Figure 30-1.
Schematic representing the pathophysiology of erectile dysfunction after radical prostatectomy. *Apoptosis occurs in nerves, smooth muscle, and endothelium as a result of neural trauma. APA accessory pudendal artery, CCSM corpora cavernosa smooth muscle, NVB neurovascular bundle, pO 2 partial pressure of oxygen. [Reprinted from Mulhall JP, Bivalacqua TJ, Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. Journal of Sexual Medicine. 2013;10(1):195–203 with permission from Elsevier].
Many men regain some amount of erectile function within 6–24 months after prostatectomy, with better outcomes observed in men who use some form of “penile rehabilitation”—use of oral phosphodiesterase type-5 inhibitors (PDE-5i) or intracavernosal injections to maintain penile blood flow and/or to assist erectile function during sexual activity [14]. Recovery of erectile function without any pharmacologic intervention 6–12 months after nerve-sparing RP ranges from 4% (recovery of preoperative erectile function) to 29% of men reporting erectile function sufficient for vaginal penetration. With some form of penile rehabilitation, estimates range from 29% to 86% of men reporting erectile function sufficient for vaginal penetration at 6–12 months post-surgery [14]. Unfortunately, little research exists with men for whom penile-vaginal intercourse is not a primary outcome (e.g., men who have sex with men, single men, or men in relationships in which vaginal penetration is not part of sex for some other reason). Variation in reported outcomes is due in part to differing medications, dosages, treatment protocols, and measured outcomes across studies. Table 30-1 summarizes erectile function outcomes from trials of penile rehabilitation after radical prostatectomy. Variability in erectile function post-RP is also influenced by premorbid erectile function, patient age (with younger patients recovering greater function), and surgical variables such as surgeon skill and preservation of nerves [15].
Table 30-1.
Pharmacological erectile rehabilitation studies
Author | Year | N a | Design | Intervention | Outcomes summary |
|---|---|---|---|---|---|
Montorsi | 1997 | 27 | Single-center, non-PC, RCT | IC alprostadil vs. no treatment | Natural erection (unassisted) at 6 months 67% ICI vs. 20% non-treatment |
Mulhall | 2005 | 132 | Single-center, non-R, comparative analysis (rehab vs. no rehab) | Sildenafil nonresponders used ICI | Erectile function recovery at 18 months Natural erection: 52% rehab vs. 19% non-rehab Sildenafil response: 64% rehab vs. 24% non-rehab ICI response: 95% rehab vs. 76% non-rehab |
Bannowsky | 2008 | 41 | Single center non-R, comparative analysis in patients with preserved nocturnal erections (rehab vs. no rehab) | 25 mg sildenafil (s) nightly vs. no treatment (c) | SHIM score: (s) Pre: 20.8 at 12 months: 14.1 (c) Pre: 21.2; at 12 months: 9.3 Erections sufficient for vaginal penetration: 47 (s) vs. 28% (c) without sildenafil on demand 86 (s) vs. 66% (c) with sildenafil on demand |
Padma- Nathan | 2008 | 76 | Multicenter, DB, PC-RCT | Sildenafil 100 mg vs. sildenafil 50 mg vs. placebo | Return to baseline erectile function at 11 months Sildenafil 27% vs. placebo 4% RigiScan “responders”: 100 mg: 33%, 50 mg: 24%, placebo: 5% |
Montorsi | 2008 | 423 | Multicenter, DB, PC-RCT | Vardenafil 10 mg nightly + placebo for sex (N); Vardenafil 10 or 20 mg for sex + placebo nightly (OD); Placebo for sex and placebo nightly (P) | Proportion EFD ≥ 22 At 9 months: N 32%, OD 48%, P 25% At 11 months: N 24%, OD 29%, P 29% At 13 months: N 53%, OD 54%, P 48% % with “yes” response to SEP 3b At 9 months: N 34%, OD 46%, P 25% At 11 months: N 32%, OD 42%, P 34% At 13 months: not reported |
Radical cystectomy for bladder cancer also involves removal of the prostate and seminal vesicles, and has similar risks for erectile function. For some men, treatment of bone marrow or lymphatic cancers with bone marrow transplants can result in genital graft-vs.-host disease with associated scarring, pain, and penile curvature with erections.
Radiation. Both external-beam and seed implant radiation to the prostate are also associated with ED, though onset is later than with prostatectomy [15]. The type of external-beam radiation matters, with more precisely targeted methods such as three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) causing less damage to erectile function. Similarly, more precise placement of radioactive seeds is associated with fewer sexual side effects [15].
