02 November 2023
Written by Bernie Riley, Head of Telenursing and Supportive Care Programs
Changes in sexual function can be a significant concern for men affected by prostate cancer.
Even among men who have not had active treatment, around 20% report significant bother twelve months after diagnosis, with prevalence increasing among men who have had surgery, radiotherapy or hormone or chemotherapy for prostate cancer. This bother is not limited to just erectile dysfunction.
Prostate cancer and its treatments can cause an inability to get or maintain erection, changes in penile length and girth, genital shrinkage, changes in sexual desire, differences in experience of orgasm and ejaculation and impacts on relationships.
Many men experience changes in erectile function as they age and it’s important to recognise this and other potential factors. High blood pressure, high blood lipid and cholesterol levels, poor peripheral circulation, diabetes, obstructive sleep apnea, a sedentary lifestyle and obesity, smoking and misuse of drugs and alcohol can all affect erectile function too.
A comprehensive assessment of these factors with a GP can help identify certain controllable factors and discuss the treatment options that are right for you. Please also reach out to our Telenursing team on 1800 22 00 99 if to speak with a Prostate Cancer Nurse.
Below we cover some existing treatments, along with insights into new treatments on the horizon.
As discussed in previous blogs, the most common treatments for erectile function are oral medications, injections into the penis, vacuum erection devices and penile implants:
Oral Medications: Medications known as Phosphodiesterase Type 5 Inhibitors (PDEi5) are tablets used to treat erection problems. They relax the smooth muscle cells lining the blood vessels and allow blood flow to the penis. Common PDEi5 medications are Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil) and Spedra (Avanafil).
Penile implants: A penile implant creates a mechanical erection, and a penile implant is generally used when all else has failed. Surgery is required to insert the implants.
Intracavenosal injections: If oral medication does not work or remaining penile nerves are not functioning effectively, penile injections may be more effective. Alprostadil is one of a range of drugs that may be injected into the penis to induce erections.
Vacuum erection devices: A vacuum erection device (VED) helps draw blood into the penis to stimulate an erection by creating a negative pressure. Your treating doctor may be able to tell you where to purchase the devices and advise you on correct technique.
For various reasons there remains a great deal of interest in other options for treatment of erectile dysfunction.
Clinical trials are underway in some international centres modifying nerve sparing techniques during radical prostatectomy, adding nerve grafts to improve nerve regeneration, trials of new oral and topical medications and testing the use of low intensity shockwave therapy (LiSWT). All of these new methods while promising are still considered investigational and experimental and the results need to be replicated in larger scale trials before they can be considered safe, effective and suitable options to be offered as an alternative or addition to the standards of care.
As such current clinical guidelines suggest the use of these should be offered within a clinical trial setting. This aims to reduce physical, psychological and financial burden to patients.
Caution has also been recommended by USANZ and the Australasian Chapter if Sexual Health Medicine (AChSHM) in the adoption of other cell based injection therapies such as Stem Cell and Platelet Rich Plasma (PRP) injections due the lack of high level evidence and concerns over potential immune reactions, infection risk and unknown long term genomic and epigenetic changes.
With this in mind, it’s promising to see the investment into research and clinical trials in this area to provide nearer term solutions for men.
We look forward to treatments evolving in this space and will keep you up to date with any news that comes to light in this area.
It’s important to remember that looking after your wellbeing is also a very important part of improving sexual function.
The body and brains natural response to stress situations such as sexual difficulties, erectile dysfunction and cancer is to divert blood flow from non-essential areas (like the penis) in the short term. When stress is an ongoing issue, it can reduce testosterone which affects sexual desire and may lead to further impaired erections.
This is just one of the ways PCFA’s counsellors can help people with sexual difficulties, as well as, helping identify people’s reactions to stressful situations, helping them manage this stress more effective, working with men and their partners on improving sexual function, relationship communication, and maintaining intimacy.
Chung, E., Lowy, M., Gillman, M., Love, C., Katz, D.,and Neilsen, G. Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction. Med J Aust 2022; 217 (6): 318-324. doi:10.5694/mja2.51694
Chung E. A review of regenerative therapies as penile rehabilitation in men following primary prostate cancer treatment: Evidence for erectile restoration and cavernous nerve regeneration. Asian J Urol. 2022 Jul;9(3):287-293. doi: 10.1016/j.ajur.2021.11.005. Epub 2021 Nov 20. PMID: 36035357; PMCID: PMC9399549.
Chung E. Regenerative technology to restore and preserve erectile function in men following prostate cancer treatment: evidence for penile rehabilitation in the context of prostate cancer survivorship. Ther Adv Urol. 2021 Aug 21;13:17562872211026421. doi: 10.1177/17562872211026421. PMID: 34434257; PMCID: PMC8381411.
Drury R, Natale C, Hellstrom WJG. Reviewing the evidence for shockwave- and cell-based regenerative therapies in the treatment of erectile dysfunction. Ther Adv Urol. 2021 Mar 15;13:17562872211002059. doi: 10.1177/17562872211002059. PMID: 33796149; PMCID: PMC7968013.
EAU Sexual and Reproductive Health Guidelines, Arnhem, The Netherlands.
How do stress and anxiety affect sexual performance and erectile dysfunction?
Islam MM, Naveen NR, Anitha P, Goudanavar PS, Rao GSNK, Fattepur S, Rahman MM, Shiroorkar PN, Habeebuddin M, Meravanige G, Telsang M, Nagaraja S, Asdaq SMB, Anwer MDK. The Race to Replace PDE5i: Recent Advances and Interventions to Treat or Manage Erectile Dysfunction: Evidence from Patent Landscape (2016-2021). J Clin Med. 2022 May 31;11(11):3140. doi: 10.3390/jcm11113140. PMID: 35683526; PMCID: PMC9181403. https://pubmed.ncbi.nlm.nih.gov/35683526/
Papa, N., O’Callaghan, M., James, E. and Millar, J. Prostate Cancer in Australia and New Zealand Men: Patterns of care within PCOR-ANZ 2015-2018. Melbourne, VIC: Monash University & Movember; March 2021
Reece, JC, Dangerfield, DC, Coombs, CJ (2019) End-to-side Somatic-to-autonomic Nerve Grafting to Restore Erectile Function and Improve Quality of Life After Radical Prostatectomy. European Urology DOI: 10.1016/j.eururo.2019.03.036 https://www.ncbi.nlm.nih.gov/pubmed/30955973