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1 Manitoba Prostate Centre Being sexual after prostate cancer... Visit our website at This publication is supported by an unrestricted educational grant from Pfizer Canada Inc.

2 Treatment for Prostate Cancer and Sexual Functioning Difficulties with erections are very common following treatment for prostate cancer. Surgery and radiation therapy may damage the nerves that are responsible for erections. Sexual changes after treatment are common. This booklet will guide you about what to expect and what may help.

3 What is an erection? Erections occur when there is an increase in blood in the penis when the penis is stimulated physically or when you think about sex. Special nerves (the cavernous nerves) cause the release of chemicals in the tissues of the penis which trap blood, increasing the size and firmness of the penis. After orgasm occurs, the blood drains away and the penis becomes soft again. These nerves run in two bundles along the outside of the prostate gland, one on each side. During surgery the urologist will try to move these nerve bundles off the surface of the prostate whenever possible. This is called nerve sparing surgery. This may cause bruising of the nerves. The nerves may recover over months or years. Sometimes one or both nerves cannot be spared and must be cut so that as much of the cancer as possible can be removed. Why do men have difficulties with erections? There are many different reasons why men experience erectile difficulties. As men age the blood vessels in the body may become damaged and this affects the vessels in the penis too. Lifestyle factors (smoking, obesity, excess alcohol and sedentary lifestyles) also impact on your ability to have an erection. Other diseases such as diabetes affect blood vessels and nerves including those in the penis. Some of the medications you take (for control of blood pressure or depression) can have a negative effect on your erections. Depression and stress can affect your sex life too. What is the effect of radical prostatectomy on erections? Immediately after surgery for prostate cancer (radical prostatectomy) almost all men will be unable to have an erection. Erections may return over the following weeks, months or even years. Return of erections depends on what your erections were like before surgery, your age, your general health and lifestyle factors, and the amount of damage to the nerves. Many men will have erectile problems after surgery. You may not have any erections at all, they may not be hard enough for penetration, and they may not last long enough to satisfy either you or your partner. Many men also notice that the penis is both shorter and smaller in girth than before. This results from both the surgery and shrinkage of tissue in the period following surgery when there is reduced blood flow to the penis due to lack of erections. What is the effect of radiation therapy on erections? Radiation therapy (external beam or internal seeds [brachytherapy]) also poses a risk to erections although this tends to occur one to two years after treatment is completed and is much more gradual than the changes noticed after surgery. What about relationship and communication issues? Your emotional state also plays a part and many men are very anxious about having an erection which then affects your ability to have one. It is important to talk to your partner about what is happening and what you are feeling. Not talking about this may lead to both a physical and emotional distance between the two of you. Your partner may think that you are rejecting her/him. Couples often stop touching and talking when they experience problems in their sex life and this can lead to misunderstandings and hurt feelings. So what can be done about this? There are a number of treatments that can help a man to have an erection after treatment for prostate cancer.

4 What are some treatment options? 1. Oral medications (PDE5 inhibitors) There are a number of oral medications that can be taken that may help you have an erection. These medications prevent blood from leaving the penis once it has entered the tissues following physical stimulation of the penis. This is the least invasive method of treating erectile difficulties and is usually the first treatment that your doctor will suggest. The three medications that are available are very similar but have some unique differences from each other. Sildenafil (Viagra) usually works in 30 to 60 minutes. If taken on after a fatty meal it make take longer to work. It remains effective for four to six hours. Tadalafil (Cialis) works within about 30 minutes and remains effective for as long as 36 hours. It may be taken with or without food. This medication should only be taken every second day (48 hours after first taking it) as it remains in the blood stream for an extended period of time. Vardenfil (Levitra) becomes effective in about 25 minutes and remains effective for about four to six hours. It should not be taken after a high fat meal. It is essential that physical stimulation of the penis occurs for these medications to work. If you are on certain heart medications (containing nitrates) you should not take these medications. You should also report any visual changes (flashing lights, blurred vision) after taking these medications. They will not work if you take them and then just wait for something to happen. You need to have physical stimulation of the penis to move the blood into the tissues. You should also talk to your partner about his/her interest in sexual activity before taking these medications. However if you want to pleasure yourself or just want to see if the medication works for you without the pressure to perform, take the medication, stimulate yourself, and see what happens. You should also not give up with the medication if it does not work the first or second time. Some men may need up to eight doses on separate occasions before we can say that the particular medication does not work. Switching to a different brand may bring a better result. 2. Penile self-injection therapy This involves injecting a small amount of medication into the side of the penis. This causes a local response in the tissues of the penis causing an erection. You may not experience any feelings of sexual excitement but you will have an erection. It may take some time and a number of attempts to find the correct dose of medication that will work for you. There is a risk that some scarring will occur where you place the needle and you are encouraged to switch the site where the needle is inserted. If scarring does occur, it can cause pain and some curving of the penis. There is also a risk that you may have an erection that does not go down (this is called priapism). This needs to be treated urgently and if your erection does not go down in two to four hours, you need to go the Emergency Department where this will be treated. Failure to treat this condition may lead to permanent tissue damage. If you are interested in this form of therapy, your doctor will arrange for a test dose and a teaching session for you to learn how to do this properly. Cross-section of penis showing injection correctly placed in corpus cavernosum. Injection sites (shaded areas)

