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Welcome to this educational program, this module provides an introduction to sexual dysfunction associated with prostate cancer and it’s treatments. This information is taken from a recent review of the medical literature and attempts to be as comprehensive as possible. This material is independently produced and the mention of any drug or medical product does not imply it’s endorsement. Prostate cancer is unfortunately relatively common among men and all treatments for prostate cancer, including surgery, radiation, cryoablation and hormone therapy, can cause or worsen sexual problems. This is obviously a very important issue for men, as approximately 25 percent of them will choose their treatment based on such side-effects. Please take your time to review this module closely and feel free to view it as many times as you, like. Other modules on specific situations and treatments are also available. Prostate cancer treatments can have several effects on sexual function, nerve, injury and tissue damage can lead to erectile dysfunction or edie. Removal of or damage to, the ejaculatory system means that there may be very little to no semen during ejaculation and cutting or injury to the vas deferens can create infertility. Some men may also experience less sensation of orgasm or urine loss during sexual activity, both of which can also be distressing along with the physical effects. Prostate cancer treatment can have an emotional toll as well. Some men may experience emotional stress and anxiety about their cancer diagnosis, anger and fear, loss of their normal sense of control, impaired body, image and confidence, or even clinical depression. Unfortunately, with the loss of erections after treatment, some men become discouraged and this situation is worsened if there are also associated urinary difficulties. His partner in trying to be supportive may not push for intercourse, and this can be mistaken by some men as rejection, which again worsens his discouragement. As this continues. The couple may unfortunately settle into a relationship without vaginal intercourse. The rest of this presentation will focus on erectile dysfunction after prostate cancer treatment simply put erectile dysfunction. Is the inability to get or maintain an erection good enough for intercourse. It is also commonly referred to as II D erectile difficulties or impotence. Ii D may be caused by the interruption of any of the essential steps in the erection process. This includes poor nerve transmission of sexual stimulation to the brain and back to the penis poor blood flow into the penis hardening of the penile tissues or an inability to contain the blood within the penis. Ii D is unfortunately common in men treated for prostate cancer, and there are many contributing factors it may be present already and unrelated to the prostate cancer. It may be caused or worsened by the effects of the cancer and, of course it can be caused or worsened directly by treatment for prostate cancer. Edie is a common condition in the general population and may be present before prostate cancer ever becomes an issue. It is estimated that 15 to 30 million American men suffer from edy the chance of experiencing problems, increases with age and about one third of men aged 50 to 90, experienced it in a large study of more than 1200 men undergoing prostatectomy for prostate cancer, 44 percent of them had IDI before undergoing treatment, and 16 percent of them were totally unable to have intercourse. Prostate cancer can have both physical and psychological effects on a man that can affect his ability to have erections. Uncommonly advanced cancer can directly invade the nerves that supply erection more commonly. The diagnosis of cancer can cause a reactive, depression, anxiety or fear, which can all affect a man’s sexual function. Approximately 10 to 20 percent of men may lose interest in sexual activity following their initial diagnosis. Finally, as noted, all treatments for prostate cancer can impair a man’s erectile function, surgery most commonly causes damage to the nerves that provide the stimulation for the erection response. Radiation can injure nerves and blood vessels and also directly damages the erectile tissue hormone therapy used alone or combined with other treatments, lowers a man’s testosterone level, which is required for normal sex drive and also helps in the erection process. The nerves that provide the erection response and stimulate the erectile tissues called the cavernous nerves, arise from the lower part of the spine and travel immediately next to the prostate on their way through the pelvis to the penis. This location right next to the prostate, makes them vulnerable to injury during any local treatment for prostate cancer. The penis is composed of two erectile bodies called the corpora cavernosa and the urine channel called the urethra. The erectile bodies contain multiple spaces called sinusoid which fill with and trap blood to create an erection after radiation or a prolonged period, with no oxygen carrying blood flow into them. This erectile tissue can become damaged and no longer functioned properly. During the erection response, radical prostatectomy involves the complete removal of the prostate, along with part of the seminal vesicles and the ejaculatory ducts. The bladder is then reconnected to the urethra or urine channel. Some men are candidates for a so-called nerve-sparing radical prostatectomy, where the cavernous nerves are peeled away from the prostate and spared, depending on the stage of the tumor. This may be unilateral, meaning just one side is spared or bilateral, meaning both sides are spared. This technique improves one’s chances of recovering good erections after surgery. Unfortunately, not all men are candidates for this procedure. When the tumor is close to the nerves, the excision should include them in order to get a wider margin around the tumor for cancer control. Your surgeon will discuss with you whether or not you’re a candidate. Sometimes the final decision cannot be made until you are in the operating room when edie occurs after radical prostatectomy, then it is usually due to injury of these nerves and usually occurs immediately. If the nerves were spared function will improve as the nerves recover. It is important to understand that, even with nerve sparing the cavernous nerves may get stretched and pushed around or bruised so to speak and even well preserved nerves may not function normally right away. Few men, in fact, will recover function in less than six months, and for most it takes 18 to 24 months to recover fully. It is very difficult to know for certain just how common ID is after prostatectomy and potency or good erection rates of 10 to 90% have been reported. Overall, it is safe to say that roughly 50% of men will experience some IDI after surgery and less than 10% of men report having the same function after surgery as before. Great effort has been made to try to improve nerve, sparing the cavern map device is a nerve stimulator designed to help surgeons, locate the cavernous nerves and, hopefully, spare them more successfully nerve. Grafting techniques have also been developed whereby a patient’s nerve, such as the genital, femoral, nerve or sural nerve, is transplanted to replace the cavernous nerve. Unfortunately, both of these techniques at operating time are expensive and can add risk to the patient. Furthermore, neither of them is yet to be proven effective in improving nerve sparing in the future. Drugs may be available which can help speed