ED After Prostate Cancer

Take-home points

• ‍‍Erectile dysfunction is a very common consequence of prostate cancer treatments. 
• A range of treatment options for ‍erectile dysfunction can help patients with prostate cancer after treatment, including (first line) noninvasive and invasive options.
• Preventing treatment risks a permanent loss of erectile function. Always reports ‍erectile dysfunction to a healthcare professional and discuss suitable treatment options. 

What is prostate cancer?

The walnut-shaped prostate gland is found only in men. Its main role is to produce the seminal fluid that nourishes and transports sperm. When cancers are found within this gland, men are diagnosed with prostate cancer. Approximately 1 in 4 new cancer diagnoses are prostate cancer, topping the list of the most common cancers in males. The genes that mutate during prostate cancer are typically those involved with testosterone metabolism; early in development, prostate cancers need testosterone and other androgens to grow. 

What is erectile dysfunction?

Erectile dysfunction, formerly known as impotence, is defined as the persistent inability to achieve or maintain a rigid penile erection suitable for satisfactory sexual intercourse. Researchers estimate that approximately 40% of men in their 40s experience some form of erectile dysfunction, with a 10% increased prevalence in each decade that follows.¹ Younger men can experience these symptoms too, as 1 in 4 men seeking medical help for erectile dysfunction are under the age of 40. How accurate these estimates are, however, is a topic of debate. Our recent survey found that nearly half of (2,000 surveyed) British men would not visit their doctor if they had erectile dysfunction.

Learn more about erectile dysfunction

Prostate cancer after erectile dysfunction: Is it common?

Here at TRTed, we regularly discuss erectile dysfunction's strong link to to cardiovascular disease. World-leading cardiologists consider it an early predictor of atherosclerosis (plaque buildup in the arteries) and urge patients with ED to consult a doctor immediately. But the mounting research investigating erectile dysfunction and prostate cancer is another cause for concern.

According to the UK-wide Life After Prostate Cancer Diagnosis study, examining over 30,000 prostate cancer survivors at 18–42 months after diagnosis, 81% of patients describe their sexual function as “poor” or “very poor”.² Erectile dysfunction, as one of the two most common sexual disorders, is a likely explanation for this self-report. Similarly, in another study, when men treated for prostate cancer were asked to score their ability to “have and maintain an erection” on a 1 to 5 scale (5 representing the best function), the mean score was 2: "a little bit."³

Erectile dysfunction does not always occur immediately after prostate cancer diagnosis and depends on the treatment plan. Typically, erectile dysfunction, accompanied by gradual structural changes in the penis, develops in the months and years after prostate cancer treatment and may be permanent. For example, the prevalence of erectile dysfunction in men with prostate cancer after radiation therapy is 67–85% and may take up to 24 months to develop.⁴ One analysis in 16 men after radiation therapy for prostate cancer found that it developed after 8 months, on average.⁵

Why does prostate cancer treatment cause erectile dysfunction? (Prostatectomy, radiation therapy)

Most experts consider erectile dysfunction a consequence of prostate cancer treatment, rather than the disease itself. Most of the common treatments - whether it be radiotherapy, androgen deprivation therapy, or radical prostatectomy- can lead to erectile dysfunction. 

The Prostate Cancer Foundation state that “The nerves and blood vessels that control the physical aspect of an erection are incredibly delicate, and any trauma to the area can result in changes.” But they continue on to claim that “within one year after treatment, most men with intact nerves will see a substantial improvement.”  A summary of how the main treatments options can lead to erectile dysfunction follows: ‍

Radical prostatectomy:

• A prostectomy involves the partial or complete removal of the prostate and is the most common clinical treatment for prostate cancer. However, this treatment can damage the arteries and cavernous nerve in the penile region, possibly leading to oxygen deficiency, inflammation, and death of smooth muscle cells. One study showed that some patients can experience symptoms postoperative erectile dysfunction up to two years a prostatectomy.⁶

Radiotherapy:

• Radiotherapy for prostate cancer uses high energy waves similar to x-rays to destroy prostate cancer cells. This treatment can impact the vascular structures (narrow the arteries) leading into and within the penis, and radiation damage to these structures mediates the decline observed in erectile function.⁷ An analysis of almost 3,000 patients found reviewed that diminished erectile function post radiotherapy was common.⁸ Depending on the type of radiotherapy, the median increase in men reporting ED was between 17% - 26% after two years. Men treated for prostate cancer with radiotherapy have poignantly described the negative impact of erectile dysfunction on their sense of masculinity and self-esteem.

