Managing side effects

Friday 1 April, 2016

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On this page: Urinary problems | Erection problems | Other changes to sexuality | Improving the quality of your erections | Restoring your sex life | Other side effects | Key points


Treatment for prostate cancer may damage nerves and muscles near the prostate, bladder and bowel. This may cause side effects including urinary incontinence, changes in bowel habits, erectile dysfunction and infertility. Lower testosterone levels as a result of ADT can also cause loss of interest in sex (libido).

Side effects will vary from person to person. Some men will not have any, while 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. Many go away in time and most men are able to continue to lead active lives after their treatment.

Urinary problems

Urinary incontinence, accidental or involuntary leakage of urine, is a common side effect of treatment that is usually temporary.

After prostate 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. For others, symptoms may be more severe and require the use of incontinence pads. Incontinence is usually worse shortly after surgery, but generally improves within a year.

Although rare, radiotherapy can reduce the capacity of the bladder to store urine, irritate the bladder, narrow the urethra and weaken the pelvic floor muscles. This can lead to urinary urgency and difficulty passing urine. Talk to your doctor or a continence nurse or physiotherapist if these problems occur.

Surgery for incontinence may be considered if incontinence hasn’t improved significantly after 12 months. There are two surgical options: a sling or an artificial sphincter. These devices work by putting pressure on the urethra to close it off and control urinary flow. Talk to your doctor or urologist to see if surgical treatment may be an option for you.

Coping with urinary incontinence
  • Men who do pelvic floor exercises before surgery are less likely to have ongoing urinary incontinence after surgery. Exercises are also important after surgery. Ask your doctor, urologist, physiotherapist or continence nurse for more information.
  • Limit bladder irritants such as tea, coffee, alcohol and carbonated drinks.
  • Drink plenty of water as concentrated urine can irritate the bladder.
  • Avoid restricting your fluid intake because you are afraid of leakage. Dehydration can cause constipation, which can also lead to leakage.
  • Continence aids that help absorb urine loss include absorbent pads to wear in your underpants, and sheets and chair covers. A continence nurse can inform you about continence aids that might be suitable for you.
  • Ask your GP about the Continence Aids Payment Scheme. This assists men who have severe or long term incontinence with the cost of continence products.
  • The Continence Foundation of Australia offers resources: Pelvic Floor Muscle Training for Men and Continence and Prostate. Call 1800 330 066 or visit continence.org.au.

Erection problems

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. The quality of erections usually declines naturally as men get older.

Erection problems are common in men following treatment for prostate cancer, particularly radiotherapy and prostate surgery. The prostate lies close to nerves and blood vessels that are important for erectile function. These can be damaged during surgery or radiotherapy.

The body needs time to heal after surgery. There may be a gradual recovery, with some men noticing their erectile function continues to improve for up to three years after treatment has finished.

There is increasing evidence that sexual rehabilitation before and after surgery and radiotherapy helps recovery. Your chance of a strong recovery of erectile functioning may be improved by:

  • engaging in foreplay with your partner
  • encouraging erections as soon as a month after surgery
  • using medication prior to surgery, or in the early post-operative period
  • using a vacuum erection device or having penile injections.

For many men, an orgasm can still be achieved without a full erection. See tips on managing changes to your sex life after prostate cancer treatment.

Other causes of erectile dysfunction

Sometimes cancer treatment adds to existing erection problems, which may be caused by:

  • getting older
  • diseases, such as diabetes, heart and vascular disease
  • certain medications, such as those used to treat blood pressure or depression
  • previous surgery to the bowel or abdomen
  • a history of smoking or high alcohol intake
  • emotional or mental distress.

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

There are prescription medications that can help the body’s natural response to sexual stimulation by increasing blood flow to the penis. These are only effective if the nerves necessary for erections are working. Possible side effects include headaches, nausea, facial flushing and backache, but these only last a few hours, until the drug is out of your system.

Men with existing heart problems should check with their doctor before using these medications. These medications can cause changes in blood pressure, and some heart medications are not recommended (contraindicated) with these tablets.

Injections

Penile injection therapy is a commonly used and effective treatment prescribed by a doctor. Men are taught to inject their penis with medication that causes blood vessels in the penis to expand and fill with blood, causing an erection. An erection usually occurs within 15 minutes and lasts 30–60 minutes.

