While the cancer patient may be affected by sexual dysfunction throughout the entire course of the disease, sexual health is largely underevaluated and undertreated. Sexual problems should be anticipated and patients should be actively screened as they are unlikely to initiate discussion on sexual issues.
Medical, surgical, and technologic advances have significantly decreased morbidity and improved survival and quality of life in men with cancer. However, sexual dysfunction after oncologic treatment is common and sadly underevaluated and undertreated despite the availability of effective, safe, and simple treatment options. The true prevalence of sexual problems after cancer treatment is unknown due to methodologic problems such as the use of patient self-reports, demographic differences between study and control groups, and unclear definitions.
For example, to define functional erections, investigators have used different cutoff scores of the Sexual Health Inventory for Men (SHIM) or the International Index of Erectile Function (IIEF) with or without phosphodiesterase type J inhibitors, which makes interpretation of the available data very difficult. In addition, physicians tend to only report on erectile dysfunction after cancer treatment, overlooking other sexual dysfunctions such as penile deformities, hypoactive sexual desire disorder, and ejaculatory or orgasmic disorders.
General Sexual Issues
Malignancies and/or cancer treatment can cause a wide variety of sexual health issues. Physical changes (eg, alopecia, weight loss, loss of penile size) and symptoms (eg, fatigue, sleep disorders, nausea, diarrhea) may have a dramatic impact on the patient’s self-esteem and self-image, causing distress, guilt, mood alterations, and an inability to discuss sexual and relationship issues with their partner and physician. Depression or its treatment (selective serotonin-reuptake inhibitors [SSRIs], tricyclic antidepressants [TCAs]) may affect sexual desire as well as erectile, ejaculatory, and orgasmic function. Consequently, psychological support and the use of non-SSRIs/TCAs such as bupropion should always be considered in the management of men with cancer and depression.
More specifically, prostate cancer treatment (radiation therapy, radical surgery, androgen ablation) can cause erectile dysfunction (in 14%-98% of patients),[1,2] penile shortening (by 0.5-5 cm in two-thirds of patients), penile deformities (Peyronie’s disease), and ejaculatory/orgasmic problems. In addition, radiation therapy and radical surgery may be associated with severe urinary incontinence, which may interfere with sexual activity. Furthermore, hypogonadism after androgen ablation for adjunctive or palliative prostate cancer management, chemotherapy, opioid use, and stress may further worsen general physical and psychological symptoms, erectile dysfunction, and sexual desire.
Invasive bladder cancer due to its high morbidity, mortality, and impact on body image may be associated with more profound sexual problems. In addition, clinical experience suggests that PDE-5 inhibitors and intracavernosal therapy are not as effective in men who have undergone cystoprostatectomy compared to men who undergo radical prostatectomies.
Ejaculatory and fertility problems are also common in men with cancer. Anejaculation after retroperitoneal lymph node dissection with or without chemotherapy or radiation therapy has been reported in up to 81% of patients. Infertility caused by poor spermatogenesis (due to testicular cancer), chemotherapy, or anejaculation is also common. Extensive fertility counseling and sperm banking should always be discussed.
Unfortunately, men with cancer are often misled or poorly informed as to the potential sexual side effects of different cancer treatments, which may lead to overall dissatisfaction, frustration, anger, and deterioration of the patient-clinician relationship. The reasons why patients are poorly informed about sexual side effects are complex and multifactorial but often easy to fix by including a sexual medicine physician on the oncology team. This measure would not only improve patient care, satisfaction, and quality of life, but would also allow for faster biologic and psychological recovery after cancer treatment. For example, small pilot studies have shown that postprostatectomy penile rehabilitation strategies (eg, the use of PDE-5 inhibitors or intracavernosal prostaglandin E1) can improve erectile function recovery.
The article by Tal and Mulhall is an excellent, comprehensive, and most needed review of sexual health issues in men with cancer. This article should be read by all health-care professionals who provide care to cancer patients, to maximize patient care, satisfaction, and physical and psychological recovery.
-Ricardo Munarriz, MD
The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
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