Radiation contributes to ED by damaging the lining of blood vessels in and near the penis, damaging the nerves that create erections, and, in some cases, damaging erectile tissues so that they are unable to hold blood in the penis to maintain erection (a condition called venous leak). Erection problems show up, on average, 1 year after radiation, though the peak negative effects on erections often occur 3–5 years post-treatment. Problems associated with venous leak may occur shortly after radiation. Long-term studies of erectile function post-radiation provide estimates of 37–59% incidence of erectile problems at 3-year follow-up [15].
Assessment
The most common written assessment tool for ED is the International Index of Erectile Function (IIEF) [16]. The brief 5-item version of the scale (IIEF-5 [17]) is a reliable self-report measure of erectile function. One limitation of the IIEF-5 is that it was designed to assess erectile function during penile–vaginal intercourse, and some items may not be applicable to men who have sex with men, or those who are not attempting intercourse. Alternatively, a briefer, validated one-item checklist questionnaire assessing multiple domains of sexual function may be used to screen for sexual problems including ED [18]. For more comprehensive written assessment or for research purposes, the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction measure (PROMIS SexFS) [19] includes items assessing various domains of sexual function and has been validated with individuals with cancer.
Conducting a clinical interview is also an appropriate way to screen for ED, with the advantage of being more personal and specific to an individual than a written assessment. Verbal screening questions might include whether the patient has any sexual concerns he would like to discuss. Further assessment questions might include whether the patient is sexually active with a partner and partner gender; during the last sexual encounter, whether the patient was able to get some amount of erection, and how much (e.g., percentage of full erection); level of satisfaction with the hardness of erection; whether the erection was sufficient for desired sexual activities; and overall satisfaction with the sexual encounter.
Patients who report ED should also have a thorough physical assessment, including examination of genital appearance and health, test for testosterone levels, and prostate exam (if applicable).
Intervention Strategies
Physical/medical: Men diagnosed with cancers whose treatment may impact sexual function should be counseled about sexual effects prior to treatment, and should be advised of alternative treatments, if any, and strategies to minimize sexual side effects or aid sexual recovery. When pelvic surgery is necessary, patients should be counseled to ask—or advised about—whether nerve-sparing procedures are available.
After nerve-sparing radical prostatectomy, regaining erectile function is often improved by a process of penile rehabilitation, which includes daily use of PDE-5 inhibitors (PDE-5i) to increase blood flow and oxygenation to erectile tissues, maintain endothelial health, and prevent collagenation of smooth muscle tissues after prostatectomy [14, 15]. Some experts recommend beginning PDE-5i prior to surgery and then continuing afterward, so patients should be counseled prior to treatment about rehabilitation possibilities in order to make informed decisions [14]. Many trials of penile rehabilitation have shown better recovery of erectile function, better response to on-demand PDE-5i, and better response to intracavernosal injections post-prostatectomy, though one large randomized controlled trial showed benefit of PDE-5i at 9 months post-prostatectomy, but no significant benefit over placebo at 13 months [14].
Vacuum erection devices (VEDs) were often prescribed for the same purpose in the past—to increase blood flow to penile tissues—though PDE-5i are preferred nowadays. While VEDs do draw blood into the penis, this blood is not as oxygen-rich as blood circulated to the penis by PDE-5i, and therefore may not be as beneficial in promoting tissue health and erectile function [15].
Psychosocial : Many men experience embarrassment, shame, frustration, and a sense of not being masculine, manly, or potent with erectile dysfunction [20]. Additionally, while many men regain erectile function after cancer treatment, others do not, depending on type of treatment and individual differences in physiology and recovery. Psychosocial intervention is an integral part of sexual recovery for anyone surviving cancer , but particularly for those for whom full physical recovery is not possible.
Support groups . Support groups for men surviving cancer can provide space for acknowledging feelings of grief and loss with changes in sexual function, normalizing the experience, and providing validation for feelings. Anecdotally, many cancer survivors and their partners report that sexuality is an infrequent topic in support groups, if it comes up at all. Group leaders may be instrumental in broaching the topic or dedicating certain group sessions to discussion of sexuality.
Sex therapy. Sex therapy for ED can help in adjusting to the loss of previous erectile function, identifying and changing unhelpful thoughts and behaviors about sex or sexuality, clarifying goals and desires for sex and intimacy, expanding repertoire of sexual activity with existing sexual function, and identifying conditions under which arousal and erectile function are likely to be best [21]. Research supports the efficacy of sex therapy for ED in improving sexual satisfaction, and recent meta-analyses suggest that a combination of PDE-5i and psychological intervention produces the best outcomes for men with ED, though these studies were not specific to cancer survivors [22, 23].
