Managing side effects


Treatment for prostate cancer may cause a range of side effects, which will vary depending on the treatment and from person to person. Keep in mind that some men do not have any of the side effects listed below. When men do experience side effects, the changes often last for only a few weeks or months, although in some cases they will be permanent. Fortunately, there are many ways to reduce or manage side effects.

Common side effects

Surgery (prostatectomy)

  • Erection problems
  • Loss of libido
  • Dry orgasm
  • Urine leakage during sex
  • Infertility
  • Urinary problems
  • Fatigue

EBRT

  • Erection problems
  • Loss of libido
  • Dry orgasm
  • Infertility
  • Urinary problems
  • Bowel problems
  • Fatigue
  • Skin irritation

Brachytherapy

  • Erection problems
  • Loss of libido
  • Dry orgasm
  • Infertility
  • Urinary problems

ADT

  • Erection problems
  • Loss of libido
  • Dry orgasm
  • Infertility
  • Bowel problems
  • Fatigue
  • Hot flushes
  • Osteoporosis
  • Heart problems
  • Breast growth
  • Mood swings

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. It can also be affected by other factors, including health conditions such as diabetes and heart disease; certain medicines for blood pressure or depression; previous surgery to the bowel or abdomen; smoking or heavy drinking; or emotional or mental distress.

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

Before and after treatment, various methods can help preserve the health of the penis (penile rehabilitation). These may include:

  • engaging in foreplay and other sexual intimacy with your partner
  • encouraging erections, starting a month after surgery
  • taking prescribed medicines to maintain blood flow in the penis
  • using a vacuum erection device to stop the penis shortening or losing flexibility
  • injections of medicine into the penis.

See below for more detail about these methods. For many men, an orgasm can still be achieved without a full erection. See tips on managing changes to your sex life.

Ways to improve erections

There are several medical options for trying to improve the quality of your erections, regardless of the type of prostate cancer treatment you have had. Ask your treatment team for more details about these methods.

Oral medicines

There are tablets available on prescription that can help the body's natural response to sexual stimulation by increasing blood flow to the penis. These can only help with erections if the nerves are working, which is unlikely in the early stages of recovery. However, your doctor may recommend using the tablets before and soon after surgery, as the increased blood flow can help preserve penis health until the nerves recover.

Side effects may include nausea, headaches, facial flushing and backache, but these only last for a few hours after taking a tablet. The drugs can cause blood pressure changes and should not be taken with some heart medicines.

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.

You place a rigid tube over the penis. A manual or battery-operated pump then creates a vacuum that forces blood to flow into the penis so it gets hard. A band at the base of the penis keeps the erection firm after the pump is removed, and can be worn comfortably for 30 minutes.

Download the complete booklet for further information on vacuum erection devices.

Injections

Penile injection therapy (PIT) has to be prescribed by a doctor.

You will be taught to inject the penis with medicine that makes blood vessels in the penis expand and fill with blood, causing an erection. The erection usually occurs within 15 minutes and lasts 30–60 minutes.

Most often, the syringes come pre-loaded with the medicine and are single use. The needle is very short and fine, and usually causes only a moment of discomfort.

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

Implants

A penile prosthesis is an implant that is inserted into the penis during surgery under general anaesthetic. This implant allows you to mechanically create an erection. Flexible rods or thin, inflatable cylinders are placed in the penis and connected to a pump in the scrotum. The pump is turned on or squeezed when an erection is desired.

Penile implants can be expensive, so check costs with your doctor. They generally won't be offered for at least a year after prostate cancer treatment, and less invasive options, such as oral medicines or injections, will usually be tried first. Implants can be effective, but part of the tissue within the penis is removed to implant the device. This is a permanent change to the structure of the penis and a man will be unable to achieve an erection if the device is removed.

Download the complete booklet for further information on penile prostheses/implants.

You may see or hear ads offering treatment for erection problems. Products that are widely available include herbal preparations, natural therapies, nasal sprays and lozenges. Talk to your doctor before using any of these, as there could be risks without any benefits. Those that contain testosterone or act like testosterone in the body may encourage the prostate cancer to grow.

Other changes to sexuality

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, libido can also be affected by ADT, which lowers testosterone levels, and by the sexual side effects associated with radiation therapy or surgery.

Most men notice that their sex drive returns when treatment ends, 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. You may find these tips helpful.

Dry orgasm

After a prostatectomy, you won't produce semen, as the prostate and seminal vesicles have been removed and the vas deferens are sealed. You will still feel the muscular spasms and pleasure that accompany an orgasm, but you will not ejaculate. This is called a dry orgasm. Some men notice that their orgasms feel less intense. 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 may also be reduced after radiation therapy.

Urine leakage during sex

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

Urine leakage during sex can be embarrassing, but is not harmful to your partner. If this is a problem for you, empty your bladder (urinate) before sex. You can use a condom or a constriction ring (available from sex shops) at the base of the penis during sex to prevent leakage. Speak with your doctor if you are still concerned.

Fertility problems

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

To find out more, see Fertility and Cancer or call Cancer Council 13 11 20.

Restoring your sex life

Whether you are single, in a relationship, heterosexual, gay, bisexual or transgender, cancer can affect your sexuality in both physical and emotional ways. The impact of these changes depends on many factors, such as the cancer treatment and its side effects, how you and your partner communicate, and your level of 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.

Communicating with a new partner

Deciding when to tell a 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. However, it is best to talk with a new partner about your concerns before becoming sexually intimate. By communicating openly, you avoid misunderstandings and may find that your partner is more accepting and supportive.

