INTRODUCTION — For males with cancer, sexual dysfunction is a common issue that has a negative impact on their psychological functioning and quality of life, irrespective of their involvement in stable relationships or their sexual preferences. While sexual dysfunction can be directly related to the primary diagnosis of cancer, aspects of male sexuality are often impacted to a greater extent by treatment than by disease. While males treated for cancer who complain of sexual dysfunction are often assumed to have a purely physical issue (predominantly related to erectile dysfunction [ED]), a biopsychosocial model (figure 1) has been proposed in which male sexual function after cancer is a complex interplay in which physical, interpersonal, and psychological issues all play a role [1]. This includes incorporation of an individual's sexual self-schema, broadly understood as their own characterization of sexuality, which in turn, influences their own behavior, affect, and the way they process sexually relevant information [2].
Most of the data on male sexual dysfunction are derived from patients with a history of prostate cancer, although research suggests that males with other types of malignancies are also impacted negatively. This topic will discuss sexual dysfunction in male cancer survivors. A separate topic for female cancer survivors and a general overview of male sexual dysfunction are covered separately. (See "Overview of sexual dysfunction in female cancer survivors" and "Epidemiology and etiologies of male sexual dysfunction".)
MAJOR TYPES OF SEXUAL DYSFUNCTION IN MALE CANCER SURVIVORS
Erectile dysfunction — Erectile dysfunction (ED) is the most common concern for males treated for cancer. ED is defined as the persistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual activity that persists for at least three months [3]. While ED is common, it may be secondary to another issue, such as the lack of desire or orgasmic issue, medications, or depression or issues with a negative body image. (See "Epidemiology and etiologies of male sexual dysfunction", section on 'Erectile dysfunction'.)
Sexual bother — When sexual dysfunction is perceived as a problem, causes embarrassment or shame, or reduces one's ability to enjoy life, it is often characterized as sexual bother. While it is associated with the presence of ED, bother can be identified in the absence of ED as well. In one study that included over 180 males who underwent a radical prostatectomy, sexual bother (measured using a validated instrument) increased from baseline at 12 months and was sustained at 24 months in males with and without ED [4]. Of concern, only 7 percent of males with ED moved from "bothered" at 12 months to "not bothered" at 24 months. No clinical factors that predicted bother were identified.
Loss of libido — Loss of libido can be seen in males treated for cancer as a primary consequence of androgen deprivation therapy (ADT) or secondary to ED. Most males are used to living with a robust interest in sex, even though it does decrease with age, and loss of libido causes significant distress. Loss of libido may result in loss of masculine self-image and in relationship conflict due to lack of emotional intimacy [5]. (See "Epidemiology and etiologies of male sexual dysfunction", section on 'Decreased libido'.)
Orgasmic dysfunction — Complications with orgasm include orgasm-associated urinary incontinence (climacturia), lack of orgasm (anorgasmia), painful orgasm (dysorgasmia), and changes in the orgasmic threshold. In one review of males undergoing radical prostatectomy or robot-assisted prostatectomy for prostate cancer, the self-reported incidence of climacturia was 30 percent, with a similar incidence between the two surgical approaches [6]. However, dysorgasmia was more common among patients undergoing radical prostatectomy compared with those undergoing robot-assisted prostatectomy (12 versus 7 percent).
Other concerns — Although ED and sexual bother are the most common forms of sexual dysfunction in male cancer survivors, other issues have been reported. These include the following [7]:
●Disorders of ejaculation, mostly comprising the inability to ejaculate rather than premature ejaculation
●Reduced penile length
PREVALENCE AND RISK FACTORS — Sexual dysfunction is a common concern for males diagnosed with cancer. This was shown in a 2009 needs assessment survey done to inform the benefit of a sexual health clinic in a major cancer center in the United States [8]. Among male respondents, 49 and 30 percent reported the onset of erectile dysfunction (ED) and orgasmic/ejaculatory concerns, respectively, after their cancer was diagnosed. In addition, only 60 percent reported continued and ongoing sexual activity, which was down from a self-recalled sexual activity rate of 80 percent before cancer.
Overall, the prevalence of sexual dysfunction varies according to the type of cancer a male has. Sexual problems are most commonly reported amongst males with genitourinary cancers, but they also affect a large proportion of those with gastrointestinal and other cancers.
Prostate cancer — For males with prostate cancer, a reduction in sexual activity, function, and satisfaction has been noted before treatment, with 15 percent of males reporting no sexual activity in the prior month [9]. Thirty-seven percent reported ED, and 48 percent reported decreased sexual desire more than 50 percent of the time. However, sexual dysfunction in survivors of prostate cancer also arises from the treatment modalities that exist for the disease, specifically prostatectomy, radiation therapy (RT), and androgen deprivation therapy (ADT) [10,11].
