Managing side effects of treating prostate cancer

Friday 1 November, 2013

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On this page:  Urinary incontinenceBowel problemsFertility problemsErectile dysfunctionOther changes to sexualityRestoring your sex lifeKey points


Treatment for prostate cancer may damage nerves and muscles near the prostate and the bowel. This may cause side effects including urinary incontinence, changes in bowel habits, erectile dysfunction, infertility and loss of interest in sex. Side effects will vary from person to person. Some men will not have side effects; others may experience a few. Side effects may last for a few weeks or be permanent.

Fortunately, there are many ways to reduce or manage side effects, and most go away in time. Most men are able to continue to lead active lives after their treatment.

Urinary incontinence

Not being able to control the flow of urine is called urinary incontinence. This is a common temporary side effect of surgery. Incontinence can also be a side effect of radiotherapy.

After surgery, most men have some degree of incontinence for 3–6 months. Some men may lose a few drops when they cough, sneeze, strain or lift something heavy. Others have more severe problems requiring the use of incontinence pads. It is usually worse shortly after surgery, but better within a year. Incontinence lasting longer than a year may be permanent and is unlikely to improve, but most bladder problems can be managed.

Radiotherapy can shrink the bladder, narrow the urethra and weaken the pelvic floor muscles. This means that small amounts of urine may leak out. Talk to your doctor or continence nurse if this occurs.

Tips
  • Use continence aids to help cope with any urine loss and to protect your skin from the irritation this may cause.
  • Ask a continence nurse about aids, such as absorbent pads to wear in your underpants, sheets and chair covers.
  • Ask your doctor, urologist, physiotherapist or continence nurse about training your bladder (pelvic floor exercises).
  • Limit bladder irritants such as tea, coffee, alcohol and carbonated drinks.
  • Speak to a dietitian on ways to try and avoid constipation.
  • Avoid restricting your fluid intake because you are afraid of leakage.
  • Drink lots of water as concentrated urine can irritate the bladder, causing urgent and/or frequent urination, and infections. Constipation caused by dehydration can also lead to leakage.
  • Patients that have had surgery may benefit from seeing a specialist physiotherapist before surgery.
  • Talk to your doctor or urologist about other treatments if incontinence hasn’t improved significantly after 6–12 months.
  • Two surgical options include a sling or an artificial sphincter. These devices work by putting pressure on the urethra to close it off and control urinary flow.
  • Surgery for incontinence is not usually considered until after 12 months.
  • Ask your GP about the Continence Aids Payment Scheme. This helps men that have severe or long term incontinence with the cost of continence products.
  • The Continence Foundation of Australia also offers support and resources, Pelvic Floor Muscle Training for Men and Continence and Prostate call 1800 330 066 or visit www.continence.org.au
Transurethral resection

A transurethral resection of the prostate (TURP) removes blockages in the urinary tract to help with symptoms of more advanced prostate cancer, such as frequent urination. TURP does not cure the cancer. This operation is also used to treat benign prostate enlargement.

You will be given a general anaesthetic or a spinal anaesthetic (epidural). A telescope-like instrument is passed through the opening of the penis and up the urethra to remove the blockage. The operation takes about an hour, but usually requires a couple of days in hospital.

Bowel problems

Rarely, radiotherapy may damage the rectum, leading to bleeding or diarrhoea. A bowel specialist (colorectal surgeon) will treat side effects with steroid suppositories or treatments applied to the bowel. For more information, talk to your radiation oncologist or continence nurse.

Fertility problems

After surgery, radiotherapy or hormone therapy for prostate cancer, most men become infertile, which means they can no longer have children naturally. If you want to have children, it is best for you and your partner to talk about your options with your doctor before treatment starts. You may be able to store sperm for use at a later time.

Erectile dysfunction

Erection problems are common in men who have had treatment for prostate cancer, particularly radiotherapy and surgery. The body needs time to heal after surgery, but generally there is a gradual recovery, with men noticing continued improvement up to four years after treatment has finished.

When a man has trouble getting or keeping an erection firm enough for intercourse or other sexual activity, it is called erectile dysfunction or impotence.

While the prostate doesn’t contribute to a man’s ability to have an erection, it lies close to nerves and blood vessels that are important for erectile function. These can be damaged during surgery or radiotherapy.

The quality of erections usually decreases as men get older. Erections may be short-lived or difficult to achieve.

