Psychosexual Issues in Prostate Cancer
Psychological Aspects of ED in Prostate Cancer
ED, a complication feared by many men diagnosed with prostate cancer, can occur from aging, the cancer itself, surgery, radiation and hormonal therapy. After treatment, men wonder whether ED is prolonged and when or whether they will be able to have sex again. For those men who are particularly bothered by sexual dysfunction, the first step should be a consultation with an urologist who specializes in male sexual dysfunction. Sex therapy with a trained therapist may help a man express the feelings engendered by this dysfunction, and may help a couple learn alternative ways of sharing sexual intimacy. Another confusing aspect for selecting treatment is the differential impact on erectile function in radical prostatectomy versus radiation therapy. Little data exist on the association between ED and depression, specifically in men with prostate cancer. It is clear from population studies conducted in other settings that there is a relationship between these two variables. The rate of depression was extremely high in men with ED and was significantly higher than in men in the control group with BPH. It is likely that the presence of distress or depression related to ED may lead to relationship problems due to the increased stress on the couple. When a man experiences ED, he often pulls away from sexual contact and sexual intimacy. Many men report that there is no use starting sexual contact when they cannot 'perform' sexually. Men state that engaging in a sexual experience reminds them of their 'lack of manliness', often times increasing their distress or depression over the loss of erections. This process leads to a lack of intimate contact in the relationship, which can lead to conflict and frustration. Preliminary data exist to support these clinical observations; studies have found that the couples where the male partner reported ED also reported less intimate contact, and lower scores on togetherness and tenderness within the relationship. Careful consideration and good history taking are a must when determining combined urological and psychological approaches for the management of ED in these cases.
Incontinence and Sexual Recovery in Prostate Cancer
The fear of urine leaking, smelling of urine, bowel accidents and having to use diapers is humiliating to many men. In fact, urinary incontinence has been rated a more bothersome outcome than ED. There are some men who begin to shun social contact. This social withdrawal is often mistaken for a major depression and this situation, however, if disregarded can lead to significant anxiety and depression, which may then need to be treated by anxiolytics or antidepressants. Both supportive psychotherapy and cognitive behavioral therapy can assist a man in coping with these changes in lifestyle. Specifically, cognitive behavioral therapy is a short-term, present-focused psychotherapy aimed at examining and altering distorted, maladaptive thoughts about oneself and their environment, whereas supportive psychotherapy is a modality with less focus where more open-ended support is provided. In order to help men cope with this symptom it is important to identify the etiology of incontinence and educate patients and families about this problem, and offer ideas to alleviate or reduce symptoms. Urinary incontinence can be alleviated with pelvic muscle reeducation, bladder training, anticholinergic medications and even artificial sphincter surgery.
Some General Issues in Prostate Cancer-related Psychological Distress
Patient education is of paramount importance in prostate cancer because often screening results in a high likelihood that further testing, treatment and treatment-related decision making would be warranted. Urologists may at times underestimate the psychiatric comorbidity in prostate cancer, and there are many patients that have a few isolated symptoms that have not been diagnosed and hence may not receive treatment. Anxious preoccupations and strained marital relationships with spouses have been reported. Body image, spouse affection, spouse worry, along with cancer distress and cancer acceptance were some other anxiety-related areas causing psychological distress in prostate cancer.[60–62] It is essential that urologists receive training in the screening and identification of various psychological problems seen in prostate cancer to enable faster diagnosis and referral to the psychiatry unit for prompt management in such cases.
Prostate Cancer Prostatic Dis. 2012;15(2):120-127. © 2012 Nature Publishing Group