Sexual Dysfunction After Prostate Cancer
- 1 Introduction
- 2 Sexual Function in Men
- 3 Sexual Dysfunction after Prostate Cancer Treatment
- 4 Sexual Dysfunction after Radical Prostatectomy
- 5 Sexual Dysfunction after Non-Surgical Treatment for Prostate Cancer
- 6 The Neglected Sexual Side Effects after Prostate Cancer Treatment
- 7 Quality of Life
- 8 How Cancer Treatment Affects Sexuality in Men
- 9 References
Normal sexual function in men relies on the complex interaction between biological, emotional, cognitive, behavioural, contextual and interpersonal factors. 
There are multiple physiological processes involved in male sexual function such as sexual desire (libido), erectile functioning, ejaculation and orgasmic ability and quality
Sexual Function in Men
Sexual desire relies on a variety of factors both physical and psychological. Testosterone levels play an important role in physiological libido.
Erectile function forms an important part of a man’s sexual function, but it is only a part of the picture. A normal erection depends on a sequence of physiological, neural, vascular, metabolic and endocrine events. There are different types of erections; reflexogenic, psychogenic and nocturnal. Reflexogenic erections occur when the penis is physically stimulated and psychogenic erections from other stimulation such as visual, auditory or psychological inputs. Nocturnal erections occur in men every night with about 5-8 per night and can last up to 30 minutes each.
Erectile dysfunction (ED) is a component of male sexual dysfunction and can be defined as the persistent inability to achieve or maintain an erection firm enough or lasting long enough to participate in sexual activities. Problems with erectile function can come from physical and psychological problems. When a man’s nocturnal erections stop it can be used as a diagnostic factor in determining a physical cause of the erectile dysfunction. The pelvic floor muscles, in particular, the bulbospongiosus and ischiocavernosus, play an important role in penile rigidity and injury or weakness can play a role in erectile dysfunction.
The prostate is responsible for the production of seminal fluid which makes up the majority of the ejaculate. When the prostate is removed or affected by radiation there is often a significant loss or absence of ejaculate. Ejaculation occurs when the smooth muscle of the prostate contract and the urethra smooth muscles relax to allow the ejaculate to enter the urethra. Thereafter a strong involuntary contraction of the bulbospongiosus expels the ejaculate.
Orgasm is still something that is not completely understood. It is mediated by the autonomic nervous system but there is also cortical involvement. The pelvic floor muscles play an important role in orgasm. Damage to the nerves and spasm of the muscles can play a role in the orgasmic dysfunction.
Sexual Dysfunction after Prostate Cancer Treatment
Early Prostate Cancer (PCa) treatment (surgery or any form of radiotherapy whether external beam radiotherapy or brachytherapy), has the unfortunate side effect of sexual dysfunction. Other common side effects could include pain and incontinence. While most men recover from pain and incontinence after PCa surgery, they often live with long-lasting and debilitating sexual dysfunction that remains untreated and unresolved.
Male sexual dysfunction may present as one or a combination of the following conditions: 
- Sexual interest dysfunctions
- Sexual arousal dysfunctions
- Erectile dysfunction (ED)
- Premature/rapid/early or delayed ejaculation
- Orgasmic dysfunction
- Sexual aversion disorder
- Priapism (prolonged erection of the penis)
- Peyronie’s disease (a painful curvature of the penis)
Sexual Dysfunction after Radical Prostatectomy
Prostate Cancer Surgery, specifically a radical prostatectomy is commonly used as a curative measure to treat prostate cancer, and surgeons aim to retain urinary continence and sexual function during the procedure of removing the prostate. A radical prostatectomy, however, remains a challenging urologic procedure because the prostate is in close proximity to the bladder, rectum, and neurovascular supply to the penis. An adequate resection of the prostate without damaging surrounding tissue presents trades off between cancer control and preservation of functional outcomes such as continence and potency. 
A study conducted found that 98-100% of men who had undergone RP surgery will have initial incontinence and impotence and an alarming 70% of these men will not recover from their initial ED.
The European Association of Urology recommends that a nerve-sparing procedure is the recommended route for surgeons to use on men with normal preoperative erectile function. Despite meticulous dissection in an attempt to preserve the neurovascular bundle during a radical prostatectomy, there is evidence that neurapraxia, hypoxic nerve insults, fibrosis, and apoptosis of cavernous smooth muscle affect sexual function and create drastic effects on patients’ experience and sexual satisfaction.
There are a number of different surgical approaches and depending on the approach used, the extent of the cancer, as well as the skill of the surgeon erectile dysfunction post prostatectomy, ranges from 14%-90% 
Sexual Dysfunction after Non-Surgical Treatment for Prostate Cancer
A 2017 study found that erectile dysfunction (ED) was common regardless of the treatment modality (surgical or non-surgical) used for PCa. ED reportedly also increased during each year of follow-up after initial surgical or non-surgical intervention, while it was reported in approximately 50% of patients within a 5-year period after receiving their intervention to treat PCa.
