Overview of sexual dysfunction in male cancer survivors
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Head of Women's Cancers, Lifespan Cancer Institute
- Director of Medical Oncology, Rhode Island Hospital
- Associate Professor of Medicine, Warren Alpert Medical School of Brown University
- Anne Katz, PhD, RN, FAAN
Anne Katz, PhD, RN, FAAN
- CancerCare Manitoba
- Winnipeg MB
For men with cancer, sexual dysfunction is a common issue that has a negative impact on psychological functioning and on 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 men treated for cancer who complain of sexual dysfunction are often assumed to have a purely physical issue (and predominantly related to erectile dysfunction [ED]), a biopsychosocial model 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 . This includes incorporation of one’s sexual self-schema, broadly understood as an individual’s own characterization of sexuality, which in turn influences their own behavior, affect, and the way they process sexually relevant information .
Most of the data on male sexual dysfunction are derived from men with a history of prostate cancer, though research suggests that men 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 "Overview of male sexual dysfunction".)
MAJOR TYPES OF SEXUAL DYSFUNCTION IN MALE CANCER SURVIVORS
Erectile dysfunction — Erectile dysfunction (ED) is the most common concern for men 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 . 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 "Overview 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 men 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 men with and without ED . Of concern, only 7 percent of men 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 men treated for cancer as a primary consequence of androgen deprivation therapy (ADT) or secondary to ED. Most men 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 relationship conflict due to lack of emotional intimacy . (See "Overview of male sexual dysfunction", section on 'Decreased libido'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Katz A, Dizon DS. Sexuality After Cancer: A Model for Male Survivors. J Sex Med 2016; 13:70.
- Hoyt MA, Carpenter KM. Sexual self-schema and depressive symptoms after prostate cancer. Psychooncology 2015; 24:395.
- Montorsi F, Adaikan G, Becher E, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med 2010; 7:3572.
- Nelson CJ, Deveci S, Stasi J, et al. Sexual bother following radical prostatectomyjsm. J Sex Med 2010; 7:129.
- Walker LM, Robinson JW. The unique needs of couples experiencing androgen deprivation therapy for prostate cancer. J Sex Marital Ther 2010; 36:154.
- Schover LR. Sexuality and fertility after cancer. Hematology Am Soc Hematol Educ Program 2005; :523.
- Huyghe E, Sui D, Odensky E, Schover LR. Needs assessment survey to justify establishing a reproductive health clinic at a comprehensive cancer center. J Sex Med 2009; 6:149.
- Saitz TR, Serefoglu EC, Trost LW, et al. The pre-treatment prevalence and types of sexual dysfunction among patients diagnosed with prostate cancer. Andrology 2013; 1:859.
- Mulhall JP, Bella AJ, Briganti A, et al. Erectile function rehabilitation in the radical prostatectomy patient. J Sex Med 2010; 7:1687.
- Mulhall JP. Defining and reporting erectile function outcomes after radical prostatectomy: challenges and misconceptions. J Urol 2009; 181:462.
- Lee JK, Assel M, Thong AE, et al. Unexpected Long-term Improvements in Urinary and Erectile Function in a Large Cohort of Men with Self-reported Outcomes Following Radical Prostatectomy. Eur Urol 2015; 68:899.
- Frey AU, Sønksen J, Fode M. Neglected side effects after radical prostatectomy: a systematic review. J Sex Med 2014; 11:374.
- van der Wielen GJ, Hoogeman MS, Dohle GR, et al. Dose-volume parameters of the corpora cavernosa do not correlate with erectile dysfunction after external beam radiotherapy for prostate cancer: results from a dose-escalation trial. Int J Radiat Oncol Biol Phys 2008; 71:795.
- Corona G, Gacci M, Baldi E, et al. Androgen deprivation therapy in prostate cancer: focusing on sexual side effects. J Sex Med 2012; 9:887.
- SEER Stat Fact Sheets: Testis Cancer. http://seer.cancer.gov/statfacts/html/testis.html (Accessed on April 21, 2015).
- Rosendal S, Kristensen E, Giraldi AG. Sexual dysfunctions in men treated for testicular cancer--secondary publication. Dan Med Bull 2008; 55:211.
