Hitting a Nerve: Nerve Damage From Cancer Treatment Can Impair Sexual Function
A cancer diagnosis is a life-changing event for anyone, but for men with prostate cancer and other pelvic malignancies, the long-term effects of the disease and its treatments can be particularly challenging. In the aftermath of treatment, men not only can experience distressing physical and psychological effects, but many also have their first experiences with sexual dysfunction.
This distressing side effect can result from treatments for bladder, colon, rectal or penile cancer, but men treated for prostate cancer have especially high rates of sexual dysfunction, as high as 75 to 85 percent, depending on the situation. Causes across this spectrum of cancers can include low testosterone levels due to hormone therapy, chemotherapy or radiation; damage to nerves near the prostate as a result of surgery or chemotherapy; compromised blood flow to the penis due to surgery or radiation; and surgical damage to nerves that control semen outflow.
Unfortunately, the topic’s sensitive nature and a lack of accurate information can keep men from getting the help they need.
SPARING NERVES DURING SURGERY
Until the ‘80s, permanent impotence was considered an unfortunate but inevitable byproduct of prostatectomy. But in 1977, after studying ways to lessen the bleeding that often accompanied the procedure, Johns Hopkins Urologist in Chief Patrick C. Walsh, M.D., was stunned to learn that one of his surgical patients had regained sexual function. Walsh subsequently developed what have become standard nerve-sparing techniques for the operation, performing the first one himself in 1982. Nerve-sparing techniques can also be used in radical cystectomies and in lymph node removal for testicular cancer.
The complicating factor in nerve-sparing prostatectomy is that the nerves are microscopic, which presents a significant challenge to the surgeon, says Andrew Matthew, Ph.D., C.Psych., a psychologist at the Prostate Cancer Rehabilitation Clinic at the University of Toronto’s Princess Margaret Cancer Centre. In addition, the nerve bundles are extremely delicate, and any manipulation inevitably results in some damage. “Removing the nerves from the sides of the prostate traumatizes them so they’re no longer functional for a period of time,” he notes. “It’s quite difficult to determine how much damage has been done to either or both bundles after the procedure.” Further complicating matters: Prostatic nerves can also be disturbed during other procedures, such as surgery for bladder or rectal cancer.
The amount of inflammation and nerve injury directly translates to how long it will take for the nerves to recover, and until they do, men will experience erectile problems. To say that this is distressing for most men is an understatement, especially for younger men. “With the advent of PSA (prostate-specific antigen) tests (of the blood to screen for the disease), we’ve seen more and more young guys diagnosed with prostate cancer in the last decade,” notes Jeffrey Albaugh, Ph.D., APRN, CUCNS, director of sexual health at NorthShore Medical Group in Evanston, Illinois. “They generally do better in terms of recovery, even those in their 40s and 50s, but we still can’t predict how each patient will do.”
Radiation therapy can hit spots near the prostate and seminal vesicles when it’s used in treatment for rectal, bladder or prostate cancer. While it represents a non-surgical alternative to prostatectomy in prostate cancer, it still comes with a risk of sexual dysfunction.
“The same nerves that are damaged by surgery are often within the field of the beam, and can be damaged by the radiation,” says Matthew. The side effects of radiation therapy often develop more gradually, so men may see a decline in erection quality for a few years after the procedure. After about four years, the incidence of erectile problems is about the same for those treated with either surgery or radiation. Another form of radiation therapy called brachytherapy, in which small radioactive “seeds” are placed directly into the prostate, seems to have fewer negative effects than external beam radiation, says Matthew.
Lastly, hormone therapy — also known as androgen deprivation therapy — which lowers the amount of testosterone in the body, can also be used to treat prostate cancer. Because testosterone stimulates the growth of prostate cancer cells, depriving them of it can slow their growth or even cause tumors to shrink. But as Matthew notes, the technique has “quite a broad side effect profile, and the one that seems to be the most problematic for men is the loss of sex drive.” Erectile dysfunction can also be a problem, along with hot flashes, fatigue and a side effect called loss of stoic expression, which can cause men to tear up in emotional situations.
Because of the undesirable side effects, practitioners will sometimes suspend hormone treatment for a period of time, says Frank delaRama, R.N., M.S.N., a clinical nurse specialist who serves as a prostate cancer navigator for patients at Palo Alto Medical Foundation. “Some guys are on the drugs for many months, so if their PSA levels are OK, we’ll take them off hormones temporarily just to give them a break,” he says. “Of course, if you’re on hormones and radiation, that can be more complicated.”
Postsurgical urinary incontinence, although usually temporary, can be another unpleasant side effect. “About a third leak urine when they climax, even if they don’t leak at other times,” says Albaugh. “That can be a huge issue for some men.” Chicago attorney Jim Schraidt can confirm that. Schraidt, who had a prostatectomy in 2010, found that “I had a persistent problem of leaking urine during sexual activity, which nobody had said anything about.”
