Intimacy after prostate cancer: Solutions do exist!

What are the different treatments for prostate cancer?

There are several treatment options in the treatment of prostate cancer. The choice depends on the patient's age, overall condition, and how far the cancer has progressed. 

At the end of a series of evaluative tests, which aim to determine the diagnosis and stage of the disease, the treatment strategy best suited to the patient is defined by the medical team during a multidisciplinary consultation meeting bringing together the various specialists: oncologist, surgeon, radiotherapist, etc.

The preferred therapeutic option is then presented to the patient during a specific consultation and decided upon with the patient's agreement.

All the information is collected in a written document and given to the patient and his or her doctor.

There are different treatments options for prostate cancer:

Active surveillance

When the tumour is in its early stages not causing symptoms, the patient and medical team may decide to postponing treatment and keep an active watch on it to see if any symptoms develop before starting treatment.

External radiotherapy

This is a treatment using high-energy rays: focused on the tumour, these rays destroy the cancerous cells.

Internal radiotherapy (brachytherapy)

This is a method of radiotherapy in which radiation is delivered locally by implanting radioactive iodine seeds into the prostate tissue through the perineum.

Radical prostatectomy

This involves the surgical removal of the prostate gland but also the surrounding tissue. The operation can be carried out by the conventional route, i.e. by making an incision in the abdomen, also known as laparotomy or laparoscopy. 

Hormone therapy

This is a treatment that acts on the whole body and aims to prevent the stimulation of certain hormones on the cancer cells.

Chemotherapy

It is a cancer treatment based on the use of drugs. Chemotherapy aims to eliminate cancer cells wherever they are in the body.

What are the adverse effects of prostate cancer treatment on sexuality?

Most prostate cancer treatments can have both short and long-term side effects, especially on the quality of sexual life. 

Sexual health is a holistic concept and is not just about the sexual act itself. It encompasses different areas, both physical and psychological: body image, the stages of desire, arousal and orgasm, as well as tenderness, sensuality and eroticism.

Many difficulties can arise during and after prostate cancer treatment. These difficulties may be psychological: fear of being belittled in the eyes of one's partner, a feeling of loss of virility, a loss of self-esteem, doubts about one's ability to seduce, etc. But also physical difficulties such as erectile dysfunction, problems with ejaculation, a decrease in libido or urinary incontinence.

These difficulties can appear in a variable way and depend on the erectile and urinary problems that the patient may have encountered before treatment, as well as on the treatments undergone. Erectile dysfunction may appear immediately after the treatments or more gradually, in the months or even years that follow.

Prostate cancer treatments can also lead to a loss of fertility. If you are considering becoming a father, you should talk to your doctor before starting treatment in order to put in place fertility preservation measures.

What are the solutions to overcome these side effects?

First of all, couples should be precisely informed about the consequences that treatment could have on their intimate life and the possibilities that will be offered to remedy them. This information must be provided before and after treatment.

The removal of the prostate gland permanently prevents ejaculation. However, according to the French Federation of Sexology and Sexual Health: "as the mechanism of orgasm is independent of that of semen production, sensations of pleasure and orgasm itself remain possible after the prostatectomy and are even more intense for many patients".

Prostate cancer treatments can cause erectile dysfunction, but there are many drug-based solutions to overcome these difficulties. In order to maintain the erection mechanism, it is important to consider re-education aimed at maintaining the elasticity of the corpus cavernosa (two regions of erectile tissue within the penis that fill up with blood during erection) by ensuring regular oxygenation. To do this, regular erections should be induced by oral medications (5-phosphodiesterase inhibitors), injections into the corpus cavernosa, a cream applied to the urinary meatus (external opening of the urethra), a vacuum pump or a penile implant as a last resort.

Several types of treatment for erectile dysfunction exist. They must be prescribed by a doctor after a thorough medical examination. 

Oral treatments (PDE5 inhibitors)

The erectile mechanisms in men are made possible by cyclic guanosine monophosphate (or cGMP). cGMP works by relaxing the smooth muscles of the penis and increasing the flow of blood into them, which causes an erection. The more cGMP, the stronger and longer-lasting the erection will be.

When erectile dysfunction occurs, it is usually because PDE5 (5-phosphodiesterase) is too active and impairs cGMP, preventing it from having its usual effect on the erection. 

Ingesting 5-phosphodiesterase inhibitors limits the action of PDE5 to let cGMP do its work on the erection.

The following oral therapies are PDE5 inhibitors for the treatment of erectile dysfunction:

• VIAGRA (whose active and generic ingredient is sildenafil)
• CIALIS (whose active and generic ingredient is tadalafil)
• LEVITRA (whose active ingredient is vardenafil)
• SPEDRA (whose active ingredient is avanafil)

Injections into the corpus cavernosa

Injections of erectogenic substances into the corpus cavernosa of the penis relax the smooth muscle fibres and thus quickly produce an erection without the need for sexual stimulation.

There are various treatments available:

• VIRIDAL (whose active ingredient is alprostadil)
• Caverject or Caverject Dual (whose active ingredient is also alprostadil)

Topical treatment for the urinary meatus

VITAROS is a cream applied locally to the opening (meatus) of the penis with a special applicator. "It is a real innovation in that it is a local, non-invasive treatment", says Dr. Sylvain Mimoun, a gynaecologist-andrologist in Paris.

Local treatment of erectile dysfunction acts on the same principle as injections: a molecule, prostaglandin, stimulates blood circulation only in the genital area.

Vacuum pump

The action of vacuum pumps (also called penis pumps or vacuum erection devices) is purely mechanical. This device creates a vacuum that pulls blood into the penis. A tourniquet placed at the base of the penis will then maintain the erection.

Penile implant

Penile prostheses (implants) are used when the other previously mentioned treatments for erectile dysfunction have failed.

Three types of penile implants exist:

• Malleable implant: this type of implant consists of two flexible rods that are permanently rigid, but can be bent into an upward position prior to intercourse. The penis is in constant erection, its size remains that of the flaccid penis, the patient must expect post-operative pain because the penile tissue must get used to being in constant erection. They account for less than 10% of penis implants and are especially useful in men with complex medical problems.
• Inflatable, two part implant: This device consists of two cylinders in the penis and a scrotal pump. The pump is activated by hand and fluid is transferred between the pump and the cylinders, closely mimicking a natural erection. This type of prosthesis is easy to use, but it does not become as flaccid when deflated as the three-part implant.
• Inflatable, three part implant: This type of implant includes two cylinders in the penis, a pump in the scrotum and a fluid-filled reservoir in the abdomen, behind the bladder. This type is the most popular among patients as it is the most "realistic". The reservoir allows a greater volume of liquid to be sent into the cylinders and thus improving erectile performance. These prostheses also allow an increase in the length and diameter of the penis.

Psychological follow-up can also be arranged to help the patient to regain self-confidence and regain full self-esteem. A consultation with sex therapist can also be considered alone or with one's partner.

After prostate cancer, many patients face problems with intimacy or their sexuality. However, when informed, they can regain a full and satisfying sexual life in the months following the end of treatment or surgery. Increased communication with one's partner as well as adequate treatment will allow them to quickly regain a full and satisfying intimate relationship.

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