- Wortel RC, Ghidey Alemayehu W, Incrocci L. Orchiectomy and radiotherapy for stage I-II testicular seminoma: a prospective evaluation of short-term effects on body image and sexual function. J Sex Med 2015; 12:210.
- Dahl AA, Bremnes R, Dahl O, et al. Is the sexual function compromised in long-term testicular cancer survivors? Eur Urol 2007; 52:1438.
- Delaunay B, Soh PN, Delannes M, et al. Brachytherapy for penile cancer: efficacy and impact on sexual function. Brachytherapy 2014; 13:380.
- Kieffer JM, Djajadiningrat RS, van Muilekom EA, et al. Quality of life for patients treated for penile cancer. J Urol 2014; 192:1105.
- Witty K, Branney P, Evans J, et al. The impact of surgical treatment for penile cancer -- patients' perspectives. Eur J Oncol Nurs 2013; 17:661.
- Kowalkowski MA, Chandrashekar A, Amiel GE, et al. Examining sexual dysfunction in non-muscle-invasive bladder cancer: results of cross-sectional mixed-methods research. Sex Med 2014; 2:141.
- Modh RA, Mulhall JP, Gilbert SM. Sexual dysfunction after cystectomy and urinary diversion. Nat Rev Urol 2014; 11:445.
- Lange MM, Marijnen CA, Maas CP, et al. Risk factors for sexual dysfunction after rectal cancer treatment. Eur J Cancer 2009; 45:1578.
- Russell MM, Ganz PA, Lopa S, et al. Comparative effectiveness of sphincter-sparing surgery versus abdominoperineal resection in rectal cancer: patient-reported outcomes in National Surgical Adjuvant Breast and Bowel Project randomized trial R-04. Ann Surg 2015; 261:144.
- Sendur MA, Aksoy S, Ozdemir NY, et al. Evaluation of erectile dysfunction risk factors in young male survivors of colorectal cancer. J BUON 2014; 19:115.
- Welzel G, Hägele V, Wenz F, Mai SK. Quality of life outcomes in patients with anal cancer after combined radiochemotherapy. Strahlenther Onkol 2011; 187:175.
- Nagpal K, Bennett N. Colorectal surgery and its impact on male sexual function. Curr Urol Rep 2013; 14:279.
- Breukink SO, Donovan KA. Physical and psychological effects of treatment on sexual functioning in colorectal cancer survivors. J Sex Med 2013; 10 Suppl 1:74.
- Traa MJ, De Vries J, Roukema JA, Den Oudsten BL. Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review. Ann Oncol 2012; 23:19.
- Downing A, Morris EJ, Richards M, et al. Health-related quality of life after colorectal cancer in England: a patient-reported outcomes study of individuals 12 to 36 months after diagnosis. J Clin Oncol 2015; 33:616.
- Di Fabio F, Koller M, Nascimbeni R, et al. Long-term outcome after colorectal cancer resection. Patients' self-reported quality of life, sexual dysfunction and surgeons' awareness of patients' needs. Tumori 2008; 94:30.
- Zebrack BJ, Foley S, Wittmann D, Leonard M. Sexual functioning in young adult survivors of childhood cancer. Psychooncology 2010; 19:814.
- Lee JJ. Sexual dysfunction after hematopoietic stem cell transplantation. Oncol Nurs Forum 2011; 38:409.
- Virtanen C, Paris J, Takahashi M. Identification and characterization of a novel gene, dapr, involved in skeletal muscle differentiation and protein kinase B signaling. J Biol Chem 2009; 284:1636.
- Cella D, Yount S, Rothrock N, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years. Med Care 2007; 45:S3.
- Rosen RC, Riley A, Wagner G, et al. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997; 49:822.
- Cappelleri JC, Rosen RC. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. Int J Impot Res 2005; 17:307.
- White ID, Wilson J, Aslet P, et al. Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer. Int J Clin Pract 2015; 69:106.
- Wittmann D, Foley S, Balon R. A biopsychosocial approach to sexual recovery after prostate cancer surgery: the role of grief and mourning. J Sex Marital Ther 2011; 37:130.
