Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Abstract

Prostate cancer treatment significantly impacts sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and it is important to understand the potential impacts of different treatment modalities on sexual health. Existing research has described the effects of treatment on male erectile tissues and function, including as it relates to heterosexual intercourse. There is minimal evidence regarding their impacts on sexual health and function in sexual and gender minority populations. This includes sexual minority men, or gay and bisexual men, and transgender women or trans feminine people in general. Such unique impacts might include altered sexual function in relation to receptive anal intercourse and evolutions in sexual roles. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include anodyspareunia, erectile dysfunction, climacturia, anejaculation, altered pleasurable sensation, and changes in penile length. Clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations perpetuating an uncertainty regarding optimal management. This review comprehensively identifies the toxic effects of prostate cancer treatments on sexual minority men, addresses sexual dysfunction in transgender women, summarizes therapies to assist in sexual function restoration, and highlights the nuances of management in these understudied populations. This review seeks to provide clinicians with an evidence base with which to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Short Summary:

This review discusses the impacts of prostate cancer treatments on sexual health in sexual and gender minorities, summarizes therapies to assist in sexual function restoration, and highlights the nuances of management in these historically oppressed patient populations.

Introduction

Prostate cancer is the most common cancer in the male population with a 5-year overall survival of 98%.¹ Due to the relatively high overall survival, treatment paradigms focus on both survival and quality of life (QoL). Prostate cancer can be treated with radical prostatectomy (RP), external beam radiation (EBRT), brachytherapy, androgen deprivation therapy (ADT), or combination therapies depending on risk group.² Each of these treatments is associated with toxicity profiles which can impact patient QoL.

Sexual function is a vital aspect of human health and maintaining the capacity for pleasurable sexual activity after cancer therapy is a critical component of both QoL and survivorship.³ Sexual dysfunction is one of the most common and debilitating effects of prostate cancer treatment.⁴ Substantial evidence exists describing the impact of prostate cancer treatment on male penile erectile tissues and its impact on heterosexual intercourse.^5,6

However, there are a paucity of data analyzing the impact of treatment on sexual function in sexual and gender minorities (SGM). Sexual and gender minorities include individuals who identify as lesbian, gay, bisexual, transgender, gender diverse, asexual, queer, and intersex as well as those who do not but whose sexual orientation, gender identity, or reproductive development vary from traditional, societal, cultural, or physiological norms.⁷ It is estimated that approximately 1 in 8¹ gay and bisexual men, or sexual minority men (SMM), will develop prostate cancer as there is no evidence to support SMM are at greater risk to develop prostate cancer.⁸ And while the prevalence data is limited for transgender women (TGW), people recorded male sex at birth or who have feminine gender identity; TGW likely have a substantially lower risk of developing prostate cancer compared to the cisgender male population.⁹

The most common sexual activities among SMM include masturbation, oral intercourse, and anal intercourse,¹⁰ while TGW sexual practices continue to be investigated, they also commonly include masturbation, oral intercourse, and anal intercourse.^11,12 In receptive anal intercourse, the prostate is the primary organ responsible for sexual pleasure; however, the damage and toxicity to this vital organ, the surrounding tissues, and the supplying neurovasculature is poorly understood.^13,14 Increasing the understanding of the impact of prostate cancer treatment in patients who participate in anal intercourse is essential. The American Society of Clinical Oncology (ASCO) has reported that there is insufficient knowledge on the healthcare needs and outcomes for effective interventions among SMM and TGW populations;¹⁵ furthermore, practitioners lack the necessary tools to guide treatment discussions, promote patient centered conversations, and enable shared decision making, when appropriate, in this population.^16,17 This continues to be perpetuated as both SMM and TGW remain absent from cancer related clinical trials.¹⁸

To provide a framework to guide treatment related discussions and future biomedical research with these populations with prostate cancer, this review provides a detailed overview of how sexual dysfunction in SMM and TGW patients differs from heterosexual cisgender male (HET) patients following prostate cancer treatment. To accomplish this, we aim to understand how the prostate functions in anal intercourse as a context to interpret the existing literature on sexual outcomes in SMM following prostate cancer treatment. Additionally, we identify techniques and therapies used to manage treatment-related damage responsible for sexual dysfunction in SMM following prostate cancer treatment. Lastly, given the limited literature on TGW with prostate cancer, we address sexual dysfunction in this patient population. This review seeks to establish a framework for clinicians to counsel SMM and TGW with prostate cancer as well as provide equitable and personalized care to these historically oppressed patient populations.

The prostate and anal intercourse

To understand the effects of prostate cancer treatments on sexual health for SMM, it is important to recognize the role of the prostate in receptive anal intercourse. The prostate provides seminal fluid for male ejaculate (procreative function) and facilitates orgasm (recreative function).¹⁹ An orgasm occurs with the release of neurotransmitters resulting in muscular, sensory, and vascular changes experienced locally and globally throughout the body. Although a large component of the orgasm is a neuropsychiatric phenomenon, the neural circuitry of an orgasm is poorly understood. Moreover, orgasms are multifactorial and can be experienced by physical stimulation (including areas outside the genitalia) and psychological stimulation.²⁰ In many people with a prostate gland, an orgasm is accompanied by ejaculation; however, the two events occur through separate neuropsychological pathways, and therefore can occur independently. Additionally, it is possible to have an orgasm or ejaculate without a penile erection or penile structures.^21–23

In addition to stimulation of the prostate, it is hypothesized that pleasure from receptive anal intercourse is experienced through pressure and stimulation of the surrounding nerves in the perianal skin and rectal wall. Additionally, the anus is an erogenous zone, thus making anilingus a source of sexual pleasure.^24–26 Manipulation of the anus and its surrounding area induces erotic stimulation through the perineal nerves (a branch of the pudendal nerve).^24,27 Furthermore, the neural network between the genitalia and the anorectal area suggests that stimulation of one area can cause reaction in the other (e.g., pressure on the perineum might cause an erection in a male).²⁸ Moreover, touching the skin adjacent to the anus can stimulate anal sphincter contraction, which can lead to changes in breathing and physiological behavior.²⁶

Pressure on the prostate, anal sphincter, and rectal wall can also induce penile excitation and orgasm. The anus and rectum contain their own sensory networks and stimulation of the anorectal area can heighten sexual pleasure.²⁴ Studies have suggested that involuntary erections during enemas or digital rectal exams might occur, thus implicating this connection.²⁴ Inserting an object such as a finger or penis into the anus and/or rectum can stimulate the nerves surrounding the prostate, seminal vesicles, anus, and rectal wall, leading to sexual arousal. ^24,29 Reports have suggested a greater intensity of orgasm through deep prostatic massage with 12 pelvic muscle contractions compared to 4-8 contractions associated with penile orgasm.²²

Supporting the role of the prostate in orgasm are prostate pleasure toys, which place pressure on the prostate and rectal wall in order to induce an erection and intensify orgasm.³⁰ A recent study of 806 participants analyzing differences in sexual behavior found that men in same sex relationships experienced extreme pleasure and frequent orgasms from anal intercourse. Men who have sex with men had a similar satisfaction of orgasm from anal entry (mean: 4.60, 5 is most satisfactory) compared to men who have vaginal intercourse with women (mean: 4.69). Additionally, although the significance is unknown, these orgasms were rated higher than oral-penile orgasms in male-male relationships (mean: 4.18) and male-female relationships (mean: 4.36).³¹ These studies have helped uncover the complex roles for the prostate, perianal skin and surrounding nerves on creating powerful and pleasurable orgasms during anal intercourse. Thus, a comprehensive understanding by clinicians of the anatomy and pathophysiology of anal intercourse is essential to effectively counsel SMM patients undergoing prostate cancer treatment.

Sexual dysfunction in sexual minorities

Sexual dysfunction after prostate cancer treatment is multifactorial and has significant impacts on QoL and survivorship outcomes. Issues influencing sexual dysfunction and distress include patient age, comorbidities, baseline sexual function and practices, and treatment modality (FIG. 1).

Fig. 1: Comprehensive assessment of sexual and gender minorities for sexual dysfunction.

Assessing sexual dysfunction in a patient is multifactorial. It is imperative to understand a patient’s gender identity, birth recorded sex, sexual orientation; sexual behavior and role (top, bottom, versatile, side), comorbidities that could influence sexual function (e.g. vascular disorders, heart disease, depression), medications and substances that could impair sexual function (e.g. SSRIs), patient’s relationship status and psychosocial support, as well as disease characteristics and treatment selection.

