How can prostate cancer treatment affect your sex life? Let me count the ways:

• Damage to the nerves that control erection
• Loss of ejaculate due to gland removal or whole-gland ablation
• Loss of desire and/or erectile dysfunction as a result of androgen deprivation therapy
• Psychological/identity/self-esteem issues that affect performance

According to clinical psychologist Leslie Schover, a specialist in sexual health at MD Anderson Cancer Center, “The patient education literature gives a very inaccurate idea of how many men recover good sexual function after prostate cancer… The bottom line is nobody does very well.”^[i] That stark statement may sound pessimistic, but it’s probably fairly close to the reality for prostate cancer (PCa) patients who have a whole gland treatment by radiation or ablation (destruction).

The picture is somewhat rosier for men who have a hemi-ablation (only one side of the gland treated) or a focal ablation (only the tumor plus a margin of safety). Either approach has the advantage of sparing at least one of the two neurovascular bundles that govern erectile function. While statistics vary depending on the extent and type of treatment, averages show from at least 50-90% of patients do return to baseline function with or without medical intervention.

Inconsistent data

The problem is that it’s hard to get an accurate sense of the sexual impact each treatment modality has. That’s due to inconsistent reporting. There are hundreds of published studies about short- and long-term sexual function outcomes after prostatectomy, various forms of radiation therapy, brachytherapy (seed implants), whole-gland ablation (cryotherapy, HIFU), and partial/focal gland ablation (cryotherapy, HIFU, focal, photodynamic). There are even studies that include Active Surveillance, which may sound surprising—but consider the physical impact of repeat biopsies and the mental/emotional impact of living for months or years knowing you have untreated cancer.

Among the problems getting precise figures on what percentage of men experience post-treatment sexual dysfunction and how long it lasts if not permanent are varying definitions, a number of evaluation tools and questionnaires that can be used, different follow-up periods, and lack of apples-to-apples study designs. A recent paper by Lovegrove, et al. (2019) points out that this is a problem for clinicians and patients alike, especially during the decision-making process regarding choice of treatment. They point out that with all this heterogeneity, “There is a need for standardisation of reporting outcomes following PCa treatment to facilitate evaluation of existing and emerging technologies.”^[ii]

The authors suggest a very simple way to assess the impact of treatment: return to baseline function. In other words, does a man regain the sexual performance he experienced before treatment? This necessitates that he completes an internationally validated instrument such as the International Index of Erectile Function (IIEF) prior to treatment, and that he re-takes the same tool at agreed-upon intervals following treatment for up to a certain period of time. To achieve such agreement, a panel of international experts could use a process such as the Delphi method to design a reasonable protocol that would not unduly burden patients. For instance, the 15-question IIEF could be administered prior to treatment, then again at 3, 6, 12, 24 and 60 months afterward to track the patient’s progress. It would be straightforward to record the scores in a patient’s records, and quite easy to analyze and report the data.

Quality of life decisions

The most important consideration in choice of treatment is cancer control. As one of the early pioneers of cryotherapy, Dr. Fred Lee, used to tell his patients about the fact of almost certain impotence after whole-gland cryo, “Sir, it’s more important to me that you are alive to walk your daughter down the aisle on her wedding day and live to enjoy your grandchildren than having sex.” Although blunt, Dr. Lee certainly did a good job of managing expectations and hopefully helping the patient see a silver lining in a dark cloud.

However, longevity is not the only value. Today’s patients are more aware than ever that quality of life is just as important, and if they qualify for a less-than-total gland treatment like Focal Laser Ablation (FLA), they are willing to take the chance of leaving microscopic PCa untreated. That’s because they also know that they can confidently monitor their prostate health through a combination of PSA testing and multiparametric MRI (mpMRI) scans.

The Sperling Prostate Center staff are proud to be pioneers in providing 3T mpMRI and FLA. Our expertise in PCa detection, diagnosis and image-guided focal therapy have established our leadership in ensuring that patients have a high probability of rapid return to enjoying their sex life after treatment. If a man is facing a prostate cancer treatment decision, our goal is to offer him excellent cancer control as well as satisfying sexual function—the best of both worlds.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Ness, Erik. “Satisfaction Guaranteed: Sexual Therapy after Prostate Cancer Treatment.” Cure, Sep. 23, 2015. https://www.curetoday.com/publications/cure/2015/prostate-2015/satisfaction-guaranteed-sexual-activity-after-prostate-cancer-therapy
[ii] Lovegrove CE, Ficarra V, Montorsi F, N’Dow J et al. Sexual function outcomes following interventions for prostate cancer: are contemporary reports on functional outcomes misleading? Int J Impot Res. 2019 Dec 13.