Abstract
The treatment of prostate cancer is partly guided by patient preferences. Radical prostatectomy and radiation therapy are the standard radical therapies for localized disease and render comparable oncologic outcomes. Considering that survival is high regardless of the chosen treatment, factors such as treatment-related toxicities affecting the patients’ quality of life play an important role in their decision. Notably, post-treatment sexual dysfunction, which includes decreased libido, erectile dysfunction, and ejaculatory dysfunction has been shown to be an important and prevalent concern of prostate cancer survivors. In this literature review, we sought to characterize the sexual complications associated with radiation therapy and map the available sexual rehabilitation options for prostate cancer survivors experiencing sexual dysfunction as a result of radiation therapy. We identified medical, non-biomedical, counseling, and lifestyle modification options for prostate cancer survivors seeking sexual rehabilitation. Future research in this area should address the standardization of sexual side-effect reporting and investigate sexual outcomes and rehabilitation in more diverse groups and of transgender and nonheterosexual prostate cancer survivors.
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References
Carroll PH, Mohler JL. NCCN guidelines updates: prostate cancer and prostate cancer early detection [Internet]. J Natl Compr Cancer Netw. 2018;16:620–3. https://doi.org/10.6004/jnccn.2018.0036.
Wallis CJD, Saskin R, Choo R, Herschorn S, Kodama RT, Satkunasivam R, et al. Surgery versus radiotherapy for clinically-localized prostate cancer: a systematic review and meta-analysis. Eur Urol. 2016;70:21–30.
Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375:1415–24.
Gore JL, Kwan L, Lee SP, Reiter RE, Litwin MS. Survivorship beyond convalescence: 48-month quality-of-life outcomes after treatment for localized prostate cancer. J Natl Cancer Inst. 2009;101:888–92.
Matta R, Chapple CR, Fisch M, Heidenreich A, Herschorn S, Kodama RT, et al. Pelvic complications after prostate cancer radiation therapy and their management: an international collaborative narrative review [Internet]. Eur Urol. 2019;75:464–76. https://doi.org/10.1016/j.eururo.2018.12.003.
Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358:1250–61.
Helgason AR, Adolfsson J, Dickman P, Fredrikson M, Arver S, Steineck G. Waning sexual function-the most important disease-specific distress for patients with prostate cancer. Br J Cancer. 1996;73:1417–21.
Schover LR. Sexual rehabilitation after treatment for prostate cancer. Cancer. 1993;71:1024–30.
National Research Council, Institute of Medicine, National Cancer Policy Board, Committee on Cancer Survivorship: improving care and quality of life. From cancer patient to cancer survivor: lost in transition. National Academies Press; 2005. 534 p.
Miller DC, Wei JT, Dunn RL, Montie JE, Pimentel H, Sandler HM, et al. Use of medications or devices for erectile dysfunction among long-term prostate cancer treatment survivors: Potential influence of sexual motivation and/or indifference [Internet]. Urology. 2006;68:166–71. https://doi.org/10.1016/j.urology.2006.01.077.
Donovan JL, Hamdy FC, Lane JA, Mason M, Metcalfe C, Walsh E, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375:1425–37.
Resnick MJ, Koyama T, Fan K-H, Albertsen PC, Goodman M, Hamilton AS, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013;368:436–45.
Barocas DA, Alvarez J, Resnick MJ, Koyama T, Hoffman KE, Tyson MD, et al. Association between radiation therapy, surgery, or observation for localized prostate cancer and patient-reported outcomes after 3 years. JAMA. 2017;317:1126–40.
Adam S, Koch‐Gallenkamp L, Bertram H, Eberle A, Holleczek B, Pritzkuleit R, et al. Health‐related quality of life in long‐term survivors with localised prostate cancer by therapy—results from a population‐based study [Internet]. Eur J Cancer Care. 2019;28. https://doi.org/10.1111/ecc.13076.
Walker R, Szanton S, Wenzel J. Working toward normalcy post-treatment: a qualitative study of older adult breast and prostate cancer survivors [Internet]. Oncol Nursing Forum. 2015;42:E358–67. https://doi.org/10.1188/15.onf.e358-e367.
Nguyen PL, Alibhai SMH, Basaria S, D’Amico AV, Kantoff PW, Keating NL, et al. Adverse effects of androgen deprivation therapy and strategies to mitigate them. Eur Urol. 2015;67:825–36.
Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, Zippe C, et al. The use of treatments for erectile dysfunction among survivors of prostate carcinoma [Internet]. Cancer. 2002;95:2397–407. https://doi.org/10.1002/cncr.10970.
Lemanska A, Dearnaley DP, Jena R, Sydes MR, Faithfull S. Older age, early symptoms and physical function are associated with the severity of late symptom clusters for men undergoing radiotherapy for prostate cancer. Clin Oncol. 2018;30:334–45.
NIH Consensus Conference. Impotence. NIH consensus development panel on impotence. JAMA. 1993;270:83–90.
Roach M, Nam J, Gagliardi G, El Naqa I, Deasy JO, Marks LB. Radiation dose–volume effects and the penile bulb [Internet]. Int J Radiat Oncol Biol Phys. 2010;76:S130–4. https://doi.org/10.1016/j.ijrobp.2009.04.094.
Fisch BM, Pickett B, Weinberg V, Roach M. Dose of radiation received by the bulb of the penis correlates with risk of impotence after three-dimensional conformal radiotherapy for prostate cancer. Urology. 2001;57:955–9.
Merrick GS, Wallner K, Butler WM, Galbreath RW, Lief JH, Benson ML. 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. 2001;50:597–604.
DiBiase SJ, Wallner K, Tralins K, Sutlief S. Brachytherapy radiation doses to the neurovascular bundles. Int J Radiat Oncol Biol Phys. 2000;46:1301–7.
Incrocci L. Radiation therapy for prostate cancer and erectile (dys)function: the role of imaging. Acta Oncol. 2005;44:673–8.
Miller DC, Sanda MG, Dunn RL, Montie JE, Pimentel H, Sandler HM, et al. Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy [Internet]. J Clin Oncol. 2005;23:2772–80. https://doi.org/10.1200/jco.2005.07.116.
Penson DF, Latini DM, Lubeck DP, Wallace K, Henning JM, Lue T. Is quality if life different for men with erectile dysfunction and prostate cancer compared to men with erectile dysfunction due to other causes? Results from the ExCEED data base [Internet]. J Urol. 2003;169:1458–61. https://doi.org/10.1097/01.ju.0000054462.88306.43.
Nelson CJ, Mulhall JP, Roth AJ. The association between erectile dysfunction and depressive symptoms in men treated for prostate cancer. J Sex Med. 2011;8:560–6.
Merrick GS, Butler WM, Wallner KE, Galbreath RW, Anderson RL, Kurko BS, et al. Erectile function after prostate brachytherapy [Internet]. J Urol. 2006;175:959–60. https://doi.org/10.1016/s0022-5347(05)00590-2.
Snyder KM, Stock RG, Buckstein M, Stone NN. Long-term potency preservation following brachytherapy for prostate cancer. BJU Int. 2012;110:221–5.
Budäus L, Bolla M, Bossi A, Cozzarini C, Crook J, Widmark A, et al. Functional outcomes and complications following radiation therapy for prostate cancer: a critical analysis of the literature. Eur Urol. 2012;61:112–27.
Sánchez-Ortiz RF, Broderick GA, Rovner ES, Wein AJ, Whittington R, Malkowicz SB. Erectile function and quality of life after interstitial radiation therapy for prostate cancer. Int J Impot Res. 2000;12:S18–S24.
Huyghe E, Delannes M, Wagner F, Delaunay B, Nohra J, Thoulouzan M, et al. Ejaculatory function after permanent 125I prostate brachytherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2009;74:126–32.
Sullivan JF, Stember DS, Deveci S, Akin-Olugbade Y, Mulhall JP. Ejaculation profiles of men following radiation therapy for prostate cancer. J Sex Med. 2013;10:1410–6.
Rowland D, McMahon CG, Abdo C, Chen J, Jannini E, Waldinger MD, et al. Disorders of orgasm and ejaculation in men [Internet]. J Sex Med. 2010;7:1668–86. https://doi.org/10.1111/j.1743-6109.2010.01782.x.
Tewari A, Grover S, Sooriakumaran P, Srivastava A, Rao S, Gupta A, et al. Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy. BJU Int. 2012;109:596–602.
Sipski M, Alexander CJ, Gómez-Marín O. Effects of level and degree of spinal cord injury on male orgasm. Spinal Cord. 2006;44:798–804.
Chung E, Brock G. Sexual rehabilitation and cancer survivorship: a state of art review of current literature and management strategies in male sexual dysfunction among prostate cancer survivors. J Sex Med. 2013;10:102–11.