the process of nerve regeneration after surgery and research is now focusing in this area. The next few slides discuss radiotherapy for the prostate. There are two ways to radiate: the prostate external beam radiotherapy delivers radiation from outside the body focused in on the prostate, while brachytherapy involves the placement of radioactive seeds directly into the prostate erectile dysfunction caused by radiation is caused by injury to the nerves and blood vessels, as well as direct damage to the erectile tissues compared to surgery. Erections may be normal at first then worsen with time, and it may take several years to develop. Furthermore, many, if not most treatment plans require hormone therapy given as well, which can worsen the problem again. It is difficult to determine just how common ID is after radiation therapy, and this will depend on numerous factors, such as the technique used and the experience of the center. The number of treatments given and the radiation dose erection quality before treatment, age of the patient, the stage of the prostate cancer, the size of the prostate and whether or not hormone treatment was also used. Unfortunately, there are very few well-done studies evaluating the risk of erectile dysfunction after radiation therapy that provide long term data within the first year. Potency is fairly well preserved, following both brachytherapy and external beam radiation, with IDI rates of less than 30% by 3 years. However, the likelihood of erectile difficulties increases to about 50% in general erections are better preserved after brachytherapy than external beam or combination therapy. As noted, potency can worsen with time and by 3 years after treatment. The risk of VD is about 50%, cryotherapy or cryo. Ablation of the prostate involves freezing the prostate tissue with special probes passed directly into it. The neurovascular bundle is damaged by freezing in this process. An erectile dysfunction is to be expected in general. Cryotherapy should not be undertaken by young men with good erectile function. Hormone therapy aims to stop the production of the male hormone testosterone, which fuels the growth of prostate cancer. The most commonly used hormone therapy shuts down the hormone signal from the brain, which stimulates testosterone production from the testicles. This treatment is used for cancer that has spread outside the prostate or short term to improve the effectiveness of other treatments, such as radiotherapy testosterone is responsible for a man’s sex drive or libido, and also helps to facilitate erections. The main side effect of hormone therapy, therefore, is a lowered sex drive. Other side effects include hot flashes, like a woman going through menopause, reduced energy and strength and an altered body image and loss of masculinity. Overall, more than half of men will lose their sex drive on hormone therapy and 80 to 90 percent will experience erectile dysfunction. Most men will recover these functions after the treatment is stopped or paused. However, this recovery is variable, as mentioned. Edie can be treated at any age and many treatment options exist. The best treatment varies depending on an individual situation, and your doctor will use all the information at hand to choose the best treatment for you. Treatment options include lifestyle changes, adjusting medications, psychotherapy such as counseling and behavior modification oral medications or pills, topical medications such as creams, gels and suppositories vacu devices, injection of medication into the penis and surgery, including penile implants. These treatments are briefly introduced in the next few slides and many are reviewed in much more detail in separate modules. All patients before and after prostate cancer treatment should strive to introduce lifestyle changes which may improve the quality of their erections and other aspects of their sexual function. These include smoking cessation, an exercise program that emphasizes cardiovascular conditioning, improving dietary habits and weight loss. Finally, couples should take time to focus on their relationship and make changes where necessary. Beyond lifestyle changes, oral medications or pills have become the standard of initial treatment for edy. Three medications are now available for the treatment of edy and dominate the market, sildenafil viagra, vard, NFL or levitra, and tadalafil or cialis. All three of these fall within a class of drugs called pde5 inhibitors as they block an enzyme in the penis called phosphodiesterase v to improve blood flow to the erectile tissue. Beyond the commonly used pills, alternative treatments include topical therapies, vacu devices, injections and implant surgery. The most commonly used topical treatment is called Muse, which stands for medical urethral suppository for injection. This contains the drug, prostaglandin or ALP rasta dill and is sold as a pellet that is applied to the tip of the urethra. Then rubbed in mechanical vacu devices also called vacu constriction devices or VCDs create an erection by drawing blood into the penis and gorging and expanding it once the blood has been drawn in a constriction ring is placed around the base of the penis to keep it in. As the figure shows, the devices have three components: a plastic cylinder into which the penis is placed, a pump which draws air out of the cylinder and an elastic band which is placed around the base of the penis. To maintain the erection. Direct injection of medication into the penis is extremely effective, fast-acting and creates a normal-looking erection. It may be cumbersome for some to do and does require manual, dexterity and training to learn the technical skill of injection. The major potential risks of these medications are an abnormally long, lasting erection and start tissue formation in the erectile tissue. Penile implants are a last resort for some men when other options are not suitable or have not been effective. There are several types of implants, and these are discussed in more detail in a separate module. This is specialized surgery done by urologist with an interest in this field. In summary, many men experience edie before ever being found to have prostate cancer. All prostate cancer treatments can cause or worsen Edie, and no treatment can totally avoid Edie in all men. The development of erectile dysfunction after prostate cancer treatment depends on a number of factors, including the quality of erections before treatment, the patient’s age, other medical conditions, the stage of the prostate cancer, the type of treatment and technical factors such as nerve, sparing. Every man’s situation, therefore, is unique. It is important that, prior to choosing treatment for prostate cancer, you talk to your doctor and to your partner about these issues and that you have realistic expectations about things once you have made your decision stay committed to it and avoid looking back if erectile dysfunction does become an issue after treatment, be reassured that successful treatments for it are available. This slide lists some of the many resources available where you can find more information about erectile dysfunction. These references are available at your local medical library. If you wish to do further reading on this subject, these references were also used to assist in preparing this presentation. We sincerely hope that this module has furthered your understanding of erectile dysfunction. We wish you the best for the future and thank you once again for viewing this educational program.
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