Patient demographics including age and comorbidities can influence sexual dysfunction and are an important consideration. SMM with prostate cancer might be younger compared to the general population, but also might have a higher comorbidity burden. The median age of a prostate cancer patient is 67 years old.³² A cross-sectional survey study of 401 SMM with prostate cancer revealed a mean age of 63.5 years (standard deviation [SD]: 6.6),³³ while a cross-sectional survey study of 92 SMM from the US and Canada found that the average age of diagnosis was 57.8.³⁴ Another cross-sectional study from Australia of 119 SMM and 224 HET found a significant difference in age with SMM having a younger average age of 64.25 (SD: 8.18) compared to 71.54 (SD: 8.98) (p < 0.001).³⁵ It is hypothesized that SMM are diagnosed with prostate cancer at a younger age due to older SMM not disclosing their sexual orientations^8,36 potentially skewing data as well as higher PSA detection among this population due to prostate stimulation during receptive anal intercourse.³⁷ Moreover, the earlier detection of prostate cancer in SMM might also be explained by the unique health-seeking behavior of this cohort. Due to a potential lack of incomplete healthcare services from a primary care provider, many SMM might have multiple caregivers to address their specific healthcare needs. For example, many SMM separate their sexual health provider from their primary care provider.³⁸ Additionally, sexual health, along with mental health, is a primary health concern for SMM.³⁹ Thus, due to this healthcare fragmentation and increased concern regarding sexual health compared to HET, SMM might be more inclined to seek medical care for sexual dysfunction—which can be from an underlying cause, such as prostate cancer—leading to earlier detection of prostate cancer.

Comorbidities might also differ for SMM. Polter et al. analyzed 383 SMM and compared comorbidity prevalence to published samples of HET prostate cancer survivors. They found a similar prevalence of diabetes for SMM (12%) and HET (13%), and a lower prevalence of obesity for SMM (20%) compared to HET (32%).⁴⁰ However, both blood vessel disease and mental health disorders were significantly more common among SMM (53% versus 45% and 46.6% versus 15–27%, respectively). This study also found that comorbidities within SMM were associated with worse QoL and sexual function. It has been demonstrated that patients with higher comorbidity scores experience decreased recovery to baseline erectile function following RP (independent of age). ⁴¹ Additionally, baseline erectile score is an important prognosticator for erectile function following treatment¹⁷.

Maintaining the capacity for pleasurable sexual activity after cancer therapy³ is especially important for SMM survivors who might engage in more frequent and variable sexual activities than HET. In fact, studies show that SMM are more sexually active than HET and have more casual and multiple sexual partnerships.^42,43 In a study of SMM prostate cancer survivors, the frequency of sexual practices among this populations included: masturbation (87%), penile oral intercourse performance (55%), penile oral intercourse reception (42%), receptive anal intercourse (37%), insertive anal intercourse (25%), and insertive vaginal intercourse (6%).⁴⁴ Moreover, compared to HET, SMM were more likely to be single with approximately 46%- 50% of SMM being married and/or living with a partner.^33,34 Differences in relationship status are further underlined by Ussher et al., where 50% of SMM were partnered compared to 86% of HET (p < 0.001).³⁵ This study also found that the length of the relationship for partnered SMM patients is significantly shorter, as only 81% of SMM relationships are more than 2 years compared to 93% of HET relationships. Sexual dysfunction following treatment can be distressing to patients without a partner who might be sexually active and seeking relationships.

In addition to age, comorbidities, relationship status, and baseline sexual function/practices, sexual dysfunction is affected by treatment modality,² as well as anatomical preservation during treatment.^45,46 In both surgery and radiotherapy, the extent of anatomical preservation, including nerve and vessel preservation, can be predictive of the extent of erectile dysfunction.^45,46 In the general population, RP is associated with short-term worsening of sexual function compared to EBRT alone for the treatment of localized prostate cancer. The prospective CEASAR study compared RP, EBRT, and active surveillance at 3 year follow up, and found that the adjusted mean expanded prostate index composite (EPIC) sexual domain score for men undergoing RP had declined significantly more than for men undergoing EBRT (mean difference −11.9 points, 95% CI [−15.1, −8,7]).¹⁷ Follow-up data from the ProtecT trial illustrated that RP had an increased incidence of erectile dysfunction compared to EBRT at 6 years.⁵ Additionally, on the Prostate Cancer Outcomes Study (PCOS), patients undergoing RP were more likely to have erectile dysfunction compared to EBRT at 2 years and 5 years, though no difference was observed at 16 years.⁶ Moreover, EBRT might be given with ADT; when compared to EBRT alone, the addition of ADT is associated with worse sexual outcomes, including an increased incidence of erectile dysfunction, ejaculatory issues, decreased libido, and worse sexual recovery.^47,48 While different fractionation regimens are commonly employed for EBRT, data have demonstrated that hypofractionated radiotherapy does not increase erectile dysfunction when compared to conventionally fractionated radiotherapy.^48,49 Thus, shorter courses of EBRT can be utilized without an increased risk of erectile dysfunction. Additionally, brachytherapy might be associated with better erectile function compared to EBRT.⁴⁷ Lastly, while limited data exists regarding proton irradiation, one study found that erections firm enough for vaginal penetration decreased from 90% to 72% and 67% at 1 and 5 year follow up, respectively. Comparative studies investigating photon and proton therapy are required to understand the effects of these treatment modalities on sexual dysfunction.⁵⁰ However, a bias might be present, as younger patients with prostate cancer with fewer comorbidities tend to select surgery compared to EBRT and brachytherapy.⁵¹ Nevertheless, it is important to note that not all treatment options are available to all patients as treatment recommendations are a function of cancer characteristics, disease extent, patient comorbidities, and patient age.

The effects of prostate cancer treatments on QoL within the SMM community are multifactorial. Restore-2, one of the largest studies investigating the toxic effects of prostate cancer treatment on SMM observed that when compared to the general population, SMM had significantly worse urinary, sexual, bowel, and hormonal functional outcomes.³³ Within the SMM cohort of 401 patients, the type of treatment significantly affected sexual and hormonal outcomes, while age and race/ethnicity did not. More specifically, there was no difference in sexual outcomes between RP (mean=38.2, SD: 21.7) and radiation only (mean=45.0, SD: 22.5); however, combination with hormonal treatment was statistically worse 25.9 (18.8) measured by the Expanded Prostate Index Composite (EPIC)-Domain Scores.³³ In a study by the same group, there was no significant difference between surgery and radiation alone on sexual function QoL by multivariate analysis; however, combination therapies had significantly worse outcomes when controlled for race, age, relationship status, and sexual orientation.⁴⁴

The toxic effects of treatment

The toxic effects following prostate cancer treatment experienced by SMM include: anejaculation (94%), erectile dysfunction (90%), change in orgasm (87%), decreased sexual confidence (78%), penile changes (66%), anodyspareunia (65%), and climacturia (49%). ⁵²

Anodyspareunia

Anodyspareunia refers to pain during or after receptive anal intercourse. Anatomical and physiological factors that can make receptive anal intercourse painful include lack of natural lubrication, the anorectal angle, and the tightness of the anal sphincter.^53,54 Painful receptive anal intercourse was first acknowledged as a sexual dysfunction by Rosser et al. in 1997, who cited parallels between painful vaginal intercourse or dyspareunia and painful anal intercourse or anodyspareunia.⁵⁵ Inadequate lubrication, lack of foreplay, and psychological factors such as anxiety and internalized homophobia were identified as increasing the risk of anodyspareunia.^56,57 The lifetime prevalence of anodyspareunia in the general SMM community is 61%, which is notably higher than the lifetime prevalence of difficulty getting an erection (40%) and difficulty ejaculating (39%) in SMM.⁵⁵ Damon et al. observed that 14% of 404 SMM in the general population could not have intercourse at all due to anodyspareunia.⁵⁷ A larger study of 1,752 SMM found that 59% of 1,190 SMM engaging in receptive anal intercourse experienced some degree of pain in the last 4 weeks.⁵⁶ Still, while painful receptive intercourse and anodyspareunia are exceedingly prevalent in the SMM population, only 6% of SMM with prostate cancer reported that their providers even discuss anal intercourse let alone mention anodyspareunia as a toxic effect of prostate cancer treatment.⁵⁸

In Restore-1, 35% of SMM with prostate cancer described receptive anal intercourse as poor to fair and 27% reported dissatisfaction with quality of receptive anal intercourse after treatment. A single painful anal intercourse event was reported by 57% of participants and anodyspareunia was reported by 34% of participants, markedly higher than the general population.⁴⁴ In a secondary analysis of Restore-1, the authors sought to understand anodyspareunia further.⁵⁸ In this study, the prevalence of anodyspareunia was 23% in SMM, again notably higher than in the general population; additionally, patient demographics did not correlate with anodyspareunia.⁵⁷ Worse mental health function (measured by SF-12 Mental) correlated with a higher likelihood of experiencing anodyspareunia (Odds Ratio [OR]: 0.95; 95% CI: 0.91–0.99). While not statistically significant, worse bowel symptomatology trended toward a higher likelihood of experiencing anodyspareunia (OR: 0.97; 95% CI: 0.94–1.00). Following surgery, 24% of SMM experienced anodyspareunia, while following radiation (EBRT/brachytherapy), 1 of 4 (25%) SMM experienced anodyspareunia. Surprisingly, following combination therapy (e.g., EBRT+ADT) 0 of 7 (0%) SMM experienced anodyspareunia. Thus, ADT might offer a protective effect on bowel symptoms and anodyspareunia. In a retrospective study of 2,752 prostate cancer patients, ADT was shown to have a protective effect against proctitis and rectal bleeding when combined with brachytherapy.⁵⁹ The authors hypothesize that this is likely due to ADTs reduction of prostate size and resultant reduction in radiation target volume. As ADT is known to decrease libido and affect erectile function negatively, it is of relevance that ADT might help protect against anodyspareunia. Further studies are required to elucidate how various treatment modalities and combinations influence the incidence of anodyspareunia in prostate cancer survivors (Table 1).

