Reframing sexuality for men on ADT

The management of sexual dysfunction caused by androgen deprivation therapy (ADT) for prostate cancer is a critical aspect of survivorship; Dr Jireh Serfontein expands on this.

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Prostate cancer is a prevalent malignancy in men, and androgen deprivation therapy (ADT) is a cornerstone in the management of advanced disease. Sexual dysfunction is a common adverse effect, with rates approaching 80 – 90% in men undergoing ADT for advanced prostate carcinoma.

It’s essential to provide state-of-the-art review and management strategies for sexual rehabilitation in prostate cancer survivors. The impact of sexual dysfunction extends to partners; understanding the spousal communication and relationship factors are crucial for developing interventions to improve the quality of life for both partners. The assessment of sexual function tends to focus largely on erectile function, but it’s important to consider other aspects, such as interest, desire, satisfaction, arousal, and orgasm, along with the rating of how much of a problem sexual dysfunction presents.

Men and their partners require individualised help and guidance to manage sexual dysfunction, indicating the need for personalised approaches.⁶ Additionally, the psychosocial aspects of sexual recovery after prostate cancer treatment, including the impact on couples’ relationships, should be considered when developing management strategies.

The adverse effects of prostate cancer treatment on sexual function should be taken into consideration in routine clinical practice, and healthcare professionals should be equipped with adequate information and resources to address sexual dysfunction.⁸

Management of sexual dysfunctions caused by ADT

1. Erectile dysfunction

Testosterone plays a vital role in maintaining penile tissue health and regulating the nitric oxide pathway, which is essential for achieving and maintaining erections. The reduction in testosterone levels due to ADT can lead to impaired erectile function, affecting sexual performance and satisfaction. Men who have good erectile function before starting ADT may benefit from penile rehabilitation using established medical treatments several times a week to ensure that erectile tissue is oxygenated.

Phosphodiesterase-5 inhibitor medications such as sildenafil, tadalafil, and vardenafil are commonly used. These drugs enhance the effects of nitric oxide, increasing blood flow and facilitating erections.

Intracavernous injections (ICI) are indicated for patients who undergo a non-nerve-sparing radical prostatectomy or whose condition fails to respond to PDE-5 inhibitors. Intracavernous agents can be used either individually or as a combination regimen. The most widely studied regimens are currently prostaglandin E1 (PGE1) and a combination of phentolamine, papaverine, and PGE1 (Trimix). Quadrimix (Trimix + atropine) is also available. ICI therapy is effective in 64 to 98% of patients with erectile dysfunction and is associated with an increase in sexual activity, improvement in the quality of erections, and improvements in sexual satisfaction for both the patient and his partner.

Vacuum erection devices offer an additional option for post–radical prostatectomy patients who fail to have response to PDE-5 inhibitors. They promote engorgement of the penis through negative pressure effects on the corporeal chambers. When used with a venous constriction ring to maintain tumescence, they have proved to be highly-effective in providing patients with a minimally-invasive, reasonably inexpensive means to obtain an erection.

Penile implants may be considered for patients with severe erectile dysfunction that doesn’t respond to other treatments. These devices are surgically implanted into the penis to enable erections when desired.¹²

2. Decreased libido

Testosterone exerts its effects centrally and peripherally; libido is thought to be affected by testosterone’s role within the central nervous system (CNS). Libido, or sexual drive, is difficult to isolate as there are numerous physiological, environmental, and psychological factors that may influence it.¹⁴ The suppression of testosterone levels by ADT can lead to a decline in libido, impacting sexual interest and motivation of patients.

Bupropion, according to some data, has a positive effect on sexual desire due to the dopamine agonistic effect and can be considered as a treatment option for low libido.¹⁴ Some explanations of testosterone’s role on libido are based on increased dopamine release within the CNS. Dopamine may directly influence libido.

Intermittent androgen deprivation therapy (IAD) has emerged as a treatment option that can improve symptoms and quality of life by allowing the return to sexual function in men with prostate cancer. Compared to continuous ADT, IAD has shown improvements in sexual desire and libido.¹⁵

Psychosexual support (consulting a professional sexual therapist) can invoke awareness of sexual fantasies, relying on their potential to trigger sexual desire and arousal. Counselling can also recruit past sexual fantasies and explore expanding erogenous zones. Cognitive reframing of sexual experiences and mindfulness techniques may also be helpful for men on ADT.

3. Orgasmic dysfunction

Orgasm is the brain’s perception and interpretation of the various striated and smooth muscle (accessory glands) contractions and sensory neuronal stimulation in the pelvic region and other erogenous zones. Prostate cancer treatments can remove or radiate the prostate and surrounding bladder neck, seminal vesicles, and vas deferens which may result in altered orgasmic sensation or orgasmic threshold. Psychological and physiological variants, such as depression, altered erectile function, and reduced testosterone with ADT can further reduce the chance of reaching and enjoying orgasm.¹² But orgasm can still be achieved even if erections aren’t firm.

Physiotherapy includes treatments for orgasmic dysfunction, such as pelvic floor therapy for general pelvic floor hyperspasticity, but no direct literature exists.

Psychosexual support can play a role again. Successful treatment of a patient with orgasmic difficulties requires experimentation and open-mindedness regarding the use of sexual aids, such as vibrators, masturbatory aids or penetrative aids to induce orgasm. Referral to a sexual therapist can also aid in experimentation with other sources of stimulation (new breast sensitivity, perineal or perianal stimulation). Men should also be instructed that prolonged stimulation will be required to achieve orgasm with a flaccid penis, and that the use of a lubricant can help protect the skin from potential irritation.

Sensate focus therapy is a behavioural therapy that involves gradual and structured exercises  to enhance sensory awareness and improve sexual response. It can be beneficial in addressing orgasmic dysfunction.

Medical adjustments can be used in some cases. Adjusting the dosage or type of ADT medication may help alleviate orgasmic dysfunction and other sexual side effects.¹⁵ Consulting with a healthcare provider to explore alternative treatment options is essential.

4. Sexual aversion

Some men on ADT may develop aversion to sexual activity due to the physical and psychological changes associated with treatment. The impact of ADT on sexual function, body image, and emotional well-being can contribute to sexual aversion, leading to avoidance of intimate relationships and sexual encounters.

Couples therapy can be beneficial in cases where sexual aversion is impacting intimate relationships. Addressing communication barriers, emotional concerns, and relationship dynamics can help improve sexual intimacy and reduce aversion.

Mindfulness and relaxation techniques can help reduce anxiety and stress related to sexual activity, promoting a more positive and relaxed approach to intimacy. By tailoring treatment strategies to address specific sexual dysfunctions induced by ADT, healthcare providers can optimise the management of these challenges and improve the sexual health and overall well-being of prostate cancer patients undergoing this treatment.

References

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