Sexual Function In Prostate Cancer
Problems related to sexual functioning may include erection problems, ejaculation disturbance or loss of libido or interest. The very diagnosis of prostate cancer alone may be enough to disturb sexual functioning. This is particularly so as many men in their 60s and 70s already have waning erections.
All treatments aimed at eradicating localised prostate cancer carry a risk of erection problems.
Radical prostatectomy causes impotence in between 10% and 90% of patients. The quality of the erections prior to surgery, the age of the patient, the quality of the nerve preservation and the number of nerves spared and the timing of follow-up after the surgery all influence outcome. Erectile functioning may take as long as three years to recover. If the patient is less than 50 years old and two nerves are spared, there is an 80%-90% chance of erections returning, to a moderate degree, whilst if one nerve is spared in this age group, it is 50%-70%. If the patient is between 50 and 59 years of age and two nerves are spared, there is an 80% chance of erection return and if one nerve is spared, 30-60% chance depending on the amount of damage done to the nerve.
If the patient is between 60 and 69 years of age and two nerves are spared, there is a 60% chance of adequate potency whilst if only one nerve is spared, there is only a 20-40% chance of erection return. All these figures are for patients with good erections prior to surgery and with a 2-3 year follow-up. They are a compilation of Dr Catelona╠s Walsh╠s and Rabbani╠s results as well as Associate Professor Stricker╠s results.
Brachytherapy seeds also cause impotence. Five years after brachytherapy, 50%-70% of patients under the age of 60 years are potent whilst 41% are potent if they are greater than 60 years old. Potency depends on the patient╠s age, time after treatment, pre-operative potency and the presence of neoadjuvant hormone therapy. The severity of the impotence which occurs after brachytherapy is mild to moderate usually responding to oral medication.
External beam radiotherapy and high dose rate brachytherapy also cause impotence. The incidence is approximately 50% at 5 years of follow-up and again it depends on the age of the patient and the quality of the erections beforehand.
The therapy for erection problems is initially medications such as Sildenafil (Viagra), Vardenafil (Cialis) or Tardanefil (Levitra). The medication Apomorphine (Uprima), can also be used or a combination of the above. If oral medications taken correctly at maximum dosage are unsuccessful, or if they have side effects then other options include using vacuum constriction devices, penile injection therapy with prostaglandin E1 or combinations of medications, or if all else fails a penile implant.
There is a lot of evidence now to suggest that the early encouragement of erections after surgery for prostate cancer appears to be beneficial to the ultimate recovery of erection functioning. This involves frequent foreplay as soon as four weeks after the surgery, as well as the use of daily medications such as Viagra, Cialis, or Levitra, or regular use of penile injections, as a form of penile physiotherapy. There are now several studies to suggest this improves the ultimate recovery of erections and also the speed of recovery of erections.
The severity of erectile dysfunction after surgery is more severe than after brachytherapy. Patients after surgery who use the penile injection therapy have an increased chance of scarring and fibrosis (Peyronie╠s disease). It appears that the incidence is approximately 10%.
With all forms of surgery, radiotherapy or brachytherapy the volume of ejaculate is reduced or absent. Libido (interest) is usually maintained after all forms of treatment after the original insult of the treatment passes. When hormone therapy is used, as it is for more advanced disease, this may unfortunately affect libido. Some forms of hormone therapy can be used to preserve both libido and erectile functioning (certain anti-androgens).