Individual therapy: Single men with ED as a result of cancer may feel in the minority, as much of the content in this area is directed to couples. Sexual function and self-concept are critical areas to address for men who are dating or looking for a relationship. Individual or group counseling can help to normalize and validate concerns. Information to help navigate dating with ED can be integral to approaching this area. Counseling on interpersonal issues might help with identifying potential dating partners, talking to a dating partner about sex, identifying sexual possibilities within existing sexual function, and coping with risk and rejection [24].
Couples therapy : In addition to individual distress, ED can contribute to distance or conflict in an intimate relationship, or may serve as a barrier to developing intimate relationships with new partners. Couples counseling can help to improve communication about sex and intimacy, decrease shame or embarrassment between partners, and enhance understanding about partners’ desires for current sex life. Incorporating relationship-oriented content into existing support groups or workshops may be helpful in settings where formal couples counseling may not be available. Similarly, including partners in follow-up visits can be helpful in addressing partners’ questions and concerns, and opening dialogue between partners about ED [25, 26].
Changes in Ejaculation and Orgasm
Here we differentiate between the specific process of ejaculation—the expulsion of semen—and the larger process of orgasm—the collection of physical and mental processes often including pelvic floor muscle contraction, ejaculation, and subjective sense of pleasure and release, that often results from sexual arousal and stimulation. A man can experience orgasm without ejaculation. Further, an erection is not needed to experience orgasm or ejaculation.
Risk Factors
Men who have been treated for many types of pelvic cancers can experience anejaculation (no semen is expelled with orgasm) and changes in the subjective experience of orgasm, with some describing it as less intense, less pleasurable, or just “different.” Less commonly, a surgical procedure or medication may cause retrograde ejaculation, in which semen is pushed into the bladder, rather than out through the urethra, at the time of ejaculation. These changes are concerning for many men who are struggling to cope with multiple changes related to the experience of cancer [27, 28].
Anejaculation. Cancer treatment can cause anejaculation in two broad ways (a) through removal or damage to semen-producing structures including the testicles, prostate, and seminal vesicles, or (b) by damage to the nerves that control emission of semen. The seminal vesicles and prostate produce seminal fluid that mixes with sperm cells from the testicles to make semen, and the prostate is involved in the expulsion of semen at the time of ejaculation. Radical prostatectomy (removal of the prostate and seminal vesicles), radical cystectomy (removal of the bladder, prostate, seminal vesicles, and part of the urethra), and radiation therapy to the prostate result in anejaculation or “dry” orgasms, in which men typically have the sensation of orgasm but without release of semen.
Nerve damage from surgery can also affect ejaculation. Nerves from the spinal cord to the pelvis govern emission of semen at the time of orgasm. These nerves are distinct from the nerves that govern erections, and can be damaged during some types of surgery, including retroperitoneal lymphadenectomy in testicular cancer, and abdominoperitoneal resection or sigmoidectomy in colorectal cancer [24].
Retrograde ejaculation. Retrograde ejaculation occurs when the valve that normally closes off the path to the bladder at the time of ejaculation (the internal sphincter) is damaged, and semen shoots back into the bladder rather than being expelled out the end of the urethra with ejaculation. Certain surgical procedures cause retrograde ejaculation, including transurethral resection of the prostate (TURP). This common procedure for an enlarged prostate gland involves hollowing out the core of the prostate via the urethra, and often damages the internal sphincter. Men with retrograde ejaculation experience orgasm, though may report changes in the sensation or intensity of orgasm [15, 24].
Changes in orgasm. Changes in the sensation of orgasm, or ability to reach orgasm, are common with changes in ejaculation. With anejaculation, some men report a difference in the sensation of “fullness” or inevitability preceding orgasm, as semen is not building up to be released. Some men report less intense orgasms as a result. In a recent survey of men’s sexual side effects post-prostatectomy, 60% reported decreased orgasm intensity, 57% reported delayed orgasms, 5% reported anorgasmia, and 10% had experienced pain during orgasm [27].
In addition to prostatectomy, hormonal treatment and pelvic radiation can also cause changes in orgasm. Androgen-blocking therapies are associated with delayed orgasm or anorgasmia, as testosterone has a role in orgasmic function. Some men experience sharp pain with orgasm after radiation treatment for prostate cancer, which may be a result of irritation to the urethra or spasms in the pelvic floor muscles [15, 27, 28]. Sometimes the pelvic floor muscles, which contract during ejaculation and orgasm, are damaged during pelvic surgery. This can also create changes in reaching orgasm, or in the feeling or intensity of orgasm. Finally, though not part of cancer treatment per se, many patients going through cancer treatment may be prescribed antidepressant medication. SSRI antidepressants are associated with delayed or absent orgasm, so men complaining of these symptoms should be asked about antidepressant use.