Bober SL, Varela VS. Sexuality in adult cancer survivors: challenges and intervention [Internet]. J Clin Oncol. 2012;30:3712–9. https://doi.org/10.1200/jco.2012.41.7915.
Higano CS. Sexuality and intimacy after definitive treatment and subsequent androgen deprivation therapy for prostate cancer [Internet]. J Clin Oncol. 2012;30:3720–5. https://doi.org/10.1200/jco.2012.41.8509.
Mykoniatis I, van Renterghem K, Sokolakis I, Hatzichristodoulou G, Sempels M, Andrianne R. Climacturia: a comprehensive review assessing pathophysiology, prevalence, impact, and treatment options regarding the “leak of pleasure” [Internet]. Int J Impot Res. 2020. https://doi.org/10.1038/s41443-020-0257-1.
Frey A, Pedersen C, Lindberg H, Bisbjerg R, Sønksen J, Fode M. Prevalence and predicting factors for commonly neglected sexual side effects to external-beam radiation therapy for prostate cancer. J Sex Med. 2017;14:558–65.
Sadovsky R, Basson R, Krychman M, Morales AM, Schover L, Wang R, et al. Cancer and sexual problems [Internet]. J Sex Med. 2010:7:349–73. https://doi.org/10.1111/j.1743-6109.2009.01620.x.
Bokhour BG, Clark JA, Inui TS, Silliman RA, Talcott JA. Sexuality after treatment for early prostate cancer: exploring the meanings of “erectile dysfunction”. J Gen Intern Med. 2001;16:649–55.
Michael C, Barnett F, Gray M. The experiences of prostate cancer survivors: changes to physical function and its impact on quality of life [Internet]. Int J Ther Rehab. 2016;23:323–30. https://doi.org/10.12968/ijtr.2016.23.7.323.
Duthie CJ, Calich HJ, Rapsey CM, Wibowo E. Maintenance of sexual activity following androgen deprivation in males. Crit Rev Oncol Hematol. 2020;153:103064.
Bourke L, Boorjian SA, Briganti A, Klotz L, Mucci L, Resnick MJ, et al. Survivorship and improving quality of life in men with prostate cancer. Eur Urol. 2015;68:374–83.
Tucker SR, Speer SA, Peters S. Development of an explanatory model of sexual intimacy following treatment for localised prostate cancer: a systematic review and meta-synthesis of qualitative evidence. Soc Sci Med. 2016;163:80–8.
Zaider T, Manne S, Nelson C, Mulhall J, Kissane D. Loss of masculine identity, marital affection, and sexual bother in men with localized prostate cancer. J Sex Med. 2012;9:2724–32.
Hoyt MA, Stanton AL, Irwin MR, Thomas KS. Cancer-related masculine threat, emotional approach coping, and physical functioning following treatment for prostate cancer. Health Psychol. 2013;32:66–74.
Wittmann D, Northouse L, Foley S, Gilbert S, Wood DP, Balon R, et al. The psychosocial aspects of sexual recovery after prostate cancer treatment [Internet]. Vol. 21, Int J Impot Res. 2009;21:99–106. https://doi.org/10.1038/ijir.2008.66.
Cliff AM, Macdonagh RP Psychosocial morbidity in prostate cancer: II. A comparison of patients and partners [Internet]. BJU Int. 2001;86:834–9. https://doi.org/10.1046/j.1464-410x.2000.00914.x.
Garos S, Kluck A, Aronoff D. Prostate cancer patients and their partners: differences in satisfaction indices and psychological variables. J Sex Med. 2007;4:1394–403.
Elterman DS, Petrella AR, Walker LM, Van Asseldonk B, Jamnicky L, Brock GB, et al. Canadian consensus algorithm for erectile rehabilitation following prostate cancer treatment. Can Urol Assoc J. 2018;13.8:239–45.
Merrick GS, Butler WM, Lief JH, Stipetich RL, Abel LJ, Dorsey AT. Efficacy of sildenafil citrate in prostate brachytherapy patients with erectile dysfunction. Urology. 1999;53:1112–6.
Zelefsky MJ, Shasha D, Branco RD, Kollmeier M, Baser RE, Pei X, et al. Prophylactic sildenafil citrate improves select aspects of sexual function in men treated with radiotherapy for prostate cancer. J Urol. 2014;192:868–74.
Incrocci L, Slob AK, Hop WCJ. Tadalafil (Cialis) and erectile dysfunction after radiotherapy for prostate cancer: an open-label extension of a blinded trial. Urology 2007;70:1190–3.
