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Definition sexual rehabilitation

Sexual rehabilitation is a process to restore sexual function that is often affected by prostate cancer treatments: 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 (neuropraxia) may delay return of natural erectile function. Neuropraxia often occurs after surgery, usually 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 may 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. The outcome depends on many factors surrounding the nature of the surgery plus age and pre-surgery sexual functioning. 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.

The intention of this handout is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.

Copyright The Male Clinic © 2017

What is the prostate?

The prostate is a variable sized gland located in the male pelvis, usually the size of a walnut measuring 3-4cm long and 3-5cm wide. On average the gland weighs about 20gm. The prostate surrounds the urethra which carries urine from the bladder to the penis. The seminal vesicles attach to the prostate and produce material that mixes with the prostatic fluid to form semen. The tubes from the testicles carry sperm to the prostate where the sperm are mixed with the prostate and the seminal vesicle fluid. The fluid is then ejaculated during orgasm by a connection to the urethra called the ejaculatory ducts.

Three main prostate disorders

Prostate disease is a term used to describe any medical problem involving the prostate gland. Common prostate problems experienced by men include:

• Prostatitis is inflammation and swelling of the prostate gland, occurs mainly in younger men
• Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland, occurs as men age
• Prostate cancer occurs in men after 40-45 year of age, it is the most common form of cancer in men in Australia

Prostatitis is a difficult to treat inflammation of the prostate gland in younger men. Often bacteria can’t be identified, so the condition is then described as non-bacterial prostatitis, even though antibiotics may be used for treatment. Prostatitis may present with pain on urination, pain on ejaculation and a chronic pelvic/genital discomfort.

BPH is one of the most common diseases affecting the prostate and is the most common benign tumour in men as they get older. This condition is present in 50% of men over 50 years.

Symptoms of BPH: The symptoms involve noticeable changes in urination due to the effects of enlargement of the prostate around the urethra, called lower urinary tract symptoms (LUTS). The urinary symptoms may be voiding (weak stream, dribbling, intermittency and inadequate emptying) or storage (urgency, frequency, nocturia and incontinence).

Assessment of BPH: The prostate can be assessed by a digital rectal examination (DRE) where a gloved and lubricated finger is inserted into the anus. The back of the prostate can thus be felt and an assessment of its size may be possible. This digital examination may also feel a cancerous lump though not all prostate cancers are palpable in this manner.

The PSA blood test (prostate specific antigen) is an important marker of prostate cancer though it is not cancer specific. It is very sensitive to the detection of prostate cancer, however it is not able to tell how aggressive the cancer is. It may also be raised in benign enlargement or prostatitis. Normal values for PSA blood test results are available for different age groups.

Treatment of BPH: Treatments for BPH range from watchful waiting to medication to surgery. Medications derived from plants have shown some benefit, for example, Saw Palmetto. Prescription medications may reduce the prostate size thus improving symptoms, yet often this is only a temporary relief. These medications include alpha blockers, 5 alpha reductase inhibitors and a combination of both. LUTS can be also associated with symptoms of an overactive bladder, and if primary treatments are not effective then oral anti-cholinergic medications can assist. However, sudden occurrence of overactive bladder symptoms can mean an insidious cause such as bladder cancer. Overactive bladder symptoms may respond to pelvic floor physiotherapy.

Treatments for BPH causing bladder outlet obstruction can be divided into cavitating (creation of a new channel) or non cavitating (no creation of a new channel).
Cavitating treatments include transurethral resection of the prostate (TURP) or HoLEP (holmium laser enucleation of the prostate). This involves removal of obstructive prostate tissue with an electrical blade or laser. Newer modalities of laser (greenlight) or heat treatment do not seem to create as large a channel as TURP/HoLEP but benefit from less bleeding .

A new treatment for BPH is the UroliftTM which can be performed as a day stay and most men will return to normal activities within a week. The UroliftTM uses implants to essentially stent apart the prostate that is blocking the urethra. Your urologist will discuss the most appropriate treatment for you.

Prostate cancer is the commonest cancer in men. It usually does not present with urinary symptoms unlike BPH. Prostate cancer has an increased incidence in men who have a close relative diagnosed with this condition or in men who have an African American heritage. It may be diagnosed by routine testing with the PSA blood test and DRE (digital rectal exam). Recently the use of high strength 3T MRI (magnetic resonance imaging) can assist with precision of diagnosis.
Prostate cancer needs confirmation by a biopsy and this can be done in a variety of ways. Transrectal ultrasound guided prostate biopsy (TRUS) requires the use of a rectal ultrasound probe to guide biopsy needles into the prostate. This can be done either awake using local anaesthetic or asleep with a general anaesthetic. Transperineal (TP) ultrasound guided prostate biopsy (TP) is similar to TRUS except the needles are placed through the perineum (skin between the scrotum and anus). The latter requires day stay in hospital and a general anaesthetic but has less risk of infective complications. If a patient has had an MRI, a computer can extrapolate areas to an ultrasound image and a biopsy this way is called a MRI/US fusion biopsy. Recently, a robot (Biobot) can be used to in conjunction with MRI and US fusion techniques to target areas of interest transperineally and via only two needle punctures. The most accurate way to target the smallest area of concern in a prostate is via MRI in gantry guided prostate biopsies. This will require both a dedicated MRI radiologist and a Urologist to guide the needle into the prostate. Once confirmed, the aggressiveness of the cancer is measured by the Gleason score.

Treatment of prostate cancer is complex and the decision on the most appropriate treatment involves many factors, the grade and stage of the cancer and importantly, the patient’s own preferences. If the cancer has the potential for cure then the choices are active surveillance, seed brachytherapy, external beam radiotherapy, or radical prostatectomy (open or robotic). If the cancer is advanced then treatment is usually with hormones or chemotherapy. Your urologist will discuss the most appropriate treatment with you for prostate cancer.

The intention of this handout is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.

Copyright The Male Clinic © 2017