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International Urology and Nephrology

, Volume 40, Issue 2, pp 355–363 | Cite as

Erectile dysfunction following radiotherapy and brachytherapy for prostate cancer: pathophysiology, prevention and treatment

  • Cem Akbal
  • İlker Tinay
  • Ferruh Şimşek
  • Levent N. Turkeri
Review

Abstract

Objectives

Although detrimental impact on sexual function following radiotherapy (RT) and brachytherapy decreases the quality of life of prostate cancer survivors, the etiology, pathophysiology, prophylaxis and treatment of this condition has not yet been fully clarified. We reviewed the published literature in terms of etiology, treatment and possible prevention of erectile dysfunction (ED) following RT and/or brachytherapy.

Method

We have reviewed the literature through a MEDLINE search. Prostate cancer, erectile dysfunction, radiotherapy, brachytherapy, treatment and quality of life were used as keywords.

Conclusion

Both RT and brachytherapy result in high rates of ED. Although arterial damage seems to be the main cause of ED after RT, exposure of neurovascular bundle to high levels of radiation dose has been also implicated in some studies with brachytherapy. The radiation dose received by the corpora cavernosa at the crurae of the penis may also be important in the etiology of ED. The most important predictive factor of ED following RT is the treatment modality. Intensity-modulated radiotherapy and vessel-sparing prostate radiotherapy are new techniques but those treatments may not guarantee complete preservation of the erectile function. Patients need to be correctly informed on the possible sequela of radiation-based treatments on their sexual well-being while planning their treatment. Patients should also be informed about the possible treatment modalities for ED, which may develop in due course.