Assessment
For screening purposes, the single-item screener for sexual problems mentioned previously is an appropriate starting point for assessing problems related to ejaculation and orgasm [18]. One of the checklist items relates to problems with orgasm. For more comprehensive assessment or for research purposes, the PROMIS SexFS [19] includes items assessing ejaculation and orgasm and has been validated with patients with cancer. Conducting a clinical interview can also assess concerns about ejaculation and orgasm. Providers may ask patients whether they have experienced any problems with ejaculation and orgasm , the nature of those problems, onset, history and frequency of concerns, and interventions attempted. Physical assessment for concerns related to ejaculation and orgasm may include visual examination of the genitals, tests of penile tactile sensitivity, pelvic floor muscle tone, testosterone level, and prostate examination (if applicable).
Intervention Strategies
Physical/medical: Anejaculation resulting from surgery or radiation is, unfortunately, permanent, as part of the machinery for making or expelling semen has been permanently altered or removed. Though changes to ejaculation may be permanent, changes in orgasm may be amenable to treatment. If pelvic floor muscles have been damaged or weakened by surgery, physical therapy can help to restore proper muscle tone, which can improve orgasmic ability and sensation. For men who experience difficulty reaching orgasm as a result of changes in sensation, muscle tone, or new and unfamiliar physical functioning, increasing penile stimulation may help [24, 28]. This can be achieved by using a vibrator to stimulate the head of the penis, or by exploring different types of manual, oral, or other types of stimulation.
Pharmacologic interventions may help with reaching orgasm. Taking the hormone oxytocin intra-nasally during sexual activity, shortly before desired time of orgasm, helps some men with achieving orgasm [29, 30], though larger randomized controlled trials have not found consistent evidence for efficacy [31]. The drug cabergoline may also help orgasmic function by interfering with the release of prolactin, a hormone that has a role in governing a man’s refractory period, or time between orgasms [32, 33]. A recent pilot study [32] of 131 men reported about 66% of those treated with cabergoline for anorgasmia or delayed orgasm experienced subjective improvement in orgasm. Participants included 23 men with prior prostatectomy, and no difference was observed in response to cabergoline between this group and men without prostatectomy. However, cabergoline efficacy appeared to be improved with concomitant testosterone therapy, which is contraindicated for survivors of hormone-sensitive cancers [32].
Psychosocial : Men experiencing changes to ejaculation and orgasm may report a sense of loss of valued aspects of sexual experience, fear or anxiety about partner response to changes, decrease in pleasure from sex, changes in sense of masculinity, low mood, and sexual avoidance [7, 27].
Brief consultation : It may be important for providers to ask specifically about ejaculation and orgasm, as men may not themselves broach the topic even in general discussions of sexual function. Providers can be helpful in normalizing the experience (e.g., many men with this type of treatment report this issue), answering questions, and directing the client to additional resources. Providers can also provide psychoeducation about relationship concerns. Brief consultation may help men to identify concerns they might like to discuss with their partners, and providers can normalize and encourage discussion about these matters. Alternatively, partners can be included in patient visits. This allows providers to provide information and answer questions related to sexual changes.
Men for whom ejaculation or fertility are important parts of sexual activity for having children, or for cultural or religious reasons may have particular difficulty with changes to these functions. Fertility and fertility preservation are discussed in the upcoming section on Infertility. Providers might ask about men’s comfort in continuing sexual activity without ejaculation, and with exploring alternative sexual activities. In addition, men from many backgrounds might share the cultural experience of ejaculation symbolizing potency, masculinity, and virility. It may be helpful to acknowledge the meaning and importance of the loss of this function and take care not to minimize its value in attempting to reassure patients; for example, avoiding statements like, “An orgasm is mostly mental anyway,” or “your partner probably doesn’t mind.”
Sex therapy. Sex therapy can address men’s concerns about sexual function and partner response, help to process feelings of grief and loss for previous sexual functioning, and help to regain a healthy sexual self-concept and decrease feelings of embarrassment, shame, or inadequacy about changes. Cognitive and behavioral strategies can help to reduce anxiety and cognitive distraction and increase focus on sexual stimulation, which may improve delayed or absent orgasm [34]. Sex therapy can also help to identify strategies for increasing sexual arousal, and for maximizing enjoyment of current sexual function.
Couples therapy : Like ED, changes to ejaculation and orgasm can affect relationships as well as individuals. Couples therapy can help partners openly discuss sexual matters, feelings about loss of ejaculation or changes in orgasm, and their impact on sex in the relationship. For couples who have difficulty or conflict in coping with sexual changes, or additional relationship problems that affect sex and intimacy, couples counseling can be especially helpful.