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. Reassure them that intimacy is still important to you.
  • 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. Start by touching each other's skin, then include genital touching.
  • Attempt intercourse even with a partial erection. This stimulation may encourage further and better erections.
  • Explore your ability to enjoy sex and understand any changes by masturbating.
  • Ask your partner to be gentle, as the genital area may be tender. Use silicone-based lubricants for prolonged stimulation. Practise reaching orgasm through methods such as hand-stroking.
  • 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.
  • See Sexuality, Intimacy and Cancer or call Cancer Council 13 11 20.
  • Read Understanding Sexual Issues Following Prostate Cancer Treatment from the Prostate Cancer Foundation of Australia ( prostate.org.au or 1800 22 00 99).

Urinary problems

Trouble controlling the flow of urine (urinary incontinence) is a common side effect of treatment. It is usually temporary. After prostate surgery, most men have some degree of incontinence for 3–6 months. Some lose a few drops of urine when they cough, sneeze, strain or lift something heavy. For others, symptoms may be more severe and require the use of incontinence pads.

In rare cases, radiation therapy can reduce how much urine the bladder can store, irritate the bladder, narrow the urethra and weaken the pelvic floor muscles. This can lead to urinary urgency (feeling like you just can't wait) and difficulty passing urine.

Other side effects

Treatment for prostate cancer may lead to a range of other concerns, but most of these can be managed.

Bowel problems

Although this is no longer a common side effect, radiation therapy can damage the rectum, leading to bleeding and/or diarrhoea. A bowel specialist such as a gastroenterologist or colorectal surgeon may treat these bowel problems with steroid suppositories (a tablet that you insert into the rectum through the anus) or other treatments applied to the bowel. For more information, talk to your radiation oncologist or a continence nurse. You may also want to read Understanding Bowel Disturbance Following Prostate Cancer Treatment, available from the Prostate Cancer Foundation of Australia ( prostate.org.au or 1800 22 00 99).

Coping with urinary incontinence

  • Find out about pelvic floor exercises. Men who do pelvic floor exercises before surgery are less likely to have ongoing urinary incontinence after surgery. The exercises are also important after surgery. Ask your doctor, urologist, physiotherapist or continence nurse for more information.
  • Drink plenty of water to dilute your urine - 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.
  • Limit tea, coffee, alcohol and carbonated drinks – these can all irritate the bladder.
  • Talk to a continence nurse about continence aids if needed. These aids can include absorbent pads to wear in your underpants, and bed and chair covers. The nurse may also recommend medicines or special clamps.
  • Ask your continence nurse or GP about the Continence Aids Payment Scheme. This assists men who have ongoing incontinence with the cost of continence products.
  • If incontinence hasn't improved after 12 months, talk to your doctor or urologist about whether surgical treatment is an option. For example, a surgically inserted sling or artificial sphincter works by putting pressure on the urethra to close it off and control urinary flow.
  • See Exercise for People Living with Cancer or call Cancer Council Call 13 11 20.
  • Get more resources from the Prostate Cancer Foundation of Australia (1800 22 00 99 or prostate.org.au) and the Continence Foundation of Australia (1800 33 00 66 or continence.org.au).

Fatigue

Cancer treatment often makes people very tired. After surgery, it may take some time to get back strength. With external beam radiation therapy, you may get particularly tired near the end of treatment and for some weeks or months afterwards. Regular exercise can help to reduce tiredness. Call Cancer Council 13 11 20 to find out about programs that can help. You can see Exercise for People Living with Cancer.

Skin irritation

External beam radiation therapy can make the skin in the genital area red and sore for a time. Follow skin care instructions from your treatment team, even before you notice skin changes. Check with your treatment team before using any over-the-counter creams.

Hot flushes

You may experience hot flushes if you are having ADT. Reducing alcohol intake, avoiding hot drinks, getting regular exercise and learning relaxation may help.

Osteoporosis

Osteoporosis can be a delayed side effect of ADT, so your GP may need to monitor your bone mineral density.

Heart problems

Because ADT can lead to heart problems and strokes, your GP or specialist will monitor your heart function and may refer you to a dietitian or exercise physiologist for advice.

Other ADT side effects

Weight gain, mood swings, enlarged breasts, decreased muscle mass, change in body shape, and high cholesterol may be associated with prolonged use of ADT.

Key points

  • Prostate cancer treatment may damage nerves and muscles near the prostate, bladder and bowel.
  • Side effects may include erection problems, urinary incontinence, a lowered sex drive and infertility. These vary from person to person.
  • 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 by taking tablets, using a vacuum erection device, giving yourself injections or getting 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).
  • Most men become infertile after treatment for prostate cancer. If you want to have children, talk to your doctor about options such as sperm storage before the cancer treatment starts.
  • Urinary incontinence is trouble controlling the flow of urine. It may be worse soon after treatment and improve over time. A continence nurse or a continence physiotherapist can help. Surgery may be an option.
  • Taking time to adjust and getting support from your partner and medical team may help you cope with side effects.

Expert content reviewers:

A/Prof Declan Murphy, Urologist and Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC; Gregory Bock, Acting Coordinator of Nursing, WA Cancer & Palliative Care Network, Department of Health, WA; A/Prof Martin Borg, Radiation Oncologist, Adelaide Radiotherapy Centre, SA; Carmen Heathcote, 13 11 20 Consultant, Cancer Council Queensland; Dr Michael Lowy, Sexual Health Physician, Sydney Men's Health, NSW; Dr David Millar, Sexual Health Physician, Perth Men's Health, WA; Jennifer Siemsen, Clinical Nurse Consultant – Cancer Care, WP Holman Clinic, Launceston General Hospital, TAS; A/Prof David Smith, Senior Research Fellow and Cancer Epidemiologist, Cancer Council NSW; Dr Ben Tran, Medical Oncologist, Peter MacCallum Cancer Centre, Melbourne, VIC; Derek Wells, Consumer. 

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