Keywords

Brachytherapy Erectile dysfunction Prostate carcinoma Radiotherapy Treatment 

References

  1. 1.
    Sobin LH, Wittekind CH (1997) UICC TNM Classification of Malignant Tumors, 5th edn. New YorkGoogle Scholar
  2. 2.
    McCammon KA, Kolm P, Main B et al (1999) Comparative quality-of-life analysis after radical prostatectomy or external beam radiation for localized prostate cancer. Urology 54:509–516PubMedCrossRefGoogle Scholar
  3. 3.
    Lim AJ, Brandon AH, Fiedler J et al (1995) Quality of life: radical prostatectomy versus radiation therapy for prostate cancer. J Urol 154:1420–1425PubMedCrossRefGoogle Scholar
  4. 4.
    Bacon CG, Mittleman MA, Kawachi I et al (2003) Sexual function in men older than 50 years of age: results from the Health Professionals Follow-up Study. Ann Intern Med 139:161–168PubMedGoogle Scholar
  5. 5.
    Stanford JL, Stephenson RA, Coyle LM. Prostate Cancer Trends 1973–1995. NIH Publication No. 99–4543. Bethesda, SEER Program, National Cancer Institute, 1999. Google Scholar
  6. 6.
    Fransson P, Widmark A (1996) Self-assessed sexual function after pelvic irradiation for prostate carcinoma. Cancer 78:1066–1078PubMedCrossRefGoogle Scholar
  7. 7.
    Goldstein I, Feldman MI, Deckers PJ et al (1984) Radiation associated impotence. A clinical study of its mechanism. JAMA 251:903–910 PubMedCrossRefGoogle Scholar
  8. 8.
    Zelefsky MJ, Eid JF (1998) Elucidating the etiology of erectile dysfunction after definitive therapy for prostatic cancer. Int J Radiat Oncol Biol Phys 40:129–133PubMedCrossRefGoogle Scholar
  9. 9.
    Mulhall J, Ahmed A, Parker M et al (2005) The hemodynamics of erectile dysfunction following external beam radiation for prostate cancer. J Sex Med 2:432–437PubMedCrossRefGoogle Scholar
  10. 10.
    Mittal B (1985) A study of penile circulation before and after radiation in patients with prostate cancer and its effect on impotence. Int J Radiat Oncol Biol Phys 11:1121–1125PubMedGoogle Scholar
  11. 11.
    Carrier S, Hricak H, Lee SS et al (1995) Radiation-induced decrease in nitric oxide synthase-containing nerves in the rat penis. Radiology 195:95–99PubMedGoogle Scholar
  12. 12.
    Fisch BM, Pickett B, Weinberg V et al (2001) Dose of radiation received by the bulb of the penis correlates with risk of impotence after three-dimensional conformal radiotherapy for prostate cancer. Urology 57:955–959PubMedCrossRefGoogle Scholar
  13. 13.
    Roach M, Winter K, Michalski JM et al (2004) Penile bulb dose and impotence after three-dimensional conformal radiotherapy for prostate cancer on RTOG 9406: findings from a prospective, multi-institutional, phase I/II dose– escalation study. Int J Radiat Oncol Biol Phys 60:1351–1356PubMedCrossRefGoogle Scholar
  14. 14.
    Wernicke AG, Valicenti R, Dieva K et al (2004) Radiation dose delivered to the proximal penis as a predictor of the risk of erectile dysfunction after three-dimensional conformal radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 60:1357–1363PubMedCrossRefGoogle Scholar
  15. 15.
    Mulhall JP, Yonover P, Sethi A et al (2002) Radiation exposure to the corporeal bodies during 3-dimensional conformal radiation therapy for prostate cancer. J Urol 167:539–542PubMedCrossRefGoogle Scholar
  16. 16.
    Mulhall JP, Yonover P (2001) Correlation of radiation dose and impotence risk after three-dimensional conformal radiotherapy for prostate. Urology 58:828PubMedCrossRefGoogle Scholar
  17. 17.
    Namiki S, Ishidoya S, Tochigi T et al (2006) Health-related quality of life after intensity modulated radiation therapy for localized prostate cancer: comparison with conventional and conformal radiotherapy. Jpn J Clin Oncol 36:224–230PubMedCrossRefGoogle Scholar
  18. 18.
    Wilder RB, Chou RH, Ryu JK et al (2000) Potency preservation after three-dimensional conformal radiotherapy for prostate cancer: preliminary results. Am J Clin Oncol 23:330–333PubMedCrossRefGoogle Scholar
  19. 19.
    Al-Abany M, Steineck G, Agren Cronqvist AK et al (2000) Improving the preservation of erectile function after external beam radiation therapy for prostate cancer. Radiother Oncol 57:201–206PubMedCrossRefGoogle Scholar
  20. 20.
    Mulhall JP, Yonover P, Sethi A et al (2002) Radiation exposure to the corporeal bodies during 3-dimensional conformal radiation therapy for prostate cancer. J Urol 167:539–542PubMedCrossRefGoogle Scholar
  21. 21.
    Hisasue S, Takahashi A, Kato R et al (2004) Erectile function following external beam radiotherapy for clinically organ-confined or locally advanced prostate cancer. Jpn J Clin Oncol 34:269–273PubMedCrossRefGoogle Scholar
  22. 22.
    Kao J, Turian J, Meyers A et al (2004) Sparing of the penile bulb and proximal penile structures with intensity-modulated radiation therapy for prostate cancer. Br J Radiol 77:129–136PubMedCrossRefGoogle Scholar
  23. 23.
    Narayana V, Meirovitz A, Troyer S et al (2005) Vessel-sparing prostate radiotherapy: dose limitation to critical erectile vascular structures (internal pudendal artery and corpus cavernosum) defined by MRI. Int J Radiat Oncol Biol Phys 61:1–2Google Scholar