●Sexual dysfunction after prostatectomy – ED is common after radical prostatectomy, with estimates ranging from 27 to 77 percent after radical prostatectomy. Increased surgical experience is generally associated with better postoperative ED outcomes [12]. However, radical prostatectomy places traction on the cavernosal nerves which may induce neurologic damage, no matter what the surgical approach (open, laparoscopic, or robotic-assisted). In addition, electrocautery in the vicinity of these nerves during the surgery can also cause damage [13]. While bilateral nerve-sparing surgery may reduce the incidence of ED, there is wide variation in the prevalence of ED reported after this type of surgery, and it is still not a rare outcome [14]. There can be improvement over time, although recovery can be delayed and can continue even beyond two years [15]. (See "Radical prostatectomy for localized prostate cancer", section on 'Erectile dysfunction'.)
Other sexual side effects reported after prostatectomy include subjective loss of penile length (47 percent), climacturia (the loss of urine during orgasm; 23 percent) [16], penile curvature (10 percent), and sensory changes (25 percent) [17]. Males also report altered experience of orgasm, including lack of pleasurable orgasm (anorgasmia), as discussed above. (See 'Orgasmic dysfunction' above.)
●Sexual dysfunction after RT – RT to the pelvis has similar effects on erections, although they are slower in onset, with some symptoms of ED delayed up to two years after treatment [18]. RT for prostate cancer is theorized to cause ED through damage to the neurovascular bundles, the interior and accessory pudendal arteries, the corpora cavernosa, and the penile bulb [18]. In one series of males treated with RT for prostate cancer, 30 to 45 percent of males who were able to have erections prior to RT developed ED after therapy, with the frequency increasing over time. In another study, over fifty percent of males reported ED five years after RT [19]. (See "External beam radiation therapy for localized prostate cancer", section on 'Sexual dysfunction'.)
●Sexual dysfunction with ADT – ADT is a treatment for males with advanced or recurrent prostate cancer that can affect sexual function. Unfortunately, sexual dysfunction is a direct consequence of ADT, and males report significant issues related to both libido and erections [20]. Testosterone recovery after cessation of ADT is related to age, duration of ADT, and baseline testosterone levels. Sexual dysfunction often worsens over time. Up to 10 percent of males will remain with castrate testosterone levels 24 months after cessation of treatment [21]; in a majority of patients, return to baseline levels of sexual function will never occur [22]. ADT-related sexual dysfunction also may impact emotional intimacy or cause distress with their partner, because loss of libido may affect the patient's displays of affection towards the partner [23].
Testicular cancer — Testicular cancer affects a predominantly young population and is the most common cancer in males between the ages of 20 and 34 years [24]. While the cancer itself is not associated with sexual dysfunction, treatment is associated with sexual dysfunction in approximately one-third of patients [25]. As an example, in a prospective study that included over 160 males treated for early-stage seminoma with orchiectomy and RT [26]:
●Over 60 percent reported changes in their body image following orchiectomy
●Over 20 percent complained of reductions in sexual interest, activity, and pleasure six months following treatment
Gonadal effects of treatment include reduced spermatogenesis, impaired fertility, and hormonal changes that may be due to surgery (especially retroperitoneal surgery), RT, or chemotherapy. There appears to be no clear association of hypogonadism and sexual function; the diagnosis itself and treatment may be a factor in sexual problems [27]. (See "Treatment-related toxicity in men with testicular germ cell tumors", section on 'Gonadal effects'.)
Serial evaluation of hormone levels should be performed as part of the long-term follow-up of testicular cancer survivors. (See "Approach to the care of long-term testicular cancer survivors", section on 'Hypogonadism'.)
Fortunately, gonadal dysfunction does not appear to be a long-term issue, with most studies indicating that sexual function normalizes over time. In one study, for example, the prevalence of overall sexual dysfunction reported by survivors was not much different than that for a normative sample (39 versus 36 percent, respectively), although specific scores related to ejaculation were lower [28]. The presence of a partner is important for quality of life after treatment; unpartnered males may worry about the impact of testicular on future relationships [29].
While rare, bilateral testicular cancer is seen, with an incidence reported to be <2 percent, although only 0.56 percent present as synchronous tumors. For these patients, bilateral orchiectomy may be necessary, and as a result, they require long-term testosterone supplementation. Fortunately, in one study, survivors of bilateral testicular cancer were not found to have greater sexual problems than those with unilateral testicular cancer [10]. (See "Testosterone treatment of male hypogonadism".)