Table 1.

Treatment-related sexual dysfunction in sexual minority men

Sexual Dysfunction	Importance	Treatment Consideration	Rehabilitation and restoration
Anodyspareunia	In the general SMM, lifetime prevalence of AD is 61%55 and point prevalence is 14%.57 In SMM prostate cancer survivors, the point prevalence of AD ranges from 23%-34%.57,58	RP: removes prostate (24%).58 EBRT: damages prostate, surrounding structures; causes bowel toxicity (25%).58 BT: damages prostate, surrounding structures; causes bowel toxicity (25%).58 ADT: might be protective against AD and bowel toxicity when combined with radiation.58,59	Anal dilator,140 Dildos, Butt plugs,140 Prostate massage vibrator,150,151 Lubricant,30,152 Alkyl nitrites (‘poppers’) 130
Climacturia	Oral intercourse is more common in SMM compared to HET.79 This toxicity can be embarrassing when engaging in insertive oral intercourse.	More studies are needed to understand treatment differences.	Pelvic floor exercises,134 Penile constriction ring (‘cock’ ring),135 Surgical management (mini-jupette) 137,138
Anejaculation	Ejaculate can be important to some SMM and be symbolic of sexual pleasure. 71–74	RP: 100%.66 EBRT: 11-91%.67 BT: 11-91%.67 ADT: might worsen ejaculatory dysfunction. 68	Research is needed to circumvent anejaculation following prostate cancer treatment.
Erectile Dysfunction	An erection must be 33% more rigid for anal intercourse compared to vaginal intercourse.63,64	RP: worse at 6 years,5 no difference at 16 years compared to EBRT.6 EBRT: worse with ADT.47,48	PDE-5 inhibitors, 125,126 VEDs, 128,129 Penile constriction ring (‘cock’ ring)
Penile Changes	The size and shape of the penis is important to participants of insertive anal and oral intercourse. Penis size is emphasized in gay culture.99	RP: penile shortening ranges from 0.5 to 5 cm. 95,96 EBRT: when combined with ADT, there might be penile shortening.98	PDE-5 inhibitors, 133 VEDs129,132
Orgasm changes	Orgasm function and type at baseline might differ between the SMM and HET.92	RP: anorgasmia (37%),82 dysorgasmia (12%-18%).83 84 EBRT: anorgasmia (29%)86 and dysorgamia (15%).88 BT: anorgasmia (49%)86 and dysorgasmia (26% to 40%).89 90 ADT: Might weaken orgasm sensation.91	Tamsulosin82 Cabergoline139

AD, anodyspareunia; SMM, sexual minority men; HET, cisgender heterosexual men; RP, radical prostatectomy; EBRT, external beam radiation therapy, BT, brachytherapy; ADT, androgen deprivation therapy; PDE-5, phosphodiesterase-5; VED, Vacuum erectile device

Erectile Dysfunction

Erectile dysfunction is a common, well-established toxic effect of prostate cancer treatment (Table 1). In a study of SMM following prostate cancer treatment, 85% reported that their erections were not firm enough for intercourse.⁴⁴ However, in a study by Ussher et al., the authors found that erectile function was significantly better for SMM (EPIC EF: 21.2) compared to heterosexual men (16.5) following treatment.³⁵ In subsequent analyses by Ussher et al., they identified that 72% of SMM reported erectile dysfunction approximately 5.9 years following diagnosis.⁶⁰ In a study by Hart et al., 89 SMM patients noted better erectile function (38.7, SD: 2.6) versus 225 heterosexual patients (29.5, SD: 1.5) using the EPIC instrument to assess sexual function.³⁴ Additionally, using EPIC sexual function, SMM from Restore 1 (40.5, SD: 23.6) noted significantly better erectile scores compared to SMM in Restore-2 (35.5, SD: 21.2) and the HET validation sample (29.5, SD: 23.8).³³ Wassersug et al. found that there were similar rates of erectile dysfunction (p = 0.83) and ability to orgasm with penetration (p = 0.91) between SMM and HET. ⁶¹ Conversely, a pilot study analyzing bicalutamide (ADT monotherapy) for prostate cancer treatment in SMM (12 patients) and heterosexual men (17 patients), found that SMM scored lower (28.7) than heterosexual men (56.1) on the international index of erectile function score.⁶²

While erectile function is important to all patients, it might be of particular clinical significance among the SMM community, as studies have estimated that an erection must be 33% more rigid for anal intercourse compared to vaginal intercourse.^63,64 Furthermore, there might be increased distress regarding erectile dysfunction in the SMM community as a survey study in the general community found that patients who engage in more sexual activity reported more distress from erectile dysfunction.⁶⁵

Anejaculation

Anejaculation is an expected sequalae following RP,⁶⁶ as it is due to the removal of the prostate and seminal vesicles (Table 1). Reported rates of anejaculation vary widely, ranging from 11-91%.⁶⁷ In a prospective study of 225 men receiving EBRT and 112 receiving brachytherapy, 72% of patients lost the ability to ejaculate normally. The proportion of patients experiencing anejaculation at 1, 3, and 5 years was 16%, 69%, and 89%, respectively.⁶⁸ The etiology of ejaculatory dysfunction following radiation therapy might be due to atrophy, fibrosis, scarring of ejaculatory ducts, and urethral strictures leading to obstruction. The addition of ADT to a radiation regimen will likely worsen ejaculatory dysfunction. ⁶⁸

In a study of 1,273 healthy men in the general population without prostate cancer, 46% reported reduced ejaculatory volume and 66% were bothered by this condition.⁶⁹ However, in a study conducted by Wassersug et al., ejaculatory dysfunction following prostate cancer treatment caused more distress for SMM than heterosexual men.⁶¹ A database review of 308 SMM and 306 heterosexual men illustrated that while treatment effectiveness was most important to both SMM and heterosexual men (69.1% SMM versus 70.4% HSM, p = 0.54), ejaculatory function was significantly more important for SMM (53.7%) compared to heterosexual men (26.4%, p < 0.0001). In this study, there was no difference in importance of preservation of penile length or erectile function between SMM and heterosexual men, further underlining the importance of ejaculation to SMM.⁷⁰ Ussher et al. also identified that ejaculatory concern was significantly greater for SMM compared to HET (2.62 versus 1.85, p < 0.0001).³⁵ Ejaculation is considered important in some SMM relationships and intercourse, as the visual representation of ejaculate can be symbolic to show that sexual pleasure was achieved.^71,72 In fact, it is noted that following RP, SMM associate the inability to visualize ejaculate with worse sexual outcomes.^73,74

Climacturia

Climacturia or orgasm-associated urinary incontinence occurs when there is expulsion of urine during orgasm (Table 1). O’Neil et al. published a retrospective study of 412 patients who underwent EBRT or RP. They found climacturia to be present in 5.2% and 28.3% of post EBRT and RP patients, respectively. ⁷⁵ Approximately 47% of all prostate cancer survivors find climacturia bothersome.⁷⁶ Climacturia tends to improve over time. The mechanism and development of climacturia are unknown and might be due to damage to the internal sphincter combined with relaxation of the external sphincter during orgasm, leading to urination.⁷⁷ There has not been an association between incontinence and climacturia.⁶⁶ Additionally, loss of urethral length during surgery might be a cause of climacturia, as decrease in penile length was found to be an independent predictor of climacturia.⁷⁸

Climacturia causes distress to the SMM community, possibly because both insertive and receptive oral intercourse are more common in this population compared to heterosexual men.⁷⁹ Approximately 52% of SMM following prostate cancer treatment reported involuntary urination during intercourse or at orgasm.⁴⁴ In a study of 124 SMM, 65% noted change in urinary patterns and 40% noted that activities were limited due to urinary issues.⁶⁰ In a qualitative study of 16 SMM, urinary incontinence and climacturia were particularly anxiety provoking as the majority of the patients participated in oral sex and mutual masturbation.⁸⁰ Further studies are needed to understand how treatment modality affects climacturia in this patient population and how climacturia might differ between SMM and HET.

