Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer.
Key sentence from the paper: “The most effective strategy depended on patients and partner needs, e.g. low sexual desire may require psychosexual therapy or counselling in addition to PDE5 inhibitors.”
For the full abstract, see: http://www.ncbi.nlm.nih.gov/pubmed/25283500
Commentary: This is an important review addressing the issue of ADT and sexual function for prostate cancer patients. It is structured as a consensus paper built on both a literature survey and the opinions of 28 experts in the UK on who treat erectile dysfunction (ED). The paper includes a lot of blunt statements about the challenges of staying sexually active on ADT. So, for example, we are told that generally, less than “20% [of] men undergoing ADT maintain any sexual activity” and “69% of the men who were potent [i.e., had good erections] before ADT treatment lost their potency after treatment...”
It’s important to note that the paper is about ED treatments and not about strategies for maintaining sexual activity that do not rely on erectile rigidity. To the credit of the authors, they recognize a need for involving partners in treatments related to sexual function and also providing psychological counseling. Yet, at the same time they present discouraging data regarding how frequently prostate cancer patients are referred for counseling in the UK. Here is what they say:
“A Canadian Working Group [that’s us! The managers of this blog and authors of the ADT book] that evaluated interventions to limit the physiological and emotional difficulties experienced by men and their partners after ADT recommended providing information about ADT side effects before administration of ADT and, where appropriate, providing referrals for psychosocial support. These recommendations included offering psychological interventions for sexual sequalae to men and their partner.
In our clinician survey, approximately 89% of the expert respondents agreed that involving partners was beneficial when assessing and managing patients’ ED, though they would only involve partners if they attended consultations with patients. However, only 36% of participants routinely involved partners in practice and 11% of respondents either did not feel that involving the partner was important or never had an opportunity to involve partners, suggesting that professional opinion did not always translate into clinical practice.”
Further thoughts on sexual recovery in ADT patients:
We (as authors of the ADT book) are somewhat skeptical that the protocol for treating ED in patients on ADT offered in this paper would be very effective. The authors of this paper take a traditional view of ED treatments and recommend starting patients on drugs, like Viagra, Levitra or Cialis. What we have found in clinical practice and research, is that these drugs are often of little effect in treating ED in patients who are on ADT. It is our view that starting these patients on drugs that may not work for them, might just set them up for failure and discouragement.
Perhaps ADT patients would be better off if introduced as a first line ED treatment to interventions that are more likely to work in this population, such as intracavernosal injection. It may be better, in fact, for ADT patients to be encouraged to explore sexual practices that are not dependent on penile rigidity, such as using sex toys, engaging in non-penetrative sexual activities and possibly using an external penile prosthesis (see Warkentin KM, Gray RE, Wassersug RJ. 2006. Restoration of satisfying sex for a castrated cancer patient with complete impotence: a case study. J. Sex Marital Ther. 32(5):389-399). Such options are not mentioned in this paper, but admittedly, as the title of the paper suggests, it is about ED treatment specifically and not sexual recovery in general, which could include a variety of alternative sexual practices.
White ID, Wilson J, Aslet P, Baxter AB, Birtle A, Challacombe B, Coe J, Grover L, Payne H, Russell S, Sangar V, Van As N, Kirby M. 2014. Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer. International Journal of Clinical Practice 5 October 2014 [Epub ahead of print]