received radiation from an age perspective – 64 years, with an average follow-up of 6 years, which would put the average patient at age 70 at the end of the study. This age range is one where there is a substantial loss of orgasmic ability even for healthy men. While my layman’s impression is that the losses reflected in the study indicate that radiation is contributing to the loss for many men, I suspect the loss would be nowhere near as steep if normal aging were factored out. I’ve checked the abstract but do not have ready access to the full paper, and I’m wondering if the MSKCC team tried to adjust for the aging effect.

    I’m also curious what the baseline orgasm score was. In a group with an average age of 60, I suspect it was well below 10 even prior to the start of radiation. That’s an important fact from my viewpoint, and I’m a little surprised the authors did not provide the baseline score. Possibly that data was not collected.

    Second, Dr. Mulhall is a strong advocate of countermeasures to preserve sexual ability. I’m curious whether the full paper addresses whether all or some of the men were using countermeasures, specifically Viagra, Cialis and like drugs, or other measures to maintain erectile function and interest in sex. My hunch is that there was little use of countermeasures, possibly because the research was done before the need for countermeasures was recognized. What we really also need is a study of orgasmic ability for comparable men on radiation who WERE using countermeasures. I suspect that no one has that data at present, or at least that it is not yet sufficiently mature.

    I’m thinking that orgasmic function will ultimately turn out to be much better than reflected in the research for men who use countermeasures. That is the case for those of us on hormonal therapy intermittently, at least according to leading medical oncologists who specialize in prostate cancer exclusively. The analogy with hormonal therapy helps illuminate the potential of success with radiation, I think. It was once thought that potency and libido were essentially lost for those of us on hormonal therapy. Now, with countermeasures, that is clearly not true for many of us, though also clearly sexual aspects are more challenging and for many of us there is substantial impact. As a 13 years and counting survivor on intermittent hormonal therapy throughout that time, including 75 months on Lupron shots and counting, it is credible to me that countermeasures are at fairly effective. By the way, at least based on his conference talk a couple of years ago, it appeared to me that Dr. Mulhall was not that familiar with the effectiveness of countermeasures to aid patients on hormonal therapy. I hope and believe that will change.

  15. I understood the main reason to combine IMRT with brachytherapy was to achieve coverage of the pelvic girdle. This is what Mack Roach pushes.

    The IMRT portion is not focused on the prostate gland but on the bed, lymphatics, and more remote areas where cancer may reside. This may well be why the PSA approaches a very low nadir.

    In my own case, it took 5 years but my last PSA test did show a PSA of < .1, notwithstanding it had gotten as high as 1.0 post-radiation and after 2+ years of androgen deprivation therapy.

  16. Dear Rick:

    You’d have to ask Mack Roach, but I don’t think that he would think particularly highly of the way that Dr. Critz’s group applies the combination of brachytherapy and external beam radiation therapy (so-called ProstRCision”).

  17. Jim, you are one of my favorite net people, and I find your posts are always insightful and most welcome. I agree with you completely that most of these studies that report sexual EPIC or SHIM/IEFF-5 scores fail to account for the long-term natural decline. If I were reporting it, I would index the score by age (this data is presumably available from the validated measurements of these popular tools). An age-indexed score would be independent of age, so that we could proceed to determine the degree to which it is affected by other variables, like baseline age-indexed score, treatment type, ADT use, and co-morbidities (e.g., diabetes, heart disease, obesity, drug use, etc.).

    For me, anejaculation detracts from my perception of the pleasure of orgasm although I’m finding that with some mindful mental adjustments, that need not be so. For over 45 years, I associated the pleasure of orgasm with the sight, feeling and scent of ejaculation. That kind of strong conditioned response is not changed without some effort. Perhaps some kind of psychotherapy like Mindfulness or Cognitive Behavior Therapy could be routinely taught to men who are treated.

  18. Aloha,

    My field of work was radiation physics. I was diagnosed with 12 of 12 cores containing prostate cancer and was treated with IMRT (Sept/Oct 07), half to the pelvic cavity, the other half to the prostate. Ultrasound was used before each dose of radiation to target the dose. The gross dose was more than 90 Gy over the 2-month treatment. In July 2012 my bladder and prostate were removed. There was sign of prostate cancer.

