Managing prostate disease should involve routine assessment of sexual function and be a normal part of the patient’s management. Bancroft suggests that there is ‘an important need for adequate counselling pre-operatively, as well as the opportunity for discussing sexual function in the post operative period’ (1). I understand this may be difficult for some patients and clinicians to discuss but knowing what to do and where to get reliable help is half the battle!
The word SEX can evoke many emotions. There are many’myths and misconceptions’ surrounding it! Sexual activity varies for all of us, and our patients. For some people it is a large part of their existence, to others it is of no concern. Zilbergeld quotes there is no right or normal way to have a sexual experience. Your response is the result of a complex interaction among many variables, including, for example your age, your physical and emotional state, how turned on you are, what your partner does, and how you feel about her’ (2). During or after prostate cancer management these _complex inter-actions’ may be altered and there can be additional concerns regarding the intimate part of a patient’s life, although initially this may be the last thing on the patient’s mind or the clinician’s dealing with _removing the cancer’. The potential adverse effects of treatment include erectile dysfunction, lack of orgasm, reduced desire and inability to ejaculate. Schover et al in 2002 concluded that ‘the great majority of men who survive prostate carcinoma do not achieve a return to functional sexual activity in the years after treatment (3). Men were as distressed about loss of desire and trouble having satisfying orgasms as they were about erectile dysfunction. Although the treatment for prostate cancer may have been the cause of the erectile dysfunction, it can still have a significant impact on the patient and their relationship. Initially sexual activity may not be an issue as the patient overcomes surgery and continence issues are usually the first concern.
The pleasure of enjoying spontaneous sexual activity may change, but the ability to be sexually functional (which does not necessarily mean intercourse) can still be important. There are certainly things that can be done and it is vital that the patient (and if in a relationship) their partner seek help. Following radical prostatectomy it is important (if erectile dysfunction exists) to encourage penile rehabilitation by stimulating the penis to become erect as often as possible. This can involve the use of pharmacotherapy and\or a vacuum constriction device (4&5).
Men often find it difficult to admit to a sexual problem and can feel very isolated. They will typically never have previously discussed their ‘private parts’ with anyone. A feeling of not being complete and no longer a proper man’ is often described to me by men that have undergone prostatectomy. There can be a shift in a relationship when there is an underlying organic cause for the ED such as prostate cancer. Riley and Riley (2001) noted that only 1:1O people keep any form of sexual contact going when there is a change in their relationship caused by ED (6). Discussion of treatment options should include consideration of medication and psychosexual therapy (7).
I routinely discuss the potential changes regarding their sexual functioning and the impact on their sexual relationship that can occur. The use of behavioural exercises as well as medical therapies can improve the sexual outcome of patients 1 see (8). The man’s identity in an established relationship may change from involvement as a husband and \ or lover to one of child-like dependency on their partner, who will often adopt a mothering role. This scenario has frequently been described to me by patients that I have seen.
A man who is not in a relationship also needs support. He may have anxieties regarding future potential sexual encounters.
In the United Kingdom recent National Institute for Health and Clinical Excellence (NICE) guidelines for prostate cancer recommend that before starting treatment all relevant management options should be discussed (9). This should include the offer of ongoing access to erectile dysfunction services and specialist psychosexual services. This is definitely a step in the right direction as it recognises and highlights the importance of maintaining sexual function. Recently being told by a patient that after seeing me was the breakthrough’ for him in managing his sexual dysfunction was extremely rewarding So please do not feel awkward about speaking to patients about their sexual wellbeing and refer them for specialist help if necessary.
1) Bancroft J. (1989), Human Sexuality and Its Problems, London. Churchill Livingstone
2) Zilbergeld B. (1999) The New Male Sexuality, USA & Canada Bantam Books.
3) Schover LR. Foulad! RT,Warneke CL, Neese L, Klein EA, Zippe C, Kupelian. Defining Sexual Outcomes after Treatment for Local|sec Prostate Carcinoma. Cancer October l5th, 2 oo 2 /Volume 95/Number 8.
4) Eardley I. Rehabilitation of Erectile Funct!on after Radical Prostatectomy.
Nature Clinical Practice Urology 2 o 06; 3(2):72-73.
5) Zippe CD, Raina R, Thukral M, Lakin MM, Klein EA, Agarwal A. Management of erectile dysfunction following radical prostatectomy. Cur Urol Rep 2001; 2: 495-503.
6) Riley A. et aI. Behavioural and clinical findings in couples where the man presents with erectile disorder: a retrospective study. International Journal of Clinical Practice 2 ODO; 54220 -2 24.
7) Weeks G. R. et aI. (2000) Integrating Psychological and medical Treatments. Erectile Dysfunct ion. Integrating Couple Therapy, Sex Therapy, and Medical Treatment. WW Norton & Company. New York.
8) Grover L. Male erectile dysfunction. Primary Health Care. 2006; 16(6):43-5o.
9) Nice Institute for Health and Clinical Excellence (NICE). Prostate cancer diagnosis and treatment. February 2 008.