As men age, their prostates become larger causing difficulty in urinating. This is known as benign prostatic hypertrophy and is not cancerous, but one out of six men will be diagnosed with prostate cancer (PC) during their lifetime, and PC treatments can affect sexual functioning.
What is a prostate?
It is a walnut-sized gland, which is part of the reproductive system in men. It lies below the bladder and in front of the rectum. It surrounds part of the urethra, which is the tube that transports urine from the bladder to exit the body. Its main function is the production of prostatic fluid, which is a component of semen. The muscles around the prostate contract to cause ejaculation.
All PC treatments, including surgery, radiation therapy and hormone therapy, can affect sexual functioning. In advanced PC, the cancer itself can also cause erectile dysfunction by invading the bundles of nerves that lie close to the prostate. Additionally, many men experience sexual difficulties as a result of anxiety of having cancer, poor self-image, and negative feelings about their sexuality. Sexual avoidance can occur which can lead to relationship problems.
Side effects of surgery
One of the most common treatments is surgery; there are various options. A radical prostatectomy involves removal of the entire prostate gland; this is generally offered to men with localised PC and, in some instances, to men with locally advanced PC.
The side effects relate to physical changes in the area of the prostate gland and always lead to orgasm problems. After removal, there is no ejaculation during orgasms. Usually the muscular spasm and pleasure is still present, but the orgasm is dry. If this is problematic for a man or his partner, they should speak to a sexologist or sex therapist to discuss strategies to deal with this change.
Orgasms may be painful after surgery. This generally resolves over time without any treatment. Some men leak a small amount of urine during an orgasm; this is potentially embarrassing and may lead to avoidance of sex. Simple interventions like emptying the bladder before intercourse or using a condom are usually successful in alleviating this problem.
The ability to conceive naturally is usually also lost after a prostatectomy. Radiation and chemotherapy may cause infertility. If a man wishes to have children after treatment is complete, it may be necessary to consult a fertility clinic or a sperm bank.
It’s likely that after surgery and even after brachytherapy (where radioactive pellets are inserted into the prostate) men will experience difficulties getting and maintaining erections. This will depend on the nature of the procedure, and if a nerve-sparing prostatectomy was performed.
If the nerves are damaged, assistance in the form of intracavernous injections will be necessary to get and keep an erection. If the nerves are spared, there is the chance of spontaneous recovery of erectile functioning. Some men can achieve erections with the use of PDE5 inhibitors like Cialis. Other interventions include the use of a vacuum pump or a bendable or inflatable penile prosthesis.
Remember, that it’s possible to have sex without penetration in a way that is mutually pleasurable. Men can achieve orgasms even if they’re not completely erect.
Another potential complication of a radical prostatectomy is penile shortening. It’s not clear why this happens, but it may be due to nerve damage, scar tissue or reconstruction of the urethra.
Most men experience urinary incontinence, in the short term, following surgery. This usually resolves spontaneously. If it doesn’t resolve on its own, there are treatments available, such as pelvic floor physiotherapy.
Side effects of radiotherapy
External beam radiotherapy (EBRT) uses high-energy X-ray beams, directed at the prostate. During radiotherapy and for a short period afterwards, men may experience urinary incontinence with ejaculation. Additionally, because of the damage to prostate cells, ejaculation fluid may be reduced in volume or completely absent, leading to a dry orgasm.
Unlike surgery, where the effects on erectile function are immediate and, in some cases, improve, the effects of radiotherapy are delayed. Symptoms usually start about six months following treatment and slowly progress. Just as with surgery, there are medications and techniques that make achieving an erection possible. Other forms of radiotherapy, including low-dose rate (LDR) – and high-dose rate (HDR) brachytherapy, have variable effects on sexual functioning.
Hormone suppression therapy may be used in conjunction with radiotherapy; this can cause a decreased libido as well as erectile difficulties. Androgen deprivation therapy leads to loss of muscle mass, weight gain, hot flushes and growth in breast tissue. This often negatively impacts on the way a man feels about himself and his sexuality.
My Sexual Health has a team of healthcare providers who can help men with prostate cancer to improve and optimise their sexual functioning. Visit www.MySexualHealth.co.za.
MEET OUR EXPERT
Dr Careen Rascher is a psychiatrist and a Sexual Medicine Specialist. She is also a Fellow of the European Committee for Sexual Medicine. She serves on the membership Committee for SASHA (Southern African Sexual Health Association) and is a member of Bayer Men’s Health Advisory Committee.