Penile cancer — There are limited data on the sexual outcomes of this rare cancer; however, for males with low-risk tumors, organ-sparing treatments (eg, laser therapy, brachytherapy) appear to have few sexual side effects [30]. On the other hand, males who have partial penectomy experience problems with orgasm and body image [31]. Male cancer survivors may also lose confidence in their masculinity, although some are able to resume an active sex life after treatment; this is in part dependent on age, relationship status, and treatment modality [32]. (See "Carcinoma of the penis: Surgical and medical treatment", section on 'Treatment of the primary tumor'.)
Bladder cancer — ED is present in up to 60 percent of male patients with bladder cancer, with the prevalence highest amongst those treated with radical cystectomy and resection of the prostate and seminal vesicles [33]. Orgasmic dysfunction is also a common problem after such procedures, and the etiology appears to be similar to that seen after radical prostatectomy [34]. Male patients treated with radical cystectomy report poor sexual function, decreased sexual enjoyment, and increased discomfort with sexual intimacy [35]. Those with neobladder reconstruction also may experience profound sexual dysfunction and body image changes related to incontinence, and many never resume any sexual activity postoperatively [36]. (See "Radical cystectomy", section on 'Men'.)
Gastrointestinal cancer — A wide variety of sexual dysfunctions are experienced by males who have been treated for colon, rectal, and anal cancer, which may impact their quality of life. These include decreased libido, ED, and ejaculatory disorders, including retrograde ejaculations [37-40].
Males with colorectal cancer who undergo surgical resection of disease experience similar effects to those who undergo radical prostatectomy due to proximity of the bowel to the prostate. Damage to the periprostatic plexus results in partial or complete ED, and damage to the sympathetic fibers can result in ejaculatory disorders [41]. Total mesorectal excision is associated with both ED and ejaculatory dysfunction [42]. Risk factors for sexual dysfunction include preoperative treatment in the form of RT, lower tumor location, older age, presence of a stoma, and complications during and after surgery [43].
In general, sexual dysfunction is more common in patients treated for rectal than colon cancer [44]. In addition, certain types of treatment for these cancers, such as RT or an abdominoperineal resection approach, are major risk factors. (See "Approach to the long-term survivor of colorectal cancer", section on 'Sexual dysfunction'.)
As examples:
●In one study that included over 600 males treated with surgery, with or without RT, for rectal cancer, the rate of general sexual dysfunction was 76 percent, with 72 percent reporting issues with ejaculation [37]. Overall, 32 percent of those who were sexually active before treatment were not at three months and out to two years following surgery [37]. Males who were sexually active prior to cancer surgery also reported general sexual function deterioration postoperatively, which did not improve over time. Among the main risk factors for sexual dysfunction were pelvic RT and the presence of a stoma.
●Others also report higher rates of sexual dysfunction after abdominoperineal resection than after sphincter-sparing surgery. In a study that included over 900 patients (66 percent males) treated as part of a National Surgical Breast and Bowel Project (NSABP) randomized trial, quality of life was assessed at baseline and then one year later [38]. At one year, compared with patients who underwent a sphincter-sparing surgery, those who underwent abdominoperineal resection reported significantly worse body image and, for males, significantly worse sexual enjoyment.
●Males with colon cancer report less sexual satisfaction and lower frequency of sexual intercourse. Partner distress also has a negative effect on the patient's sexual quality of life [45]. Sexual problems can also persist for years. In one study, 37 percent of males reported poor sexual well-being at five years after treatment. Risk factors associated with poor sexual well-being included depression and the presence of a stoma [46].
●Sexual dysfunction is impacted by the presence of a stoma. In one study, males with a stoma more frequently reported problems achieving and maintaining an erection after surgery compared with those with an anastomosis (70 versus 60 percent) [47]. Fecal incontinence is another major concern [48] and fear of this happening during sex is a contributor to loss of sexual desire.
The majority of male anal cancer survivors who are treated with combined-modality RT and chemotherapy report inability to achieve or sustain an erection, difficulty with climaxing, lack of interest in sex, and less energy. (See "Treatment of anal cancer", section on 'Toxicity and quality of life issues'.)
Other cancers
Hematologic malignancies/stem cell transplantation — Sexual dysfunction is a common and persistent long-term problem for those treated with stem cell transplantation [49]. Treatment for leukemia is associated with sexual dysfunction [50,51]. In a study of adolescent and young adult cancer survivors (mean 16 years since the index diagnosis of cancer), 62 percent had a hematologic malignancy [50]. Of males surveyed, 32 percent reported at least one type of sexual dysfunction. (See "Effects of cytotoxic agents on gonadal function in adult men".)
