Sexual Rehabilitation following Prostate Cancer

Definition sexual rehabilitation

Sexual rehabilitation is a process to restore sexual function that is often affected by prostate cancer treatments, which are surgery, either open or robotic radical prostatectomy, radiation therapy, brachytherapy or androgen deprivation therapy (ADT).

Sexual changes and outcomes

The sexual dysfunctions that may occur after these treatments include erectile dysfunction, loss of ejaculation, shortened penis and climacturia (passing of urine during orgasm). Loss of libido occurs particularly with ADT.

The outcome of sexual function after treatment depends on the age of the patient, the level of sexual function present before treatment and in the case of surgery, the sparing of the nerve bundles (better outcome if both sides are spared). Even if the erection nerves are spared, nerve paralysis also called neuropraxia may delay return of natural erectile function. Neuropraxia often occurs after surgery, hopefully a temporary situation.

Surgery tends to result in immediate loss of erections, whereas radiation and hormone deprivation treatments may result in a delayed loss of erections, up to 6 months after treatment. Sexual rehabilitation addresses these sexual dysfunctions, especially erectile dysfunction, that men may experience as a result of treatment for prostate cancer. It is an important part of the holistic care of men undergoing treatment.

Treatments

There is evidence that the earlier the erectile dysfunction is treated, the better the chance of a return of erections. If natural erectile function returns after treatment, the quality of the erections may not be as good as in the past. Erections may take up to 3 years to recover, but usually an indication of the outcome is seen at 18 to 24 months.

Penile injections: erections can be induced within 2 to 3 weeks of surgery with penile injection therapy using alprostadil (Caverject Impulse™) or compounded alprostadil, phentolamine and papaverine known as Trimix. The penis is initially injected with a low dose of alprostadil, about 2.5 to 5 mcg once or twice a week. The early and regular “exercising” of the penis to erection has been shown to expedite the return of erections (but only when the erection nerves have been saved). This exercising regime can be with your partner or by yourself.

Penile injection treatment has been safely used for many years but sometimes its use is painful due to a “chemical post-injection pain”. Care must be taken with the amount injected to avoid a prolonged erection known as priapism and there is a risk of scarring occurring in the penile tissues.

This “exercising” regime allows oxygenation of the erection tissues thus minimising the risk of deterioration of these tissues due to lack of use and low oxygen (hypoxia) levels. If there appears to be an improvement in natural erections whilst on injection therapy, oral treatment can be tried about every 3 months.

Oral medications: the oral treatments are known as PDE5 inhibitors, there are 3 available (Viagra™, Levitra™ and Cialis™). The tablets are swallowed about 1 hour before planned sexual activity when used on an as required basis. But initially they are usually taken daily and later that may be changed to an as required basis. However during the first few months after surgery, these oral tablets may not have the same erection inducing effect that injections have, but some men may prefer tablets to injections at the early stage of recovery, either due to personal preference or not being ready to engage in sexual activity.

The tablets may result in a softer erection not firm enough for penetration, but sexual play is encouraged as part of the “exercise” concept. An orgasm is entirely possible with a soft erection or indeed with no erection when adequate stimulation to the penis occurs. But there is some evidence that just by taking PDE5 inhibitors even without an erection occurring, there may be benefit in prevention of deterioration of the erection tissues.
The common side effects include flushing of the face, headache and blocked nose. PDE5 inhibitors cannot be taken by men who are on cardiac medication known as nitrates.

Vacuum device: another treatment choice is the use of a vacuum erection device which is a non invasive method involving placement of a cylinder over the penis. Air is extracted by a pump which results in the formation of an erection that is held in place by a rubber constriction ring. The vacuum device is also used to “exercise” the penis without the rings as a daily or second daily routine for a few minutes. The constrictions rings can be used with the device to create and hold the erection to allow sexual intercourse to occur.

Penile implant: the surgical insertion of a penile implant or prothesis is considered when all other treatments have proven ineffective. This hydraulic device allows an erection suitable for penetrative intercourse to occur with the simple activation of a pump discreetly placed in the scrotum.

Summary

Sexual rehabilitation is a process to restore erectile function following prostate cancer treatment. After surgery, the loss of the erection is immediate and the return of that function can be a slow and unpredictable process. Brachytherapy and radiation treatment have a delayed onset of erectile dysfunction. Each rehabilitation program is individually designed and regular review is required as adjustments in treatments are often made. The outcome depends on many factors surrounding the nature of the surgery plus age and pre-surgery sexual functioning. Sometimes the final outcome of the return of erectile function 2 to 3 years after surgery may not be as good as the situation beforehand, even when nerve sparing surgery has been carried out. Persistence and repetition of the recommended exercises in a regular routine may improve the outcome. If you do not have partner it is still important to carry out the treatment program on your own. However if you are in a relationship, do not forget the sexual needs of your partner. If your erections are not firm enough for penetration, consider non-penetrative sexual activity known as outercourse. Negotiate with your partner over the exercises that you can both participate in and discuss what level of sexual activity you both wish to achieve. Your treating doctor or sex therapist can always assist with these decisions.