Orgasm changes

Changes in orgasm function include anorgasmia, altered or decreased orgasm sensation, and dysorgasmia (orgasm-associated pain, Table 1). Treatment for prostate cancer has been associated with all of these changes.⁸¹ After RP, patients might experience anorgasmia (37%),⁸² decreased orgasm (37%),⁸² or dysorgasmia (12%-18%).^{83 84} Nerve sparing techniques and younger age might be associated with better orgasm-related outcomes.⁸⁵ Following radiation, patients might also experience anorgasmia (EBRT: 29.1%, brachytherapy: 49.3% [decreased orgasm/anorgasmia])⁸⁶ decreased orgasm (29.6% EBRT, 23.7% EBRT + brachytherapy),⁸⁷ or dysorgasmia (EBRT: 15%,⁸⁸ brachytherapy: 26%-40%).^{89 90} Additionally, when combining radiation with hormonal therapy, orgasm function might be further diminished.⁹¹

Orgasm changes following prostate cancer treatment might not differ significantly between SMM and HET. A study of 460 HET and 96 SMM showed there was no difference in orgasm satisfaction after prostate cancer treatment between the two groups.⁶¹ In another study, SMM had better orgasms (4.24; SD: 3.31) compared to HET (2.33; SD: 2.53; p < 0.001) following prostate cancer treatment.³⁵ Conversely, in the general population, SMM might have more difficulty experiencing orgasm pleasure: orgasm ability was the same among gay (52.2; 95% confidence interval [CI]: 50.8-53.7, n = 293) bisexual (50.6; 95% CI: 48.2-53.1, n = 121), and heterosexual (52.0; 95% CI: 51.4-52.6, n = 1382) men, but orgasm pleasure was lower for gay (48.9; 95% CI: 47.6-50.2) and bisexual (46.7; 95% CI: 44.0-49.5) men compared to heterosexual men (51.1; 95% CI: 50.5-51.7).⁹² Thus, while changes in orgasm after prostate cancer treatment might not differ between SMM and HET, it is important to recognize that orgasm function at baseline might differ between the cohorts.

Decreased libido

Loss of libido following prostate cancer and its treatment is very common and can be worsened by hormone therapy⁹³ (Table 1). In a study by Ussher et al., SMM had significantly better sexual interest (7.82; SD: 3.12) and sexual frequency (4.40; SD: 1.97) compared to HET (interest: 5.43; SD: 3.22; frequency: 2.63; SD: 2.22) following prostate cancer treatment.³⁵ Another study by Ussher et al. analyzing 124 SMM prostate cancer survivors found that 58% of men report “absent,” “poor,” or “okay” libido and 65% of these patients state that low libido was problematic.⁶⁰ In an exploratory qualitative study of three gay couples managing sexual dysfunction after RP, patients noted a decrease in libido after RP and one patient stated that he felt “castrated.” However, within this exploratory study, two of the three patients also attributed symptoms to confounding variables, such as medical comorbidities and advancing age.⁹⁴

Change in penis size and shape

Prostate cancer treatment can affect the length and girth of the penis (Table 1). In the general population, following RP, studies show penile shortening ranges from 0.5 cm to 5 cm.^95,96 This might be due to hypoxia in the penile tissue and resultant muscle loss and fibrosis.⁹⁷ Although substantially less evidence exists describing radiation affecting the size and shape of the penis, one study found that EBRT combined with ADT can shorten the penis.⁹⁸

Among men who have sex with men, penis size might be more emphasized due to the focus on body image in gay culture and the “double presence” of the penis in sexual minority relationships and encounters.⁹⁹ Additionally, the size and shape of the penis might be particularly important to those who participate in the insertive role in anal intercourse.¹⁰⁰ Regardless, even if there are treatment effects on penile shape from prostate cancer therapies, SMM might not experience any difference in self-esteem and self-image compared to HET following RP¹⁰¹ or other treatments. However, these data should be interpreted with caution as a major limitation of this study was a small sample size (SMM, n=16 and HET, n=131). Still, it is possible that penile size and shape is not the only thing important to self-esteem and image for SMM, underscoring that overall sexual satisfaction in SMM is multifactorial.

Change in sexual role

In patients with prostate cancer and survivors who participate in anal related intercourse, the damage and toxic effects to the prostate, rectal wall, perianal skin and the surrounding neurovasculature necessary for sexual pleasure can lead to a change in sexual role.¹³ Within the general SMM community, 8%-29% of SMM are the insertive partner (“tops”), 13-50% are the receptive partner (“bottoms”), and 29-58% are both (“versatile” or “vers”),^102,103 Change in role can have many negative implications on intercourse and mental health as sexual role can be part of one’s identity in the SMM community.¹⁰⁴

In a study by Ussher et al. examining change or loss in sexual role before and after surgery or radiation, the authors found that patients identifying as the insertive partner (“tops”) decreased from 31% to 12%, the receptive partner (“bottoms”) increased from 19% to 24%, the versatile partners (“vers”) decreased from 20% to 8%, and engaging in no anal intercourse increased from 31% to 56%.⁶⁰ Additionally, patient interviews have identified that change in sexual role challenged relationship dynamics due to partner incompatibility.⁶⁰ This sentiment was echoed by Hart et al. who noted from qualitative interviews that changes in sexual function and position were distressing to partners of SMM prostate cancer survivors. Similarly, from this study, Hart noted that of the insertive patients who were “tops” before treatment, only 40% continued to be strict “tops”.³⁴ In Restore-1, Rosser et al. also noted that while approximately 92% of SMM had a strong sense of sexual role pretreatment, only 45% had any sense of sexual role posttreatment.⁴⁴ More specifically, the authors noted that patient sexual role identification included: 42% “tops/vers-tops”, 37% “bottoms/vers-bottoms”, and 18% “vers” pretreatment compared to 8% “tops/vers-tops”, 65% “bottoms/vers-bottoms” and 5% “vers” posttreatment. Moreover, an overall decrease in total percentage suggests treatment affects sexual role and sexual activity (FIG 2).

Figure 2: Patient centered conversations based on sexual role.

At consultation inquire about the sexual role of a patient. A patient’s sexual role can influence treatment recommendations, guide conversations, and, when applicable, impact shared decision making. While discussing all treatment-related sexual dysfunctions is important, particular toxic effects of interest include—top: erectile dysfunction, penile changes, anejaculation, dysorgasmia as it relates to the penis, libido; versatile: anodyspareunia, erectile dysfunction, penile changes, anejaculation, dysorgasmia as it relates to the penis and prostate, libido; bottom: anodyspareunia, anejaculation, dysorgasmia as it relates to prostate sensation, libido; and side: climacturia, erectile dysfunction, penile changes, anejaculation, libido. Additionally at consultation and again at follow up, physicians should explain the implications of changing sexual role, the contraindication of combining alkyl nitrites (‘poppers’) with PDE-5 inhibitors, and the time course of abstinence from engaging in receptive anal intercourse with sexual and gender minorities.

Changes in role might be dependent on treatment modality. In a study of 15 SMM who underwent different prostate cancer therapies, patients were asked about role before and after treatment. Within the surgery group, 3 of 4 “tops” and 3 of 3 “bottoms” had to change their sexual role identity. Within the radiation group (EBRT +/− ADT and brachytherapy), all patients maintained their sexual role identity before and after treatment (5 “tops” continued to be “tops” and 2 “bottoms” continued to be “bottoms”). These results similarly suggest that prostate cancer treatments might affect sexual roles, however, such a small sample size warrants further study and evaluation.¹⁰⁵

Anal penetration requires preparation for the receptive partner which can be burdensome for some SMM and a barrier to participate. An internet-based survey of 24,787 SMM aged 18–87 years old in the United States showed that the most common behavior among SMM was kissing a partner on the mouth (74.5%), oral sex (72.7%), and partnered masturbation (68.4%). In this cohort, anal intercourse occurred among less than half of participants (37.2%) and was most common among younger SMM aged 18–24 (42.7%),¹⁰ which is younger than the median age of SMM with prostate cancer. This suggests that there might be SMM who do not engage in anal intercourse (insertive or receptive) and engage in other sexual activities such as oral intercourse. This sexual role has recently been colloquially termed “side.”