Temporary or permanent hypogonadism is common in males after both autologous and allogeneic stem cell transplantation, and this may lead to lack of libido and ED. In addition, the chronic administration of glucocorticoids for treatment of chronic graft-versus-host disease can suppress the hypothalamic-pituitary-adrenal axis, and the side effects of high-dose corticosteroids can also have a negative impact on body image [52]. (See "Survival, quality-of-life, and late complications after hematopoietic cell transplantation in adults", section on 'Hypogonadism and fertility issues'.)
Graft-versus-host disease is also known to cause disruption of body image and sexual problems [53]. Males report a range of sexual problems after allogeneic stem cell transplant including ED (72 percent) and for some, this persisted for more than five years [54]; however, more males remain sexually active compared with females [55]. Fear of infection because of immunocompromise has also been shown to have an impact on sexual relationships [56]. (See "Clinical manifestations and diagnosis of chronic graft-versus-host disease".)
Head and neck cancer — Male patients who were treated for head and neck cancer report a high prevalence of sexual dysfunction. In one study that included 192 males treated for laryngeal cancer, sexual difficulties were the second most common problem reported, with 53 percent reporting that their sex life was worse or much worse than before cancer [57]. Decreased sexual activity due to loss of libido and fatigue is common [58] but recovery has been shown to occur after a year following treatment [59]. (See "Overview of approach to long-term survivors of head and neck cancer", section on 'Sexual dysfunction'.)
For these patients, sexual dysfunction may also have an anatomic basis (eg, chemotherapy-induced peripheral neuropathy) or a more complex etiology related to body image disruption, intimacy issues, and psychological distress [60]. (See "Overview of approach to long-term survivors of head and neck cancer", section on 'Neuromuscular toxicity' and "Overview of approach to long-term survivors of head and neck cancer", section on 'Psychosocial issues'.)
Lung cancer — Sexual side effects are common in males treated for lung cancer, with contributing factors including dyspnea, fatigue, and worsened self-image related to either the disease or its treatment. Males treated with thoracotomy are four times more likely to experience ED, since hypoxia is related to nitric oxide, a key component in erections. The challenge of a lung cancer diagnosis may also contribute to emotional well-being and psychological function [61]. These issues are covered in detail separately. (See "Overview of approach to lung cancer survivors", section on 'Sexual dysfunction'.)
SCREENING AND COUNSELING — Ideally, males at risk for sexual dysfunction should be screened prior to cancer treatment. While, in practice, screening may be more commonly performed for males with tumors involving the pelvis, it should be offered to all males with cancer, given the prevalence of sexual dysfunction across all cancer types. Many of the common side effects of cancer, including fatigue, pain, and altered body image, may affect sexual functioning, especially libido. Additionally, screening should be ongoing following treatment, both in the tertiary and primary care settings, as sexual dysfunction may be a late effect of cancer treatment [62].
Assessing these aspects may identify sexual problems, especially if the man does not volunteer information about sexual issues. Early interventions for sexual dysfunction may ameliorate some of the negative sexual effects of cancer and its treatment. (See 'Management' below.)
These recommendations are in keeping with an American Society of Clinical Oncology Clinical Practice Guideline adaptation of Cancer Care Ontario's guideline [63] on interventions to address sexual problems in individuals with cancer, which recommends the following [64]:
●A discussion with the patient, initiated by a member of the health care team, regarding sexual health and dysfunction resulting from cancer or its treatment. The conversation could include the patient's partner if the patient wishes. Discussions should be congruent with the patient's literacy level, cultural/religious beliefs, and sexual orientation. This discussion should be offered at the time of diagnosis and should be repeated periodically during follow-up.
●Specific recommendations are made for management of erectile dysfunction (ED), stress urinary incontinence, body image changes, and vasomotor symptoms; for prevention of penile length loss; and for psychosocial counseling to potentially improve sexual functioning and satisfaction. The recommendations also support checking testosterone levels, even if the patient has a cancer that is not typically associated with hormone changes. Options should be discussed when testosterone levels are within normal range but the patient or clinician feels that supplementation might have a clinical benefit and it is not contraindicated. (See 'Management' below.)
Sexual health questionnaires — Several validated instruments exist to evaluate male sexual dysfunction. (See "Evaluation of male sexual dysfunction", section on 'Validated instruments to assess sexual function'.)
