Fact Sheets

Sexual Rehabilitation following treatment for prostate cancer

The main treatments for prostate cancer are radical prostatectomy (open, laparoscopic, robotic), radiotherapy, brachytherapy and HIFU.

The sexual dysfunctions that may occur after these treatments include erectile dysfunction, loss of ejaculation, shortened penis and passing of urine during orgasm. Loss of libido occurs particularly when anti-androgen hormone therapy is used.

The outcome of sexual function after treatment depends on the age of the patient, the level of sexual function present before treatment and in the case of surgery, the sparing of the nerve bundles (better outcome if both sides are spared).

Surgery tends to result in immediate loss of erections, whereas the other treatments may result in a delayed loss of erections, up to 6 months after treatment.

Sexual rehabilitation addresses these sexual dysfunctions, especially erectile dysfunction, that men may experience as a result of treatment for prostate cancer. It is an important part of the holistic care of men undergoing treatment.

There is evidence that the earlier the erectile dysfunction is treated, the better the chance of a return of erections. If natural erectile function returns after treatment, the quality of the erections may not be as good as in the past. Erections may take up to 3 years to recover, but usually an indication of the outcome is seen at 12 to 18 months.

Erections can be induced within 2 to 3 weeks of surgery with penile injection therapy using prostaglandin E1 (PGE1). The penis is injected with a low dose of PGE1, about 2.5 to 5 mcg once or twice a week, whether sexual activity occurs or not. The early and regular "exercising" of the penis to erection has been shown to expedite the return of erections (but only when the nerves have been saved).

PGE1 injection treatment has been safely used for many years but sometimes its use is painful due to a "chemical" pain. Care must be taken with the amount injected to avoid a prolonged erection and there is a risk of scarring occurring in the penile tissues.

This "exercising" regime allows oxygenation of the erection tissues thus minimising the risk of deterioration of these tissues due to lack of use and low oxygen (hypoxia) levels. If there appears to be an improvement in natural erections whilst on PGE1 therapy, oral treatment can be tried about every 3 months.

The oral treatments are known as PDE5 inhibitors, there are 3 available (ViagraT, LevitraT and CialisT). The tablets are swallowed about 1 hour before planned sexual activity. They can be used on an as required basis. However during the first few months after surgery, these oral tablets may not have the same erection inducing effect that injections have. But there is some evidence that just by taking PDE5 inhibitors even without an erection occurring, there may be benefit in prevention of deterioration of the erection tissues.

The tablets are used by men who may not be ready to engage in sexual intercourse in the first few months after surgery. The tablets may result in a softer erection not firm enough for penetration, but sexual play is encouraged as part of the "exercise" concept. An orgasm is entirely possible with a soft erection or indeed with no erection when adequate stimulation to the penis occurs.

Another concept of use of the oral tablets is regular dosing to optimise the return of erections and to keep the erection tissues healthy during the period of absent erections. It has been proposed that these tablets be taken at lower doses on a daily or second daily basis. The common side effects include flushing of the face, headache and blocked nose. PDE5 inhibitors cannot be taken by men who are on cardiac medication known as nitrates.

Other treatment choices are use of a vacuum erection device which is a non invasive method involving placement of a cylinder over the penis. Air is extracted by a pump which results in the formation of an erection that is held in place by a rubber constriction ring.

The surgical insertion of a penile prothesis is considered when all other treatment have proven ineffective. This device allows an erection suitable for penetrative intercourse to occur with the simple activation of a pump discreetly placed in the scrotum.

Dr Michael Lowy
MBBS MPM FAChSHM
Sydney Men's Health
St Vincent's Prostate Cancer Centre
www.sydneymenshealth.com.au