Prostate Cancer Canada Network

In The News

Well-Done Meat Consumption May Increase Prostate Cancer Risk
Research into the dietary habits of about a thousand men from the Cleveland area has found that a high consumption of meats, especially of red meat prepared by grilling, is positively associated with an increased risk of developing aggressive prostate cancer. This particular study, which was led by Dr. John Witte of the University of California, San Francisco (UCSF), has a number of limitations, but it does add support to other investigations connecting meat consumption with cancer risk.

Toronto researchers speculate regarding a link between prostate cancer and oral contraceptive use
Very preliminary and speculative research, designed to spark further inquires, suggests that there may be a connection between oral contraceptive use and rising rates of prostate cancer. One theory is that the widespread use of birth-control pills in various populations may result in a higher level of estrogen in the environment, which might, in turn, increase prostate cancer risk.

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Erectile Dysfunction (ED)

Erectile dysfunction or ED, which is sometimes referred to as impotence, is the inability to achieve or maintain an erection that is hard enough to have sexual intercourse. The term encompasses a broad range of difficulties with erections. It can be used to refer to a man who can’t get an erection at all or to a man whose erection is a bit soft and too easily lost for penetration. What ED does not refer to is the end of a man’s sex life. Most men with ED can achieve an orgasm, and they have the usual sensations in response to stimulation. Often, their sex drive is also similar to what it was before they began having difficulty.

That’s the good news. The bad news is that ED is one of the possible side effects of various treatments for prostate cancer. Why? The prostate gland is part of the complex male reproductive system. It reacts to male hormones, and it stores and secretes a fluid that forms part of the semen in which sperm are transported. During sex and orgasm, this semen enters the urethra, which the prostate surrounds, and passes through the penis. So the prostate is involved in ejaculation. (Because of this involvement, all men who have their prostates removed surgically will no longer ejaculate, even when they have an orgasm; the prostate is no longer available to produce the fluid.) But a main reason that prostate cancer treatments can cause ED is that the prostate is immediately adjacent to a number of very important nerves and blood vessels. These supply the penis and are necessary if a man is to achieve a normal erection. Because most prostate cancer treatments involve destroying the cells of the prostate or surgically removing them, a man undergoing these treatments risks damage to some of the structures, nerves, and blood vessels near the prostate that are necessary in achieving an erection.

Surgery and ED
Men treated with a prostatectomy commonly have trouble getting an erection, at least until they recover. After all, surgery is traumatic for the body. Whether you are able to have an erection after surgery depends on the kind of surgery you had. Was the doctor able to spare both of the bundles of nerves surrounding the prostate? Only one? Of course, the more nerves spared the better. Also, men who are younger than 60 and who have the highest levels of sexual activity before the operation usually recover potency more quickly.

Even if a doctor is able to spare both bundles of nerves, in a procedure called bilateral nerve-sparing surgery because these “bundles” are located on either side of the prostate gland, it may take a man up to 18 to 24 months before he can achieve a reasonable erection. But most men who do not have long-term ED will see substantial improvement after about 6 to 18 months.

Important note: Many urologists recommend self-stimulation within the first 2 weeks after a man’s catheter has been removed. They often prescribe drugs such as Viagra or Cialis or sometimes other ED treatments in order to enhance the flow of blood and oxygen to the penis. The concept is a bit like “use it or lose it”: the frequent and stronger erections, helped out by treatments as soon as this is safe after surgery, are thought to promote the return of a man’s own erections.

(For more information, see the video of Dr. Larry Goldenberg’s presentation “Penile Rehabilitation after Radical Prostatectomy.”)

Radiation and ED
Radiation therapy, including brachytherapy, can cause ED. Again, the problem is collateral damage to he blood vessels, nerves, and tissues needed to achieve an erection. The important issues are how much radiation (dose) and over how much of the body (the width of the field). The stronger the dose and the wider the field, the more likely the ED. Other factors, such as age and general health and frequency of pre-treatment erections also come into play.

Unlike after surgery, however, after radiation, men may not experience erectile dysfunction right away and then improve. They may, instead, start having ED about six months or more after their radiation therapy is over; if this happens, the ED does not usually get better.

Hormone Therapy and ED
The connection between hormone therapy and sexual dysfunction is well known, but this therapy is the best option for men with advanced prostate cancer as it slows the progression of the disease and increases life expectancy.

The form of hormone therapy known as LH-RH analog therapy (or “chemical castration”) causes ED by suppressing the production of testosterone, the male hormone that both “feeds” prostate cancer and is responsible for a man’s sex drive. Typically, after a few months of this therapy, men will start to have a loss of libido (interest in sex) and then lose the ability to achieve natural erections.

Some men opt for intermittent hormone therapy, which gives them “break periods” during which the side effects of the drugs wear off, including ED. However, intermittent androgen deprivation therapy, as it is called, is still being tested to see whether it achieves the same long-term survival rates and other health outcomes as the more commonly prescribed continuous hormone therapy.

