In the UK, about 1 in 8 men will get prostate cancer at some point in their lives with the average age being 66.
The impact of undergoing surgery for prostate cancer can affect the sex lives of both partners.
Regaining normal erectile function after the most common prostate operation, radical prostatectomy, is rare according to a study by Dr Mikkel Fode from the Herlev Hospital in Copenhagen (2015).
This study raises the problem of erectile dysfunction after surgery, which resolves erectile issues but leaves many men with a less than satisfactory erection. They found that of the 210 men involved in the survey, 93% of the men said they experienced sexual problems post operatively.
This highlights the need to inform the man and his partner of the potential side effects to give a realistic view of the problems which may occur and how to overcome them. The average age of patients undergoing a radical prostatectomy is decreasing, so the ability to have an erection after surgery is important.
Many treatments for erectile dysfunction after prostate cancer improve erectile firmness, yet most couples stop using aids within 1–2 years according to Walker et al (2015). Beginning intervention early and taking a couples led approach is ideal to help recovery.
Sexual expectations of men and their partners is often high as they expect immediate and complete success following ED treatment. When the treatment is ineffective, they become demoralised and give up on their sex lives, rather than exploring other ways in which to enjoy sexual intimacy and pleasure that don’t focus on erectile function.
Research at the University of Texas MD Anderson Cancer Centre (2011) found that both internet based sexual counselling and traditional sex therapy were equally effective in improving sexual function and satisfaction. Couples waiting for counselling did not improve.
According to Professor Leslie Shrover PhD, “One of the crucial factors in a man having a good sexual outcome after treatment is a partner who also wants their sex life to get better”. Supportive partners had a positive effect upon sexual intimacy which was hugely beneficial.
New research from the Institute of Cancer Research, London (2017) found 60 per cent of women said they wanted more support from medical staff after their partner was diagnosed with prostate cancer. The impact of treatment affected their sex lives and relationships with 62 per cent saying they had become less sexually active since their partner’s diagnosis.
We are working with healthcare professionals, including specialist physiotherapists to help them advise their patients about the sexual side effects of treament and ways in which couples can still remain intimacte through rethinking the way in which they enjoy sex and incorporating sex toys into their sex play.
Regular sexual activity can help prevent or slow the normal vaginal changes that occur during or after the menopause. However, after a period of abstinence women can be surprised that sex is painful.
We recommend female partners invest in a simple vibrator to keep things in working order whilst their partner is recovering from his treatment. Using a sex toy is a great way to continue sexual intimacy and pleasure even when sexual intercourse isn’t possible.
For men in same sex relationships, the impact on sexual pleasure can be huge. However focusing on other ways to pleasure each other is important such as oral sex and masturbation, through using your mouth, hands or sex toys. The Pulse III Solo Essential is a male masturbator that has unique oscillating PulsePlates and can be used whether the penis is erect or flaccid, meaning those with ED can still enjoy the scintillating sensations.
The innovative PulsePlates stimulate the nerves of the penis and help promote blood flow and sexual sensation. SOLO can be used with or without lubricant, creating two completely different sensations for you to discover.
In addition to experiencing these symptoms, the stress of cancer treatment and the disruption to a couple’s normal sexual activity can lead to a decline in interest in sexual intimacy and make getting back into a normal sexual routine difficult.
Some longer term studies have found that sexual and emotional intimacy, in addition to relationship satisfaction, declines.
Low libido can be problematic if taking PDE51s (viagra) as you need to be aroused for it to work. So using vacuum pumps and penile implants can help create a partial or even full erection even if libido is low.
Research conducted at Geneva University Hospital recommend that couples should undertake counselling prior to the surgery to ensure that they fully understand the side effects, and what they can do to ensure that they maintain sexual intimacy and pleasure.
By making couples aware of the changes that may happen to male sexual function after surgery, they can be prepared. Changing the way in which you view your sex life and sexual activity can help and making changes to way in which you enjoy sexual intimacy and pleasure will enable a couple to come through the postoperative period feeling sexually connected.
Ways to overcome Sexual Dysfunction
For people who have cancer, renegotiating sex involves being adventurous and exploring all avenues of sexual pleasure, whatever sexual orientation you are. Great sex without intercourse can often lead to increased sexual pleasure and intimacy than prior to the diagnosis.
A study by Ussher et al (2013) explored renegotiation of sex in people with cancer and their partners, and found that 70% of the participants reported that exploring non coital sexual practices such as masturbation, mutual genital touching or oral sex was considered to be just as satisfying as coital sex.
The couples who said there was an absence of sexual renegotiation were more likely to say they didn’t discuss sex before cancer and were very unlikely to be discussed now.
For many couples, sexual intimacy had been lacking in their relationships and therefore it now became more of a focus, improving their sexual relationship. Opening channels of communciation is important in sexual relationships.
Working with a pelvic health physiotherapist
Working with a pelvic health physiotherpist pre op is so important but not often recommended to men requiring prostate surgery. Teaching them how to do their pelvic floor exercises is much easier before surgery than post op when they may be in discomfort or feeling the side effects of chemotherapy or radiotherapy.
Often seen as something only done by women, pelvic floor exercises can benefit the sexual health of men, making erections stronger, last longer and improving sexual performance. Research by the University of the West of England Bristol (2003) found that pelvic floor exercises may be very effective in treating erectile problems when performed regularly.
