Andrew Siegel MD 8/8/2020
Today’s entry is a continuation of last week’s introduction to sexual functioning after prostate cancer treatments.
Thank you, Pixabay, for image above
Under most circumstances, treatments for prostate cancer are highly effective and have excellent survival rates. Once concerns and fears about the cancer are gone or diminished, side effects that affect quality of life assume greater significance. A new “grief” can surface for patient and partner—worry, anxiety, distress, frustration, despair and even depression—over the possible impairment of sexual function. The psychological consequences of sexual side effects following prostate cancer treatments cannot be understated, profoundly effecting masculine identity and self-esteem and impacting one’s partner as well as one’s relationship with their partner.
Sexual Issues After Radical Prostatectomy
Erectile dysfunction and dry ejaculation are the most common adverse sexual effects experienced after prostatectomy. Other sexual effects that may be encountered include: urinary leakage with sexual stimulation; ejaculation of urine at the time of sexual climax; altered sensation of sexual climax; pain with sexual climax; penile shortening and deformity; and Peyronie’s disease.
ERECTILE DYSFUNCTION
Many men prior to prostate cancer treatment had experienced daily erections, and had done so for the entirety of their lives. However, immediately following prostatectomy, erections often are brought to an abrupt halt. Understandably, in many men this generates major concerns about their own sexuality and apprehension about their ability to satisfy their partners.
To compound the issue, both the prostate cancer patient and his partner are often in the age group where sexual dysfunction is common, with “andropause” (a controversial term referring to the gradual decline in testosterone levels experienced at midlife and beyond) and menopause, respectively, affecting sexual health. The female partners of men treated for prostate cancer are often post-menopausal and experience parallel issues that affect sexuality—decreased libido, vaginal dryness and irritation, insufficient lubrication, vaginal narrowing and shortening, painful intercourse, urinary incontinence, pelvic organ prolapse, etc. The positive side to this is that the sexual issue is mutual and shared, but the negative side is that having both parties compromised negatively impacts the couple’s ability to have sexual intercourse since it “takes two to tango.” The recently introduced concept of “couple-pause” strives to address the sexual needs of the couple as a whole—a couple-oriented approach—rather than treating each partner in isolation.
The prostate does not directly contribute to the ability to obtain and maintain an erection, so its removal per se does not inevitably mean erectile dysfunction. However, the prostate is surrounded by nerves and blood vessels that are vital for normal erectile function, and it is the trauma to these structures that fosters the erectile dysfunction.
Unquestionably, there are men who undergo prostatectomies performed by skilled robotic urologists who experience no complications whatsoever, achieving “trifecta” status: undetectable PSA, full urinary control and intact erectile function (although the recovery process can be lengthy and require penile rehabilitation techniques). That stated, regardless of whether the prostatectomy spared the nerves or not, erectile dysfunction remains the leading post-operative complication, caused by damage to the delicate neuro-vascular bundles and tying off of the accessory arterial supply to the penis. The vast majority of men after prostatectomy will experience erectile dysfunction, many of whom will recover function. The best post-operative erectile function will occur in younger men, those with excellent erectile function preceding the surgery, and in those who undergo a bilateral nerve sparing procedure performed by a skilled and experienced surgeon.
The “acute” erectile dysfunction following prostatectomy that is a consequence of the temporary loss of nerve conduction can ultimately result in “chronic” erectile dysfunction. The lack of nerve transmission results in a constantly flaccid penis with poor oxygen flow to the erectile tissues. In a vicious cycle, erectile smooth muscle cells are replaced with collagen (scar tissue) resulting in further impairment of function with loss of the mechanism that ensures blood trapping in the erectile chambers. This venous leak from the erectile chambers impairs both erectile rigidity and durability. The bottom line is that future erections demand current erections, since erections are needed to maintain the health, tissue integrity and function of the erectile tissues.
Fortunately, despite the importance of sex for many couples, intimacy can be equally important to, if not more so, than sex. Furthermore, all forms of sex can be enjoyable and there are numerous ways one can sexually satisfy one’s partner aside from penetrative penile-vaginal intercourse. Both partners are capable of achieving sexual gratification and climax without the involvement of an erect penis.
It is important to know that there are numerous effective methods of treating the erectile dysfunction that follows prostatectomy, the topic of future entries.
DRY EJACULATION
Although there is no release of semen following removal of the prostate gland, seminal vesicles and ejaculatory ducts, one is still capable of feeling the sensation, muscle contractions and pleasure experienced prior to surgery. However, the absence of ejaculation can be disturbing to some men, younger men in particular.
All patients following prostatectomy lose the ability to father children. If one wishes to retain fertility following prostatectomy, it is important to talk to his urologist about the possibility of banking sperm in advance of the surgical procedure. Sperm banking involves freezing semen in liquid nitrogen and storing it for future use with assisted reproduction techniques such as in vitro fertilization. Alternatively, since the testes continue to produce sperm for a number of years, testicular sperm aspiration (removing sperm cells using a tiny needle) with in vitro fertilization is another possibility.
URINARY LEAKAGE WITH SEXUAL STIMULATION
Urinary leakage can sometimes occur with sexual foreplay and stimulation, potentially an embarrassing issue for patient and partner. This most commonly occurs during the first year after surgery and thereafter tends to improve. Possible solutions include pelvic floor muscle training, emptying one’s bladder completely before engaging in sexual activity, and using either a condom that will collect any leaked urine or a penile constriction loop that compresses the urethra.
EJACULATION OF URINE
Although ejaculation is typically dry after prostatectomy, it is estimated that at least 20% of men may ejaculate some urine at the time of sexual climax. The actual number of men who experience this may be even greater because of a “no ask” and “no tell” phenomenon in which doctors are reluctant to ask about the problem and patients are reluctant to bring up the problem.