Teloken PE, Parker M, Mohideen N, Mulhall JP. Predictors of response to sildenafil citrate following radiation therapy for prostate cancer. J Sex Med. 2009;6:1135–40.
Pahlajani G, Raina R, Jones S, Ali M, Zippe C. Vacuum erection devices revisited: its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy. J Sex Med. 2012;9:1182–9.
Haliloglu A, Baltaci S, Yaman O. Penile length changes in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer [Internet]. J Urol. 2007;177:128–30. https://doi.org/10.1016/j.juro.2006.08.113.
Dubocq FM, Bianco FJ Jr, Maralani SJ, Forman JD, Dhabuwala CB. Outcome analysis of penile implant surgery after external beam radiation for prostate cancer. J Urol. 1997;158:1787–90.
Loh-Doyle J, Patil MB, Nakhoda Z, Nassiri N, Yip W, Wayne K, et al. Three-piece inflatable penile prosthesis placement following pelvic radiation: technical considerations and contemporary outcomes. J Sex Med. 2018;15:1049–54.
Clavijo RI, Kohn TP, Kohn JR, Ramasamy R. Effects of low-intensity extracorporeal shockwave therapy on erectile dysfunction: a systematic review and meta-analysis. J Sex Med. 2017;14:27–35.
Usta MF, Gabrielson AT, Bivalacqua TJ. Low-intensity extracorporeal shockwave therapy in the treatment of erectile dysfunction following radical prostatectomy: a critical review. Int J Impot Res. 2019;31:231–8.
Young Academic Urologists Men’s Health Group, Fode M, Hatzichristodoulou G, Serefoglu EC, Verze P, Albersen M. Low-intensity shockwave therapy for erectile dysfunction: is the evidence strong enough? Nat Rev Urol. 2017;14:593–606.
Barbera L, Zwaal C, Elterman D, McPherson K, Wolfman W, Katz A, et al. Interventions to address sexual problems in people with cancer. Curr Oncol. 2017;24:192–200.
Collins AL, Love AW, Bloch S, Street AF, Duchesne GM, Dunai J, et al. Cognitive Existential Couple Therapy for newly diagnosed prostate cancer patients and their partners: a descriptive pilot study. Psychooncology. 2013;22:465–9.
Brotto LA, Yule M, Breckon E. Psychological interventions for the sexual sequelae of cancer: a review of the literature [Internet]. PsycEXTRA Dataset. 2010. https://doi.org/10.1037/e512632013-033.
Canada AL, Neese LE, Sui D, Schover LR. Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Cancer. 2005;104:2689–700.
Candy B, Jones L, Vickerstaff V, Tookman A, King M. Interventions for sexual dysfunction following treatments for cancer in women. Cochrane Database Syst Rev. 2016;2:CD005540.
Titta M, Tavolini IM, Moro FD, Cisternino A, Bassi P. ORIGINAL RESEARCH—PSYCHOLOGY: Sexual counseling improved erectile rehabilitation after non‐nerve‐sparing radical retropubic prostatectomy or cystectomy—results of a randomized prospective study [Internet]. J Sex Med. 2006;3:267–73. https://doi.org/10.1111/j.1743-6109.2006.00219.x.
Wittmann D, Montie JE, Hamstra DA, Sandler H, Wood DP Jr. Counseling patients about sexual health when considering post-prostatectomy radiation treatment. Int J Impot Res. 2009;21:275–84.
Forbat L, White I, Marshall-Lucette S, Kelly D. Discussing the sexual consequences of treatment in radiotherapy and urology consultations with couples affected by prostate cancer. BJU Int. 2012;109:98–103.
Boberg EW, Gustafson DH, Hawkins RP, Offord KP, Koch C, Wen K-Y, et al. Assessing the unmet information, support and care delivery needs of men with prostate cancer [Internet]. Patient Educ Counsel. 2003;49:233–42. https://doi.org/10.1016/s0738-3991(02)00183-0.
Latini DM, Hart SL, Coon DW, Knight SJ. Sexual rehabilitation after localized prostate cancer: current interventions and future directions. Cancer J. 2009;15:34–40.
Segal RJ, Reid RD, Courneya KS, Sigal RJ, Kenny GP, Prud’Homme DG, et al. Randomized controlled trial of resistance or aerobic exercise in men receiving radiation therapy for prostate cancer [Internet]. J Clin Oncol. 2009;27:344–51. https://doi.org/10.1200/jco.2007.15.4963.