5 3. Intra-urethral therapy This involves inserting a small pellet of medication into the opening of the penis using a special applicator. Once the pellet has been inserted you must apply physical stimulation to the penis in order to disperse the medication. After taking this medication, some men experience burning inside the penis or when they pass urine. Pellet is inserted through applicator into the urethra. 4. Vacuum therapy This therapy involves the use of a special vacuum device which draws blood into the penis. A special rubber band is placed at the base of the penis to trap the blood in the tissues. This can remain in place for thirty minutes and must then be Penis placed inside the cylinder, and pump produces a vacuum that pulls blood into the penis. The tension ring is slipped off the cylinder onto the base of the penis and the cylinder is removed. Rub penis between hands to disperse the medication. The vacuum creates an erection within a few minutes Once the tension ring is removed, the penis returns to flaccid state. removed to avoid damage to the tissues. Some men find that they have bruising of the penis after using this and sometimes the penis feels cold to the touch. 5. Surgical implants If none of the methods discussed above work, some men may consider having a permanent surgical implant inserted. A surgeon places two cylinders into the penis which are inflated by activating a small pump in the scrotum when the man wishes to have an erection. This is done under general anesthetic and has the usual risks of surgery however it is a permanent solution and does not require you to take medications. What else can be done? It has been suggested that taking low dose PDE5 inhibitors in the months following surgery can help normal erections to return more quickly. If you are interested in this, please ask your urologist about this at your post-op appointment. Your age, your pre-operative erectile status and the type of surgery (nerve sparing or non-nerve sparing) can influence whether this will be helpful or not. You will be given a prescription for a low dose of one of the PDE5 inhibitors to take every night whether you want to have an erection or not. The theory is that these medications help to keep blood flow to the penis while you are sleeping and thus keep the tissues healthy. You need to take the medication every night (sildenafil or vardenafil) or every second night (tadalifil). You may have to take these medications for many months however early studies suggest that men who do this may see a faster return to spontaneous erections. If you want to have intercourse, you should take the full dose of the medication instead of the low dose. We will monitor your response to these medications on a regular basis. Some men do not respond at all and they may then want to consider using the injections three times a week in addition to taking the pills. This may speed up the return of normal erections.

6 What are the alternatives to intercourse? Some couples find that they are more interested in non-penetrative sexual activities in the time after treatment and are not interested in taking medications to cause erections. This is a good alternative for many couples. What other help is available? Some men or couples experience feelings of sadness when they face difficulties in their sex life. Other couples find that a change in their sex life causes stress for the relationship. There is help available to deal with these problems. Your urologist can refer you to a professional for help with this. Your urologist can refer you to a professional for help with relationships. Questionnaire Please answer the following five questions as they apply to your situation before you had treatment for prostate cancer. Tick off the answer that best describes your own situation in the month before your treatment (surgery or radiation). Be sure to select only one response to each question. In the month before your treatment for prostate cancer; 1. How do your rate your confidence that you could get and keep an erection? Very low High Low Very high Moderate 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? No sexual activity Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? Did not attempt intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always 4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Did not attempt intercourse Difficult Extremely difficult Slightly difficult Very difficult Not difficult 5. When you attempted sexual intercourse, how often was it satisfactory for you? Did not attempt intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always When you complete these questions, please give them to your health care provider to open a dialogue on erectile functioning.

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