Men who have undergone hormone deprivation treatment as a management strategy for Prostate Cancer will have lowered or absent testosterone levels. This will negatively affect their sexual desire or libido
The Neglected Sexual Side Effects after Prostate Cancer Treatment
With a research field full of data on general sexual dysfunction, there still remains a host of sexual dysfunction side effects after early stage prostate treatment that are being neglected and left untreated by medical professionals. Most literature to date focuses on erectile functioning but this is one component of male sexual function and problems related to sexual desire, ejaculation and orgasm have been neglected. These conditions may include orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasm associated pain (OAP), penile shortening (PS), and penile deformity. These conditions are collectively referred to as the “neglected sexual side effects”. Frey et al 2014 reported in their systematic review of post prostatectomy patients that OAI and UISS are experienced by 20–93% of RP patients, orgasmic function was altered in 80% of patients, OAP was experienced by 3-19% of patients and PS occurred in 15–68% of patients.
Quality of Life
Sexual function has been identified as the quality of life domain most strongly associated with outcome satisfaction after treatment for prostate cancer. Amidst multiple physical and psychosocial factors, erectile function has been shown to be an independent predictor of both bother and depression in men after radical prostatectomy. Sexual function is inversely associated with depressive symptoms in patients treated for prostate cancer. This association remains evident for at least four years after the diagnosis of prostate cancer, even after correction for possible confounders 
How Cancer Treatment Affects Sexuality in Men
- Hatzichristou D, Kirana PS, Banner L, Althof SE, Lonnee-Hoffmann RA, Dennerstein L, Rosen RC. Diagnosing sexual dysfunction in men and women: sexual history taking and the role of symptom scales and questionnaires. The journal of sexual medicine. 2016 Aug 1;13(8):1166-82.
- Elliott S, Matthew A. Sexual recovery following prostate cancer: recommendations from 2 established Canadian sexual rehabilitation clinics. Sexual medicine reviews. 2018 Apr 1;6(2):279-94.
- Hackett G, Kirby M, Wylie K, Heald A, Ossei-Gerning N, Edwards D, Muneer A. British Society for Sexual Medicine guidelines on the management of erectile dysfunction in men—2017. The journal of sexual medicine. 2018 Apr 1;15(4):430-57.
- Briganti A, Salonia A, Zanni G, Fabbri F, Saccà A, Bertini R, Suardi N, Fantini GV, Rigatti P, Montorsi F. Erectile dysfunction and radical prostatectomy: an update. EAU update series. 2004 Jun 1;2(2):84-92.
- Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sexual medicine reviews. 2016 Jan 1;4(1):53-62.
- Frey AU, Sønksen J, Fode M. Neglected side effects after radical prostatectomy: a systematic review. The journal of sexual medicine. 2014 Feb 1;11(2):374-85.
- Hatzimouratidis K, Hatzichristou D. Sexual dysfunctions: classifications and definitions. The journal of sexual medicine. 2007 Jan;4(1):241-50.
- Trinh QD, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, Sun M, Vickers AJ. A systematic review of the volume–outcome relationship for radical prostatectomy. European urology. 2013 Nov 1;64(5):786-98.
- Wennberg JE, Roos N, Sola L, Schori A, Jaffe R. Use of claims data systems to evaluate health care outcomes: mortality and reoperation following prostatectomy. Jama. 1987 Feb 20;257(7):933-6.
- Nelson CJ, Deveci S, Stasi J, Scardino PT, Mulhall JP. Sexual bother following radical prostatectomy. The journal of sexual medicine. 2010 Jan;7(1pt1):129-35.
- Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Mottet N, Schmid HP, van der Kwast T, Wiegel T, Zattoni F. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. European urology. 2011 Jan 1;59(1):61-71.
- Clavell-Hernández J, Wang R. The controversy surrounding penile rehabilitation after radical prostatectomy. Translational andrology and urology. 2017 Feb;6(1):2.
- Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Khera M. Sexual rehabilitation after treatment for prostate cancer—part 1: recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). The journal of sexual medicine. 2017 Mar 1;14(3):285-96.
- Gaither TW, Awad MA, Osterberg EC, Murphy GP, Allen IE, Chang A, Rosen RC, Breyer BN. The natural history of erectile dysfunction after prostatic radiotherapy: a systematic review and meta-analysis. The journal of sexual medicine. 2017 Sep 1;14(9):1071-8.
- Albaugh JA, Sufrin N, Lapin BR, Petkewicz J, Tenfelde S. Life after prostate cancer treatment: a mixed methods study of the experiences of men with sexual dysfunction and their partners. BMC urology. 2017 Dec;17(1):45.
- Nelson CJ, Choi JM, Mulhall JP, Roth AJ. Erectile dysfunction: Determinants of sexual satisfaction in men with prostate cancer. The journal of sexual medicine. 2007 Sep 1;4(5):1422-7.