Psychological Distress

The impact of a cancer diagnosis can lead to significant psychological distress, including anxiety, depression and potentially decreased sexual desire. Prostate cancer patients are not an exception, and are known to suffer from mental health conditions including depression and anxiety.¹⁰⁶ Associated psychological treatments might also contribute to sexual dysfunction. Antidepressants such as selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (e.g. clomipramine), antipsychotics,¹⁰⁷ benzodiazepines¹⁰⁸ have a risk of sexual dysfunction and might cause decreased libido, ejaculatory issues, and erectile dysfunction^109,110 (FIG. 1).

Compared to the general population, SMM are known to have more mental health conditions, including anxiety, depression, and substance use disorder.¹¹¹ Consistently, SMM prostate cancer survivors have worse mental health compared to HET. In one study of SMM prostate cancer survivors, SMM patients scored significantly worse (mean: 46, SD: 0.8) compared to HET (mean: 58, SD:−0.7; p < 0.0001) using the short form-12 QoL survey.⁴⁴ This is further underlined by both Rosser³³ et al. and Ussher³⁵ et al. who found that SMM scored significantly worse on Functional Assessment of Cancer Therapy Prostate (FACT-P) subscales and overall FACT-P compared to normative samples. Additionally, these studies found that SMM scored significantly higher on the psychological distress QoL scales including higher on the depression, anxiety, and overall psychological distress scale. Mental disorders and associated treatments might develop and contribute to sexual dysfunction in SMM prostate cancer survivors. It is essential to review medications and monitor the development of these conditions from treatment in this vulnerable population.

Mitigating sexual toxicity

Patient centered communication

It is essential for practitioners to inquire about sexual orientation and practices with their patients¹³ (FIG. 3). Frameworks to help physicians ask about sexual orientation and sexual health include consensus reports from the National Academy of Science Engineering and Medicine (NASEM) and the British Association of Sexual Health and HIV (BASHH). The report from NASEM offers principles (inclusiveness, precision, autonomy, parsimony, and privacy) for collecting sexual orientation and gender identity data and proposes specific questions to ask.¹¹² Key principles from BASHH guidelines include confidentiality, communication, sexual health, documentation, and specific circumstances.¹¹³ These resources exist and might be useful to help physicians overcome anxiety when discussing sexuality and sexual health with SMM.

Figure 3: Patient centered consultation guidance for patients with prostate cancer.

To guide patient centered conversations about prostate cancer treatment selection, physicians should inquire about gender identity, sexual orientation, sexual practices, sexual role, gender affirming hormone therapy, gender affirming surgery (specifically genital reconstruction surgery). Answers to these questions will guide patient centered treatment conversations that align with sexual role, sexual orientation, and gender identity and allow for informed treatment selection.

However, these guidelines are not specific to cancer patients and more research is needed to assist oncological physicians in discussing sexual orientation and sexual practices. In one study, only two thirds of SMM report being out to their healthcare prostate cancer provider.⁴⁴ In a survey from the American Urological Society, 112 adult urologists (89 males, 23 females) reported that they were significantly more comfortable discussing sexual health with heterosexual patients (80%) compared to SMM (64%). Additionally, 63% of respondents do not ask patients about sexual orientation and 26% assume the patient to be heterosexual.¹¹⁴ A survey study of ASCO members revealed that less than half of providers ask about sexual orientation, and that 17% of respondents thought it was not important to collect sexual orientation data.¹¹⁵ This study cited healthcare provider discomfort, institutional culture, and lack of training, resources, and time as barriers to sexual orientation collection. Similarly, a systematic review revealed that healthcare professionals might fail to discuss sexual health related issues with patients due to time constraints, lack of education, concern for offending the patient, and personal discomfort.¹¹⁶

Nevertheless, on the masculine self-esteem scale, SMM patients who disclosed their sexual orientation had a significantly higher self-esteem (77, SD: 18) compared to those who did not (62, SD: 20). This openness likely improves the physician-patient relationships, which can promote better sexual and disease outcomes.¹¹⁷ Lack of sexual orientation and preference discussion might be related to reported reduced satisfaction with prostate cancer care among SMM patients. This was demonstrated by Ussher et al. who reported that SMM have a significantly lower satisfaction level with treatment than HET.³⁵

When considering prostate cancer treatments and the associated toxic effects, it is important to not only ask about sexuality and sexual practices, but also sexual role (FIG. 1 and FIG 3). Knowing the sexual role of a patient might influence treatment recommendations, guide conversations, and impact shared decision making in this population as the side effects differ and interests of men might be different (FIG. 2).¹¹⁸ For example, from a qualitative interview, a prostate cancer survivor who identified as a “bottom” noted that treatment-related erectile dysfunction was not distressing due to the lack of importance his erection has on his sexual life and identity.⁹⁴ Thus, a “bottom” or “vers” might be interested in learning about anodyspareunia, dysorgasmia and prostate sensation after prostate cancer treatment, a “top” or “vers” might be interested in learning how specific therapies affect erection firmness and penile shape/length, and a “side” might be interested in learning about climacturia and anejaculation.¹³ By appropriately guiding conversations, patients will be able to make an informed decision, which could help decrease the rate of sexual identity change in this patient population. Thus, it is extremely important to consider the entire patient when discussing treatment options treatment related sexual dysfunction, especially in SMM (FIG. 2).

Sexual rehabilitation and devices

Sexual devices and medications can help patients restore their capacity to experience arousal and orgasm by altering physiology and increasing sensation, and sexual rehabilitation, restoration and assistance is important to SMM with prostate cancer. A qualitative study conducted by Ussher et al. identified that significantly more SMM prostate cancer survivors are likely to try an assistive sexual aid compared to heterosexual prostate cancer survivors.¹¹⁹ These aids include oral medications, penile injections/implants, vacuum pumps, and vibrators. Furthermore, while both SMM and HET were dissatisfied with sexual aids, SMM were more likely to seek information and support about sexual rehabilitation from the internet, therapists, and support groups.¹¹⁹ This further illustrates SMM openness to utilizing sexual assistive devices and the need for providers to discuss sexual rehabilitation with this population.

Information regarding sexual assistive devices should be provided to prostate cancer patients at consultation to help guide treatment option discussion and future sexual rehabilitation.¹²⁰ SMM prostate cancer survivors report that limited information is provided on sexual restoration at consultation. This lack of education about sexual rehabilitation might delay treatment and lead to worse sexual outcomes.^121–123

Erectile Dysfunction Rehabilitation

Sexual restoration after prostate cancer treatment has been primarily focused on improving erectile function. Common treatments for erectile dysfunction following prostate cancer treatment include phosphodiesterase-5 (PDE-5) inhibitors (e.g., tadalafil, sildenafil), penile injection therapy, penile implants, and vacuum erectile devices (VED).^121,124 In the general population, approximately half of prostate cancer survivors utilize a rehabilitation method for penile erection restoration. Although penile rigidity increases, approximately 73% of general patients discontinue these rehabilitation methods.^119,121 Compared to heterosexual patients, SMM are more likely to use oral medications (66% versus 38%, p < 0.001), penile injections (26% versus 13%, p < 0.001), vacuum pumps (27% versus 11%, p < 0.001), and penile constriction rings (36% versus 16%, p < 0.001)¹¹⁹ (Table 1).

In the general population, sildenafil has been found to help with erectile dysfunction. Initiating sildenafil before radiation and continuing it during radiation demonstrated improved erectile function.¹²⁵ Additionally, in a randomized controlled cross-over study, 36% of men responded to sildenafil but not to placebo.¹²⁶ Similarly, starting sildenafil after RP helps improve erectile dysfunction and starting sildenafil sooner shows better rehabilitation.¹²⁷ In addition to PDE-5 inhibitors, VEDs might help with erectile dysfunction following radiation therapy and RP. This is especially important in patients who might have a contraindication to PDE-5 inhibitors due to a concomitant medication or comorbidity. ^128,129

Of important note to clinicians is the recreational use of alkyl nitrites (“poppers”) in the SMM community. “Poppers” are inhalants used to circumvent anodyspareunia through the the upregulation of cyclic guanosine monophosphate (cGMP). This promotes relaxation of musculature, including the internal sphincter, which can assist with accommodation of a partner’s penis. One study found that approximately 46% of 1,745 general SMM used alkyl nitrites in the last 6 months, primarily to facilitate penetration.¹³⁰ It is essential to inquire about and counsel patients on the use of “poppers” when prescribing a PDE-5 inhibitor (e.g., sildenafil, tadalafil), as the combination of these drugs can cause hemodynamic instability, hypotension and syncope¹³¹ (FIG. 2).