Galvão DA, Spry N, Denham J, Taaffe DR, Cormie P, Joseph D, et al. A multicentre year-long randomised controlled trial of exercise training targeting physical functioning in men with prostate cancer previously treated with androgen suppression and radiation from TROG 03.04 RADAR [Internet]. Eur Urol. 2014;65:856–64. https://doi.org/10.1016/j.eururo.2013.09.041.
Cormie P, Newton RU, Taaffe DR, Spry N, Galvão DA. Exercise therapy for sexual dysfunction after prostate cancer. Nat Rev Urol. 2013;10:731–6.
Bourke L, Smith D, Steed L, Hooper R, Carter A, Catto J, et al. Exercise for men with prostate cancer: a systematic review and meta-analysis. Eur Urol. 2016;69:693–703.
Ben-Josef AM, Chen J, Wileyto P, Doucette A, Bekelman J, Christodouleas J, et al. Effect of Eischens yoga during radiation therapy on prostate cancer patient symptoms and quality of life: a randomized phase II trial. Int J Radiat Oncol Biol Phys. 2017;98:1036–44.
Vignera SL, La Vignera S, Condorelli R, Vicari E, D’Agata R, Calogero AE. Physical activity and erectile dysfunction in middle-aged men [Internet]. Vol. 33, J Androl. 2012;33:154–61. https://doi.org/10.2164/jandrol.111.013649.
Maas R, Schwedhelm E, Albsmeier J, Böger RH. The pathophysiology of erectile dysfunction related to endothelial dysfunction and mediators of vascular function. Vasc Med. 2002;7:213–25.
Lyons KS, Winters-Stone KM, Bennett JA, Beer TM. The effects of partnered exercise on physical intimacy in couples coping with prostate cancer. Health Psychol. 2016;35:509–13.
Esposito K, Giugliano F, De Sio M, Carleo D, Di Palo C, D’Armiento M, et al. Dietary factors in erectile dysfunction. Int J Impot Res. 2006;18:370–4.
Pastuszak AW, Moon YM, Scovell J, Badal J, Lamb DJ, Link RE, et al. Poor sleep quality predicts hypogonadal symptoms and sexual dysfunction in male nonstandard shift workers. Urology. 2017;102:121–5.
Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, et al. Sexual rehabilitation after treatment for prostate cancer—Part 2: Recommendations from the fourth international consultation for sexual medicine (ICSM 2015) [Internet]. J Sex Med. 2017;14:297–315. https://doi.org/10.1016/j.jsxm.2016.11.324.
Matthew A, Elterman D. Men’s mental health: Connection to urologic health [Internet]. Can Urol Assoc J. 2014;8: 153. https://doi.org/10.5489/cuaj.2312.
Matthew A, Lutzky-Cohen N, Jamnicky L, Currie K, Gentile A, Santa Mina D, et al. The prostate cancer rehabilitation clinic: a biopsychosocial clinic for sexual dysfunction after radical prostatectomy [Internet]. Curr Oncol. 2018;25. https://doi.org/10.3747/co.25.4111.
Fode M, Jensen CFS, Østergren PB. Standardized reporting for sexual function following prostate cancer treatment. Int J Impot Res [Internet]. 2020; https://doi.org/10.1038/s41443-020-0251-7.
Lovegrove CE, Ficarra V, Montorsi F, N’Dow J, Salonia A, Minhas S. Sexual function outcomes following interventions for prostate cancer: are contemporary reports on functional outcomes misleading? Int J Impot Res [Internet]. 2019; https://doi.org/10.1038/s41443-019-0220-1.
McInnis MK, Pukall CF. Sex after prostate cancer in gay and bisexual men: a review of the literature [Internet]. Sex Med Rev. 2020. https://doi.org/10.1016/j.sxmr.2020.01.004.
Rosser BRS, Hunt SL, Capistrant BD, Kohli N, Konety BR, Mitteldorf D, et al. Understanding prostate cancer in gay, bisexual, and other men who have sex with men and transgender women: a review of the literature. Curr Sex Health Rep. 2019;11:430–41.
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Nguyen, DD., Berlin, A., Matthew, A.G. et al. Sexual function and rehabilitation after radiation therapy for prostate cancer: a review. Int J Impot Res 33, 410–417 (2021). https://doi.org/10.1038/s41443-020-00389-1
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