 Home: PCU
4|2003: Leslie R Schover, PhD
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Leslie
R Schover, PhD |
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Associate Professor,
Department of Behavioral Science,
University of Texas, MD Anderson Cancer Center
Member, University of Texas at Houston Graduate
School
of Biomedical Sciences Graduate Faculty
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Edited comments by Dr Schover
Problems with studies of erectile dysfunction
after local therapy for prostate cancer
I believe that the literature sells these men a “false
bill of goods.” They receive overestimates of the likelihood
of recovering erectile function after prostate cancer treatment — whether
it’s surgery or radiation therapy.
Part of the problem with the literature is the way erectile function
had been measured. Many of the published studies were conducted
at academic medical centers where relatively healthy men with early
stage disease often seek out a particular physician. These men
are less likely to have erectile dysfunction before their prostate
cancer and may be more likely to recover no matter what they do.
Secondly, in some of these studies, recovery was defined by the
ability to have intercourse after treatment, and we know that most
men can have intercourse occasionally or without a very rigid erection,
but they are not satisfied with their level of recovery. Many men
in that category were classified as recovered, while they were
likely to be using treatments for their erectile dysfunction.
Another problem with the literature is that partners are often
not included in the assessments, and I believe this is an important
factor in recovery. The literature suggests that most men do not
continue treatment because it is a hassle, they don’t know
how to troubleshoot when it stops working or their partner doesn’t
like it. Ultimately, only about one-third of the men being treated
are satisfied and continue to use the treatment long-term.
Sexual outcomes after treatment for localized
prostate cancer
In our study, erectile function was assessed for the month prior
to the survey, so we were able to assess not just whether a man
had intercourse once since the treatment, but whether he had intercourse
during the last month. We also evaluated whether he was consistently
able to have an erection when he wanted to and to maintain it for
satisfying intercourse.
The most salient finding was that the rates of recovery for erectile
function were much lower than had been previously reported. At
least 75 percent of men did not have satisfying erections after
their prostate cancer treatment. No group had more than a 20 percent
rate of recovery of functional erections.
Bilateral nerve-sparing prostatectomy yielded better recovery
rates than unilateral or non-nerve-sparing prostatectomy. In the
radiation therapy group, men treated with brachytherapy had better
recovery rates, followed by those treated with conformal-3D or
intensity-modulated radiation therapy. Men treated with standard
external beam radiation had the worst results in this group.
Influence of age on recovery of sexual function
We found that men under the age of 62 had the best chance for
recovery of totally normal sexual function. Aman in his mid-50s,
with normal sexual function and libido prior to treatment, would
have a one in three chance of recovering good erectile function
after a bilateral nerve-sparing prostatectomy. He would probably
have another 20 percent chance of achieving good erectile function
with medical interventions. The chances of recovery with brachytherapy
in a younger man are similar to those with bilateral, nervesparing
prostatectomy, and the chances are less with radiation therapy.
Sexual function after prostatectomy versus radiation
therapy
After radical prostatectomy, sexual function is as bad as it’s
going to get and often improves over the next one to two years.
Radiation therapy has the opposite effect. Often, men still have
good erectile function right after radiation therapy, but over
the next one to three years, sexual function gradually deteriorates.
Most prior studies demonstrating that radiation therapy has less
of an effect on sexual function than surgery, have had a very short
follow-up — one or two years. The average length of follow
up in our study was four and one-half years, which provides a more
fair comparison. I think our follow-up is long enough to show that
there is no “free lunch” when it comes to prostate
cancer treatment. A man can have surgery and have immediate dysfunction
or he can have radiation therapy and end up with just as many problems — it
just takes longer to develop.
Rates of seeking treatment for erectile dysfunction
among prostate cancer survivors
The National Health and Social Life Survey published in JAMA
a few years ago found that only 10 percent of men with sexual problems
ever seek professional help. I wondered how this pattern compared
to patients treated for prostate cancer.
When we analyzed the data from our survey, many more men sought
help than we originally expected. We found that seeking medical
treatment for erectile dysfunction was more of a process than an
event. Many of these men sought help more than once, and the men
who ended up with a successful outcome had tried, on average, at
least two treatments.
Types of treatment for erectile dysfunction
Men in our study preferred noninvasive treatments. While more
than one-half of men who attempted treatment had tried sildenafil,
only a small fraction reported that it greatly improved their sex
lives and were still using it. Unfortunately, this agent doesn’t
work very well after prostate cancer treatment.
Sildenafil provided some extra firmness for men who could achieve
partial erections that were almost firm enough for intercourse;
therefore, it tended to work best for men who had bilateral, nerve-sparing
prostatectomy or brachytherapy.
We found that the more invasive methods were more effective,
but fewer men used them. With regard to penile injection, many
couples find that the pain, eventual complications like penile
fibrosis, and the lack of spontaneity with injection therapy are
difficult to deal with. The couples who do well with the vacuum
device tend to be older (in their late 60s or 70s), have been married
for a long time, don’t expect perfection in their sex life
and are willing to deal with the hassle.
I think the penile prosthesis is underutilized. In general, urologists
guide men away from the prosthesis because it’s irreversible.
First, they try sildenafil injections and then a vacuum device.
While this is a reasonable approach, many couples become so fatigued
and frustrated after trying all those things, they don’t
consider surgical placement of a prosthesis. It’s also difficult
for the men who have had radical prostatectomy to consider surgery
again, however, I think penile prostheses are much more reliable,
and the erections are much closer to natural erections. It’s
a treatment that results in a higher satisfaction rate than anything
else.
Role of counseling in sexual rehabilitation
While counseling will not restore erections in a man who has
organic erectile dysfunction, it enhances sexual communication
and helps couples integrate the medical treatments for erectile
dysfunction into their sex lives.
Very often, partners are left out of the treatment decision and
are apprehensive about how these treatments will affect their partner’s
health — I see this quite often with older couples. This
can result in the patient’s partner being unresponsive when
they try to initiate sex because they are afraid it will be harmful
to their partner’s health. Therefore, it’s very important
that the partner is included in the decision and understands the
treatments available.
At each follow-up visit, couples should be asked: What’s
going on with your sexual activity? Are you still showing affection
to each other? Have you tried any sexual touching?
Even without an erection, with the right kind of penile caressing,
men may experience an orgasm; however, it will be a dry orgasm.
We focus so much on the erection that we forget to reassure couples
about things like sexual desire and the ability to reach orgasm.
Men and women need to understand that erections, interest in sex
and penile sensation are all very separate parts of the sexual
response.
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