Being Sexual after Prostate Cancer

Manitoba Prostate Centre
Being
sexual after
prostate cancer...
Visit our website at
www.cancercare.mb.ca
This publication is supported
by an unrestricted educational
grant from Pfizer Canada Inc.
Treatment for Prostate Cancer
and Sexual Functioning
D
ifficulties with erections
are very common following treatment for prostate
cancer. Surgery and radiation
therapy may damage the nerves
that are responsible for erections.
Sexual changes after treatment
are common. This booklet will
guide you about what to expect
and what may help.
What is an erection?
E
rections occur when there is an increase
in blood in the penis when the penis is
stimulated physically or when you think
about sex. Special nerves (the cavernous nerves)
cause the release of chemicals in the tissues of the
penis which trap blood, increasing the size and
firmness of the penis. After orgasm occurs, the
blood drains away and the penis becomes
soft again.
These nerves run in two bundles along the
outside of the prostate gland, one on each side.
During surgery the urologist will try to move
these nerve bundles off the surface of the prostate
whenever possible. This is called “nerve sparing
surgery”. This may cause bruising of the nerves.
The nerves may recover over months or years.
Sometimes one or both nerves cannot be spared
and must be cut so that as much of the cancer as
possible can be removed.
Many men will have erectile problems after
surgery. You may not have any erections at all,
they may not be hard enough for penetration,
and they may not last long enough to satisfy
either you or your partner. Many men also notice
that the penis is both shorter and smaller in girth
than before. This results from both the surgery
and shrinkage of tissue in the period following
surgery when there is reduced blood flow to the
penis due to lack of erections.
What is the effect of radiation
therapy on erections?
R
adiation therapy (external beam or
internal seeds [brachytherapy]) also
poses a risk to erections although this
tends to occur one to two years after treatment
is completed and is much more gradual than the
changes noticed after surgery.
Why do men have difficulties
with erections?
What about relationship and
communication issues?
here are many different reasons why men
experience erectile difficulties. As men
age the blood vessels in the body may
become damaged and this affects the vessels in
the penis too. Lifestyle factors (smoking, obesity,
excess alcohol and sedentary lifestyles) also
impact on your ability to have an erection. Other
diseases such as diabetes affect blood vessels and
nerves including those in the penis. Some of
the medications you take (for control of blood
pressure or depression) can have a negative effect
on your erections. Depression and stress can affect
your sex life too.
our emotional state also plays a part and
many men are very anxious about having
an erection which then affects your ability
to have one. It is important to talk to your partner
about what is happening and what you are
feeling. Not talking about this may lead to both
a physical and emotional distance between the
two of you. Your partner may think that you are
rejecting her/him. Couples often stop touching
and talking when they experience problems in
their sex life and this can lead to misunderstandings and hurt feelings.
So what can be done about this? There are a
number of treatments that can help a man to
have an erection after treatment for prostate
cancer.
T
What is the effect of radical
prostatectomy on erections?
I
mmediately after surgery for prostate cancer
(radical prostatectomy) almost all men will
be unable to have an erection. Erections may
return over the following weeks, months or even
years. Return of erections depends on what your
erections were like before surgery, your age,
your general health and lifestyle factors, and the
amount of damage to the nerves.
Y
What are some treatment
options?
1. Oral medications (PDE5 inhibitors)
There are a number of oral medications that
can be taken that may help you have an erection.
These medications prevent blood from leaving
the penis once it has entered the tissues following
physical stimulation of the penis. This is the least
invasive method of treating erectile difficulties and
is usually the first treatment that your doctor will
suggest. The three medications that are available
are very similar but have some unique differences
from each other.
• Sildenafil (Viagra) usually works in 30 to 60
minutes. If taken on after a fatty meal it make
take longer to work. It remains effective for four
to six hours.
• Tadalafil (Cialis) works within about 30 minutes
and remains effective for as long as 36 hours.
It may be taken with or without food. This
medication should only be taken every second
day (48 hours after first taking it) as it remains in
the blood stream for an extended period of time.
• Vardenfil (Levitra) becomes effective in about 25
minutes and remains effective for about four to
six hours. It should not be taken after a high fat
meal.
It is essential that physical stimulation of the penis
occurs for these medications to work.
If you are on certain heart medications
(containing nitrates) you should not take these
medications. You should also report any visual
changes (flashing lights, blurred vision) after
taking these medications.
They will not work if you take them and then
just wait for something to happen. You need to
have physical stimulation of the penis to move
the blood into the tissues. You should also talk
to your partner about his/her interest in sexual
activity before taking these medications. However
if you want to pleasure yourself or just want
to see if the medication works for you without
the pressure to perform, take the medication,
stimulate yourself, and see what happens.
You should also not give up with the
medication if it does not work the first or second
time. Some men may need up to eight doses on
separate occasions before we can say that the
particular medication does not work. Switching to
a different brand may bring a better result.