Case Study: Karl S. Karl is a 62-year-old White male with a busy professional life and history of good sexual function and high sexual satisfaction, who presented for sex therapy after undergoing radical prostatectomy 2 years prior. He reported having regained good erectile function post-treatment with use of PDE-5i and reported overall positive sexual recovery. Karl had recently begun dating a new female partner and reported distress and anxiety about his anejaculation and “dependence” on PDE-5i for erectile function. He was particularly concerned about his partner’s reaction and feared she would perceive him as less masculine or less sexually satisfying than other partners she’d had. Since appropriate medical intervention was already in place, counseling focused on improving communication between Karl and his partner, specifically in talking with her about his concerns and having the opportunity to hear her reaction. In this case, his partner reassured him of her desire and attraction for him, and the lack of importance to her of his PDE-5i use or absence of semen with orgasm. Counseling additionally focused on helping him to prioritize her feedback as evidence for his sexual function being satisfactory to her, and to de-prioritize his own fears. Finally, we discussed cognitive and behavioral methods for stopping his tendency to compare himself to idealized versions of her past sexual partners. Karl’s anxiety was reduced and sexual satisfaction in their relationship improved.
Low Sexual Desire
Risk Factors
Low desire is an extremely common complaint among both men and women facing cancer [7, 8]. During cancer diagnosis and the active phase of treatment, loss of desire can stem from fear, stress, and anxiety about having cancer, or fatigue, pain, nausea, or illness associated with treatment. Many people in the active phase of treatment focus temporarily on survival, with other concerns, including sex, taking a back seat.
Androgen deprivation therapy . Some cancer treatments have direct effects on sexual desire. For men, androgen deprivation therapy (ADT) has an especially dulling effect on sexual desire. Androgen-blocking drugs and, less commonly, orchiectomy (removal of testicles) are used to reduce testosterone levels in order to prevent certain prostate cancers from growing or spreading. The resulting drop in testosterone results in significant decrease or altogether loss of sexual desire for many men. Other side effects that may not directly impact sex drive, but which may harm body image and sexual self-concept, include hot flashes, decreased energy and motivation, erectile dysfunction, delayed orgasm, weight gain, and breast enlargement [15]. Together, these changes create distress, frustration, relationship difficulties, and an altered sense of masculinity for many men. Men who experience such changes may feel anxious about approaching sexual situations, which can also lead to reduced desire and avoidance of sexual situations. ADT is also associated with depression, which may further diminish sexual desire [35].
Surgery or radiation to the testicles . The testicles produce about 95% of testosterone in men’s bodies [15]. In most cases of testicular cancer, only one testicle must be removed, and the other continues to produce enough testosterone to maintain adequate levels. Rarely though, cancer has spread to both testicles, or a remaining testicle does not function properly, and a man’s testosterone levels drop after orchiectomy [24]. Radiation can also affect testicular production of testosterone. Pelvic radiation to other organs can scatter to the testicles, temporarily damaging testosterone production. Direct radiation to the testicles is more likely to cause permanent damage.
Endocrine tumors . Pituitary gland tumors can alter hormone levels. For example, some types of pituitary adenoma can cause excess secretion of prolactin, leading to a condition called hyperprolactinemia. Excess prolactin is associated with low sexual desire [36].
Other medications . Narcotic pain medications, anti-nausea drugs, anxiolytics, beta-blockers (for blood pressure reduction), and antidepressants can all decrease libido. While these drugs are not specific to the treatment of cancer, they are often used to treat side effects or concerns that frequently co-occur in cancer patients.
Assessment
For screening purposes, the single-item screener for sexual problems mentioned previously is a good starting point [18]. One of the checklist items relates to problems with sexual desire, or wanting to have sex . For more comprehensive assessment or for research purposes, the PROMIS SexFS [19] includes items assessing sexual interest. A clinical interview can also be used to assess concerns about sexual desire. Providers may ask patients whether they have experienced any changes in sexual desire—including masturbation, sexual initiation or receptivity, sexual fantasies, feelings of sexual drive—along with history and course of the problem, any notable exceptions, current medications, and aspects of the sexual relationship that may be contributing. Patients should also be asked about related aspects of sexual function that may indirectly contribute to low desire, including erectile dysfunction, ejaculatory or orgasm problems, or pain with sex. Physiologic assessment should include tests for testosterone, prolactin, and thyroid function, along with assessment for comorbid sexual problems and psychological concerns [36].
