Andrew Siegel MD 8/1/2020
The next series of entries will focus on sexual function following prostate cancer treatments; however, the content will be relevant to anyone interested in male sexuality.
Prostate cancer can negatively affect sexual health and function through each stage of the journey from diagnosis to treatment. The anxiety experienced when one is found to have an elevated/accelerated PSA and/or abnormal prostate exam and that a biopsy will be needed is enough to stifle sexual function. Following prostate biopsy, the transient blood in the semen and apprehension concerning the pending results also negatively impacts sexuality. All treatment options for prostate cancer, including surgery, radiation, androgen deprivation therapy, and focal therapies—active surveillance excluded—incur the potential risk of altered sexual function. Sexual issues can run the gamut from mild to severe and are potentially emotionally overwhelming, affecting psychological well-being and at times leading to loss of self-esteem, avoidance of intimacy and depression.
The newly diagnosed patient with a prostate malignancy typically receives ample information about the evaluation, prognosis and treatment of the cancer. However, counseling regarding issues that may result from prostate cancer treatments are sometimes given short shrift or neglected. Sexual side effects may receive incomplete attention, perhaps understandable as being lower in the hierarchy of priorities since a prostate malignancy is potentially a life-and-death cancer issue. Nonetheless, sexuality is vital to the well-being of many men and sexual dysfunction is the most common quality of life issue in prostate cancer survivors.
Prostate cancer patients and their partners are entitled to be informed of the possible sexual side effects of treatment and provided with realistic expectations regarding sexual functioning after treatment. The intent of this entry is an introduction to the sexual issues that may result following the various treatments for prostate cancer.
WHY SEXUAL SIDE EFFECTS MAY BE GIVEN SHORT SHRIFT
Some physicians are not comfortable addressing and discussing sexuality. Others do not consider themselves adequately trained to do so. Some patients feel ashamed or embarrassed to ask questions about sexuality after treatment or may regard sexual dysfunction as an inevitable and acceptable side effect in the face of a serious cancer.
PROSTATE CANCER–IN AND OF ITSELF–CAN AT TIMES CAUSE SEXUAL DYSFUNCTION
Under certain circumstances, untreated prostate cancer can give rise to sexual dysfunction. However, it is unusual for early prostate cancer that is confined to the prostate to have adverse sexual effects. Locally advanced prostate cancer can directly invade the all-important-to-erections neurovascular bundles that are situated in close proximity to the prostate. On rare occasions, locally advanced prostate cancer can directly invade the erectile chambers of the penis, rendering them poorly functional. Advanced prostate cancer that has spread to the vertebral column can compress the spinal cord and nerves, which may give rise to a host of neurological problems, including sexual issues.
SEXUAL DYSFUNCTION IS MORE COMMONLY A SIDE EFFECT OF TREATMENT
Most of the time, it is not the presence of prostate cancer that causes sexual dysfunction, but rather the side effects of the treatment. Patients who undergo surgery, radiation, androgen deprivation therapy and focal ablative therapies commonly experience impairments in sexual function. High levels of sexual “distress” may be associated with sexual dysfunction following treatment, marked by concern, anxiety, frustration, feelings of inadequacy and other negative emotions.
MALE SEXUALITY: LIBIDO, ERECTIONS, EJACULATION, ORGASM
The four components of male sexual function can all be affected by prostate cancer treatments: Libido (sex drive); erections; ejaculation; and orgasm.
Although libido is complex and multifactorial, it is chemically driven by the hormone testosterone. Androgen deprivation therapy achieves “castrate” levels of testosterone, which drastically reduces one’s interest in sex. Additionally, poor quality or absent erections as a side effect from prostate cancer treatments or due to other reasons can secondarily diminish libido, as one tends to lose interest in activities that cannot be successfully achieved. Other factors influencing libido are stress, fatigue, anxiety, depression and relationship issues, all of which can be affected by the diagnosis and treatment of prostate cancer.
Because of the prostate’s location—in a busy sector at the crossroads of the urinary and reproductive tracts, connected to the bladder on one end, the urethra on the other, touching upon the rectum, and nestled behind the pubic bone in a well-protected nook of the body—its surgical removal or treatment with radiation or focal therapies has the potential for causing undesirable side effects. The paired bundles of nerves and blood vessels (neurovascular bundles) that provide the nerve supply to the erection mechanism are delicate, intimately attached to the prostate gland, and can easily be traumatized by prostate cancer treatments as can muscles surrounding and supporting the prostate, resulting in altered sexual function and urinary control. Since the nerves are responsible for relaying the message to the penile arteries to expand and fill the erectile chambers of the penis with blood, if one is “unnerved” by surgery, radiation or other treatments, erectile consequences are likely to follow. Furthermore, lack of or diminished erections often perpetuate erectile dysfunction because of a “use it or lose it” phenomenon with the need for ongoing erections to maintain health and integrity of the penile tissues.
Ejaculation is the physical aspect of sexual climax in which semen is expelled by rhythmic contractions of the pelvic floor muscles. Erections and ejaculation are wired independently in the nervous system and thus it is possible to experience ejaculation even in the absence of an erection. Ejaculation after prostatectomy is “dry” because of the removal of the ejaculatory apparatus, including the prostate gland, seminal vesicles and the ejaculatory ducts. Even though no semen is ejaculated, the sensation of release is often preserved, although it may be different than before the surgery. At times, a consequence of prostatectomy can be leakage of urine with sexual stimulation and/or ejaculation of urine at the time of sexual climax. Radiation therapy commonly results in diminished or absent ejaculation volumes and may cause an altered quality of ejaculation.
Orgasm is the psychological and emotional aspect of sexual climax that takes place in the brain. Although orgasm is possible even with the reproductive organs removed or irradiated, it may be of a different quality and intensity than prior to the treatment.
…To be continued next week.
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 