Androgen deprivation therapy:

• Targeting the deprivation of androgens is a treatment often used in preperation for or alongside other prostate cancer treatments, and rarely in isolation. The main aims of androgen deprivation therapy are to reduce prostate gland size and block androgens from interacting with the prostate. However, as expected given the name, androgen deprivation therapy reduces the serum testosterone that closely relates to sexual desire and sexual function.⁹ Erectile function, while not solely dependent on serum testosterone levels, is usually affected in ∽85% of men receiving androgen deprivation therapy. In the Prostate Cancer Outcomes Study of the Surveillance, Epidemiology and End Results programme, 69% of the men who were potent before androgen deprivation therapy treatment lost their potency after treatment.¹⁰

Here at TRTed, we are also mindful that prostate cancer can increase the risk of depression and loss of self-esteem, which are two psychological outcomes associated with erectile dysfunction. One study that measured self-reported quality of life, anxiety, and depression, in male patients treated for prostate cancer, found clear links between these variables.³ Erectile function and depression were significantly associated, and erectile function remained a significant predictor of depression even after other explanatory factors were considered. 

Erectile dysfunction treatment: Post prostate cancer diagnosis

As always, seeking the best standard of professional care is vital. In their investigations, researcher Amy Dyer and colleagues stated that “…despite being at high risk from treatment-induced erectile dysfunction, many men were not treated according to recognised/available erectile dysfunction treatment guidelines available at the time of this study and many were dissatisfied with their erectile dysfunction management.”¹¹ There is no one set path for patients with erectile dysfunction after prostate cancer; a well-informed health professional will help you find a treatment plan suited to your rehabilitation goals, expectations, motivations, comorbidities, intimate relationships, and cancer adjuvant therapies. 

Various treatment options are available for erectile function rehabilitation, including both invasive and non-invasive interventions. Phosphodiesterase phosphate-5 inhibitors (PDE5-Is) are the most commonly recommended noninvasive therapeutic option for erectile dysfunction after prostate cancer treatment. This therapeutic option is generally considered effective, easy to use, well-tolerated, and displays an acceptable safety profile. Despite this, PDE5-Is are not suitable for all patients, particularly men with a history of cardiovascular disease. Additionally, approximately 25–50% of men seem to be unresponsive to PDE5I within 12 months of prostate cancer treatment, and this number is thought to be higher for men with certain conditions like type 2 diabetes.¹²

If first-line treatments are not effective, more invasive options, such as intracavernosal injection (ICI) and transurethral prostaglandin E1 (PGE1) injections, may be elected. Alprostadil cream is a much less invasive therapy compared to intracavernosal injections and can be the preferred choice for many patients. The European Guidelines  on male sexual dysfunction recommend alprostadil cream as an alternative choice for men who prefer a less-invasive treatment option to injections, although the drawback being they are a less effective therapy.¹³ Alprostadil cream is applied into the urethra of the penis with the onset of an erection between 5–30 minutes following application. The erection can last between one and two hours.

Other possible non-invasive treatments include testosterone replacement therapy and psychological counselling for anxiety and depression. Preliminary data from a small number of studies even suggests that certain exercise interventions can improve sexual dysfunction in prostate cancer patients.¹⁴

Find out more about erectile dysfunction treatment

If in doubt, speak to a healthcare professional 

 If your situation requires consideration of these treatments, we recommend discussing their uses and intricacies with a healthcare professional.

References:

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