We use the Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function Profile (table 1) [65]. The PROMIS group has developed a sexual function scale specific to males who have cancer. This questionnaire consists of eight questions that screen for erectile function, satisfaction, orgasm/climax, and enjoyment. It is available online after registration. (See "Evaluation of health-related quality of life (HRQL) in patients with a serious life-threatening illness", section on 'PROMIS'.)
Alternative questionnaires include the following:
●The International Index of Erectile Function (IIEF) is a 15-item self-report measure that records erectile function, orgasm, desire, intercourse satisfaction, and overall satisfaction (table 2) [66]. The IIEF is valid and reliable; however, it does include items related to ejaculation that cannot be answered by males after radical prostatectomy and is suitable only for heterosexual males.
●The Sexual Health Inventory for Men (SHIM), also called IIEF-5 (table 3) [67], is a five-item questionnaire that has been validated to the domain of erectile functioning.
●The Prostate Cancer Index (PCI) Sexual Function and Sexual Bother score is a 20-item self-report measure of health-related quality of life specific to males with prostate cancer that includes items about urinary, bowel, and sexual domains. While valid and reliable in this population, we find it is too lengthy for use in clinical practice.
EVALUATION — The evaluation of sexual dysfunction in males with cancer, including history, physical examination, and laboratory testing, mirrors the approach to males without a history of cancer. A more detailed discussion on the evaluation of males with sexual dysfunction is covered separately. (See "Evaluation of male sexual dysfunction".)
Importance of involving the partner — For males with sexual dysfunction, the evaluation should include an assessment of the relationship they have with their partner (if one is present) because both patient and partner-related factors are important for sexual recovery [68].
It is important to recognize that cancer represents a threat to relationships. Males may refuse to acknowledge that this has occurred, place the blame of the situation on their partner, or abandon sexual relationships altogether [69]. This in turn may result in a detrimental effect on their partner, with data suggesting that there is a negative impact on their sexual functioning and mental health [70].
MANAGEMENT — In general, treating male sexual dysfunction requires a multidisciplinary approach consisting of medical and psychological support, which should be offered to both the patient and their partner. (See 'Treatment team and referral' below.)
Because the most common issue for males after cancer is erectile dysfunction (ED), much of this discussion will focus on treatment for this particular condition. Briefer discussions below touch on the management of other sexual dysfunctions. (See 'Other sexual concerns' below.)
A more detailed discussion on the treatment of males with sexual dysfunction is covered separately. (See "Treatment of male sexual dysfunction".)
In addition, attention should be paid to the etiology of treatment-related side effects causing sexual dysfunction in males with cancer, with recognition that idiopathic etiology is more likely in these patients. Management of sexual dysfunction in males with specific cancer types or following specific procedures is also discussed in detail elsewhere. (See "Radical prostatectomy for localized prostate cancer", section on 'Management' and "Overview of approach to prostate cancer survivors".)
Treatment team and referral — A multidisciplinary approach is important so that not only physiologic, but also psychological and relationship issues are addressed. Knowledge of cancer is important, so attention should be paid to referring males to sex therapists or sexuality counselors who are well versed in treatment effects for cancers affecting males. Sexual medicine specialists are ideally suited to provide care for these patients.
Some penile rehabilitation programs rely heavily on pharmacotherapeutics, which we generally do not endorse because of the above value of a multidisciplinary approach.
Erectile dysfunction — For male cancer survivors who want to pursue therapy for ED, the options include medications, vacuum devices, and penile implants. All of these interventions have data suggesting efficacy. Nonpharmacologic approaches such as pelvic floor physiotherapy and mindfulness practices may also supplement these approaches. Our initial approach begins with oral medications coupled with psychological support.
We reserve more invasive therapies for those who do not achieve a self-defined good response to more conservative treatment. Data are limited for the efficacy of low-intensity shock therapy to the penis in male cancer survivors [71,72]. (See "Treatment of male sexual dysfunction".)
Despite the prevalence of ED in male cancer survivors, most are often reluctant to seek treatment [73]. In addition, expectations of success are often not realized, which may lead to nonadherence to therapeutic suggestions [73]. Patients who use erectile aids (oral medications, vacuum pump, or penile injections) report barriers to their use including side effects, lack of efficacy, lack of spontaneity, cost, and changes in sensation during the use of such erectile aids [74].
Phosphodiesterase-5 inhibitors
Rationale — Evidence suggests that phosphodiesterase-5 (PDE-5) inhibitors may be a useful treatment for ED in cancer patients [75-77]. Data regarding mechanism of action as well as use of specific PDE-5 inhibitors are covered elsewhere. (See "Treatment of male sexual dysfunction", section on 'Phosphodiesterase-5 inhibitors'.)