    At first I believed along the lines of Allen’s statements about radiation damage to healthy vs. cancerous tissue. The side effects of IMRT to the pelvic cavity were difficult and began during the third week of treatment with fecal incontinence. The damage to the bladder and prostatic urethra became evident about 2.5 years later.

    After 1.5 years of pain management and antibiotics I asked for a uro-ostomy. After 3 months of testing my urologist said it was too risky and referred me to a uro-oncologist. After 4 months of testing, he agreed.

    An MRI showed what appeared to be bone marrow damage in the pelvic cavity.

    It is clear to me there are upper dosing limits beyond which healthy tissue can’t recover.

    Back to the subject, anejaculation, I was started on ADT several months before IMRT and have experienced anejaculation ever since.

    Joe

  19. Thank you for clarifying the situation.

    My experience:

    D — Radiation will damage the DNA of the cancer cells, thus these will not reproduce; the non-cancerous cells will repair themselves.
    P — Therefore fluid will return
    D — No, it will eventually stop
    P — But if the heathly cells can produce …
    D — Eventually there will be no fluid. Period. End of discussion.

    Now I have a more complete explanation.

  20. Hi Joe,

    I’m responding to your post of April 2 at 5:34 PM about your experience with IMRT. I’m sorry that you have had such a rough time. We all take certain risks, and sometimes the consequences are harsh.

    I’m a not sure I understand the dosing you received. I’m thinking you got 90 Gy to the prostate but with a substantial dose also to the pelvic area. (Half of 90, or 45 Gy, to the prostate would have been far below the standard for 2007, leading me to think you got 90 Gy to the prostate.)

    I know that MSKCC was exploring doses above 80 even earlier than 2007, but my somewhat hazy impression is that their top dose by IMRT alone was around 84, or perhaps 86 Gy. I’m fairly sure they were reporting somewhat greater effectiveness but also greater side effects at such doses, as compared to their earlier well-documented success with doses around 78-81 Gy with IMRT. I’m thinking that upping the IMRT dose to 90 Gy would have risked a clear jump up on the “ouch” scale. It’s understandable to me that a dose of 90 Gy delivered by IMRT alone (as contrasted with a brachytherapy component), especially when guided only by ultrasound, could well be toxic to healthy prostate cells, though I’m speculating as a layman with a still unfirm grasp of radiation.

    If you care to share more of your experience, were you under a special protocol, or, with your professional background, were you asking for extra radiation because of the 12 positive cores? You wrote that there “WAS sign of cancer” after treatment in your bladder and prostate when they were removed. Did you mean that or inadvertently omit the word “no” after “was”.

  21. Hi Sitemaster. I’m responding to your post of April 1 at 9:05 PM. My bottom line: Dr. Critz’s research may be misleading regarding the extent of healthy cells remaining after radiation, but it may also unfortunately, ironically, underestimate the success his group is achieving despite the group’s effort to put its best foot forward. Some of us have been following the RCOG story for some time, not with unalloyed enthusiasm. Here’s my take.

    AN UNFORTUNATE “ARTIFACT” IN DR. CRITZ’S DATA?

    Last month, Dr. Critz, leader of the RCOG group in Atlanta, and colleagues at long-last published long-term results after years without updating their series: their 25-year follow-up data for their combination of seeds first then external beam radiation, as reported on this site. I obtained a copy of the full paper courtesy of my local hospital’s medical library.

    My primary reaction to the paper is that the results indicate a “glass half empty” rather than “half full” for patients with challenging cases. That’s because other series have done substantially better with intermediate- and high-risk patients. I’m specifically thinking of the well-reported research by Drs. Dattoli and Sorace regarding their long-running series of patients getting a rival, somewhat differently designed combo of external beam plus seeds, often with ADT support for more challenging cases. (For instance, using Figure 2b re 15-year success covering the intermediate and high risk groups, the Critz group achieves 73% success for the intermediate-risk group but only 42% for the high-risk group. This contrasts to the Dattoli/Sorace success at “16 years” of 82% for the intermediate-risk group and 74% for the high-risk group, per their 2010 paper. The difference for the high-risk group is striking, though as Sitemaster observed earlier, such comparisons involve their own risks of misunderstanding.)