This treatment works well for most men, but a few may experience pain and scarring. A rare side effect is a prolonged and painful erection (priapism); this requires emergency medical attention.

Vacuum erection device

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

Using a VED is painless and relatively easy; however, it may take some practice to feel confident. VEDs are available on prescription or from sex aid shops.

Other therapies for erectile dysfunction

You may see and hear advertisements for products offering treatment for erectile dysfunction. Products include herbal preparations, natural therapies, nasal sprays and lozenges.

Be cautious about using testosterone or natural products that act like testosterone in the body, as they may involve risks without any benefits.

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

Implants

A penile prosthesis is an implant that is surgically placed in the penis. This implant allows men to mechanically create an erection.

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

Implants are usually performed no sooner than 12 months after prostate cancer treatment. They are generally considered only after other less invasive penile rehabilitation options have been trialled, such as medications or injections. Implantation is effective, however the surgery permanently changes the structure of the penis, as part of the tissue within the penis is removed to implant the device. If the device is removed, a man will be unable to achieve an erection.

Penile prosthesis implant

Other changes to sexuality

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

Fertility problems

After surgery, radiotherapy or hormone therapy for prostate cancer, most men become infertile. This means they can no longer have children naturally. If you want to have children, you and your partner should talk to your doctor about your options before treatment starts. You may be able to have your sperm stored at a fertility clinic for use at a later time when you are ready to start a family.

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 sexual side effects associated with 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 their partners. See the restoring your sex life section for tips to help with this issue.

Dry orgasm

After a prostatectomy, you will no longer produce semen, as the prostate, vas deferens and seminal vesicles have been removed. You will still feel the rhythmic muscular spasms and pleasure that accompany an orgasm, but you will no longer ejaculate. This is called a dry orgasm.

Some men notice a reduction in the sensation of the orgasm. You may worry that a dry orgasm will be less pleasurable for your partner. However, most partners say this is not the case, especially as many do not feel the release of semen during intercourse. Semen production is also affected (reduced) following radiotherapy.

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. This can be embarrassing, but is not harmful to your partner. 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
Communicating with a new partner

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

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 more accepting and understanding.

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. Some men link their sense of masculinity with their sex drive, making adjusting to changes difficult. Others might feel they have lost a part of themselves or 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.

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

Other side effects

Bowel problems

Although less common now, radiotherapy may damage the rectum, leading to bleeding and/or diarrhoea. A bowel specialist (a gastroenterologist or a colorectal surgeon) may treat these side effects with steroid suppositories or treatments applied to the bowel. For more information, talk to your radiation oncologist or continence nurse.

Hot flushes

Hot flushes may occur as a result of ADT. Reducing alcohol intake, avoiding hot drinks, getting regular exercise and relaxation may help.

Osteoporosis

Osteoporosis can be a delayed side effect of hormone therapy and monitoring of your bone mineral density by your GP may be required.

Heart problems

These may occur as a result of hormone therapy and may be monitored by your doctor. You may be referred to a dietitian or exercise physiologist for advice.

Key points

  • Prostate cancer treatment may damage nerves and muscles near the prostate, bladder and bowel.
  • Side effects may include urinary incontinence, erectile dysfunction, infertility and a lowered sex drive. These vary from person to person.
  • Incontinence is not being able to control the flow of urine.
  • Incontinence 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. 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 this side effect 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 Nicholas Brook, Consultant Urological Surgeon, Royal Adelaide Hospital and Clinical Associate Professor in Surgery, University of Adelaide, SA; Prof Ian Davis, Professor of Medicine and Head of Eastern Health Clinical School, Monash University and Senior Oncologist, Eastern Health, VIC; A/Prof David Smith, Senior Research Fellow and Cancer Epidemiologist, Cancer Council NSW, NSW; A/Prof Peter Reaburn, Associate Professor in Exercise and Sport Sciences, CQU, QLD; Sylvia Burns, Senior Cancer Specialist, Cancer Council Queensland, QLD; Robyn Tucker, Clinical Nurse Specialist, Cancer Information and Support, Cancer Council Victoria, VIC. 
Updated: 01 Apr, 2016