Sexual dysfunction among prostate cancer survivors — a new review article

In a newly published article in the Journal of Sexual Medicine, Chung and Brock offer a state of art review of the various types of sexual dysfunction identified among prostate cancer survivors and the management strategies currently available for sexual rehabilitation after treatment.

“Sexual function,” the authors write, “remains an important issue [for] men, who often continue to be interested in sex after prostate cancer treatment.” (This may not come as a complete shock to most of the regular readers of The “New” Prostate Cancer InfoLink!)

Chung and Brock note carefully that prostate cancer treatment-related forms of sexual dysfunction include:

  • Penile deformitions (e.g., Peyronie’s disease)
  • Erectile dysfunction (ED)
  • Loss of or reduction in the level of sexual desire
  • Other mental health-related issues
  • Ejaculatory and orgasmic dysfunctions
  • Changes in partner relationships and dynamics

In other words, the complete spectrum of problems that can lead to sexual dysfunction is wide and complex.

The authors note that there has been a considerable expansion of the volume of data available on prostate cancer-related male sexual dysfunction in recent years. However, the availability of much more data has not necessarily (as yet) led to any massive advances in either the prevention or the effective treatment of the problem.

Here are the key points made by the authors about what we now know:

  • Penile deformities and ED have a shared and similar pathophysiology (i.e., that fibrosis of smooth muscle in the penis ultimately leads to structural alterations and end-organ failure).
  • The early use of oral phosphodiesterase type 5 (PDE5) inhibitors is currently considered to be the standard of care for penile rehabilitation after first-line treatment for prostate cancer.
    • This is particularly the case for men treated with a bilateral nerve-sparing radical prostatectomy.
    • PDE5 inhibitor therapy should be instituted as soon as possible post-surgery to prevent corporal endothelial and smooth muscle damage.
  • There is, as yet, no consensus on the exact timing, dose, and duration of PDE5 inhibitor therapy.
  • There is also no consensus on the impact of PDE5 inhibitor therapy after non-nerve-sparing radical surgery or after other forms of first-line treatment for localized prostate cancer.
  • The literature on such issues as hypoactive sexual desire, ejaculatory dysfunction, and orgasmic dysfunction after first-line treatment for prostate cancer treatment is limited.
  • Psychological and sexual counseling play an important role in rehabilitation and treatment of various forms of male sexual dysfunctions.

The bottom line is that there are still no really specific recommendations or consensus guidelines exist regarding the optimal methods of penile rehabilitation or treatment for sexual dysfunction.

Obviously, most readers who have been faced with this problem will have become aware of such options as Bimix and Trimix injections, the potential value of vacuum erection devices, and other methods to address erectile dysfunction. For carefully selected men, there may also be a place for testosterone supplements (with very careful monitoring to minimize risks associated with prostate cancer recurrence. However, what is clear is that:

  • Men need much greater clarity — prior to making their treatment decisions — of the risks inherent in the first-line treatment of low- and very low-risk prostate cancer, particularly with regard to the potential for impact on sexual function for males who still have a high level of potency and sexual interest pre-treatment.
  • While newer treatments, like high-intensity focused ultrasound (HIFU), appear to offer lower levels of risk of sexual function post-treatment, they are still not risk-free, and we need much better ways to offer effective treatment for localized prostate cancer to men with lower-risk disease (above and beyond just active surveillance).
  • We still need completely new ways to be able to improve sexual function for those men whose need for treatment inevitably leads to an impact on sexual function that, today, is often irreversible (unless the patient is willing and able to consider penile implant surgery).

The impact of male sexual dysfunction on the partners of men who are treated for prostate cancer is still a sadly under-researched topic.

4 Responses

  1. Those of us who have made it a practice to study these side effects of treatment are well aware of the information provided in the referenced article. Dr. John Mulhall of Memorial Sloan-Kettering has addressed these issues and provided recommendations of early use of PDE5 inhibitor (e.g., Viagra, Levitra, Cialis) as well as penile injections to provide arterial blood flow and oxygenation of penile tissue to enhance penile rehab and hopeful earlier return of erectile function. Use of a vacuum erection device (VED) can exercise and help retain penile length, but because the blood drawn in the penis is venous rather than arterial blood, this product does little to nothing as to penile tissue rehab.

    Much more information has to be provided by physicians administering surgical removal of or radiation to the prostate gland regarding their effect on sexual function so that appropriate counseling regarding anticipated side effects and truthful expectations are well known by the patient and his partner before treatment is administered.

  2. Here’s what pisses me off: I had a radical prostectomy 2 months ago. I have not had an erection since. I even talked to my surgeon about it and he prescribed Viagra and gave me literature on a vacuum device. I walked out of his office with both the prescription and the information and little else. Not once has anyone followed up to see how I’m doing, if I need counseling on not being able to perform as a man or if there is anything else that they could do to help me through this very difficult time. Nothing. Just call me in 3 months to set up another appointment. You may be good with the knife but what I need now is somebody to talk to to figure out what my options are and how I am supposed to live like this.

  3. Dear Gary:

    Ask for a referral to someone who actually specializes in this issue (e.g., John Mulhall at Memorial Sloan-Kettering Cancer Center and others). The average urologic surgeon is neither sufficiently skilled nor competent to address this.

  4. Dear Gary,

    You should find a good mental health provider or sex therapist to help you through this. As a sex therapist, I see clients and discuss different options with them and also help both partners work through the changes that a long term illiness can create.

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