Even though the ejaculation consists of urine and not semen, the sensation at climax is often the same. Urine is generally sterile, so there is limited potential for spreading an infection to a partner. However, this “climacturia” as it is known in medical speak can be a nuisance and a source of embarrassment for both patient and partner and can be a significant impediment that may lead to avoidance of sexual intimacy.
It typically is most prevalent during the first year after prostatectomy and thereafter tends to improve. Coping strategies are urinating immediately prior to engaging in sexual activity and using a condom or a constrictive penile loop, as are used for urinary leakage with foreplay and sexual stimulation. Pelvic floor muscle training has been shown to help this issue. If this situation does not respond well to conservative means, the male sling can be an effective means of management.
ALTERED CLIMAX
Sexual climax after prostatectomy may feel different than before the surgery. Some men feel a diminished sense of pleasure and intensity. In others, the dry ejaculation negatively impacts their perception of orgasm. In some men, sexual climax does not occur at all. A small percentage of men experience more intense orgasms than before the surgery. Overall, the most influential factors that are predictive of which men will have better preserved orgasmic function following prostatectomy are the following: extent of nerve preservation (better with nerve sparing), the extent of lymph node sampling (worse with more extensive sampling), age (younger better), and time elapsed since prostatectomy (more time better).
PAINFUL CLIMAX
After prostatectomy, some men will experience discomfort or pain with sexual climax, which can be perceived in the penis, testes, perineum or rectum. In time, both the intensity and frequency of pain usually diminish, although a fraction of men may have persistent pain that persists beyond several years.
PENILE CHANGES
After prostatectomy, it is not uncommon to experience decreased penile length and/or girth. This shrinkage occurs during the first several months after the prostatectomy. The shortening is likely based on several factors. The gap in the urethra (because of the removed prostate) is bridged by sewing the bladder neck to the urethral stump, with a consequent loss of length from a telescoping phenomenon. Traumatized and impaired nerves and blood vessels vital for erections cause acute onset of erectile dysfunction. Thereafter, the lack of regular erections results in less oxygen delivery to penile smooth muscle and elastic fibers resulting in scarring, shortening and narrowing of the penile tissue, a phenomenon referred to as “disuse atrophy.”
Resuming sexual activity as soon as possible after surgery will help “rehabilitate” the penis and prevent disuse atrophy. There are a variety of effective penile rehabilitation methods to help avoid disuse atrophy and to help get one “back in the saddle,” to be discussed in a future entry.
PEYRONIE’S DISEASE
Peyronie’s disease is an acquired deformity of the penis that has been reported to occur in up to 15% or so of men after prostatectomy. It occurs due to scarring of the sheath of the erectile chambers, resulting in findings that may include the following: a hard penile lump, penile shortening, curvature with erections, penile narrowing, a visual indentation that can be described as an “hour-glass” deformity, pain with erections and decreased erectile rigidity. Penile pain, curvature and poor expansion of the erectile chambers contribute to difficulty in having a functional and anatomically correct rigid erection suitable for intercourse. Although the scarring is physical, it often has psychological ramifications, causing anxiety and depression.
During “acute” Peyronie’s disease, erections are painful and there is an evolving scar, curvature and deformity. The “chronic” phase occurs up to 18 months or so after initial onset, at which time the pain and inflammation resolve, the curvature and deformity stabilize and erectile dysfunction is often noted. Treatment options (the topic of future entries) include oral medications, topical agents, penile traction therapy, low-intensity shock wave therapy, injections of medications directly into the scar tissue and a variety of surgical managements, depending on circumstances.
Sexual Issues After Prostate Radiation Therapy
Erectile dysfunction is the most common long-term side effect following radiation therapy (external beam radiation and brachytherapy), occurring in about 30-40% of men, regardless if the most recent version of image-guided radiation therapy was used.
Whereas the decline in erectile function is immediate after prostatectomy with gradual improvement and a delayed recovery that can take 2 years or longer, erectile dysfunction after radiation therapy has the opposite trajectory—a slow and gradual decline over 18-24 months. The cause of erectile dysfunction following radiation therapy is radiation-induced trauma and damage to blood vessels (small blood vessel obliteration), the neuro-vascular bundles and to the parts of the penile anatomy that are within the radiation field.
Ejaculation changes following radiation may include diminished or absent volume of semen, discomfort during ejaculation, blood in the ejaculate, a small amount of urine released with ejaculation and decreased intensity of orgasm.
Androgen deprivation therapy that is often combined with radiation therapy to optimize the effect of the radiation can compound the potential sexual side effects of the radiation, particularly with respect to loss of libido.
Sexual Issues After Androgen Deprivation Therapy
Androgen deprivation therapy results in castrate levels of testosterone with loss of libido. Although testosterone is not a necessity for achieving and maintaining erections (e.g., pre-pubertal boys have excellent erections, but lack libido), it certainly helps the process. Additionally, since testosterone helps sustain penile tissue health and integrity, long-term androgen deprivation therapy may result in diminished penile length and girth. Furthermore, the consequences of long-term androgen deprivation, including loss of muscle and bone mass, weight gain, hot flashes and occasional breast growth and tenderness, can negatively affect body image, masculinity, confidence and sexuality.
Sexual Issues After Focal Ablative Therapies
Erectile dysfunction is an expected outcome following cryosurgery. High intensity focused ultrasound uses heat to destroy prostate tissue, which can potentially damage nerves and give rise to erectile dysfunction as well as other sexual issues.
Bottom Line: Despite the high likelihood of experiencing changes in sexual function following treatments for prostate cancer, the good news is that in most situations the issue is readily treatable by a variety of techniques and methods, the topic for upcoming entries.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Our Greatest Wealth Is Health 