Researchers from the Sapienza University of Rome (2014) have demonstrated that pelvic floor exercises can help men control premature ejaculation, making sexual intercourse more pleasurable and satisfactory for them and their partners. According to researchers, Kegel exercises also increases blood flow to the penis so men can sustain erections and orgasm.
Seek advice from a physiotherapist who can teach you how to perform pelvic floor exercises to ensure that you learn how to do them correctly, in order to benefit your sexual health. Your doctor should be able to recommend a suitable physiotherapist who is trained to treat male sexual health problems.
Using sex toys
Incorporating sex toys into your sex play can allow couples to continue to enjoy sexual pleasure and intimacy even when penetrative sex isn’t possible. Many healthcare professionals aren’t aware of what products can be beneficial to sexual health and stick to medical devices and medication, which often leads to less satisfactory sexual outcomes. A combination of medical treatment and sex toys can be more beneficial to sexual function (Walker 2015).
Involving both partners in the discussion
To ensure that couples fully understand the implications of prostate cancer and treatment on their sexual relationship, partners need to be included in the discussion right from the start.
Being made aware that there are ways in which you overcome some of these problems, if or when they arise, helps couples to deal with any problems, as well as involving them in the treatment process. It also speeds up the rate of recovery for the man, allowing a couple to return to enjoying sexual pleasure and intimacy, in whatever way they can or want to.
Wait and See
New research conducted by the National Institute for Health Research published in the New England Journal of Medicine (2016) followed 1,643 men with small prostate cancers over 10 years and found that those who didn’t receive surgery or radiotherapy had the same 99% survival rate than men who underwent treatment. Side effects to treatment, such as sexual dysfunction and incontinence, in addition to bowel problems following radiotherapy doubled by 50%.
However, the prostate cancer progressed in one in five men under surveillance. These men could be treated but it may impact on the outcome of their survival beyond 10 years.
According to a new study at the Dana-Faber Cancer Institute (2019) many men with low-risk prostate cancer who most likely previously would have undergone immediate surgery or radiation are now adopting a more conservative ‘active surveillance’ strategy. The use of active surveillance increased from 14.5 percent to 42.1 percent of men with low-risk prostate cancer between 2010 and 2015
In a landmark decision in May 2019, NHS rationing watchdog NICE ( National Institute of Clinical Excellence) has now included active surveillance in its official guidance for men with localised low risk cancer which included blood tests and scans.
Surveillance is suitable for men who have early stage cancers. Those who have more aggressive tumours require treatment.
Many men and their partners often cite that they wished they’d never had treatment because of the impact of the side effects upon their relationships.
Radiation Therapy v Surgery
New research published in the Journal of Clinical Oncology (July 2017) has found in a survey of almost 1,000 patients that nearly 15% of men with localized prostate cancer regretted the decisions they made regarding treatment, because it impacted upon their sexual function. About twice as many men expressed regret after radical prostatectomy or radiation therapy as compared with active surveillance, highlighting the need for informed discussions about treatment side effects between patients and medical professionals before deciding how to manage early prostate cancer.
The CEASAR study (2011-12) found that men who underwent radical prostatectomy experienced more issues with urinary and sexual functioning than those treated with external beam radiotherapy.
Published in the Cancer Network-Home of the Oncology (2017) Dr James Hu and Dr Daniel Hamstra compared radiotherapy and prostatectomy for localised prostate cancer to discover the impact upon quality of life and concluded that recent innovation in radiation treatment have shown it leads to better quality of life compared to outcomes from new surgical innovations.
It is reassuring that survival rates are the same for men who undergo surveillance of their prostate cancers compared to those who have treatment. More men who have early stage prostate cancer may opt for surveillance rather than having treatment. Those who do want to have treatment may be suitable for radiation treatment rather than surgery as it has fewer side effects.
Although this article is about prostate cancer, many men experience ED following prostate surgery for an enlarged prostate and much of the advice is the same. However, through the work we do at Jo Divine we often hear about men who experience incontinence and ED following surgery and have not been given any support or advice beyond take Viagra. The impact upon the physical and mental health of men and their partners can be devasting which is why support, practical advice and pelvic physiotherapy should be offered when patients undergo any medical/surgical intervention that can and will have an impact upon their sexual function, intimacy and pleasure.
Prostate UK have created leaflets for people who are LGBTQ+and have a dedeicated group on their online forum for Gay, bisexual, MSM (men who have sex with men).
One of the positive benefits of twitter is that I have been able to connect with some amazing, inspirational people across the world, includng those who cancer. Gogs Gagnon asked if I would read his book about his experience of Prostate cancer, the honest and intimate impact it has had upon his physical and mental wellbeing and relationship with his lovely wife, explaining his treament in layman terms that people can understand and how one size doesn’t fit all, choosing the right treament for you is so important. I always enjoy books written by patient experts and this was no exception. As a former nurse I strongly believe the patient expert is the way forward in educating and informing other patients and healthcare professionals.
“Prostate Cancer Strikes: Navigating the Storm by Gogs Gagnon”, Granville Island Publishing Ltd
Prostate Cancer UK : www.prostatecanceruk.org
Macmillan : www.macmillan.org.uk
Orchid : www.orchid-cancer.org.uk
Tackle Prostate Cancer : www.tackleprostate.org
College of Relationship and Sexual Therapists : www.cosrt.org.uk
British Association of Urological Surgeons : www.baus.org.uk
British Association of Urology Nurses : www.baun.co.uk