Much of the data regarding the role of PDE-5 inhibitors (eg, sildenafil, tadalafil, vardenafil) in cancer come from studies in male patients with prostate cancer. Overall, the data support the use of these medications after either surgical or radiation therapy (RT) for this disease, with no apparent evidence that the available agents differ in efficacy, safety, or tolerability (table 4). Despite this, patients tend not to consistently use them, and significant attrition has been reported [75].
The use of PDE-5 inhibitors for ED after cancer is supported by a 2015 meta-analysis that included six studies of males who underwent a nerve-sparing radical prostatectomy (n = 1678) and who were treated with a PDE-5 inhibitor or placebo [76]. Compared with placebo, PDE-5 inhibitor therapy resulted in significant improvements in the following:
●Erectile function (measured using the International Index of Erectile Function [IIEF] Erectile Function domain score)
●An almost 15-fold improvement in successful vaginal penetration (odds ratio [OR] 14.87, 95% CI 4.57-48.37)
●A 47-fold increase in the odds of successful intercourse (OR 47, 95% CI 3-13.98)
For males treated with definitive RT, more limited data suggest that PDE-5 inhibitors are also beneficial. In one systematic review, four randomized trials were included [77]. Erectile function appeared to respond to PDE-5 inhibitors when evaluated using the IIEF questionnaire. Compared with placebo, PDE-5 inhibitors resulted in significant improvements in the following:
●Erection frequency (hazard ratio [HR] 0.71, 95% CI 0.5-0.92)
●Erection firmness (HR 0.78, 95% CI 0.57-0.99)
●Maintenance frequency (HR 0.56, 95% CI 0.44-0.87)
Dosing strategy — Traditionally, PDE-5 inhibitors are dosed on demand. Some suggest attempting a trial of daily low-dose PDE-5 inhibitor therapy coupled with on-demand dosing prior to any sexual encounter. While there does not appear to be a difference in effectiveness between dosing strategies (ie, daily versus on-demand dosing) [78,79], some data suggest that daily dosing is associated with increased compliance [80]. There are limited data to inform a consensus approach in this setting. One of our experts offers daily dosing on a trial basis, particularly for males who do not respond to on-demand dosing; the other expert refrains from offering this approach due to the lack of evidence on benefits. (See "Treatment of male sexual dysfunction", section on 'Phosphodiesterase-5 inhibitors'.)
Locally applied therapy — For males who do not respond to oral PDE-5 inhibitors, we suggest either intracavernosal injections (ICI) or intraurethral (IU) suppositories. The choice between them is based on patient and provider preferences [81,82]. Details on these treatments are discussed elsewhere. (See "Treatment of male sexual dysfunction", section on 'Penile self-injection'.)
ICI therapy is available as a single agent (using alprostadil or papaverine) or as a combination of phentolamine papaverine and prostaglandin E1 (PGE1). The data evaluating their effectiveness are limited, but one nonrandomized trial was performed that supports their application. In this study, 58 males who did not respond to oral sildenafil were instructed to use ICI (three times a week). At 18 months, compared with a control group who did not undergo therapy (n = 74), ICI treatment was associated with the following:
●A significantly increased proportion of males were able to have medication-unassisted intercourse (52 versus 19 percent)
●Significantly higher erectile rigidity (mean 52 versus 26 percent)
●A significantly higher rate of reporting normal erectile function (22 versus 6 percent)
The PGE1 analog, alprostadil, is the most commonly administered IU suppository; it theoretically increases blood flow to the corpus cavernosum, promoting tissue oxygenation. Despite data that it may be as effective as oral treatment, discomfort with insertion of the agent appears to limit its acceptability. This was shown in a trial that included 139 males with ED one month after radical prostatectomy who were randomly assigned to treatment with IU alprostadil or oral sildenafil for nine months, followed by on-demand treatment using sildenafil for one month. Major results included the following:
●There was no difference in erectile function or intercourse success rates.
●However, more males treated with oral therapy completed the protocol (80 versus 70 percent). (See "Treatment of male sexual dysfunction", section on 'Intraurethral alprostadil'.)
Vacuum devices — For males who do not respond to oral treatment, vacuum devices may provide some benefit and are gaining acceptance, especially in those treated with radical prostatectomy [83]. The vacuum device, without the constriction ring, may also have a role in penile rehabilitation by improving oxygenation of the penile tissues [84].
