All prostate cancer treatments currently available affect sexual function. The recovery time varies, but all will have an impact on quality of life. At the time of diagnosis, men are usually most interested in making the treatment decision that will get rid of the cancer and give them the best chance of survival. Since sexual function is often not foremost in their minds then, men often forget to ask how each treatment will impact on their erectile function, orgasm, ejaculation, how they feel as a man, and present and future relationships. Men without a partner often express different concerns than couples who have been together for several years.
The need for penile rehabilitation programs varies, as each treatment affects sexual function differently. For example, men who have radiation treatment (brachytherapy or external beam) continue to retain pretreatment erectile function for two to three years following treatment, after which time the function is compromised. With radical prostatectomy, sexual function is at its lowest immediately following surgery and gradually improves over the next two to three years. The need for education and support for men (and their partners) changes at different times, depending on the treatment chosen.
The impact of surgery
Not all surgeries have an equal effect on erectile function. While it’s thought that the new robotic surgery will improve chances of retaining erectile function due to better visualization of nerves and surrounding structures, there are no hard data to prove this. It’s important to remember that the extent of disease dictates whether one or both nerves required for erection can be spared. Several criteria contribute to the likelihood that sexual function will return, including: if the man is younger; has good pre-treatment erectile function; is sexually active; has both nerves spared in the operation (the chance of recovery is cut in half when only one nerve is spared). Sexual function will never be as good as it was prior to surgery, but significant recovery is possible.
At one year following surgery, many men and their partners express distress over their level of sexual function. Men report feeling less masculine, having less sexual enjoyment, and experiencing discomfort during sex. Men with sexual difficulties will often avoid intimacy and expressing affection for fear that their partner may mistake this for a sexual advance, which they would find anxiety-provoking. Unfortunately, many of these couples and single men suffer silently and do not ask their doctors for help.
Specialized programs
More recently, the focus of prostate cancer care has shifted to include the development of sexual rehabilitation programs, and specialists are currently exploring the need for establishing specific clinics for men following treatment. The aim of these programs is to optimize the recovery of both erectile and orgasmic function. They include the use of any and all means — drugs, devices, counselling — necessary to achieve this goal. Counselling is beneficial for patients who are having difficulties achieving orgasm, to help them identify sources of stimulation, increase fantasy, and learn new methods of body touch and expressing affection. Two such sexual health rehabilitation programs are being established in Canada specifically for men prior to and following surgery — at the Prostate Centres at the Vancouver General Hospital and the Princess Margaret Hospital in Toronto.
But there’s an urgent need to make programs available to all men and their partners following treatment. Hopefully, these pilot programs will generate interventions that can spread into the wider urology community. Don’t be among those who are afraid to broach the subject: Ask your doctor or a member of your healthcare team where you can turn for assistance.
B. Joyce Davison, RN, PhD, is Assistant Professor in the Department of Surgery, and Research Scientist in the Prostate Centre at Vancouver General Hospital, British Columbia.