Intervention Strategies
Physical/medical . Medical treatment depends to some extent on the cause of the problem. When anxiety, fatigue, depression, pain, or nausea related to treatment are barriers to sexual desire, treating these conditions with antianxiety, antidepressant, painkiller, or anti-nausea medication may improve sexual interest, though this is a delicate balance as all of these medications may also have the side effect of dulling sexual desire, as discussed previously. In the case of antidepressants, some have better sexual side effect profiles than others. Bupropion has the fewest reported sexual side effects, and for some patients it seems to improve sexual interest and function [15].
Hormonal adjustments can also help. Testosterone therapy, if appropriate for the patient, can improve sexual desire that stems from low testosterone [36]. If androgen deprivation is the culprit, unfortunately this is not an option, but psychosocial intervention can help in reducing the impact of low desire on a patient’s sex life. If low desire stems from hyperprolactinemia, high prolactin levels can be treated with bromocriptine or cabergoline [36].
For men who are struggling with changes in sexual function and associated dampening in sexual desire, helping to treat underlying concerns can help. Testosterone therapy and/or PDE-5 inhibitors can improve erectile function for some men, and thereby decrease anxiety about approaching sexual situations. Similarly, treating changes in ejaculation or orgasm that are causing distress can reduce sexual avoidance and improve desire.
Finally, lifestyle behaviors like exercise, adequate sleep, healthy diet, stress reduction, social interaction, fun and pleasure, and smoking cessation are foundational to physical health and therefore to sexual desire.
Psychosocial: Psychosocial intervention can help men to identify existing sexual desire that may not be as intense or frequent as before, find strategies to kindle desire, and improve communication between partners so that lack of desire presents less of a problem.
Behavioral management. Patients can be counseled on ways of managing low sexual desire to ameliorate negative effects on their sex life. One strategy may be for men become more aware of spontaneous desire throughout the day and make a note of when and where it happened, what sparked it, and what was done about it, if anything, in a “desire journal.” [28] This can provide clues as to when and under what circumstances desire manifests itself, and identify opportunities to act on desire when appropriate.
Another strategy is for men to “start from neutral” with sexual activity and let desire follow a conscious choice to engage in sexual activity. For many people, desire can follow arousal even if spontaneous desire was not there to begin with [37].
It can also help to identify “turn ons”—situations or activities that assist with becoming aroused from a starting point of feeling neutral. Turn-ons might include using erotic material to become aroused, engaging in longer foreplay with a partner, or increasing variety of sexual activities.
Sex therapy and couples therapy. If behavioral management strategies are insufficient, sex therapy can also help in managing or improving low desire. Particularly if treatment-related low desire is complicated by other factors like difficult past sexual experiences, relationship problems, or other psychological issues like anxiety or depression, sex therapy can provide in-depth and personalized intervention.
Couples therapy can help to improve communication about sexual issues between partners, resolve conflict or misunderstanding, and help partners to work together on creating a plan for improving their sex life. For many heterosexual couples, both partners may be accustomed to their sex life being driven by the man’s desire. Absent that, partners may struggle with rebuilding satisfying sexual contact. Partners of men with changes in sexual function are often careful about not pressuring their partners, and not “making them feel bad” by bringing up the topic of sex before they may be ready. Many couples find it helpful to talk about changes in sexual function and discuss fears and desires about their sex life going forward.
Both sex therapy and couples therapy have evidence for effectiveness in treating low sexual desire, and are recommended as components of best-practice treatment for low sexual desire in men [36].
Infertility
Risk Factors
Certain types of radiation, chemotherapy, and surgery can affect fertility. Whole-body radiation (e.g., for leukemia) and external-beam radiation to the abdominal and pelvic areas (e.g., for abdominal tumors, prostate cancer, or testicular cancer) can damage sperm-producing cells in the testicles. Further, some types of radiation to the brain affect the pituitary gland, which sends hormonal signals throughout the body. In some cases, damage to this gland can result in infertility [24, 28].
Some types of chemotherapy drugs also damage sperm-producing cells. These cells are especially vulnerable because they divide rapidly as do cancer cells, and rapidly dividing cells are targets of chemotherapy. Some drugs cause temporary infertility during and after treatment, and some, particularly at high doses, are known to cause permanent infertility [24, 28].
