Can you still have a sexual life after prostate cancer?

Prostate cancer affects the lives of thousands of men across Europe and is the most frequent non‐skin male malignancy in Western countries. In the USA, prostate cancer is diagnosed nearly every 3 minutes with 190,000 new cases detected every year. Prostate cancer incidence rates increased by 192% between 1973 and 1992. Two main factors have contributed to this situation: the worldwide trend for increased longevity in the general population, and the improved level of detection due to routine prostate‐specific antigen tests. Radiation therapy is together with radical prostatectomy the most effective treatment for localized disease. In the past, the use of non‐nerve sparing prostatectomy was accompanied by extremely high rates (up to 100%) of post‐surgical erectile dysfunction (ED); however, recent advances in surgical techniques have reduced the number of patients experiencing subsequent iatrogenic ED (40–70%). Both external beam radiotherapy (EBRT) and brachytherapy can be offered as curative options. Although it is commonly believed that the incidence of ED after radiotherapy is lower than after surgery, published rates of ED following EBRT vary from 7–80%, and after brachytherapy this percentage may be as high as 60%. ED after surgery has a neurogenic etiology with an immediate onset, while this is more likely vascular after radiotherapy with neurogenic and psychogenic factors also reported. Patients treated for prostate cancer still want to enjoy sexual life. Studies have shown that up to 79% of men older than 70 years still are sexually active and most of these weekly.

Intracavernosal injections of a vasoactive drug (phentolamine‐papaverine or prostaglandines or a combination) have been used since de 1980s with satisfactory results in patients complaining of ED after prostate cancer treatment. Vacuum devices are good therapy options too. Since the introduction of sildenafil citrate in 1998, most patients are nowadays treated with an oral drug. Sildenafil is effective to treat ED in up to 80% of patients after radiotherapy in non‐controlled studies, and in 60% in the only controlled study published. Efficacy after surgery is lower and depends on the surgical technique (nerve‐sparing versus non‐nerve‐sparing), age, comorbidity. The two recently introduced drugs, tadalafil and vardenafil, have also been shown to be effective after radical prostatectomy; no data have been reported after radiotherapy so far. Men can enjoy sexual life even with a non‐rigid penis, developing techniques of masturbation or lovemaking satisfactory to reach an orgasm.

Patients need to be adequately counseled on the effects of cancer treatment on their sexual life and relationship, about the different treatment possibilities and reassured of being able to enjoying a normal sexual life. Counseling on the safety of sexual activity during radiation therapy is important. Men irradiated for prostate cancer often think that cancer can be spread by sexual contact and that ejaculation may be harmful to the partner.

Unfortunately sexual counseling has not become a routine part of oncology care in most hospitals. In busy oncology clinics, where the outpatient visit is focused on addressing prognosis and treatment, physicians do not have time to assess quality‐of‐life. Another barrier is the discomfort physicians have to discuss sexuality, though sexual counseling should be routinely provided in an oncology clinic.

Open sexual communication between partners should be encouraged. The new situation after cancer treatment can be disturbing in the sexual relationship, needing to adapt to the new situation. Thus, there is still a sexual life after treatment of prostate cancer.