TREATING ERECTILE DYSFUNCTION
Of course, whether and how to treat ED depends upon its specific causes and the individual circumstances of each man. Here are some common methods:

Oral medications such as sildenafil (Viagra®), vardenafil (Levitra®), and tadalafil (Cialis®). These work by blocking the natural breakdown of the chemical substances responsible for an erection. Because they have no effect on the chemicals that cause an erection, which are triggered by nerve signals coming from the brain and around the penis, these drugs do not work without stimulation.
Injection of drugs such as such as alprostadil, papaverine, or phentolamine into the side of the penis (called intracavernous injection therapy). These medications are muscle relaxants that help increase blood flow into the penis. When they are injected, the penis becomes rigid in about 5 to 10 minutes as the blood vessels in the penis widen after the thin layer of muscle surrounding the vessel walls relax.
Use of constricting rings. These are adjustable or elastic rings that a man can place around his penis before it is aroused. The ring helps keep blood in the penis when it becomes erect, so the erection lasts.
Use of a vacuum erection device (VED), which is sometimes called a vacuum constriction device. These work by drawing blood into the penis and keeping it there by mechanical means. A man places a cylinder over the penis and pumps the air out of the device, which then draws blood into the penis and causes an erection. To maintain the erection, the man slips a constricting ring off the base of the cylinder and onto the base of his penis. The ring can stay in place for up to 30 minutes. VEDs are considered less desirable for a man who has undergone surgery, as they do not promote the circulation of fresh oxygenated blood to the penis, which can encourage healing.
Suppositories of drugs placed into the urethra through the opening in the tip of the penis (a treatment often called MUSE, which stands for “medicated urethral system of erection”). A man inserts these suppositories using a plastic applicator, and the inserted drug (alprostadil) dissolves in the urethra and is absorbed into the erectile tissue of the penis. The drug relaxes the muscles of the penis and increases blood flow to it. A gentle massaging of the penis helps the drug to dissolve. Men who have had surgery for prostate cancer report an increased incidence of a burning sensation with the use of MUSE. Success rates for this therapy also appear to be lower than for other methods.
A penile implant. This is a surgical treatment and involves implanting a mechanical device. There are two types of penile implants, inflatable and semi-rigid rods. Inflatable pumps are the most common type used in North America. Usually, these consist of three parts, a fluid-filled reservoir placed under the wall of the abdomen, two inflatable cylinders placed inside the penis, and a pump and release or deflation valve placed inside the scrotum. To achieve an erection, a man feels in the scrotum for the pump component, which feels like a small bulb. He squeezes this pump, which sends fluid from the reservoir into the cylinders inserted in the penis, and the penis gradually becomes rigid as these cylinders fill up. When he is finished with the erection, he depresses the deflation valve and holds this for 3 to 5 seconds, which lets the fluid run out of the cylinders and back to the reservoir. All components are implanted inside a man’s body, so the erection looks normal.

LIVING WITH ED
Sometimes, no ED treatment works or, in the case of hormone therapy, for example, would only work if life-extending prostate cancer treatment were potentially compromised. In this circumstance, men have reported quite extensive emotional effects, which should not be minimized. These include

the fear that a diminished ability to perform sexually will disable emotional as well as physical intimacy,
the absence of the subtle element of sexuality that once charged their everyday interactions with friends and strangers,
a sense of loss because their diminished response to sexual stimuli affected their fantasy lives, and
a feeling that ED has affected their masculinity—as one man put it, “You lose that feeling that you are a whole man.”

Men experiencing feelings of this sort should seek help from professionals. Research also suggests that “support networks might reduce distress by allowing men to ‘process’ their experience (a model familiar to those working in the trauma area).” It might be especially important for men who do feel distressed by ED to find help. Why? Men who have been diagnosed with prostate cancer frequently report that their spouses or partners are their main sources of support and comfort. One study concludes that, because of this fact, when prostate cancer survivors do report constraints on their emotional and physical intimacy, they are more distressed than female survivors of breast cancer who report the same thing.

The good with the bad
Men whose ED is a consequence of prostate cancer treatment can take heart from the comments of the women who sat on the panel “Women with Prostate Cancer.” At the national conference in 2008, these women related how their husbands’ prostate cancer had affected them and their most intimate relationships. Here are some of their comments about their husbands’ inability to achieve normal erections:

“For me, it was fine. We did other things to fill that void, and I still think we have a sex life. Our … love for each other has just become stronger and stronger through all of the things we have faced in life. I don’t think we are lacking anything in our sexual intimacy, other than intercourse. But, for us, that’s not the most important thing.”

“A depleted testosterone level led to no physical sex and no desire for sex.... We just became closer [in other ways], and we shared our feelings more.”

“Unfortunately, or fortunately, we had to work things out the hard way, but we have a very active sex life. We cuddle; we have orgasms, both of us…. There are a whole pile of alternative things; there is no reason why you should forego orgasm if that is important to you.”

And the most important advice from these women is supported by the research literature:

“Recognize that prostate cancer and its treatment will affect your relationship as a couple, and go out early on to find the psychosocial counselling or services that you need.”

To watch a video of this panel presentation, go to the web page “2008 Conference Presentations” and look for the video entitled “Panel discussion on Women with Prostate Cancer.”

References:

Barbara Bokhour and colleagues, 2001, Sexuality after treatment for early prostate cancer, Journal of General Internal Medicine, vol. 16, no 10, pp. 649–655.

S. G. Zakowski and colleagues, 2003, Social barriers to emotional expression and their relations to distress in male and female cancer patients, British Journal of Health and Psychology, vol. 8, 271–286.

Sidney Bloch, 2007, Biosocial adjustment of men with prostate cancer: A review of the literature, Biopsychosocial Medicine, vol. 1, 1751–1579.