Any diagnosis of cancer is unnerving. Prostate cancer infringes on the most intimate aspects of a man’s life. Inger Rosner, MD, in Urology at the Inova Schar Cancer Institute and Jennifer Bires, MSW, LCSW, OSW-C, executive director at Life with Cancer provides answers to commonly asked questions about prostate cancer and sexual health.
The prostate is a small, walnut-shaped organ located behind the rectum in men. It functions in partnership with the seminal glands to produce fluid to nourish and transport sperm. Prostate cancer is the most common form of cancer among men, with about 300,000 new cases diagnosed every year. Because prostate cancer affects a region of the body near the male reproductive organs, treatment can raise concerns about how it will impact a patient’s sexual health, including libido, sexual function, well-being, and body image.
Sexual arousal begins in the brain. Signals are sent to nerves to release chemicals that increase blood flow to the penis. The arteries relax, and blood fills two chambers of spongy muscle tissue on either side of the penis. At the same time, the veins constrict, holding the blood in place. The penis becomes firm, producing an erection. During climax, signals are sent to the spinal cord, which in turn sends signals to the muscles at the base of the penis to contract. The contraction forces semen out of the penis during ejaculation.
While the physical mechanics of an erection are important, treatment for prostate cancer has a psychological component. The fear of being diagnosed with cancer and the impending changes that will take place can have a profound effect on how the patient views himself. Life with Cancer, a program of the Inova Schar Cancer Institute, has individual therapists and nurses with an expertise in sexual health who can walk patients through the experience and connect them with resources to learn how to have your best sexual life during and after treatment. In addition, support groups provide patients with information on how to manage outcomes, identify topics to address with their care team, and listen to stories of people who have overcome or learned creative strategies to live with the experience.
While undergoing treatment for prostate cancer, the physician and assisting staff will take care of you. As a patient, you should feel empowered to have frank and honest conversations with your physician about your concerns about treatment. If you are having issues with your erections during and after your treatment, the care team can identify the best treatment for a patient with a full knowledge of the patient’s needs. Additional expertise can also be brought onto the care team to address specific concerns for sexual health.
A sexual health therapist can address the emotional and physical well-being of the patient, who may be grieving the changes that their body is experiencing. The sexual health therapist can help the patient and his partner understand how to maintain their intimacy throughout treatment. An endocrinologist can address hormonal well-being and muscle tone. A pelvic floor specialist can address therapy, concerns, and expectations following surgery. Each specialist can address a different component of the patient’s care to ensure a positive outcome for sexual health. A patient may not return to their previous state following treatment, but the care team can work with the patient to ensure the outcome is still satisfying.
Treatment for prostate cancer depends on the stage/grade of the cancer, the patient’s risk category, age, health, and the long-term treatment goals. Before prostate cancer treatment, it is very important to talk with your cancer care team about what to expect and the changes your body may experience during treatment and follow-up care.
Radical prostatectomy is the removal of cancer and the prostate from the body. Surgery is an option if the prostate cancer has not spread to other organs or tissues. The surgery also helps the healthcare provider know if additional treatment is needed. After removing the prostate, the urinary tract and the bladder may need to be reconstructed, which will require a temporary foley catheter while the tissue heals.
Radiation is another type of prostate cancer treatment. During treatment, a targeted beam of radiation is directed at the prostate, while minimizing exposure to the surrounding healthy tissue. It can be used as the primary treatment for prostate cancer (in place of surgery) or after surgery if the cancer is not fully removed or if it returns.
Androgen Deprivation Therapy (ADT) is a type of hormone therapy that blocks testosterone, which prostate cancer cells use to grow. ADT therapy is often used in conjunction with other treatments.
Chemotherapy uses drugs to destroy cancer cells anywhere in the body. It is used for advanced stages of prostate cancer or for cases where the cancer has spread to other organs or tissues. The drugs affect all cells so dose and frequency are carefully controlled.
Immunotherapy stimulates the body’s immune system to find and attack cancer cells. This treatment is still new and under review in clinical trials. This therapy has not been approved for widespread use.
Men often experience some degree of erectile dysfunction (ED) after most treatments for prostate cancer. ED occurs when a man cannot attain or maintain an erection long enough for satisfying sexual activity. ED occurs when the nerves that control blood flow to the penis are affected by treatment. The degree of ED a patient experiences is in part related to the degree of ED prior to surgery. It may take months to a year for ED to subside. ED treatment options are available. Despite concerns about ED, an erection is not needed for a man to climax. In addition, sexual desire is not lost with surgery or radiation treatment, unless hormones are also given as part of treatment.
ED can be treated with a variety of medications and therapies. The list below provides a brief overview of options prostate cancer patients can discuss with their healthcare team.
PDE5 inhibitors (common drug names include Viagra, Cialis, Levitra, and Stendra) are oral drugs that increase the blood flow to the penis. The pills are taken an hour or two before engaging in sex. While the medication typically helps most men attain a better erection, the response rate for cancer and diabetic patients is lower.
A vacuum erection device is a plastic tube that slips over the penis. The device seals against the skin of the body while a pump on the other end produces a low-pressure vacuum around the penis, resulting in an erection. An elastic ring is then slipped onto the base of the penis, which holds the blood in the penis, maintaining an erection for up to 30 minutes.
Intraurethral medication consists of a tiny medicated pellet that is placed in the urethra, the tube that carries urine from the body. The pellet works within 5 – 10 minutes to produce an erection that lasts for about 30 – 60 minutes. The medication may produce a burning sensation in the penis.
Penile Injections use a very fine needle to inject medication directly into the side of the penis. A health professional can instruct a patient on how to inject the medication, the dosage, and how to modify the dosage as necessary.
Penile Implants provides couples the opportunity to experience spontaneous intimacy. The implants are placed in the body to help the penis become stiff. There are two types of implants. A semi-rigid implant consists of two easy-to-bend silicon rods that provide the needed firmness for sexual penetration. The implant is bent downward to urinate and upward for sex. An inflatable implant consists of a fluid-filled cylinder that runs the length of the penis. A pump located inside the scrotum is connected to the cylinder by tubes. When the pump is engaged, the pressure in the cylinder increases, producing an erection. Neither implant affects a man’s sensation or ability to orgasm.
Cancer treatment can affect the nerves that assist in achieving an erect penis; however, men can have a soft or non-erect penis but be able to have a sexual climax or orgasm. The nerve pathways that participate in these sensations are not affected by prostate cancer treatments. After treatment, men can still experience the pleasurable sensation of an orgasm but produce little to no ejaculation, or emission of seminal fluid. This is called a ‘dry orgasm.’
As a society, conversations about sex can feel uncomfortable, but talking about concerns, fears, and the facts of the situation is incredibly important. For this reason, it is helpful to schedule time for this conversation with your partner. This approach ensures that both people are ready to engage on the topic, and it can happen without interruption. By providing a space for a dialog, both people can ensure they are on the same page and that needs are being addressed.
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