Cancer treatment may add to existing erection difficulties, or it may be the only cause of them. A man’s sexual response and activity can be affected by many things, such as:

  • getting older diseases, such as diabetes and heart disease
  • certain medications, such as those used to treat blood pressure
  • surgery to the bowel or abdomen
  • a history of smoking and/or a high alcohol intake
  • emotional or mental distress
  • how sexually active his partner is, if he has one.

There is increasing evidence that early sexual rehabilitation after surgery and radiotherapy helps recovery. Engaging in foreplay with your partner, masturbating as soon as a month after surgery, using medication, or having penile injections all improve the chance of a strong recovery of erectile functioning.

Improving the quality of your erections

There are several options for trying to improve the quality of your erections, regardless of the type of cancer treatment you have had:

Oral medication

Viagra®, Levitra® and Cialis® are prescription medications that help the body’s natural response to sexual stimulation by increasing blood flow to the penis and allowing an erection to occur.

Possible side effects are headaches, nausea, blurry vision, facial flushing and backache, but these usually only last for 1–2 hours.

Men with heart problems should check with their doctor before using these medications. Some heart medication is not recommended with these tablets (contraindicated). Men with existing heart problems may also put themselves at risk from the physical strain of sexual activity.

Vacuum erection device

A vacuum erection device (VED) or vacuum pump device A vacuum erection device (VED) or vacuum pump device uses suction to draw blood into the penis.

This may be an option if injections or tablets have not worked or are not desired. It can also help to strengthen or maintain a natural erection.

A rigid tube is placed over the penis. A manual or battery-operated pump then creates a partial vacuum that forces blood to flow into the penis so it becomes hard. A band placed onto the base of the penis keeps the erection firm. The band can be worn comfortably for up to 30 minutes. A band can also be used without a VED to help keep a natural erection.

The VED is painless and easy to use but it may take some practise to feel comfortable. VEDs are available on prescription or from sex aid shops.

Implants

A penile prosthesis is an implant that is surgically placed in the penis. This implant allows you to create an erection when it is desired. Implants are usually performed 1–2 years after surgery.

Implantation is effective, but it is usually not recommended unless other less invasive methods have been tried for a reasonable amount of time.

Flexible rods or thin, inflatable cylinders are placed in the penis and connected to a pump, which is put into the scrotum during an operation done under general anaesthetic. The pump is turned on or squeezed when an erection is desired.

Penile prosthesis implant
Injected medication

Penile injection therapy, which men can learn to do, is a commonly used and effective treatment prescribed by a doctor. Medication causes blood vessels in the penis to expand, enabling them to fill with blood and become erect. An erection usually occurs within 5–10 minutes of the injection and lasts about 30–60 minutes.

Treatment works well for most men, but a few may experience pain and scarring. Some men who inject too large a dose can experience a prolonged and painful erection (priapism). Your doctor or nurse can teach you safe injection techniques to try help reduce this risk. Carefully read the instructions included with the medication.

Other erectile dysfunction therapies

It is not unusual to see advertisements for products offering treatment for erectile dysfunction. Products include herbal preparations, natural therapies, nasal sprays and lozenges. After prostate cancer, you need to be cautious about using testosterone or natural products that act like testosterone in the body.

Talk to your doctor or sexual health physician before taking any over-the-counter or prescription medications to improve erections.

Other changes to sexuality

Sexuality means different things to different people. Whether you are single, in a relationship, heterosexual (straight), gay, bisexual or transgender, you may notice other changes to your sexual functioning, which can affect the way you experience sexuality and intimacy.

Loss of libido

Reduced interest in sex (low libido) is common during cancer treatment. Quite often it occurs due to anxiety and fatigue rather than the treatment itself. However, hormone treatment and impotence from radiotherapy or surgery can also reduce libido. Most men notice that their sex drive returns when treatment finishes, but for some men, the problem is ongoing.

Adjusting to changes in sex drive can be emotionally and physically challenging for men and partners. See the Restoring your sex life section for tips to help with this issue.

Dry ejaculation or dry orgasm

If you have radiotherapy, semen production will be reduced, and after a prostatectomy, you will no longer ejaculate. This is because you will no longer produce semen, as the prostate, vas deferens and seminal vesicles have been removed.

You will feel the same rhythmic muscular spasms and pleasure that accompany an orgasm, but no semen will come out of the penis. This is called a dry orgasm.

You may worry that a dry orgasm will be less pleasurable for your partner. However, most partners say that dry ejaculation isn’t a problem for them, especially as many people do not feel the release of semen during intercourse.

Urine leakage

Some men notice a small leakage of urine during intercourse and orgasm. This is due to damage to the sphincter muscle that controls urine flow.

