Survivorship: Sexual Dysfunction (Male), Version 1.2013

Abstract

Various anticancer treatments, especially those directed toward the pelvis, can damage blood vessels and reduce circulation of blood to the penis and/or damage the autonomic nervous system, resulting in higher rates of erectile dysfunction in survivors than in the general population. In addition, hormonal therapy can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for male sexual problems, namely erectile dysfunction.

Overview

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can often impair sexual function. In addition, depression and anxiety, which are common in survivors, can contribute to sexual problems. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life.^1–5 Nonetheless, sexual function is often not discussed with survivors.^6,7 Reasons for this include a lack of training of health care professionals, discomfort of providers with the topic, and insufficient time during visits for discussion.¹ However, effective strategies for treating both female and male sexual dysfunction exist,^8–11 making these discussions a critical part of survivorship care.

Male Aspects of Sexual Dysfunction

The NIH Consensus Conference on Impotence defined impotence, or male erectile dysfunction (ED), as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.”¹² In fact, impotence and ED are not synonymous. Impotence can involve problems of sexual desire, orgasm, or ejaculation, which are not necessarily linked with achieving or maintaining an erection.¹³

ED occurs frequently in the general population and increases with age.¹⁴ In one community-based study, 33% of men aged at least 75 years reported moderate or worse ED.¹⁵ ED is also very common in male cancer survivors. Anticancer treatment modalities used in a variety of cancers have the potential to damage blood vessels, leading to a reduction in blood circulation to the penis, and/or damage to the autonomic nervous system. Thus, higher rates of ED are seen in cancer survivors than in the general population. The prevalence of ED in male survivors of colorectal cancer has been reported to range from 45% to 75%,^2,16,17 and it has been reported in up to 90% of prostate cancer survivors.^18–22

In 2005, the American Urological Association (AUA) published a guideline on the management of ED; it was reviewed and confirmed as still valid by the AUA in 2011.¹³ Using a consensus-based approach with the AUA guideline as a guide, the NCCN Sur-vivorship Panel concluded that (1) informed patient and physician decision-making is the standard for guiding treatment decisions for ED treatment; and (2) a psychological overlay frequently exists in patients with ED and may be even more pronounced in the face of cancer survivorship. Endocrine disorders are also an important consideration in the cause of ED. Although sex therapy and the diagnosis and treatment of endocrine disorders are important management issues, these are beyond the scope of these guidelines and are therefore not addressed in depth.

Evaluation and Assessment for Male Sexual Function

Male cancer survivors should be asked about their sexual function at regular intervals. Patients should be asked about their sexual functioning before they received the cancer diagnosis, and their perceptions regarding the impact of cancer treatment on their sexual functioning and intimacy. A quantitative questionnaire such as the Sexual Health Inventory for Men can be considered to help identify patients who might benefit from treatment of ED.¹⁴

Patients with concerns about their sexual function should undergo a more thorough evaluation, including screening for possible psychosocial problems (ie, anxiety, depression, relationship issues, drug or alcohol use) that can contribute to sexual dysfunction. Identifying prescription and over-the-counter medications (especially hormone therapy or opioids) that could be a contributing factor is also important. A focused physical examination can also be helpful and should include examination of the chest (for gynecomastia), abdomen, phallus, scrotum/testicles, and cord structures.

Importantly, cardiovascular risk should be estimated for all men with ED, especially those with cardiovascular disease. Cardiovascular disease and ED share risk factors and often coexist.²³ Sexual activity is considered equivalent to walking 1 mile in 20 minutes on a flat surface or to climbing 2 flights of stairs in 20 seconds.²³ Men who cannot perform these exercises without symptoms are considered to be at high risk for experiencing adverse events associated with sexual activity and should be referred to a cardiologist before treatment for ED.²³

Interventions for Male Sexual Dysfunction

Treatment for ED begins with modification of risk factors, such as smoking cessation, weight loss, increasing physical activity, and avoiding excess alcohol consumption. In addition, treatment of psychosocial problems, with referral to sex and couples therapy as appropriate, can often alleviate symptoms of ED.

