Sex After Prostate Cancer

Most men develop ED, but there are ways to reduce your risk.

MichaelCastleman

Posted: Nov 20, 06 10:11pm

The myth is that prostate cancer treatment destroys men's erections. The truth is somewhat more complicated. Men facing treatment for this disease should prepare themselves emotionally for permanent erectile dysfunction (ED), and a major sexual adjustment. But ED is not inevitable. And if you develop ED, you can still enjoy a fulfilling sex life--including orgasms.

Treatments are Equally Effective

Most prostate cancer is diagnosed early, before it has spread outside the gland. With early detection, the prognosis is excellent. The American Cancer Society estimates 234,500 new diagnoses in 2006, but only 27,000 deaths, a death rate of 11.5 percent. For comparison, the prognosis for breast cancer is not as rosy--213,000 diagnoses in 2006, and 41,000 deaths, for a death rate of 19 percent.

The three most widely used treatments for early-stage prostate cancer--surgical removal of the gland (radical prostatectomy), high-dose radiation from an external source (external beam), and insertion of a radioactive pellet (seed implantation)--are all equally effective. Researchers at M.D. Anderson Cancer Center in Orlando, Florida, reviewed outcomes for 2,991 consecutive men: 1,034 had prostatectomy, 785 had external beam radiation, and 950 had seed implantation, and 222 had combined external beam and seed. Five-year survival rates were 81 percent for prostatectomy, 81 percent for external beam, 83 percent for seeds, and 77 percent for combined therapy.

An eight-year study of 1,682 men at the Cleveland Clinic also showed equivalent survival: 72 percent for prostatectomy, 70 percent for radiation.

ED After Treatment: Three Risk Factors

* Age. Erection capacity declines with age, typically beginning around 50 and continues through old age. The studies generally divide men into two groups--under and over 60. Not surprisingly, men treated for prostate cancer before 60 generally enjoy better sexual function than men treated over 60.

* Morning erections or partial erections. Independent of age, some men wake with morning erections or some penile tumescence. Compared with men who rarely or never wake with penile firmness, those who have at least partial erections sometimes are more likely to recover erection function after prostate cancer treatment.

* Type of treatment. Many studies have investigated sexual function after prostate cancer treatment. All treatments cause considerable ED, but in general, surgery causes more sexual impairment than radiation.

Researchers with the National Cancer Institute followed 1,187 men for five years--901 had surgery, 286 had external beam. Sexual function declined in both groups, but ED was more prevalent in those who had surgery, 79 percent after prostatectomy vs. 64 percent after radiation.

Other studies have come up with somewhat different findings--rates of ED ranging from 60 percent to 82 percent. But almost every study shows that prostatectomy cause more erection impairment than radiation.

In addition, type of treatment affects how ED appears. After surgery, most men experience sudden erection impairment, but over time, some recover some function. After radiation, fewer men report sudden ED. But over time, ED becomes more common.

Nerve-Sparing Surgery?

Why does prostate cancer treatment cause such a high rate of ED? Because the nerves involved in erection, specifically two nerve bundles, run very close to the gland. Surgery typically cuts these nerves, and radiation usually damages them.

About 20 years ago, surgeons began developing techniques to remove the prostate while leaving the two nerve bundles intact. This approach, nerve-sparing prostatectomy, reduces risk of ED. Unfortunately, nerve-sparing surgery does not work miracles. At Fred Hutchinson Cancer Center in Seattle, researchers checked in with 1,291 men 18 months after their prostatectomies were performed in the mid-1990s. Among those who had ordinary surgery, 66 percent reported serious ED. Those who had nerve-sparing surgery reported less ED, but not much less--57%. In this group, age was a better determinant of sexual function than the type of surgery. Among men under 60, 39 percent could raise erections. For the men 60 or older, the figure was 20 percent.

More recent studies have reported somewhat better results. German researchers focused on surgery in the late 1990s. Nerve-sparing surgery that cut just one nerve bundle (unilateral) resulted in at least partial erection in half of men, and erection firm enough for vaginal intercourse in 22 percent. Surgery that spared both bundles (bilateral) allowed erections sufficient for intercourse in 50 percent of men.

Some reports claim erection restoration rates with nerve-sparing surgery as high as 90 percent. That refers to "any degree of erection." Rates of erection sufficient for intercourse generally come in at 25 to 50 percent.

Finally, if the tumor is located near a nerve bundle, nerve-sparing surgery may not be possible.

Bottom line: Compared with ordinary surgery, nerve sparing surgery produces better results, but not much better.

Surgery Plus Viagra

Several studies show that Viagra and other erection drugs help restore erection after prostatectomy. However, this happens only after nerve-sparing surgery. Here's why:

Erection medications work by coaxing more blood into the penis. But if a man doesn't have enough nerve function for erection, the amount of blood in the penis doesn't matter. No nerve function means no erection. However, with nerve-sparing surgery, much or all of nerve function remains, and erection drugs can help.