It can be embarrasing for men or partners, but urine is usually sterile and is not harmful. If this is a problem for you, empty your bladder (urinate) before sex. Speak with your doctor if you are still concerned.

"I don’t feel less of a man because I have prostate cancer and the treatment has affected my sex drive. My partner almost always initiates the foreplay and that gets me interested."
John

Men without partners

Single men may avoid dating for fear of rejection. Deciding when to tell a new potential sexual partner about your cancer experience isn’t easy.

While the timing will be different for each person, it can be helpful to wait until you and your new partner have developed a mutual level of trust and caring. It is best to talk with a new partner about your concerns before becoming sexually intimate.

By communicating openly, you may find that your partner is understanding and accepting of your changes.

Restoring your sex life

Cancer can affect your sexuality in both physical and emotional ways. The impact of these changes depends on many factors, such as your treatment and its side effects, the way you and your partner communicate, and your self-confidence.

The importance of sexual activity for a man before prostate cancer will influence how changes to his sex life affect him (and his partner, if he has one) after treatment. As men often link their sense of masculinity with their sex drive, adjusting to changes can be difficult. Some men might feel they have lost a part of themselves, while others may question their self-worth.

For many people, a relationship based on trust and understanding is an important part of a satisfying intimate sexual experience.

Tips
  • Talk about the changes and your feelings about sex. If you have a partner it will probably affect you both.
  • Give your sexual partner reassurance of your need and affection for each other.
  • Be intimate without having sexual intercourse. Touching, holding, caressing and massage are other ways of expressing love.
  • Take time to get used to any changes. Look at yourself naked in the mirror and, if you feel comfortable, touch your genitals to feel any differences or soreness. Show your partner the changes so they can also adjust to them.
  • Take it slowly the first few times you have sex again. Start by touching each other, then include some genital touching.
  • Use lubricants, especially silicone-based products, if prolonged stimulation is necessary.
  • Ask your partner to be gentle, as the genital area may be tender. Practise reaching orgasm through hand-stroking or oral sex.
  • Explore your own ability to enjoy sex by masturbating. Bringing yourself to orgasm can help you find out if cancer treatment has changed your sexual response.
  • Attempt intercourse even if you have a partial erection. This stimulation may encourage further and better erections.
  • Try different positions to find out what feels comfortable for both of you. Kneeling or standing to have sex may also help with erections.
  • Talk to your doctor, a sexual health physician or counsellor if you have ongoing problems, especially if it is causing depression or relationship trouble. Cancer Council’s free Sexuality, Intimacy and Cancer booklet may also help.

Key points

  • Prostate cancer treatment may damage nerves and muscles near the prostate and bowel, which can cause side effects such as urinary incontinence, erectile dysfunction, infertility and a lowered sex drive (libido).
  • Side effects vary from person to person.
  • Incontinence is not being able to control the flow of urine. It may be worse shortly after treatment and improve over time. Surgery or treatment from a continence nurse or continence physiotherapist may help.
  • Most men become infertile after treatment for prostate cancer. If you want to have children, talk to your doctor about your options before treatment starts.
  • It is common for men with prostate cancer to have problems getting and maintaining an erection (impotence or erectile dysfunction). You may be able to improve the quality of your erections through oral or injected medication, a vacuum erection device or an implant.
  • You may have a reduced interest in sex (lowered libido). Most men notice that their sex drive returns when treatment finishes, but for some men it is ongoing.
  • If your semen production is reduced, you will have dry orgasms. This means you will feel the pleasurable sensation of an orgasm, but semen will not come out of the penis (ejaculation).
  • Talking about what you are going through, taking time to adjust and getting support from your partner and medical team may help you cope with side effects.

Reviewed by: A/Prof Declan Murphy, Director of Robotic Surgery, Peter MacCallum Cancer Centre, VIC; Tony Davison, Consumer; Peter Dornan, Consumer; Duane Duncan, Australian Research Centre in Sex, Health and Society (ARCSHS), La Trobe University, VIC; Dr Farshad Foroudi, Radiation Oncologist; Peter MacCallum Cancer Centre, VIC; Virginia Ip, Urology Care Coordinator, Sydney Cancer Centre, Royal Prince Alfred Hospital, NSW; Judy Jeffery, Cancer Connect, Cancer Council NSW; David Smith, Research Fellow, Cancer Council NSW; and Robyn Tucker, Cancer Council Helpine, VIC. 
Updated: 01 Nov, 2013