Penile stretching

In addition to assistance with erectile dysfunction, VEDs and PDE-5 inhibitors might have a role in the restoration of penile length, girth, and shape following prostate cancer treatment (Table 1). There have been trials investigating the use of VEDs for penile changes following RP. In a cohort of 28 patients following RP, VED use was found to preserve penile length when used starting one month following surgery.¹³² Additionally, the use of VEDs was associated with smaller decreases in penile size compared to no treatment.¹²⁹ While there is not as strong of an association between penile shortening and changes with radiation treatment, there are ongoing studies to understand VEDs to prevent penile shrinkage during radiation.¹²⁸ Moreover, PDE-5 inhibitors might also help with changes in penile length. In a randomized study investigating the effect of tadalafil 5 mg daily, tadalafil 20 mg as needed, or placebo following RP for prostate cancer found that 5 mg tadalafil helped preserve penile length compared to placebo.¹³³

Climacturia Rehabilitation

Climacturia rehabilitation includes pelvic floor exercises, blood flow restriction, and surgical intervention (Table 1). Additionally, emptying one’s bladder before intercourse and using condoms might help manage climacturia.⁷⁶ In a randomized controlled trial, patients who underwent RP had significantly less climacturia events after the use of pelvic floor exercises compared to those who underwent RP and did not participate in pelvic floor exercises (p = 0.004).¹³⁴ In addition to pelvic floor exercises, blood flow restriction might help decrease climacturia. Penile constriction (‘cock’) rings work similarly to VEDs and prevent blood flow out of the penile vasculature and can be a helpful intervention for patients with mild erectile difficulties, can increase pleasure during orgasm,³⁰ and can help reduce symptoms of climacturia.¹³⁵

Constriction bands have been investigated for treatment in the general population for patients with climacturia after RP. In a study of 14 men who underwent RP, a reduction of the frequency of climacturia at 6 months was found following the addition of a ‘cock’ ring. In fact, 48% of patients experienced no climacturia with a cock ring at 6 months.¹³⁵ It is important to note that cock rings should not be left on for more than 20 minutes.³⁰ Surgical management is another intervention to help alleviate climacturia. In a cohort of patients following RP, those who received an artificial urinary sphincter or sling placement had improvement in sexual urinary symptoms and QoL.¹³⁶ More recently a mini-jupette, a sling placed and sutured over the urthera, has been utilized to help climacturia.¹³⁷ In a cohort of 38 patients with erectile dysfunction, a mini-juppete was placed and among 30 patients previously with climacturia, 92.8% noticed improvement in symptoms.¹³⁸

Treatment of orgasm changes

Few studies have identified possible treatments for issues with orgasm (Table 1). In the general population, tamsulosin might help with dysorgasmia following RP and in one study, dysorgasmia pain improved in 77% of patients after tamsulosin initiation.⁸² In a retrospective study of 131 men in the general population with orgasm disorders, cabergoline helped improve dysorgasmia. A subset of men in this population had prior RP and responded positively to the treatment.¹³⁹ However, more studies are required to understand how to restore orgasms in SMM after prostate cancer treatment, especially in patients participating as the receptive partner in receptive anal intercourse.

Receptive anal intercourse rehabilitation

There is an unmet need to understand how other sexual assistive devices such as vibrators, dildos, lubricants, and other products might help SMM prostate cancer survivors’ sexual dysfunction, especially anodyspareunia (Table 1). Ussher et al. observed that SMM are more likely to use vibrators and dildos compared to heterosexual men (36% versus 16%, p < 0.001).¹¹⁹ Moreover, from the Restore-1 study, Rosser et al. identified that, while erectile enhancing drugs, pelvic floor exercises, penile injections, and vacuum pumps were the most commonly discussed treatment options with SMM; surgical implants, referral to a sexual counselor, and the use of dildos, butt plugs, or anal dilators received higher satisfaction ratings among SMM prostate cancer survivors. This highlights the critical need to investigate ways to restore receptive anal intercourse functioning.¹⁴⁰

Treatment for other cancers, such as cervical cancer, have demonstrated that sexual devices, including dilators and vibrators can assist in sexual rehabilitation in patients with reduced sensation or arousal following treatment. In a pilot study of 15 females with cervical cancer, a clitoral therapy device significantly improved sexual desire, arousal, orgasm, sexual satisfaction and decreased associated pain. The female sexual function index score increased from 17 to 29.4 after three months of treatment (maximum score of 36; p < 0.001). Gynecological examinations revealed an improvement in vaginal elasticity and mucosal color, a decrease in bleeding and ulceration, as well as an increase in moisture.¹⁴¹ Additionally, vaginal dilators are commonly used after pelvic cancer therapy to prevent stenosis and stretch the vagina.¹⁴²

Like vaginal dilators, anal dilators might be useful for SMM prostate cancer survivors receiving radiation. Acutely, radiation can cause irritation, pain, and friability due to inflammation.¹⁴³ These changes are mediated by the inflammatory response, thus fibromuscular tissue and adhesions might develop and lead to anal stenosis.¹⁴⁴ To help shape the anal canal and prevent anal stenosis, it might be useful to use anal dilators after radiation treatment.^145–147 Through the use of dilators, patients can prevent scar tissue from forming and help break down existing scar tissue^145–147 which will in turn help the anus and rectum to become more elastic.^148,149 Studies are needed to investigate the feasibility and outcome of anal dilators to help mitigate anodyspareunia in SMM prostate cancer survivors.

Moreover, prostate massage vibrators might be a useful recommendation for sexual dysfunction restoration in SMM prostate cancer survivors. Prostate massage vibrators can assist men by achieving orgasm through stimulation of the prostate gland. Even if the prostate is removed or damaged, the surrounding sensory nerves might be stimulated and enhanced by a prostate massage vibrator. In the general population, prostate massage vibrators can alleviate overall prostate pain, as two studies with a total of 115 participants found a statistically significant decrease in prostatic pain score with prostate massage vibrators compared to no intervention.^150,151 This might be a useful intervention for SMM prostate cancer survivors; however, more studies are required to confirm their benefit. These interventions to help restore and preserve receptive anal intercourse function might help SMM prostate cancer survivors preserve sexual role identity in receptive anal intercourse.

Maintaining Sexual Health

Questionnaires to monitor toxicity

In addition to discussing treatment options and outcomes at consultation, it is important to follow up with patients after treatment to monitor the toxic effects of treatment. Within the SMM community, it is important to follow up on aspects relevant to anal intercourse in addition to erectile function. Currently, many practices monitor the toxic effects of prostate cancer treatment using standardized questionnaires. These questionnaires include the Male Sexual Health Questionnaire (MSHQ),¹⁵³ Expanded Prostate Cancer Index Composite (EPIC),¹⁵⁴ International Index of Erectile Function (IIEF),¹⁵⁵ and Sexual Health Inventory for Men (SHIM), an abbreviated version of IIEF (IIEF-5).¹⁵⁶ These questionnaires focus on erectile function necessary for vaginal intercourse and omit information related to anal intercourse, neglecting the needs of many SMM patients.¹⁵⁷ Additionally, questionnaires were developed in cohorts with uniform sexual orientation and gender representation limiting the validity and usefulness within a sexually diverse patient population.¹⁵⁷ The IIEF was modified to IIEF-MSM for HIV-positive SMM which contains information relevant to insertive and receptive anal intercourse, but still focuses on erectile function.¹⁵⁸ Additionally, the score was developed for the HIV population and has not been validated among prostate cancer survivors who might suffer from different sexual toxicities than people living with HIV.

New questionnaires are being developed with more inclusive questions to address the needs of SMM. In a group of 53 SMM following prostate cancer treatment, 64% reported a belief that the prostate is a source of sexual pleasure (p < 0.0001) and 53% felt that it is important to measure sexual satisfaction after receptive anal intercourse (p < 0.01).¹⁵⁹ Lee et al.¹⁵⁷ also created a questionnaire consisting of 13 domains including libido, ejaculation, erection, orgasm, receptive/insertive anal intercourse, masturbation, oral sex, urinary incontinence or climacturia, and other general sexual questions encompassing a wider range of sexual practices. This questionnaire covers the broader SMM sexual experience; however further analysis is necessary for validation.¹⁵⁷ Polter et al.¹⁶⁰ also sought to develop and evaluate a more inclusive QoL questionnaire for SMM called the Sexual Minorities and Prostate Cancer Scale (SMACS) using patients from the Restore-2 study.^33,161,162 The questionnaire contains three sections: behavior/desire, problems, and role in sex as well as 5 validated subscales: sexual satisfaction, sexual confidence, frequency of issues, urinary incontinence in sex, and problematic receptive anal intercourse. The scale is reliable and can be used in conjunction with other existing scales. These questionnaires must be implemented into daily clinical practice and research.