  24. 24.
    Schwartz K, Bunner S, Bearer R et al (2002) Complications from treatment for prostate carcinoma among men in the Detroit area. Cancer 95:82–89 PubMedCrossRefGoogle Scholar
  25. 25.
    Helgason AR, Fredrikson M, Adolfsson J et al (1995) Decreased sexual capacity after external radiation therapy for prostate cancer impairs quality of life. Int J Radiat Oncol Biol Phys 32:33–39PubMedGoogle Scholar
  26. 26.
    McGowan DG (1977) Radiation therapy in the management of localized carcinoma of the prostate. Cancer 39:98–103. PubMedCrossRefGoogle Scholar
  27. 27.
    Tomic R (1983) Some effects of orchiectomy, oestrogen treatment and radiation therapy in patients with prostatic carcinoma. Scand J Urol Nephrol 7:1–37Google Scholar
  28. 28.
    Joly F, Brune D, Couette JE et al (1998) Health-related quality of life and sequelae in patients treated with brachytherapy and external beam irradiation for localized prostate cancer. Ann Oncol 9:751–757PubMedCrossRefGoogle Scholar
  29. 29.
    Van Heeringen C, De Schryver A, Verbeek E (1988) Sexual function disorders after local radiotherapy for carcinoma of the prostate. Radiother Oncol 13:47–52PubMedCrossRefGoogle Scholar
  30. 30.
    Beckendorf V, Hay M, Rozan R et al (1996) Changes in sexual function after radiotherapy treatment of prostate cancer. Br J Urol 77:118–123PubMedGoogle Scholar
  31. 31.
    Caffo O, Fellin G, Graffer U et al (1996) Assessment of quality of life after radical radiotherapy for prostate cancer. Br J Urol 78:557–563 PubMedGoogle Scholar
  32. 32.
    D’Amico AV, Whittington R, Malkowicz SB et al (1998) Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA 280:1584–1586CrossRefGoogle Scholar
  33. 33.
    Sanchez-Ortiz RF, Broderick GA, Rovner ES et al (2000) Erectile function and quality of life after interstitial radiation therapy for prostate cancer. Int J Impot Res 12(Suppl 3):18–24CrossRefGoogle Scholar
  34. 34.
    Matzkin H, Kaver I, Stenger A et al (2001) I125 prostate brachytherapy: short-term results of the first 150 patients in Israel [Hebrew]. Harefuah 140:694–698PubMedGoogle Scholar
  35. 35.
    Stock RG, Kao J, Stone NN (2001) Penile erectile function after permanent radioactive seed implantation for treatment of prostate cancer. J Urol 165:436–439PubMedCrossRefGoogle Scholar
  36. 36.
    Merrick GS, Butler WM, Wallner KE et al (2005) Erectile function after prostate brachytherapy. Int J Radiat Oncol Biol Phys 62:437–447 PubMedGoogle Scholar
  37. 37.
    Zelefsky MJ, Wallner KE, Ling CC et al (1999) Comparison of the 5-year outcome and morbidity of three-dimensional conformal radiotherapy versus transperineal permanent iodine-125 implantation for earlystage prostatic cancer. J Clin Oncol 17:517–522PubMedGoogle Scholar
  38. 38.
    Merrick GS, Butler WM, Dorsey AT et al (2001) Effect of prostate size and isotope selection on dosimetric quality following permanent seed implantation. Tech Urol 7: 233–240PubMedGoogle Scholar
  39. 39.
    Ritter MA, Schulz CA, Hendee E (2000) Erectile dysfunction and brachytherapy-related doses to the neurovascular bundles (Abstr). IntJ Radiat Oncol Biol Phys 48:250CrossRefGoogle Scholar
  40. 40.
    Merrick GS, Butler WM, Galbreath RW et al (2002) Erectile function after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 52:893–902PubMedCrossRefGoogle Scholar
  41. 41.
    Merrick GS, Butler WM, Lief JH et al (2001) Is brachytherapy comparable with radical prostatectomy and external-beam radiation for clinically localized prostate cancer? Tech Urol 7:12–19PubMedGoogle Scholar
  42. 42.
    Teloken C (2001) Management of erectile dysfunction secondary to treatment for localized prostate cancer. Cancer Control 8:540–45PubMedGoogle Scholar
  43. 43.
    Stone NN, Stock RG (2002) Complications following permanent prostate brachytherapy. Eur Urol 41:427–433PubMedCrossRefGoogle Scholar
  44. 44.
    Stone NN, Stock RG (2002) Permanent seed implantation for localized adenocarcinoma of the prostate. Curr Urol Rep 3:201–206PubMedCrossRefGoogle Scholar
  45. 45.
    Woolsey J, Miller N, Theodorescu D (2003) Permanent interstitial brachytherapy for prostate cancer: a current review. World J Urol 21:209–219 PubMedCrossRefGoogle Scholar
  46. 46.
    Merrick GS, Wallner KE, Butler WM (2003) Management of sexual dysfunction after prostate brachytherapy. Oncology (Huntingt) 17:52–62(discussion 62, 67–70, 73)Google Scholar
  47. 47.
    Davison BJ, Keyes M, Elliott S et al (2004) Preferences for sexual information resources in patients treated for early-stage prostate cancer with either radical prostatectomy or brachytherapy. BJU Int 93:965–969PubMedCrossRefGoogle Scholar
  48. 48.
    Raina R, Agarwal A, Goyal KK et al (2003) Long-term potency after iodine-125 radiotherapy for prostate cancer and role of sildenafil citrate. Urology 62:1103–1108PubMedCrossRefGoogle Scholar
  49. 49.