Urinary incontinence can also be a complication of tumors in other areas, such as the lungs and spine, and their treatments.
Doing pelvic floor strengthening exercises before and during the treatment period may help prevent these problems.
THE WAY BACK
The more time that passes after treatment, the more likely erection pills called PDE5 inhibitors will be effective, says Matthew, and physicians will often prescribe them first, as they’re the least invasive. Better known to consumers by their brand names of Viagra, Levitra and Cialis, among others, the drugs have revolutionized the treatment of male sexual dysfunction and can be used by prostatectomy patients, as well as patients with bladder cancer whose prostates have been removed and patients with colorectal cancer. Says Matthew: “They require some nerve function in order to work, so they don’t usually have any effect immediately following surgery.”
For those who’d like more immediate results, there is an option that can be used sooner: penile injections. “Most men have to be kind of desperate to get to the point where they’ll consider it,” says Anne Katz, Ph.D., R.N., a certified sexuality counselor, clinical nurse specialist and author of “Man Cancer Sex.” “But it’s the most effective intervention we have; it acts on a purely mechanical level. It’s actually not that painful, especially after men get used to it, and it’s relatively cheap.”
The injected medication works by dilating the arteries of the penis, says Matthew. “It’s not dependent on the nerves; it’s a localized agent that draws blood directly into the penis, so it’s usually quite effective, in the range of 90 percent or so. And it can be used very early on.”
Albaugh notes that the success rate is the same for all cancer- related types of erectile dysfunction. Schraidt began injections six weeks after his procedure, and continues to use them now after PDE5 inhibitors proved ineffective. Another alternative to pills is a therapy called MUSE (Medicated Urethral System for Erection), a “microsuppository we insert into the urethra at the tip of the penis,” Matthew explains. “Like injections, it uses a localized agent that draws blood into the penis, and works in about 50 percent of men who’ve had radical prostatectomy.” The drug starts to work in five to 20 minutes and produces an erection that lasts about an hour.
Vacuum devices — so-called penis pumps — can be used to cause erections by evacuating air from a cylinder and creating a vacuum around the penis, then placing a ring around the base to maintain the erection.
The most invasive solutions, used only when others don’t work, involve surgical placement of implants into the penis, such as flexible silicone rods that give the bearer a permanent, semi-rigid erection. The rods are bent upward for sexual activity and downward when not in use. Inflatable penile implants are another option: Tubes are inserted that can be inflated with saline solution using a small manual pump implanted under the loose skin of the scrotum.
In the aggregate, treatments for sexual dysfunction after prostate cancer have a reasonably high success rate. “About 20 to 25 percent of men will have a return of natural function sufficient to maintain an erection,” says Matthew, “although it usually won’t be as firm as before treatment. We can increase that significantly with the use of PDE5 inhibitors, although older men and those with vascular problems are less likely to respond to them. But if you’re young and had strong erectile function prior to treatment, you’re going to be up in the 80 percent range.” Success rates are similar for other types of cancers as well, says Matthew, depending on the amount of nerve damage done during the initial procedure.
On an individual basis, recovery depends on many factors, pointing out the need for clear communication between doctor and patient before a procedure. For instance, many men are surprised to find that they can still reach orgasm, although there’s no erection or any fluid expelled, says Katz. That’s true for patients treated for bladder, rectal and colon cancer, as well, says Matthew, because the nerves that allow orgasm usually remain intact. But Schraidt, who still struggles to reach orgasm, says he wasn’t informed of all the possible consequences beforehand. “Men need to have correct and full information to make an informed choice, and in my case it was very much lacking,” he says.
Matthew believes that many physicians don’t receive enough training in dealing with sexual issues, and, like patients, may have their own insecurities about broaching the subject. Katz agrees, but points out that “if you know that sexual side effects are frequent and likely to happen, you’ve got to talk to the patient about it. Avoiding the issue is not helpful.” Schraidt was so devastated by the changes in his body that he contemplated suicide at one point.
“I was just miserable for a couple of years,” he remembers. “I couldn’t even sit through a dinner with close friends.” Fortunately, he mustered the will to call his doctor and was referred to a mental health counselor. After a stint in therapy and a course of antidepressants, he joined a support group and is now its facilitator. “I was never a believer in drugs, but now I know there are times when you need them, and you should get them,” he says.
Therapy can also help with the interpersonal communication that often affects couples after a man’s surgery. “Without communication, the whole area of sexuality in the relationship suffers,” says Matthew. The same is true of gay couples, who may not seek treatment because of the fear of stigma, Katz says. “I use the word ‘partner’ when talking to couples, and one of the patients I’m seeing told me it made a huge difference, because it told him it was OK to bring his partner along when he had treatment.”
For men contemplating their options before treatment, the message is clear: Do as much research as you can, and don’t be afraid to ask questions. As Albaugh puts it, “Understanding the good, bad and ugly — the pros and cons of it all — is vital in being able to make informed decisions.”