Sexual activity after prostate cancer therapy might be different, but still possible.
Tom’s annual physical was all but done, and all systems were go when his doctor thought he detected a lump on his prostate. Then the trap door opened, and from referral to biopsy, the news grew rapidly worse: A specialist found a sizable tumor that was aggressive and inoperable.
Decisions had to be made quickly. The oncologist wanted to radiate and begin testosterone suppression immediately. Swimming upstream through the mass of new medical information, Tom says he knows he asked whether he would still be able to make love with his wife. The doctor asked if Tom was having problems now. Tom said no. The doctor turned to Tom’s wife and asked again: any erection problems? She confirmed, no. The doctor assured him he would be fine.
Tom, who requested anonymity, credits his doctors with giving him a chance to survive a brutal cancer, but wishes they had been straightforward about the fine print. Although he was able to get erections throughout his radiation treatment, after a few months the treatment and the missing testosterone brought his libido to a halt. Depression ensued. It wasn’t until Tom saw his fifth therapist that he found someone who didn’t blush when he talked about his inability to get an erection. With help, he was able to begin to heal himself. He fired his health care team and found a new doctor who spent more time talking with him about risk versus reward.
Sexual activity after prostate cancer therapy might be different, but still possible.
Despite the fact that he is a 56- year-old working professional in a mid-sized, Midwestern town, Tom didn’t have access to someone like Sharon Bober. She directs the sexual health program at Dana-Farber Cancer Institute in Boston, using an integrative and optimistic approach, addressing body and mind. “There are certain things that are never going to be the same,” Bober says frankly about prostate cancer. But she adds that sexual problems are rarely just physical; that it’s possible to “re-engineer your sex life so that it’s really satisfying. But it might look really different.”First, the bad news: Prostate cancer treatment often affects sexual function, and medical progress in this area has been slow.
“The patient education literature gives a very inaccurate idea of how many men recover good sexual function after prostate cancer,” says Leslie Schover, a clinical psychologist specializing in sexual health at the MD Anderson Cancer Center in Houston. “If you look at radical prostatectomy, it doesn’t matter if it’s done with a robot or if it’s done laparoscopically, the results are basically the same across the board. Fewer than one-fourth of men have erections afterward that resemble the ones they had before — if they had good function. And that applies overwhelmingly to the men who are under 60, with very good erections before treatment.”
Robot-assisted surgery and new radiation regimens claim better outcomes, but, Schover says, there is little difference five years after treatment. Even watchful waiting has its problems, possibly because of tumor progression, repeated prostate biopsies or other factors, she says. “The bottom line is nobody does very well.” In other words, very few men get off scot-free.
The issue is proximity, as the prostate is closely twined with the bundles of nerves and blood vessels that drive erections. Regardless of how careful and nerve-sparing the surgery is, and despite the precision of the radiation dose, the likelihood of some damage either from the procedure or subsequent scarring is high.
Regenerating damaged nerves is the ultimate treatment goal, but Boback Berookhim, a specialist in male sexual and reproductive medicine in the Urology Department at Lenox Hill Hospital in New York, says that’s still some distance over the horizon. Perhaps most promising is stem cell therapy — injecting fat-derived stem cells has shown some preliminary success in treating erectile dysfunction in men with diabetes. Unfortunately, he cautions, it’s “not even close to being ready for prime time.”
Nerves can possibly heal themselves over time, so the priority for the prostate cancer patient is to get blood flowing to the penis. Without regular erections, penile tissue will deteriorate, and “you’ll never respond to any nerve impulse,” Berookhim says. “The ultimate goal is to keep everything healthy so that if and when the nerves do wake back up you have a healthy organ that’s ready to respond.”
There are several approaches to giving men erections during the recovery period. Viagra (sildenafil citrate) and other drugs that block PDE-5 (a natural enzyme that breaks down the chemical responsible for causing erections) can be prescribed both pre- and postoperatively to encourage blood flow, and it might help protect the lining of the blood vessels going to the penis. However, not all insurance plans cover this treatment and, depending on baseline erection health and the extent of nerve injury, not all patients respond to it.
The most common and effective therapy among patients who fail oral erection medications is intracavernous injection, where a needle is used to insert an erectile cocktail directly into the corpora cavernosa, the sponge-like tissue that floods with blood in an erect penis. Some men are prescribed compounded drugs known as bi-mix or tri-mix, but most get Caverject or Edex, which only contain one drug, alprostadil, and are sold by prescription, ready to use, Schover says.