Surgery can lead to infertility by removing semen-producing structures (testicles and prostate), interfering with semen getting to the urethra, or damaging nerves that are necessary for erection or ejaculation . Surgery for testicular cancer often involves removing one or, more rarely, both testicles. Removal of one testicle should still allow for sperm production, as long as the remaining testicle is healthy and not affected by radiation. Radical prostatectomy for prostate cancer removes the prostate and seminal vesicles, which are responsible for making seminal fluid that mixes with the sperm to make semen. Surgery for some types of bladder cancer can involve removal of the bladder as well as the prostate and seminal vesicles. Without the prostate and seminal vesicles, sperm are still produced in the testicles but not able to be expelled [15, 24, 28]. Surgical removal of pelvic lymph nodes—for example, in some cases of testicular or colon cancer—can damage spinal nerves that are involved in ejaculation and orgasm. In these cases, semen may be produced but is unable to be expelled.
Assessment
All men who will receive a type of cancer treatment that is known to affect fertility should be assessed for interest in fathering children and, if interested, counseled about the risks involved and advised of fertility preservation options. It is important not to assume, due to patient age or other characteristics, that a man is not interested in fertility preservation. All patients should be assessed for these concerns . Health care providers can assess concerns about fertility either verbally or, for more extensive assessment or research purposes, a written inventory such as the Reproductive Concerns Scale [38].
Intervention Strategies
Physical/medical : Preventive measures. Men who will receive external-beam radiation to the pelvis may reduce risk of infertility by shielding the testicles from radiation. If infertility is a concern with chemotherapy, oncologists may be able to work with patients to find a chemotherapy regimen that is least likely to be toxic to sperm. With surgical intervention, nerve-sparing procedures, when feasible, provide the best opportunity for continued erectile and ejaculatory functioning and, therefore, fertility.
Sperm banking. Sperm banking may be an option for men undergoing treatment that will impair fertility. Briefly, sperm banking entails collecting semen from a patient prior to treatment and freezing it for later use in egg fertilization. This allows men to father biological children even if cancer treatment damages fertility.
Sperm retrieval. In cases in which sperm are still produced in the testicles but are unable to be expelled, there are surgical procedures for retrieving sperm cells from the testicles. When nerves that control ejaculation have been damaged, sometimes ejaculation can be stimulated by medication (usually ephedrine sulfate) or, more rarely, electrical stimulation. For men with retrograde ejaculation, sometimes sperm can be retrieved from the urine after ejaculation [24].
Psychosocial : Patient counseling. Given the possibility of permanent infertility following some cancer treatments, it is imperative that patients be counseled about risks and fertility preservation options prior to treatment. Unfortunately, some patients undergoing fertility-damaging treatment report that no one discussed fertility risks or preservation with them [39]. Whose job is it to do so? This depends on the medical center and treatment team involved. Anecdotally, some providers have noted that a barrier to discussing fertility with patients is lack of clarity about who is supposed to do so, and during which patient visit it should happen. It is helpful to clarify these details within an oncology department or treatment team so that protocol is clear.
What if fertility preservation is not possible for some reason, or if a patient discovers after treatment that he will be unable to have children? Appropriate empathy from treatment providers is helpful. It can also be helpful to acknowledge regret or anger about the loss of fertility. Support groups and individual or couples counseling can help patients come to terms with the loss of fertility, changes to anticipated life course, and any relationship concerns that arise as a result. If patients are interested, counseling can also help explore options for sperm retrieval, if possible, adoption or other ways of having children in their lives.
Fatigue
Risk Factors
The experience of cancer and treatment is a profoundly fatiguing process for many patients. Fatigue is associated with decreased sexual interest and problems with sexual function [7], and is a common contributor to low sexual desire. Some amount of fatigue is normal with illness and treatment. Chemotherapy creates fatigue for many patients, especially immediately following treatment. Surgery and radiation are also associated with fatigue, as the body directs its resources to healing. Simply having and fighting cancer engages the immune system on an ongoing basis and may result in fatigue. In addition to these factors, the stress of having cancer, fear and uncertainty about the treatment and outcome, and balancing cancer treatment with other life roles can create fatigue for many patients. Fatigue can also be a sign of depression, also common with cancer and its treatment.
Assessment
Clinical interview can be used to inquire about energy level, daytime fatigue, somnolence, ability to perform daily activities, and bother or distress due to low energy or fatigue. For more extensive assessment or research, the PROMIS Cancer Item Bank v. 1.0—Fatigue questionnaire (available from healthmeasures.net) assesses experience of and impairment due to fatigue. Patients complaining of fatigue should also be screened for depression.
Intervention Strategies
Physical/medical: Treatment to reduce correlates of fatigue like pain, nausea, or stress can help to reduce associated fatigue. Patients may consider talking to doctors about adjusting doses of painkillers or anti-nausea drugs if symptoms are inadequately controlled. Stress, anxiety, and worry can be sources of fatigue as well, which may be treated in part with anti-anxiety medication. For depression-related fatigue, antidepressant medication may help. Bupropion has some evidence for ameliorating fatigue as well as treating depression [40]. The stimulants methylphenidate and modafinil have some evidence for efficacy in treating fatigue among cancer patients [41], as does the practice of qi gong [42, 43].
