Maximizing Sexual Health After Prostate Cancer

Kate M. O'Rourke


November 13, 2015

Although a variety of treatments are available for sexual dysfunction after prostate cancer therapy, that message needs to be delivered more loudly to patients. According to a recent study of 2499 prostate cancer survivors, nearly 75% reported unresolved sexual problems 5 years after diagnosis.[1]

Improving Physiologic Functioning

Return of erectile function after radical prostatectomy became a reachable goal after the nerve-sparing surgical approach was introduced in the 1980s.[2] However, even when an experienced surgeon uses this approach, 90% of men will experience some level of erectile dysfunction in the early postsurgery recovery period.[3] Age, preoperative erectile status, comorbidities, and surgeon experience when surgery is involved are the key factors predicting sexual dysfunction after prostate cancer treatment.[3]

"All men, after any therapy for prostate cancer, can benefit from having some treatment to help restore their erectile dysfunction," said Laurence Levine, MD, a professor of urology at Rush University Medical Center in Chicago.

Inducing erections when they don't occur naturally is important for recovery. When men do not have sexual or nocturnal erections, there is relatively less arterial blood entering the penis, explained Dr Levine. This diminished oxygenation predisposes tissues to become infiltrated with collagen. "If you don't use it, you lose it, and what you lose is tissue and vascular elasticity," said Dr Levine. "Not only do men lose volume in the penis, getting smaller in length and girth, but the tissues also don't hold the blood that comes in. It doesn't trap properly; the blood runs in, but it just runs back out." Inducing erections preserves vascular tissue while the nerves are healing.

To optimize recovery of erectile function and prevent loss of penile length, penile rehabilitation should be initiated expeditiously after prostatectomy or radiation.[3]

"For the motivated man, there are a lot of things we can do. A full-court press approach is oral therapy, injection therapy, and vacuum therapy. If they are not as motivated, they can do it less aggressively," said Dr Levine.

Dr Levine, similar to many urologists, meets with men before surgery to discuss the quality of their erection using a scale of 0-10, with a 0 being no erection and over 7 signifying an erection capable of penetrative sex. Many of the men undergoing treatment are older and have comorbidities, so they already have some compromise to their erections. Diabetes, high blood pressure, unhealthy cholesterol levels, and smoking are erection-busters.[4,5]

If a man is highly motivated to retain a sex life (some are not), many urologists recommend an oral phosphodiesterase type 5 (PDE5) inhibitor (sildenafil, tadalafil, vardenafil, avanafil) before surgery. "It's called 'preconditioning'—getting things revved up before the actual event," said Dr Levine. "Physicians have used preconditioning with cholesterol-lowering medication for carotid surgery, and it seems to help surgical outcomes."

PDE5 inhibitors are widely supported as first-line options for erectile dysfunction after prostate cancer therapy, but there is no standard protocol as to how these agents are prescribed.[3] The drugs work by increasing blood flow to the penis and can induce an erection.

Men who receive a PDE5 inhibitor before surgery stay on it until they return to their physician for a follow-up visit 1 month after surgery.[3]

"At this point, I ask whether the man has any spontaneous erectile activity. Oftentimes, there is none," said Dr Levine. In men who don't respond to PDE5 inhibitors, injection therapy with a vasoactive drug that causes blood vessels to dilate and produces an erection is usually the next step.[3] "The most common is Trimix, a compounded solution of three different drugs," said Dr Levine. "Injections are done two or three times per week, whether the man is having sex or not. The injections give him an opportunity to have sexual activity.

"At least 50%-60% of men will fatigue of doing injections, but the other 40% carry on," Dr Levine continued. "I have patients who have been on injection therapy for 25 years." Injection therapy alone or combined with PDE5 inhibitors can be used indefinitely after any therapy for prostate cancer.

Vacuum erection devices are another important component of penile rehabilitation.[3] Dr Levine recommends 10 minutes of daily vacuum erection device therapy beginning roughly 1-2 months after surgery. The vacuum fully engorges the penis with blood, creating an erect-like state that is potentially usable for sexual activity. Over 80% of patients who use a vacuum device have successful intercourse; 60% have improvement in spontaneous erections.[3]

"About 70% of men will feel like they have lost some length to the penis after prostate cancer surgery, and it is not because they have had a piece of their urethra taken out with the prostate; it's because of this loss of blood flow and reduced tissue elasticity," said Dr Levine. "The only thing that has been shown to help preserve penile length is vacuum therapy. None of the other approaches, including PDE5 inhibitors and injection therapy, have definitively been shown to allow recovery of erections in the man who did not have nerve-sparing surgery."

Whereas highly motivated men will use PDE5 inhibitors, injection therapy, and the vacuum, other men may try one or two of these therapies. One year after surgery, a relatively small number will be fully functional without assistance, but the majority will have some compromise, yet may be functional with the use of a PDE5 inhibitor, said Dr Levine. "The rest may be relying on wishful thinking—'maybe if I do this for another year, my erection will come back.' There is some evidence to show that some men 1-2 years after surgery can still have progressive improvement. My general experience is that men who don't have good-quality erections with or without PDE5 inhibitors at 1 year are very unlikely to recover adequate rigidity, so that they will become functional with a PDE5 inhibitor by the next year or even 3 years out," said Dr Levine. He estimates that no more than 10%-20% of men who undergo prostate cancer surgery recover erections back to their pre-prostate cancer surgery state.

no more than 10%-20% of men who undergo prostate cancer surgery recover erections back to their pre-prostate cancer surgery state.

For men who have a non–nerve-sparing operation or men who have tried other options that have not worked, an inflatable penile prosthesis implant is an option. "A lot of people have referred to the penile prosthesis as a last resort, and that is a disservice to the prosthesis. It is actually one of the best ways to restore erectile function, without interfering with urination, sensation, or orgasm," said Dr Levine. "It allows a man to have an erection on demand. I would call the prosthesis the best option for the particular individual who is suited for it."

Studies have shown that patients are highly satisfied with their penile prosthesis.[6] "I have done surveys on what the female partners think about these implants, and the scores are very high in terms of how it looks when it is flaccid, how it looks when it is erect, and how it feels during intercourse, compared with a natural erection," said Dr Levine.

Most insurance companies do not cover oral therapy, injection therapy, or vacuum devices, but they do cover penile prostheses. Finances may dictate therapy choice. Dr Levine said vacuum devices cost between $300 and $500, on-demand PDE5 inhibitors cost $30-$50 per tablet, and a 1-month supply for daily dosing of tadalafil costs $200. Injection therapy is the cheapest option, costing roughly $150, which may provide 10-20 injections/erections.

Clinicians should provide men with realistic estimates of potential erectile recovery times and reliable estimates of erectile dysfunction rates.[7] For patients who undergo radical prostatectomy, partial recovery of erectile function can take up to 4 years, but the majority of function returns within the first 24 months.[8,9,10] Patients can be told that recovery typically takes 6-36 months, but that the level of recovery at 6 months is often predictive of long-term, overall recovery.[9,10]


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