2. Penile self-injection therapy
This involves injecting a small amount of
medication into the side of the penis. This causes
a local response in the tissues of the penis causing
an erection. You may not experience any feelings
of sexual excitement but you will have an
erection. It may take some time and a number of
attempts to find the correct dose of medication
that will work for you. There is a risk that some
scarring will occur where you place the needle
and you are encouraged to switch the site where
the needle is inserted. If scarring does occur, it can
cause pain and some curving of the penis. There
is also a risk that you may have an erection that
does not go down (this is called priapism). This
needs to be treated urgently and if your erection
does not go down in two to four hours, you need
to go the Emergency Department where this will
be treated. Failure to treat this condition may lead
to permanent tissue damage.
If you are interested in this form of therapy,
your doctor will arrange for a test dose and a
teaching session for you to learn how to do this
properly.
Injection sites
(shaded areas)
Cross-section of penis
showing injection
correctly placed in
corpus cavernosum.
3. Intra-urethral therapy
This involves inserting a small pellet of medication
into the opening of the penis using a special
applicator. Once the pellet has been inserted you
must apply physical stimulation to the penis in
order to disperse the medication. After taking this
medication, some men experience burning inside
the penis or when they pass urine.
Rub penis
between hands
to disperse the
medication.
Pellet is inserted
through applicator
into the urethra.
4. Vacuum therapy
This therapy involves the use of a special vacuum
device which draws blood into the penis. A special
rubber band is placed at the base of the penis to
trap the blood in the tissues. This can remain in
place for thirty minutes and must then be
Penis placed inside the cylinder,
and pump produces a vacuum
that pulls blood into the penis.
The vacuum creates an erection
within a few minutes
The tension ring is slipped off
the cylinder onto the base of
the penis and the cylinder is
removed.
Once the tension ring is
removed, the penis returns to
flaccid state.
removed to avoid damage to the tissues. Some
men find that they have bruising of the penis
after using this and sometimes the penis feels cold
to the touch.
5. Surgical implants
If none of the methods discussed above work,
some men may consider having a permanent
surgical implant inserted. A surgeon places two
cylinders into the penis which are inflated by
activating a small pump in the scrotum when
the man wishes to have an erection. This is done
under general anesthetic and has the usual risks
of surgery however it is a permanent solution and
does not require you to take medications.
What else can be done?
I
t has been suggested that taking low dose
PDE5 inhibitors in the months following
surgery can help normal erections to return
more quickly. If you are interested in this, please
ask your urologist about this at your post-op
appointment.
Your age, your pre-operative erectile status and
the type of surgery (nerve sparing or non-nerve
sparing) can influence whether this will be helpful
or not.
You will be given a prescription for a low dose
of one of the PDE5 inhibitors to take every night
whether you want to have an erection or not.
The theory is that these medications help to keep
blood flow to the penis while you are sleeping
and thus keep the tissues healthy. You need
to take the medication every night (sildenafil
or vardenafil) or every second night (tadalifil).
You may have to take these medications for
many months however early studies suggest
that men who do this may see a faster return
to spontaneous erections. If you want to have
intercourse, you should take the full dose of
the medication instead of the low dose. We will
monitor your response to these medications on a
regular basis.
Some men do not respond at all and they may
then want to consider using the injections three
times a week in addition to taking the pills. This
may speed up the return of normal erections.
What are the alternatives to
intercourse?
S
ome couples find that they are more
interested in non-penetrative sexual
activities in the time after treatment and
are not interested in taking medications to cause
erections. This is a good alternative for many
couples.
What other help is available?
S
ome men or couples experience feelings
of sadness when they face difficulties in
their sex life. Other couples find that a
change in their sex life causes stress for the relationship. There is help available to deal with
these problems. Your urologist can refer you to a
professional for help with this.
Your urologist can refer you to
a professional for help with
relationships.
Questionnaire
P
lease answer the following five questions
as they apply to your situation before you
had treatment for prostate cancer. Tick off
the answer that best describes your own situation
in the month before your treatment (surgery or
radiation). Be sure to select only one response to
each question.
In the month before your treatment for prostate
cancer;
1. How do your rate your confidence that
you could get and keep an erection?
■ Very low
■ High
■ Low
■ Very high
■ Moderate
2. When you had erections with sexual
stimulation, how often were your
erections hard enough for penetration?
■ No sexual activity
■ Almost never or never
■ A few times (much less than half the time)
■ Sometimes (about half the time)
■ Most times (much more than half the time)
■ Almost always or always
3. During sexual intercourse, how often were
you able to maintain your erection after
you had penetrated your partner?
■ Did not attempt intercourse
■ Almost never or never
■ A few times (much less than half the time)
■ Sometimes (about half the time)
■ Most times (much more than half the time)
■ Almost always or always
4. During sexual intercourse, how difficult
was it to maintain your erection to
completion of intercourse?
■ Did not attempt intercourse ■ Difficult
■ Extremely difficult
■ Slightly difficult
■ Very difficult
■ Not difficult
5. When you attempted sexual intercourse,
how often was it satisfactory for you?
■ Did not attempt intercourse
■ Almost never or never
■ A few times (much less than half the time)
■ Sometimes (about half the time)
■ Most times (much more than half the time)
■ Almost always or always
When you complete these questions, please give
them to your health care provider to open a
dialogue on erectile functioning.