Psychosocial: Psychoeducation. Sometimes the best treatment for fatigue is rest, especially following medical procedures from which the body needs to heal. Extended periods of needing rest can be emotionally challenging, especially for people accustomed to being busy or who derive pleasure, satisfaction, worth, or identity from their work, parenting, or other life roles. Men in particular may struggle with resting or reducing effort, as men are often socialized to work hard, take action, and be instrumental in getting things done for themselves and their families. Brief counseling can help to reassure men that fatigue and needing rest are normal, temporary, and necessary parts of cancer treatment.
Behavioral management. Counseling or brief consultation can also help to identify how to allocate limited energy, how to work around bouts of fatigue related to treatment schedule, and to prioritize valued activities. For fatigue related to stress, anxiety, or depression, counseling can be extremely helpful in identifying underlying causes and coping strategies for managing these feelings.
Counseling can also help to identify strategies for maintaining sexual activity or intimacy, if desired, through treatment-related fatigue. Patients (and their partners, if applicable) might be asked to identify a range of sexual or intimate activities they typically enjoy, and rank them from easiest (requiring least energy) to most demanding (requiring most energy). Men and their partners might then focus on the “easiest” activities in their repertoire while fatigue is present, in order to stay sexually connected during treatment.
Another strategy for coping with fatigue that comes and goes with a treatment schedule is to plan sexual activities for times that a person reliably has more energy. For example, if fatigue tends to occur after chemotherapy treatment but energy is good in the week prior to that, a couple might plan a date with sexual or intimate activity during that time.
Body Image and Sexual Self-Image
Risk Factors
During and after cancer treatment, many men experience their bodies differently than before. Men may have weight loss, hair loss due to chemotherapy, weight gain from hormonal therapy, scars, body parts removed, changes in continence or other bodily functions, ostomies or other medical devices, and changes in body appearance from surgery and radiation. These physical changes can profoundly impact a man’s view of himself, his attractiveness and desirability, “normalcy,” and sense of masculinity. Changes in body image and associated self-concept can cause a man to withdraw from sexual contact, fearing his partner’s reaction to his physical changes or not wanting to be reminded of them himself.
Particularly difficult are changes to sexual organs after treatment. Many men report shortening of penile length, and associated distress, after radical prostatectomy. One study of 126 men found average shortening of 1.3 cm in flaccid penile length, and 2.3 cm in stretched length, at 1 year post-prostatectomy [15]. Men with testicular cancer undergoing orchiectomy often experience distress associated with loss of a testicle. A silicone prosthesis can be implanted at the time of surgery to restore look and feel of the testicles, which may improve body image. The incidence of penile curvature, or Peyronie’s disease, is elevated after radical prostatectomy. About 15% of men will experience curvature after this procedure, compared to incidence of 3–9% in the general population [15]. Most men experience at least mild distress related to such changes, and many will experience clinically significant levels of anxiety and/or depression as a result.
Assessment
Clinical interview questions can be used to screen for body image concerns that are interfering with sexual or other activities; e.g., ‘are you having any concerns about your body appearance or function that get in the way of intimacy?’ The single-item screener by Flynn and colleagues [18] may also be used to indirectly screen for body image concerns. One checklist item inquires about anxiety related to sexual situations.
Intervention Strategies
Physical/medical: Physical management of bodily changes can help with sexual difficulties or embarrassment. For example, a man who experiences incontinence after prostatectomy might use a constriction band during sex to stop leakage during sexual activity or orgasm [15]. Someone with an ostomy following bladder or colon cancer might be instructed on how to empty and cover the ostomy pouch and appliances to make them less intrusive during sex [24]. Penile curvature may be treated with a variety of therapies. While no specific medical intervention exists to address body image concerns, lifestyle factors can help patients feel more positively about their bodies. Healthy diet and regular physical activity are associated with more positive mood and body image. Depression can contribute to negative self-assessment, so treating existing depression may help to address body image concerns as well.
Psychosocial: Individual or group counseling can help men to adjust to body changes and develop healthy self-concept that incorporates new aspects of physical appearance and function. Counseling can help to identify strategies to practice alone or with a partner may help patients to restore feelings of kindness, acceptance, and appreciation toward their bodies. Some strategies for body image improvement may include allowing time to grieve the loss of the pre-cancer body, desensitization to body changes through visual exposure, cultivating positive self-concept, or eliciting and accepting partners’ positive feedback.
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