Managing Erectile Dysfunction After Cancer: More Than Penile Rigidity

Indisputably, erectile dysfunction (ED) is the most common sexual problem leading men to seek professional help after cancer. For Voznesensky et al,¹ the goal of treatment is to restore a man’s ability to have hard erections. Libido is mentioned once in the introduction, but the rest of their review focuses narrowly on the penis and its rigidity. Patients, too, often express their concern in mechanical terms: “Just fix my erections, doc.” Yet, rates of sexual problems after cancer are even higher than the review suggests.² Furthermore, limiting assessment and treatment to ED has not overcome barriers to help-seeking among men with cancer-related sexual problems and has led to dismal outcomes among men who actually try a urologic treatment.

Prevalence of Sexual Problems in Men After Cancer

Sexual problems affect at least 60% of male cancer survivors in the United States.² Voznesensky et al¹ cited one of several recent studies showing that return to baseline erectile function after radical pelvic surgery has been greatly overestimated.^2-4 However, they also underestimate rates of ED after pelvic radiation therapy^3,4 and among survivors of hematologic and childhood malignancies.²

ED is also not the only sexual problem. Many men experience decreased desire for sex, difficulty reaching orgasm, decreased pleasure at orgasm, and changes such as having dry orgasms or urine leakage at orgasm. At least 10% of men treated for pelvic malignancies have pain during sexual arousal or orgasm. Sexual bother also occurs with urinary or bowel incontinence or interference from ostomy appliances.²

Why Do So Few Men Seek Help?

Unfortunately, only about 20% of men with cancer-related sexual problems ever see a health professional.^2,5 The exception are men who have radical prostatectomy, because surgeons typically suggest that they try penile rehabilitation to promote recovery of erections. A variety of surveys find that patients with cancer want and expect their medical team to initiate discussions of sexual problems.² On the other hand, health professionals believe patients will bring up the topic of sex if it is important, and although they deny being uncomfortable talking about sex, they insist it is someone else’s job.² Physicians want nurses to manage sexual problems and vice versa. Psychologists also participate in this hot potato toss. Meanwhile, sexual problems rank highly among unmet needs in surveys of cancer survivors.^2,5

Men’s Dissatisfaction With Available ED Treatments

Outcomes studies of use of ED treatments after prostate cancer suggest that the great majority of men are dissatisfied with the efficacy of treatments and stop using them.² Phosphodiesterase type 5 inhibitors (PDE5i) are the treatment tried by most cancer survivors. In a study of 39,000 Medicare patients treated for localized prostate cancer, a PDE5i was used by 26% in the first year after radical prostatectomy but only 9% after radiation therapy.⁶ Studies of patients with prostate cancer in academic medical centers show that 38% to 52% of men try a PDE5i, but only 7% to 18% use penile injection therapy, 5% to 19% use a vacuum erection device, 4% to 10% try a urethral suppository, and 2% have penile prosthesis surgery.² Unfortunately, these studies agreed that continued use of all treatments other than the penile prosthesis was well below 50% after several months. Randomized trials of penile rehabilitation have also been inconclusive because of poor adherence to the prescribed treatments.⁷

Overcoming Barriers to Successful Sexual Rehabilitation

Although sexual dysfunction after cancer typically has a physiologic cause, sexual rehabilitation requires good sexual communication between partners, enough male self-esteem to pursue sexual activity, and willingness to view sexual pleasure as possible, even if the penis is not rigid enough for penetrative sex. Outcomes are best when medical and psychosocial care are coordinated.⁸ Education and counseling should begin early to prevent sexual inactivity and to promote penile rehabilitation. I advocate the following: use internet-based resources to provide education and self-help tools to men and their partners in the privacy of their home; at each visit, starting with treatment disposition, assess problems briefly and offer referrals for urologic care coordinated with sex therapy; teach men to communicate openly about sex with their partner; ensure that female partners get care for postmenopausal sexual dysfunction; encourage men to increase their expression of affection and tenderness to partners, even when ED is causing anxiety; and encourage men or couples to view sexual activity (and even penile rehabilitation) as a chance to explore variety and fantasy rather than as a performance needing to be done correctly.

AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Managing Erectile Dysfunction After Cancer: More Than Penile Rigidity

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml.

Leslie R. Schover

Employment: Will 2 Love

Stock or Other Ownership: Will 2 Love

Research Funding: Fidia Farmaceutici, Laclede

Patents, Royalties, Other Intellectual Property: Author owns copyrights to web interventions