Maximizing Sexual Health After Prostate Cancer

Kate M. O'Rourke


November 13, 2015

Satisfaction With Sex Life

According to Daniela Wittmann, PhD, LMSW, a clinical assistant professor of urology at the University of Michigan Health System, clinicians should pay attention to more than just improving erections when treating sexual dysfunction. The World Health Organization defines sexual health as having biological, psychological, and social components.[11]

"If you think of sexuality as having biological, psychological, and relationship components, in usual care, the only treatment that men typically get is for the physiologic function," said Dr Wittmann. "There are many psychological and relationship strengths that people can employ to get back or retain their sex lives." She proposes that satisfaction with sex life, not erectile function, should be the focus of sexual dysfunction interventions.[12]

As a therapist, Dr Wittmann first helps men work through the grief they have over their functional loss. Treatment for grief and mourning, typical reactions to loss, has not been introduced into psychosocial interventions, but is increasingly recognized as a path toward a "new normal" after prostate cancer treatment.[13,14]

"People have feelings about what they are going through, and they may not always know why they are having them," said Dr Wittmann. "They may be feeling depressed, anxious, under pressure, or angry, and if you make them understand that this is normal grief, that it is normal for people to have these feelings, it is reassuring to them. If people don't deal with their feelings, they are more at risk for depression and anxiety." Repressing emotions can also repress libido, she added.

At the University of Michigan's Jan and Dave Brandon Prostate Cancer Survivorship Program, Dr Wittmann leads a multidisciplinary monthly educational seminar for men who are about to undergo surgery for prostate cancer and their partners. The seminar is designed to educate them about surgery outcomes, side effects of urinary and sexual surgery, and rehabilitation, as well as the emotional impact of the side effects on the couple. The goal is to set realistic expectations and prepare the men and their partners for the work of the recovery.

Dr Wittmann will then meet with the man and his partner, if available, roughly 6 weeks after surgery. She sometimes sees men treated with radiation and hormonal therapy as well. Some men have problems dealing with the loss of spontaneity that comes with the use of erectile aids, and others will need counseling about alternative sexual practices. She estimates that 15% of the men she sees end up in sex therapy.

When asked about sex therapy interventions, Dr Wittmann explained that for couples motivated to have a sexual life, sensate focus can be a useful tool. "Sometimes it is awkward for people to reinitiate sex. Sensate focus involves having people explore each other's bodies and their own bodies to find out what their sensitivities are and what feels pleasurable," said Dr Wittmann.

"You start with nonsexual touch, to take the pressure off, and then move to sexual touch," Dr Wittmann explained. "They might start with feet and back, and then move to more erotic areas, such as breasts and bellies, and then finally stimulation of genitals. The idea is to regain comfort with mutual touch, and what it ends up doing is giving people a better sex life. It gives them a bigger repertoire sexually."

Renegotiation of sexual activity is an essential part of sexual adaptation, and studies have shown that erection-independent ways of being sexual can be quite rewarding for men and women.[7] Methods can include oral sex, sex toys, and using hands. "Couples can work together as a team to develop a new way of relating and being sexually active, because the old way is not going to work the same," said Dr Wittmann. "Couples have to find a way of reengaging sexually in this new setting where the man's erectile function is compromised, but the man and the couple can still have access to sexual pleasure. Many men don't realize that you don't have to have an erection to have an orgasm."

In addition to sensate focus, Dr Wittmann works on getting people to talk about sex. "For many people, sex is nonverbal," she said. "People can have perfectly good sex for 30 years and never say a word, because touching, making sounds of pleasure, and moving each other has been effective, but now they may have to talk because things are not so easy."

Sometimes counseling sessions unearth underlying or preexisting problems. Roughly a year ago, she met with a 68-year-old man who was being treated for prostate cancer and his 65-year-old wife. "When I do the postsurgery assessment, I always ask if sex is of interest, because I don't want to pressure anyone into it. When I asked this couple, the partner said 'yes.' The man looked at her and was really surprised, because he thought they had given up on it," said Dr Wittmann. The man had diabetes, which caused sexual dysfunction, and the couple had not been sexually active for 5 years.

As a result of the counseling session, the couple acknowledged that they missed the sexual connection and chose to engage in sex therapy. They started with sensate focus exercises; the man learned to use an erectile aid; and 6 months later, they were having regular sex. "They realized they could have that connection again, and that made them very happy," said Dr Wittmann. "As a result, they also became more affectionate and life became richer. Sometimes therapy uncovers old problems that have been there for a long time. People may need to rework other things in their relationship to make the sexual part work."

One of the things that men complain about the most is that nobody prepared them for the side effects of treatment

Dr Wittmann believes that all men who undergo treatment for prostate cancer can benefit from education. "One of the things that men complain about the most is that nobody prepared them for the side effects of treatment," said Dr Wittmann. "Nobody told them what their rehabilitation could be, and nobody is supporting them in that aspect of their recovery. Men are given drugs such as Viagra®, but there is not much of a follow-up."

Dr Wittmann said that nurses, primary care physicians, and oncologists should discuss sexuality with prostate cancer survivors and point them in a direction where they can seek help. The website of the American Association for Sexuality Educators, Counselors, and Therapists has an interactive map that allows individuals to find local certified sex therapists. The Society for Sex Therapy and Research also has a list of qualified sex therapists. The American Cancer Society provides information about cancer, sex, and sexuality.

"If physicians would just be willing to open up the conversation, then patients can pursue available resources," said Dr Wittmann.

Dr Levine is a consultant for American Medical Systems, Coloplast, and Endo Pharmaceuticals. Dr Wittmann has received research funding from MOVEMBER.


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