Oral phosphodiesterase type 5 inhibitors (PDE5is) have been shown to improve the symptoms of ED and be well tolerated.^8,10 Many studies have also shown the efficacy and tolerability of PDE5i for treating ED in patients with cancer and survivors.^24,25 Importantly, PDE5is are contraindicated in patients taking oral nitrates, because together they can lead to a dangerous decrease in blood pressure.^26,27

The timing and dose of PDE5i should be started conservatively, and it should be titrated to maximum dose if needed.¹³ The patient should be monitored periodically for efficacy, side effects, and any significant change in health status. An adequate trial of PDE5i is defined as at least 5 separate occasions at the maximum dose before reporting it as noneffective, unless the reason for fewer trials is an unacceptable side effect. A different PDE5i can be tried after failure of first-line PDE5i therapy.

If the second PDE5i fails, additional interventions can be considered, with referral to a urologist. These options include second-level interventions, such as intraurethral alprostadil suppositories, intracavernous vasoactive drug injection therapy, and vacuum constriction. A third-level and definitive type of intervention, penile prosthesis implantation, can be considered.¹³

NCCN Survivorship Panel Members

*^,a,cCrystal S. Denlinger, MD/Chair†

Fox Chase Cancer Center

Robert W. Carlson, MD/Immediate Past Chair†

Stanford Cancer Institute

^fMadhuri Are, MD£

Fred & Pamela Buffett Cancer Center at The Nebraska Medical Center

^b,dK. Scott Baker, MD, MS€ξ

Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

*^,a,gElizabeth Davis, MDÞθ

Tewksbury Hospital

Stephen B. Edge, MD¶

Roswell Park Cancer Institute

^b,eDebra L. Friedman, MD, MS€‡

Vanderbilt-Ingram Cancer Center

*^,gMindy Goldman, MDΩ

UCSF Helen Diller Family Comprehensive Cancer Center

*^,c,eLee Jones, PhDΠ

Duke Cancer Institute

^bAllison King, MD€Ψ‡

Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

*^,b,hElizabeth Kvale, MD£

University of Alabama at Birmingham Comprehensive Cancer Center

*^,aTerry S. Langbaum, MAS¥

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

*^,c,eJennifer A. Ligibel, MD^†

Dana-Farber/Brigham and Women’s Cancer Center

*^,bMary S. McCabe, RN, BS, MS#

Memorial Sloan-Kettering Cancer Center

*^,gKevin T. McVary, MDω

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

^b,c,e,gMichelle Melisko, MD†

UCSF Helen Diller Family Comprehensive Cancer Center

*^,dJose G. Montoya, MDΦ

Stanford Cancer Institute

^a,eKathi Mooney, RN, PhD#

Huntsman Cancer Institute at the University of Utah

*^,c,dMary Ann Morgan, PhD, FNP-BC#

Moffitt Cancer Center

^e,hTracey O’Connor, MD†

Roswell Park Cancer Institute

*^,cElectra D. Paskett, PhDε

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

^f,hMuhammad Raza, MD‡

St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center

*^,fKaren L. Syrjala, PhDθ

Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

*^,fSusan G. Urba, MD†£

University of Michigan Comprehensive Cancer Center

^gMark T. Wakabayashi, MD, MPHΩ

City of Hope Comprehensive Cancer Center

*^,hPhyllis Zee, MDΨΠ

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

NCCN Staff: Nicole McMillian, MS, and Deborah Freedman-Cass, PhD

KEY:

*Writing Committee Member

Subcommittees: ^aAnxiety and Depression; ^bCognitive Function; ^cExercise; ^dFatigue; ^eImmunizations and Infections; ^fPain; ^gSexual Function; ^hSleep Disorders

Specialties: ξBone Marrow Transplantation; εEpidemiology; ΠExercise/Physiology; ΩGynecology/Gynecologic Oncology; ‡Hematology/Hematology Oncology; ΦInfectious Diseases; ÞInternal Medicine; †Medical Oncology; ΨNeurology/Neuro-Oncology; #Nursing; ¥Patient Advocacy; €Pediatric Oncology; θPsychiatry, Psychology, Including Health Behavior; £Supportive Care Including Palliative, Pain Management, Pastoral Care, and Oncology Social Work; ¶Surgery/Surgical Oncology; ωUrology