Receptive anal intercourse resumption after treatment

For men who engage in receptive anal intercourse (“bottoms”), it is important to counsel on the safe resumption of receptive anal intercourse following treatment. The UK has developed guidance based on a panel of 15 clinical oncologists and 11 urologists utilizing a modified Delphi technique to understand the timing for when patients can resume receptive anal intercourse.¹⁶³ Still no clear consensus was reached for many of the interventions, and further research is required to define the time interval necessary before intercourse can safely be resumed.

Ninety one percent of panel members agreed that patients should refrain from receptive intercourse after surgery. Abstaining from intercourse after RP will allow the vesicourethral anastomosis to heal and reduce the risk of leakage and urinary incontinence. Additionally, RP might weaken the rectal wall, leaving it susceptible to trauma from receptive anal intercourse, which could prolong recovery or cause perforation. The recommended time to avoid receptive anal intercourse after RP is 2 weeks. Seventy three percent of panel members agreed that patients should abstain from intercourse after EBRT. This time will allow the inflammation from radiation to subside. Without allowing sufficient time to heal, trauma to this area could exacerbate inflammation and radiation induced proctitis. Patients should refrain from anal intercourse for 6 weeks following EBRT.

All the panelists recommended abstinence from receptive anal intercourse after brachytherapy (high and low dose rate). Following high dose rate brachytherapy, patients should abstain for 2 months and following low dose rate, patients should abstain from anal intercourse for 1-2 months.¹⁶³ The panel members cite the need to allow prostate and rectal inflammation to subside and to decrease potential exposure to the patient’s partner as important reasons to abstain. Similarly, a study investigating wait times for receptive anal intercourse and sustained cuddling (or “spooning”) after low dose brachytherapy treatment concluded that patients treated with I¹²⁵ should avoid “spooning” for 2 months and those treated with Pd¹⁰³ do not need to avoid “spooning” following treatment. The authors additionally state that patients should avoid receptive anal intercourse following I¹²⁵ seed placement for 6 months and following Pd¹⁰³seed placement for 2 months.¹⁶⁴ The results from this study differ from the UK panel consensus demonstrating further research is needed. Additionally, given that Pd¹⁰³ is usually given in combination with EBRT, a patient should be counseled on avoiding anal intercourse for 2 months after the last day of treatment with brachytherapy or EBRT (FIG. 2).

Sexual practices following treatment

During consultation and again following treatment, patients should be counseled on common sexual practices to be avoided after treatment. For example, in any male receiving low dose rate brachytherapy, a condom should be used to avoid ejecting a radioactive seed into a partner. However, there should be specific recommendations for men who participate in receptive anal intercourse. Anal intercourse and vaginal intercourse are associated with different sets of risks. Anal mucosa is less compliant and accommodating than vaginal mucosa, resulting in a higher risk of STI and HIV contraction during anal intercourse due to mucosal tear and damage.^165–167 Within the SMM community, condom use is already sparse. In fact, within a cohort of prostate cancer SMM survivors, approximately 22% of participants reported unprotected insertive anal intercourse.⁴⁴ It is imperative as a provider to counsel patients on condom use following prostate cancer treatment to decrease the risk of HIV/STI acquisition (FIG. 2).

In both the Restore-1⁴⁴ and Restore-2¹⁶² studies, evidence showed that patients became infected with HIV or other STIs after treatment. In Restore-2¹⁶², approximately 11.4% of patients became infected with an STI following prostate cancer treatment. These infections include syphilis (4.3%) gonorrhea (2.8%), chlamydia (2.5%), and HIV (1%, n = 4).¹⁶² Similarly, in Restore-1,⁴⁴ 3 (1.8%) of the 171 at risk patients became infected with HIV following prostate cancer treatment. Risk factors for HIV/STI acquisition post treatment can include changes in sexual role (top to bottom can increase risk of STI/HIV),^44,104 varied relationships, and less condom use.¹⁶⁸ Thus, providers must discuss safe sex practices including HIV/STI risk, the importance of condoms, and HIV pre-exposure prophylaxis (PrEP). (FIG. 2)

Providers might also want to discuss the appropriate lubricant to help with anal intercourse following prostate cancer treatment. Lubricant can help with anal intercourse accommodation and can help intensify and prolong sexual intercourse.¹⁵² For receptive anal intercourse, silicone-based lubricants have the advantage of persisting on the mucous membranes and after treatment silicone lubricant can adhere to scar tissue. ^30,152

In addition to lubricant, counseling SMM on safe anal intercourse preparation following prostate cancer treatment is also recommended. Given the presence of fecal matter in the rectum, many patients will cleanse the rectal vault with douches (or enemas) before engaging in receptive anal intercourse.¹⁶⁹ In fact, in a large survey study of 5,000 SMM, approximately 88% of patients who have receptive anal intercourse practice anal douching.¹⁷⁰ Men might use regular water, soapy water, salt-water, or commercial products such as saline solution, sodium phosphates, mineral oils/glycerins and laxatives.¹⁷⁰

Douching can damage the rectal lining and cause bleeding, which in turn leads to increased risk of infection from HIV/STIs.^171,172 Additionally, it can alter the rectal microbiome,¹³⁰ which is essential for maintaining the rectal epithelium and host immunity,¹⁷³ as well as preventing surgical and procedural complications.¹⁷⁴ Furthermore, the microbiome has been implicated in acute radiation proctitis. Synbiotics, or mixtures of probiotics (helpful gut bacteria) and prebiotics (non-digestible compounds for probiotic growth assistance), have been shown to help reduce the risk of acute proctitis.¹⁷⁵ Future research is needed to understand how to safely cleanse before anal intercourse as well as the role of the microbiome in mediating toxicity. While research is ongoing,¹⁷⁶ it is important to counsel patients on the risks of vigorous anal douching following prostate cancer treatment and to consider alternatives, including high-fiber diets with external gentle shower rinsing before intercourse.

Gender Minorities with Prostate Cancer

While research is emerging regarding SMM with prostate cancer, little information exists regarding gender minority patients with prostate cancer, including transgender women and trans feminine people in general (TGW, people who are recorded male at birth with feminine gender identity). Issues surrounding gender minorities can be subsumed within discussions of sexual identity and this population’s specific needs might become neglected. In the forthcoming section we highlight issues specific to gender minorities.

Gender minorities are a diverse cohort

Contributing to the nuance of this population is that gender minorities are a heterogenous cohort with a range of anatomy and hormonal milieu with a diverse sexual script. Physicians might care for TGW who are just beginning their use of gender affirming hormone therapy (GAHT) or for TGW who have been using GAHT for extended periods of time. Additionally, physicians might care for TGW who have undergone, plan to undergo, do not plan to undergo, or are undecided about receiving gender affirming surgery (GAS). These various factors contribute to the individualized profile and resultant necessary personalized treatment discussion for TGW with prostate cancer. It is extremely important to be sensitive and aware of the range of TGW experiences and presentations when managing TGW with prostate cancer, as 48% of transgender patients avoid or delay care due to medical insensitivity.¹⁷⁷

Epidemiology and presentation of prostate cancer in gender minorities

With a lifetime prevalence of 12.1%, prostate cancer is the most common non-dermatologic malignancy in cisgender males, including SMM;¹ however, the prevalence and incidence of prostate cancer in TGW is likely significantly lower.^178,179 One of the largest studies to date of a cohort study of 2,281 TGW in the Netherlands, concluded that women receiving androgen deprivation therapy and estrogens were at substantially lower risk for prostate cancer than the general male population.⁹ The low incidence and prevalence of prostate cancer in TGW is multifactorial. Contributory factors might include barriers to care for TGW¹⁸⁰, the use of estrogen-supplementing GAHT, which might be protective against prostate cancer¹⁸¹, and a younger overall mortality for TGW.^182,183

Despite a lower relative incidence and prevalence, studies suggest that prostate cancer might have a more aggressive presentation in TGW. A non-systematic review of the literature identified 10 case reports of TGW with prostate cancer and found that 6 patients presented with metastatic disease, 3 with local or locally advanced disease, and 1 with unknown disease.¹⁸⁴ In TGW, the development of prostate cancer has been debated as the estrogen-testosterone balance plays a role in prostate cancer development. In transgender patients, estrogen is given to suppress testosterone. This combination has been shown to increase the risk of prostate cancer in rats, as the incidence of prostate cancer increased from 35-40% in rats treated with testosterone alone to 90-100% in rats treated with combination testosterone and estrogen.^185,186 Furthermore, TGW who begin their transition at older ages might have increased risk for prostate cancer than those who transitioned at a younger age and have presumably had prolonged exposure to estrogen therapy.