- Soloway CT, Soloway MS, Kim SS, Kava BR. Sexual, psychological and dyadic qualities of the prostate cancer 'couple'. BJU Int 2005; 95:780.
- Schover LR, Fouladi RT, Warneke CL, et al. Seeking help for erectile dysfunction after treatment for prostate cancer. Arch Sex Behav 2004; 33:443.
- Plym A, Folkvaljon Y, Garmo H, et al. Drug prescription for erectile dysfunction before and after diagnosis of localized prostate cancer. J Sex Med 2014; 11:2100.
- Cui Y, Liu X, Shi L, Gao Z. Efficacy and safety of phosphodiesterase type 5 (PDE5) inhibitors in treating erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Andrologia 2016; 48:20.
- Yang L, Qian S, Liu L, et al. Phosphodiesterase-5 inhibitors could be efficacious in the treatment of erectile dysfunction after radiotherapy for prostate cancer: a systematic review and meta-analysis. Urol Int 2013; 90:339.
- Montorsi F, Brock G, Stolzenburg JU, et al. Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT). Eur Urol 2014; 65:587.
- Pavlovich CP, Levinson AW, Su LM, et al. Nightly vs on-demand sildenafil for penile rehabilitation after minimally invasive nerve-sparing radical prostatectomy: results of a randomized double-blind trial with placebo. BJU Int 2013; 112:844.
- Ricardi U, Gontero P, Ciammella P, et al. Efficacy and safety of tadalafil 20 mg on demand vs. tadalafil 5 mg once-a-day in the treatment of post-radiotherapy erectile dysfunction in prostate cancer men: a randomized phase II trial. J Sex Med 2010; 7:2851.
- Mulhall J, Land S, Parker M, et al. The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med 2005; 2:532.
- McCullough AR, Hellstrom WG, Wang R, et al. Recovery of erectile function after nerve sparing radical prostatectomy and penile rehabilitation with nightly intraurethral alprostadil versus sildenafil citrate. J Urol 2010; 183:2451.
- Raina R, Pahlajani G, Agarwal A, et al. Long-term potency after early use of a vacuum erection device following radical prostatectomy. BJU Int 2010; 106:1719.
- Tal R, Jacks LM, Elkin E, Mulhall JP. Penile implant utilization following treatment for prostate cancer: analysis of the SEER-Medicare database. J Sex Med 2011; 8:1797.
- Megas G, Papadopoulos G, Stathouros G, et al. Comparison of efficacy and satisfaction profile, between penile prosthesis implantation and oral PDE5 inhibitor tadalafil therapy, in men with nerve-sparing radical prostatectomy erectile dysfunction. BJU Int 2013; 112:E169.
- Manne SL, Kissane D, Zaider T, et al. Holding back, intimacy, and psychological and relationship outcomes among couples coping with prostate cancer. J Fam Psychol 2015; 29:708.
- Nelson CJ, Emanu JC, Avildsen I. Couples-based interventions following prostate cancer treatment: a narrative review. Transl Androl Urol 2015; 4:232.
- Harrington JM, Badger TA. Body image and quality of life in men with prostate cancer. Cancer Nurs 2009; 32:E1.
- MAJOR TYPES OF SEXUAL DYSFUNCTION IN MALE CANCER SURVIVORS
- Erectile dysfunction
- Sexual bother
- Loss of libido
- Other concerns
- PREVALENCE AND RISK FACTORS
- Prostate cancer
- Testicular cancer
- Penile cancer
- Bladder cancer
- Gastrointestinal cancer
- Other cancers
- - Hematologic malignancies/stem cell transplantation
- - Head and neck cancer
- - Lung cancer
- SCREENING AND COUNSELING
- Sexual health questionnaires
- Importance of involving the partner
- Treatment team and referral
- Erectile dysfunction
- - Phosphodiesterase-5 (PDE-5) inhibitors
- Dosing strategy
- - Locally applied therapy
- - Vacuum devices
- - Penile implants
- Other sexual concerns
- Caution with testosterone replacement therapy
- SUMMARY AND RECOMMENDATIONS