Basel, Switzerland ( Dr. van Oort discussed the important topic of managing sexuality and incontinence issues in patients with advanced prostate cancer.

According to the EAU guidelines cessation of sexual activity is very common among patients treated with androgen deprivation therapy (ADT), affecting up to 93% of patients. ADT reduces both libido and the ability to gain and maintain erections. The management of acquired erectile dysfunction (ED) is mostly non-specific.

The EAU recommendations for treatment to improve the quality of life in men on ADT include:

  1. Supervised physical exercise
  2. Maintaining healthy weight and diet
  3. Quitting smoking
  4. Yearly screening for diabetes and hypercholesterolemia
  5. Supplementation with vitamin D and calcium
  6. Offer patients with T1-T3 disease multidisciplinary rehabilitation addressing incontinence, sexuality, depression and fear of recurrence, social support and positive lifestyle changes after any radical treatment.

Urinary symptoms are very common among prostate cancer patients at any stage of the disease. The most common urinary symptom which significantly bothers patients is frequency, which occurs in 18.6% of patients. Almost 13% of patients report leaking urine at least once per day. In men who underwent radical prostatectomy the reported level of incontinence is higher with 23.4% reporting of leaking urine at least once per day and 31.4% reported using at least one pad per day.

When assessing sexual symptoms, it is important to remember that 50% of prostate cancer patients will receive ADT at some point in the disease trajectory. Castrate levels of testosterone have a dramatic impact on the patient’s quality of life. ADT also significantly affects the intimate partners of patients, who often experience more distress than the patients themselves. A total of 81.5% of patients report problems reaching an erection, 76.6% have issues with reaching an orgasm, and 81% complain about their overall sexual function.

Patients also lose their libido as a result of their treatment, with some remaining troubled by the loss of erection as well, and some being relieved that the loss of erection is accompanied with the loss of libido. Improvements in ED can improve the patient’s sense of masculinity and self-esteem. Reduction in libido leads to withdrawal of emotional and physical intimacy and can lead to significant partner distress. Many times patients do not want to talk on the adverse effects of ADT while their partners do. The coping mechanisms described by patients include denial, which can lead to isolation of either or both partners, loss of hope of satisfying their partner and subsequent loss of intimacy. This can be even more detrimental than the loss of the ability to have intercourse.

It is therefore imperative that partners be included in the treatment decision, consent process, and provide adequate and appropriate support. When complex sexual and relationship issues arise, it is critical to involve a clinical psychologist, relationship counselor or/and sexologist or sexual medicine specialist.

There is very little information on male partners, and most of the literature is based on heterosexual couples. The physiologic changes due to prostate cancer treatment seem to have a greater impact on the sex life of homosexual couples. As a result of prostate cancer treatment, homosexual men appear to have a lower quality of life, reduced male self-image, and more psychological problems.

Dr. Oort also provided data on the percentage of patients that were offered medical aid to improve erections, showing that there is much room for improvement. A total of 58.6%, 77.4% and 85.2% of patients were not offered medication, devices, or specialist services, respectively, to try and improve erections.

To summarize, Dr. Oort stated that we need to pay more attention to sexuality issues in patients with hormonal treatment, as quality of life is critical for them.

Presented by: Inge van Oort, MD, PhD, Radboud Institute for Molecular Life Sciences, Nijmegen, Netherlands  

Written by: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, New York, USA, Twitter: @GoldbergHanan at the 2019  Advanced Prostate Cancer Consensus Conference (APCCC) #APCCC19, Aug 29 – 31, 2019 in Basel, Switzerland