    Merrick GS, Butler WM, Galbreath RW et al (2001) A comparison of radiation dose to the bulb of the penis in men with and without prostate brachytherapy induced erectile dysfunction. Int J Radiat Oncol Biol Phys 50:597–604PubMedGoogle Scholar
  50. 50.
    Merrick GS, Butler WM, Dorsey AT et al (2000) A comparison of radiation dose to the neurovascular bundles in men with and without prostate brachytherapy-induced erectile dysfunction. Int J Radiat Oncol Biol Phys 48:1069–1074PubMedCrossRefGoogle Scholar
  51. 51.
    Fisch BM, Pickett B, Weinberg V et al (2001) Dose of radiation received by the bulb of the penis correlates with risk of impotence after three-dimensional conformal radiotherapy for prostate cancer. Urology 57:955–959PubMedCrossRefGoogle Scholar
  52. 52.
    Merrick GS, Butler WM, Wallner KE et al (2002) The importance of radiation doses to the penile bulb vs crura in the development of postbrachytherapy erectile dysfunction. Int J Radiat Oncol Biol Phys 54:1055–1062PubMedCrossRefGoogle Scholar
  53. 53.
    Kiteley RA (2002) Radiation dose to the neurovascular bundles or penile bulb does not predict erectile dysfunction after prostate brachytherapy. Brachytherapy 1:90–94PubMedCrossRefGoogle Scholar
  54. 54.
    Talcott JA, Clark JA, Stark P et al (2001) Long-term treatment related complications of brachytherapy for early prostate cancer: a survey of patients previously treated. J Urol 166:494–499PubMedCrossRefGoogle Scholar
  55. 55.
    Potters L, Torre T, Fearn PA et al (2001) Potency after permanent prostate brachytherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 50:1235–1242PubMedGoogle Scholar
  56. 56.
    Singh MA, Gagnon G, Collins B et al (2005) Combined external beam radiotherapy and Pd-103 brachytherapy boost improves biochemical failure free survival in patients with clinically localized prostate cancer: results of a matched pair analysis. Prostate 62:54–60PubMedCrossRefGoogle Scholar
  57. 57.
    Kirby RS, Watson A, Newling DWW (1998) Prostate cancer and sexual function. Prostate Cancer Prostatic Dis 1:179–184PubMedCrossRefGoogle Scholar
  58. 58.
    Canada AL, Neese LE, Sui D et al (2005) Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Cancer 104:2689–2700PubMedCrossRefGoogle Scholar
  59. 59.
    Incrocci L, Koper PCA, Hop WC et al (2001) Sildenafil citrate (Viagra) and erectile dysfunction following external beam radiotherapy for prostate cancer: a randomized, double-blind, placebo-controlled, cross-over study. Int J Radiat Oncol Biol Phys 51:1190–1195PubMedGoogle Scholar
  60. 60.
    Incrocci L, Hop WC, Slob AK (2003) Efficacy of sildenafil in an open-label study as a continuation of a double-blind study in the treatment of erectile dysfunction after radiotherapy for prostate cancer. Urology 62:116–120PubMedCrossRefGoogle Scholar
  61. 61.
    Ohebshalom M, Parker M, Guhring P et al (2005) The efficacy of sildenafil citrate following radiation therapy for prostate cancer: temporal considerations. J Urol 174:258–262PubMedCrossRefGoogle Scholar
  62. 62.
    Kedia S, Zippe CD, Agarwal A et al (1999) Treatment of erectile dysfunction with sildenafil citrate (Viagra) after radiation therapy for prostate cancer. Urology 54:308–312PubMedCrossRefGoogle Scholar
  63. 63.
    Merrick GS, Butler WM, Lief JH et al (1999) Efficacy of sildenafil citrate in prostate brachytherapy patients with erectile dysfunction. Urology 53:1112–1116PubMedCrossRefGoogle Scholar
  64. 64.
    Shabsigh R, Seftel AD, Rosen RC et al (2006) Review of time of onset and duration of clinical efficacy of phosphodiesterase type 5 inhibitors in treatment of erectile dysfunction. Urology 68:689–696PubMedCrossRefGoogle Scholar
  65. 65.
    Doggrell SA (2005) Comparison of clinical trials with sildenafil, vardenafil and tadalafil in erectile dysfunction. Expert Opin Pharmacother 6:75–84PubMedCrossRefGoogle Scholar
  66. 66.
    Incrocci L, Slagter C, Slob AK et al (2006) A randomized, double-blind, placebo-controlled, cross-over study to assess the efficacy of Tadalafil (Cialis) in the treatment of erectile dysfunction following three-dimensional conformal external-beam radiotherapy for prostatic carcinoma. Int J Radiat Oncol Biol Phys 66:439–444PubMedGoogle Scholar
  67. 67.
    Pierce LJ, Whittington R, Hanno PM et al (1991) Pharmacologic erection with intracavernosal injection for men with sexual dysfunction following irradiation: a preliminary report. Int J Radiat Oncol Biol Phys 21:1311–1314PubMedGoogle Scholar
  68. 68.
    Dubocq FM, Bianco FJ Jr, Maralani SJ et al (1997) Outcome analysis of penile implant surgery after external beam radiation for prostate cancer. J Urol 158:1787–1790PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2007

Authors and Affiliations

  • Cem Akbal
    • 1
  • İlker Tinay
    • 1
  • Ferruh Şimşek
    • 1
  • Levent N. Turkeri
    • 1
  1. 1.Department of UrologyMarmara University School of Medicine, Marmara University HospitalAltunizade IstanbulTurkey

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