Italian researchers analyzed 11 studies of erection in men who took Viagra or other drugs after prostatectomy. After non-nerve-sparing surgery, erection medication helped from 0 to 15 percent of men. (Non-nerve-sparing surgery sometimes spares some nerves.) After surgery that spared one nerve bundle, the drugs helped 10 to 80 percent of men. When both nerve bundles were spared, Viagra helped 46 to 72 percent of men.

Bottom line: For best chance of sexual function, have bilateral nerve-sparing surgery and use erection medication.

Orgasm Without Erection

Yes, it's possible. If you develop ED from prostate cancer treatment, you can still enjoy a fulfilling sex life and have orgasms that feel just as pleasurable as those you had when you could raise erections.

Different nerves control erection and orgasm. Even if your erection nerves are damaged or severed, chances are that the nerves that govern orgasm are still intact. It's an adjustment to have a flaccid penis stimulated to orgasm. But it's not all that difficult--and after prostate cancer treatment, most men say they'd rather have orgasm without erection than erection without orgasm.

How do you have an orgasm without an erection? The same way you have an orgasm with one--with direct, sustained penis stimulation by hand or mouth or a combination of the two. It may take several months after treatment to return to orgasm, but if you work at it, either solo or with a lover, you can enjoy fulfilling orgasms with a flaccid penis.

If you have difficulty expressing orgasm, consult a sex therapist. To find a sex therapist near you, visit the American Association of Sex Educators, Counselors, and Therapists (AASECT) at www.aasect.org. Click the map of the U.S. and Canada, and get a list of all the AASECT-certified sex therapists in your state or province.

Eight Ways to Reduce Your Risk

Unfortunately, no matter how prostate cancer is treated, risk of ED is substantial. To maintain sexual function, work to prevent this disease. Here's how:

* Eat More Vegetables. As fruit and vegetable consumption increases--especially vegetables--prostate cancer risk plummets. University of Hawaii researchers compared the diets of 3,237 men, half of whom had prostate cancer. The more vegetables and beans they ate, the lower their risk. Comparing those who ate the most and fewest vegetables, the men who ate the most had 35 percent less risk.

* Eat Tomato Sauce. Tomatoes. They contain lycopene, a form of vitamin A. Many studies show that a diet high in tomato foods reduces prostate cancer risk, notably an analysis by a Harvard researcher showing that a two to four weekly servings of tomato foods reduces risk 35 percent and risk of metastatic prostate cancer 50 percent. Fresh tomatoes are good, but tomato sauce is better. Sauce contains less water than fresh tomatoes, making it a more concentrated source of lycopene, and processing tomatoes into sauce makes lycopene more available to the body. Lycopene supplements are also available.

But watch out for America's favorite tomato-sauce food, pizza. The cheese and meats (pepperoni, sausage, etc.) largely cancel the tomato sauce's benefits (see below). If you want pizza to reduce your risk of prostate cancer, opt for vegetable toppings and go easy on the cheese.

* Supplement Selenium. Plant foods contain the mineral selenium, but content varies depending on the soil, so it's prudent to take a supplement. Selenium became a cancer-prevention celebrity in 1996 when a researchers at the University of Arizona gave a supplement containing 200 micrograms (mcg) a day to people with skin cancer in hopes of preventing recurrences. Ironically, after five years, the mineral had no effect on skin cancer risk, but compared with controls, the group that took selenium was an astonishing 65 percent less likely to develop prostate cancer. Other studies corroborate those results.

* Supplement Vitamin E. Finnish researchers gave 29,000 men over 50 a placebo or a vitamin E supplement (50 mg/day). Six years later, the vitamin E group had 32 percent lower prostate cancer risk.

* Eat Less Meat and Dairy. The saturated fat in meats and dairy foods increases risk of all cancers. Comparing men who eat lots of red meat with those who eat little or none, many studies agree that a high-meat diet doubles or triples prostate cancer risk.

* Eat More Fish. The omega-3 fatty acids in cold-water fish, such as salmon, are well known for reducing risk of heart disease. Recent research shows they also help prevent prostate cancer. Harvard researchers tracked 48,000 American men for 12 years. Compared with those who ate fish less than twice a month, the men who ate it more than three times a week were 44 percent less likely to develop the disease.

* Watch Your Weight. Plant foods are low in calories, while meats and dairy items are high in calories and fat--and add pounds. So it should come as no surprise that obesity raises prostate cancer risk. Compared with men who maintained recommended weight, French researchers found that obese men had 2.5 times the prostate cancer risk.

* Prevent Sexually Transmitted Infections (STIs). Several studies show that a history of STIs, especially gonorrhea and syphilis, approximately doubles prostate cancer risk. It's not entirely clear why, but if you or your lover is non-monogamous, use condoms.

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