In our clinic, we counsel patients on the use of these devices if they are not candidates for oral medications (eg, inability to use vasodilators due to concomitant nitrates for angina) or wish to try an alternative approach to medication treatment. Further information on these treatments is provided elsewhere. (See "Treatment of male sexual dysfunction", section on 'Vacuum-assisted erection devices'.)
Penile implants — For males who do not respond to any of the above treatments and who desire help for ED, a penile implant can be performed. Data suggest that they are more likely to be used in younger males (<65 years) and Black or Hispanic male patients [85]. Male patients are usually highly satisfied with the device, and in one study, they were shown to prefer it as first-line therapy for ED following radical prostatectomy due to its reliability, erection firmness, and confidence in success [86]. Further information on this treatment is provided elsewhere. (See "Treatment of male sexual dysfunction", section on 'Penile prostheses'.)
Nonpharmacologic approaches — Nonpharmacologic approaches, such as pelvic floor physiotherapy and mindfulness practices, may both supplement other management approaches for ED and contribute to general sexual well-being in male cancer survivors.
Pelvic floor physiotherapy — There is limited high-quality evidence that pelvic floor physiotherapy with biofeedback may improve erectile function after radical prostatectomy [87].
Mindfulness-based meditation — Mindfulness-based meditation may be more effective for male cancer survivors and their partners to improve both ED and overall sexual well-being [88]. It is suggested that pharmacologic treatments focus more on erections and promote a performance-based approach that negates intimacy and sexual satisfaction. Therefore, an acceptance-based approach used by mindfulness practices may be preferred by some patients to improve ED. One study of a mindfulness-based group therapy approach for couples showed some moderate effects in sexual satisfaction [89].
Other sexual concerns — Beyond ED, male cancer survivors may complain about issues involving ejaculation, orgasm, libido, and general dissatisfaction with sexual intercourse. There is a paucity of data specific to the approach to males treated for cancer. Hence, males with these issues are treated similarly to those without a history of cancer:
●Ejaculatory disorders – Surgical removal of the prostate leads to acute anejaculation, and some males associate this with the inability to achieve orgasm, despite different mechanisms underlying each of these conditions. However, these conditions can result in the avoidance of sexual activity altogether. Sexual counseling or therapy, and psychosexual education may be helpful to correct misunderstanding. (See "Treatment of male sexual dysfunction", section on 'Ejaculatory disorders'.)
●Difficulty with orgasm or climax – For males who have difficulty with orgasm or climax, we suggest treatment directed at improving penile sensation. This may be achieved with the use of a vibrator at the base of the penis or on the scrotum. Pelvic floor physiotherapy may also be useful because laxity in these muscles can be associated with weaker or absent sensations of orgasm. (See "Epidemiology and etiologies of male sexual dysfunction", section on 'Other ejaculatory disorders'.)
●Low libido – Reactive loss of libido is seen in male cancer survivors with ED after treatment; this is psychological and may improve with sexuality counseling and encouragement to explore non-penetrative activities. For those on androgen deprivation therapy (ADT), intermittent therapy may be helpful for the return of libido; however, this may not be possible due to disease factors. Males with low libido should be evaluated for hypogonadism, in which case they may be candidates for testosterone therapy. However, if considered, a discussion must take place between the sexual health specialist and the oncologist to ensure that the benefits and risks of treatment are consistently documented. (See 'Caution with testosterone replacement therapy' below and "Testosterone treatment of male hypogonadism".)
●Dissatisfaction with sexual intercourse – A return to baseline erectile function and sexual satisfaction is uncommon for male patients after radical prostatectomy, despite the use of pharmacologic agents [90]. Sexual satisfaction remains low even for males who achieve erections sufficient for penetration. In one study, only 16 percent of males returned to baseline erectile functioning without the use of oral medication and 36 percent with the use of a PDE-5 inhibitor [90]. In addition to sexual counseling, such patients may be evaluated for alternative approaches such as pelvic floor physiotherapy or mindfulness-based practices. (See 'Counseling' below and 'Nonpharmacologic approaches' above.)
Counseling — All males with sexual dysfunction should have a component of counseling as part of their treatment program. In addition to individual counseling, for patients with a partner, involving both parties is important. Although limited, data suggest that patients who hold back discussion of sexual concerns with their partner also are more likely not to discuss cancer-specific concerns, including fear of recurrence [91]. Therefore, involvement of both individuals may not only improve the man's sexual health, but it may also improve intimacy and overall couple satisfaction, although much more work in this area is needed [92]. Referral to a counselor or therapist who is knowledgeable about cancer and its treatment as part of a comprehensive team approach is encouraged.