Prostate cancer in TGW might develop in the setting of medical or surgical castration from GAHT or feminizing GAS; therefore, prostate cancer in TGW is likely castration-resistant.¹⁸⁴ Castration resistance portends worse outcomes in patients with prostate cancer with a median overall survival ranging from 9 to 36 months depending on the extent of metastatic disease.^187–190 Thus, if TGW are at risk for prostate cancer and potentially develop more aggressive castration resistant disease, it is important to consider that the treatment course might be more aggressive,^191–193 leading to more severe sexual health-related side effects.

Sexual health and dysfunction in gender minorities

Little information exists regarding management of sexual dysfunction in TGW with prostate cancer. At baseline, there are important factors to consider when managing sexual dysfunction in TGW. A systematic review evaluating sexual dysfunction in transgender people in general identified that feminizing GAHT might decrease libido in the short term, while feminizing genital reconstruction surgery can increase libido and arousal.¹⁹⁴ Still, decreased libido might not be a concern for TGW and in one study with 45% of patients experiencing decreased libido, 20% reported it as a dysfunction and 25% reported it without causing distress.¹⁹⁵ Additionally, patients who have undergone GAS might experience dyspareunia (pain during vaginal intercourse). The standard procedure is penile inversion vaginoplasty in which the neovagina does not self-lubricate¹⁹⁶ In cases where there is insufficient penoscrotal tissue or when penile inversion failed, bowel segment vaginoplasty can be utilized which can result in different lubrication and dyspareunia outcomes.¹⁹⁷ Still, after GAHT and GAS, TGW have more sexual encounters, suggesting that these procedures increase confidence, comfort^198,199 and potentially even happiness.^194,200 Lastly, understanding the diversity of sexuality among trans feminine individuals is important. A physician might make the well-intentioned assumption that a TGW would have a similar sexual script to other women and that a TGW would not want to involve their penis as part of their sexual pleasure; however, this is not always the case as TGW might wish to use their penis in a range of sexual activities including being insertive partners.^201,202

Thus, when considering sexual dysfunction in TGW with prostate cancer, one must approach sexual toxicities differently than when considering sexual dysfunction in SMM with prostate cancer. For example, TGW might experience dyspareunia through intercourse with the neovagina. ¹⁶⁹ Additionally, within this population, questions and questionnaires must be customized as TGW might experience orgasm and sexual arousal from the neoclitoris rather than (or in addition to) the prostate.^169,203

Discussing treatment-related sexual dysfunction with gender minorities

TGW must be counseled on sexual dysfunction and treatment options for prostate cancer at consultation and follow up (FIG. 3). Managing sexual dysfunction in transgender patients with prostate cancer depends on whether the patient has already undergone, or might later undergo GAS.¹⁸⁴ For TGW who have not undergone GAS, discussion must include the patient’s desire to have GAS surgery in the future. If a TGW wishes to pursue GAS following prostate cancer treatment, further discussions are necessary before definitive cancer management. Analogous to breast reconstruction management following breast cancer management, there must be a multidisciplinary discussion among the surgical oncologist, radiation oncologist, and reconstructive surgeon.²⁰⁴ A more nuanced and detailed conversation should then ensue regarding sexual practices and relevant toxicities. Careful consideration should be given to safety and effectiveness of the cancer treatment as well as feasibility and cosmesis of future GAS. This conversation will enable fully informed treatment decisions. For example, while a labiaplasty might be feasible after RP, EBRT, or brachytherapy, a vaginoplasty after treatment might have higher risks including fistula formation, urethral meatus stenosis, and incontinence.¹⁸⁴ For TGW who have already undergone GAS, prostate cancer treatment might be complex as RP might lead to fistula formation and EBRT and brachytherapy might lead to neovaginal stenosis requiring rehabilitation with dilators.¹⁴² As such, treating surgeons and radiation oncologists must be aware of anatomical changes.²⁰⁵ In addition, as many patients might be surgically or chemically castrate, management might follow castrate-resistant prostate cancer guidelines.^191–193 While decisions in this population might focus on disease eradication, as treatments for castration resistant prostate cancer advance,²⁰⁶ conversations surrounding sexual health might move to the forefront. Further research is necessary to understand how treatment should be modified and ideally personalized for TGW with prostate cancer.

Conclusion:

There is a paucity of data regarding the impact of prostate cancer therapies on sexual health outcomes in SMM and TGW. Existing studies illustrate that there are differences in the sexual health outcomes of SMM and HET. Treatment-related sexual dysfunctions following prostate cancer treatment experienced by sexual minority men include anodyspareunia, erectile dysfunction, climacturia, anejaculation, altered pleasurable sensation, and changes in penile shape. At consultation patients should be asked about sexual orientation, gender identity, and sexual role. Patients should be counseled on treatment related toxicities tailored to sexual role (top, bottom, versatile, side). Additionally, physicians should ask gender minority patients about hormones and surgical assignment surgery. Understanding the holistic patient will allow for informed patient conversations at consultation and shared decision making, when appropriate, for prostate cancer treatment selection.

While we acknowledge the role of the prostate, rectal wall, perianal skin and the surrounding neurovasculature in receptive anal intercourse, more research is needed to understand the mechanism of damage to surrounding anatomical structures from prostate cancer treatment and resultant sexual dysfunction. Knowing the mechanism of treatment related damage to the prostate and surrounding structures can allow researchers to develop novel ways to alleviate treatment related damage to the prostate and surrounding tissues as well as potentially restore prostate sensation. These advancements would help further correct the inequities in scientific and biomedical research.

Sexual health QoL questionnaires for prostate cancer patients are beginning to incorporate domains and questions relevant to SMM patients, especially related to receptive anal intercourse. Information from more inclusive questionnaires will empower clinicians with evidence when discussing anatomy, physiology and pathophysiology of organ function related to sexual pleasure in SMM and TGW with prostate cancer. Additionally, these data could empower the sexual and gender minority community to advocate for more equitable care and further research. Further information from validated questionnaires on sexual dysfunction and research on how prostate cancer treatment affects sexual role in SMM survivors would also enable scientific advancements in technologies to prevent and mitigate these toxicities.

Prostate cancer providers should commit to understanding the management of sexual health and dysfunction in sexual and gender minorities following prostate cancer treatment. Urologists, radiation oncologists, medical oncologists, and clinical oncologists must move beyond a narrow definition of sexual activity and sexual pleasure focused on heterosexual intercourse and reproductive ability in prostate cancer patients. Providers should incorporate the functional and physiologic anatomic basis for sexual pleasure in all prostate cancer patients, regardless of sexual or gender identity.

Key Points:

1. Anal intercourse can induce orgasm through pressure on the rectal wall and stimulation of nerves surrounding the prostate and seminal vesicles as well as within the rectum and anus.

2. Sexual dysfunctions following prostate cancer treatment experienced by sexual minority men include anodyspareunia, erectile dysfunction, climacturia, anejaculation, altered pleasurable sensation, and changes in penile length.

3. Sexual minority patients with prostate cancer should be counseled on different treatment related toxicities depending on sexual role (top, bottom, versatile, side).

4. Anal dilators (to assist with receptive anal intercourse), vacuum pumps (to induce stronger erections for insertive intercourse), and penile constriction rings (to manage climacturia) should be discussed with sexual minority men.

5. Gender minorities with prostate cancer are a heterogenous cohort with a range of anatomy and hormonal milieu requiring a nuanced and detailed conversation when discussing treatment and relevant toxicities.

6. Prostate cancer consultations with sexual minority men should include counseling on receptive anal intercourse resumption, condom use, HIV pre-exposure prophylaxis, and anal douching.

Glossary of terms:

Sexual and gender minority

individuals who identify as lesbian, gay, bisexual, transgender, gender diverse, asexual, queer, and intersex as well as those who do not but whose sexual orientation, gender identity, or reproductive development varies from traditional, societal, cultural, or physiological norms

Sexual identity

refers to a person’s identity more broadly in sexual intercourse and relationships

Sexual role

the role a person identifies with during sexual intercourse (e.g. top, bottom, versatile, side)

Top

The insertive partner in anal intercourse; although this term has been generalized in sexual minority culture to include the insertive partner in oral intercourse

Bottom

The receptive partner in anal intercourse; although this term has been generalized in sexual minority culture to include the receptive partner in oral intercourse

Vers

Or verse, short for versatile, a person who engages in both the receptive and insertive role in intercourse

Side

A SMM who does not engage in anal intercourse or identify with “top,” “bottom,” or “vers”

Poppers

alkyl nitrites, inhalants used to relax anal musculature used for receptive anal intercourse

Anodyspareunia

Pain during receptive anal intercourse

Neovagina

A reconstructed or created vagina

Neoclitoris

A reconstructed or created clitoris