“Injections come the closest to simulating a natural erection in people who do not respond to Viagra,” Berookhim says. “Ultimately, some men will either fail to respond to the injections or will opt out of injecting and can select other treatments, including surgery for placement of a penile prosthesis.”
Another approach is a vacuum device, often called a penis pump. “Most men hate it,” Berookhim admits, but it’s a good, low-cost option. He believes that exercise may make a difference, too. “Erections are a barometer of your cardiovascular health,” he says. “It’s always recommended that men lead an active lifestyle.” But the exercise connection hasn’t been proven, counters Schover, pointing out that a 2014 clinical trial testing the effects of aerobic exercise after prostatectomy showed no effect on recovery of erections.
Regardless of the rehabilitation method chosen, the key here is patience, and not abandoning the therapy even if erections seem unfit for actual sex. The goal is preserving healthy penile tissue for later.
“We want men to know that this isn’t just in your mind,” Berookhim says. “There are significant changes that have been made to your anatomy. You should seek care for it, because there are things that we can offer that can help you along in your recovery.”A common blunder with the vacuum pump illuminates the bigger picture. The pump, Schover says, often works better when foreplay leads to a partial natural erection, which the pump can then fortify. But the pump is awkward, and many men use it before starting sex. Their erections may be wobbly and cold to the touch, which is problem one. But the bigger issue is that a man’s other sexual organ — his brain — isn’t primed, either.
“Men are used to saying, ‘If I have an erection, I’m ready,’ and go right ahead into penetration and intercourse. And then they can’t reach an orgasm,” Schover explains. “They’re not aroused because they didn’t get any foreplay for themselves.”
All this happens because there have been physical changes. A prostatectomy removes the prostate and seminal vesicle glands, which generate semen, so there is no material to ejaculate. What remains is a challenge: to properly engage the mind. “Orgasm is a brain event, whereas ejaculation is between the legs,” Berookhim stresses.
People are creatures of habit, and for long-term couples in particular, sex can become routine. “You do what you normally do and when things work well enough that’s fine, but once you can’t do that anymore your toolkit is out of tools. I think people feel like they’re at the end of the road,” Bober says. “I do think that people are able to recover their sexual life after prostate cancer.”
The key, she adds, is to expand the definition of sex. “If the focus is really just about erectile function and penetration, and you just can’t get an erection like you used to, or you just can’t get one at all, it sort of feels like there is no point in talking about it,” she says. But sex is a lot broader than that.
Physical pleasure and physical proximity are the starting points for sex, but where else can you take the conversation? “The power of the mind is enormous. Being able to call on memory and fantasy and relationships in order to reinvigorate one’s experience of one’s sexual self is very powerful and very real,” Bober says. “When’s the last time you sat and just kissed? You did that all the time in your 20s. You can be best friends with your partner and not have done that for 30 years.”
Results could be better than advertised. Schover says some couples report better sex than they had before because they’re communicating better. Getting there wasn’t easy, but then there is little about the cancer experience that is easy. The tools are available; making them work is the challenge.
At least the research has potential to be, well, satisfying, although Schover argues that much is not understood about the role of sexual activity in keeping penile tissue healthy. Even so, she poses the questions: “What if you just stay sexually active with your partner, even if you don’t get firm erections? Or you have nonintercourse sex with your partner? You get sexually aroused; you get some blood flowing through the penis. Is that as good [for rehabilitation] as a vacuum pump or penile injections?”
Tom advises men to talk about it with their doctors and sexual partners. He thinks the reason his doctors weren’t forthcoming about sexual side effects is that men are uncomfortable with the subject. Most simply aren’t asking enough questions. “Their patients aren’t demanding (answers), like women did years ago with regard to breast cancer,” he says. Patient advocacy can do a lot to change the treatment culture — it helped lead to full coverage for reconstructive surgery after breast cancer, for example. While coverage for urology treatment tends to be good, insurance doesn’t always cover the counseling that may contribute to a man’s sexual rehabilitation after prostate cancer, Schover says.
After a lot of experimentation, Tom realized that with a threeday medication regimen he could prime his body for a Sunday romp. He misses the spontaneity, he says, but emphasizes that the challenge of living four months without an erection was good for his marriage. He and his high school sweetheart have been married 33 years. “I still want my wife to want me, and me to pleasure her,” he says.
With no sexual therapists available in his area, he went the self-help route, with support from an online group. The results have been pleasing. “We’re better now than we ever were,” he says. “That’s because we’re a hell of a lot more intimate.”