Loss of confidence, performance anxiety, and loss of masculine self-image are common in males treated for cancer who experience sexual side effects of treatment. Penile shrinkage after radical prostatectomy and climacturia may further exacerbate psychological distress. In addition, males treated with ADT may also experience body image issues due to loss of upper body muscle mass, central adiposity, and loss of body hair. This can lead to decreased quality of life [93].
Caution with testosterone replacement therapy — In males without cancer, testosterone replacement is sometimes used for sexual dysfunction in the setting of sufficiently low testosterone levels. However, there are only limited data on the safety of testosterone in males treated for cancer, especially those diagnosed with prostate cancer.
We avoid testosterone supplementation in males with active prostate cancer, which is consistent with the findings from the International Consultation of Sexual Medicine [3]. Although the use of testosterone may be appropriate in males with definitively treated prostate cancer if they are hypogonadal [94], this is not consistent with guidelines from the American Urological Association or European Association of Urology. (See "Overview of approach to prostate cancer survivors", section on 'Hypogonadism and testosterone replacement'.)
For males with other cancers, consideration of supplemental testosterone should be individualized, taking into account the general health of the patient and the potential side effects of testosterone treatment. Guidance on dosing testosterone for males with a history of cancer is similar to that for patients with a diagnosis of male hypogonadism. (See "Testosterone treatment of male hypogonadism".)
RESOURCES
Sexuality for the Man With Cancer. The American Cancer Society.
Sexuality and Cancer: Men. Cancer.net.
Katz A. Prostate Cancer and the Man You Love: Supporting and Caring for Your Partner, Rowman & Littlefield, New York 2012.
Katz A. Man Cancer Sex, Hygeia Media, Pittsburgh 2009.
Katz A. Life, love and loss after 50. In: Living, Loving & Loss: The Interplay of Intimacy, Sexuality and Grief, Baywood Publishing Company, Amityville 2013.
Mulhall JP. Saving your Sex Life: A Guide for Men with Prostate Cancer, C-I-ACT Publishing, Bethesda 2010.
Schover LR. Sexuality and Fertility After Cancer, John Wiley and Sons, 2007.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Male sexual dysfunction".)
SUMMARY AND RECOMMENDATIONS
●Impact of sexual dysfunction – For males with cancer, sexual dysfunction is a common issue and has a negative impact on their quality of life, irrespective of their involvement in stable relationships or their sexual preferences. (See 'Introduction' above.)
●Types of sexual dysfunction – The major types of sexual dysfunction in male cancer survivors include (see 'Major types of sexual dysfunction in male cancer survivors' above):
•Erectile dysfunction – Erectile dysfunction (ED) is the most common concern for males treated for cancer. ED is defined as the persistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual activity that persists for at least three months. (See 'Erectile dysfunction' above.)
•Sexual bother – When sexual dysfunction is perceived as a problem, causes embarrassment or shame, or reduces one's ability to enjoy life, it is often characterized as sexual bother. While it is associated with the presence of ED, sexual bother can be identified in the absence of ED as well. (See 'Sexual bother' above.)
•Other symptoms – Other symptoms include loss of libido, orgasmic dysfunction, disorders of ejaculation, and reduced penile length.
●Risk factors – For most males with cancer, sexual dysfunction is often a consequence of treatment. Among those with pelvic cancer (ie, prostate or rectal cancer), surgical treatment is often the instigating event. (See 'Prevalence and risk factors' above.)
●Screening and evaluation – Ideally, males at risk for sexual dysfunction should be screened prior to treatment. For males with sexual dysfunction, the evaluation should include an assessment of the relationship they have with their partner because both patient and partner-related factors are important for sexual recovery. (See 'Screening and counseling' above and 'Evaluation' above.)
●Counseling – A multidisciplinary approach is important so that not only physiologic, but also psychological and relationship issues are addressed. All males with sexual dysfunction should have a component of therapy as part of their treatment program. (See 'Counseling' above.)
●Management of erectile dysfunction – For male cancer survivors who want to pursue therapy for ED, the options include medications, vacuum devices, penile implants, and other nonpharmacologic approaches. Our approach begins with oral medications coupled with psychological support. We reserve more invasive therapies for patients who do not achieve a self-defined good response to more conservative treatment. (See 'Management' above.)
●Caution with testosterone replacement – For males who present with sexual dysfunction, testosterone levels may be sufficiently low, and replacement may be of benefit. However, we avoid testosterone supplementation in males with active prostate cancer. For males with other cancers, the use of supplemental testosterone should be individualized, taking into account the general health of the patient and the potential side effects of testosterone treatment. (See 'Caution with testosterone replacement therapy' above.)