    However, there is a serious “apples to apples” comparison question here. While the Dattoli team report uses a reasonable but considerably more liberal definition of success (non-recurrence) (including, for some of the key results, nadir + 2 ng/ml for all but the last follow-up), my impression is that the Critz team, in their March paper, uses an exceptionally tight criterion for radiation studies: “Recurrence was defined as a prostate specific antigen increase of greater than 0.20 ng/ml or a prostate specific antigen nadir of greater than 0.20 ng/ml.”

    Advantage to RCOG in using a tight criterion: Use of that either/or criterion allows them greater, though not complete, comparability to RP studies where hitting and exceeding a PSA of 0.2 is the operational definition of recurrence, and clearly the RCOG group is eager to demonstrate success versus surgery. However, that criterion may be so tight, for radiation that leaves many mostly healthy prostate cells, that the recurrence threshold may be busted a fair proportion of the time as a false positive rather than as a true recurrence. (However, it should be noted that the criterion allows some PSA scores to reach 0.4, as I see it [not stated in the paper] before a recurrence would be scored; that would happen for patients with a nadir of 0.2 and a subsequent increase in PSA of 0.2 but not more. Also, the criterion actually applied was somewhat different than the summary, as documented by this statement in the paper: “In men who achieved a PSA nadir of 0.21 ng/ml or greater recurrence was defined at the first PSA increase above the achieved nadir.” That means that some men with a nadir of 0.21 but no subsequent increase would be scored as successes. Frankly, that discrepancy between the summary and actual practice does not foster my enthusiasm for the paper.)

    Disadvantage to RCOG, and to understanding the extent of remaining more-or-less healthy prostate cells (no longer secreting component of semen): RCOG’s success figures no doubt look poorer than they would look if the RCOG authors had used a more liberal and well-accepted criterion like nadir + 2 ng/ml, or some other well-accepted criterion. Unfortunately, the paper does not report results using a more liberal but most reasonable criterion. I have some hope the RCOG folks will appreciate the hole into which they have put themselves and will publish results with a more commonly used criterion for success with radiation therapy.

    Am I missing something here?

  22. Aloha Jim Waldenfels.

    The total dose was about 92 Gy. One half to the pelvic cavity, one half to the prostate. Since the prostate was being zapped during the first half (to the pelvic cavity) and also during the prostate targeted dose, it got the whole 92 Gy.

    I should have said that no prostate cancer or cancer of any kind was detected in the removed bladder and prostate.

    With respect to my line of work, I was not asking for special treatment. The oncologist made the recommendation based on my initial conditions (sorta bad) and work done at universities on the mainland. The idea was to try to get any cancer that might be outside the prostate but was still undetectable.

    Joe

  23. For Doug:

    My own experience with radiation plus 20 months of ADT is that a few months post ADT, and the return of erections, I was, and am still, able to orgasm albeit with anejaculation. It is indeed odd to have normal orgasmic feelings but no ejaculation. There is a very tiny amount of some clear fluid produced that my urologist tells me is some kind of lubricant the body produces.

    I don’t know if my experience is typical but all things considered I am very thankful for regaining as much capability as I have nearly 3 years post-radiation and 18 months post-ADT.

    There is also some very interesting information available on this link regarding post-treatment sexual functionality.

  24. My original urologist did not advise me of the negative after-effects of brachytherapy. These after-effects included blocked urinary flow, catheterization, TUNA surgery, TURP surgery, laser DVIU surgery,suprapubic catheterization, antibiotic therapy, and hyperbaric oxygen therapy. Fourteen years after the brachytherapy I am left with radiation necrosis of the prostate that has created bladder stones and spasms and a fistula that will require colostomy and urostomy sugery. Does anyone out there know of current successful treatment for radiation necrosis of the prostate?

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