Treating erectile dysfunction after radical radiotherapy and androgen deprivation therapy (ADT) for prostate cancer

Prostate Cancer UK and Macmillan Cancer Support


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Objectives of treating erectile dysfunction post radiotherapy/androgen deprivation therapy

  • The goal of erectile function management strategies in men undergoing radiotherapy and androgen deprivation therapy (ADT) is restoring or maintaining assisted and non-assisted erectile function and preventing radiotherapy/ADT-induced structural changes in the penis
  • Treating erectile dysfunction (ED) includes:
    • providing a holistic approach towards the assessment and management of ED, especially in patients with comorbidities
    • restoring erectile function at a level satisfactory to patient and their partner or to pre-treatment level
    • maintaining erectile function and preventing or minimising reduction in penile length
    • improving patient’s quality of life and sexual self-esteem
    • reducing anxiety levels associated with sexual intimacy
  • Erectile function rehabilitation programmes, especially if initiated early on after radiotherapy/ADT, are effective in improving or restoring sexual function
  • It is especially important for clinicians to clearly communicate the rationale behind any erectile function restoration programme and to make men aware that erectile function will not usually recover spontaneously while ADT is ongoing in the adjuvant setting

Predictive factors for recovery

  • The recovery of erectile function depends on the following factors:
    • presence of other health problems/treatments—comorbidities and concurrent medication can increase risk of ED
    • general lifestyle factors (smoking, BMI, physical activity)—men of a healthy weight are likely to have better functional outcomes
    • age of man—younger patients may have better results. Men with good pre-treatment erectile function have better results
    • testosterone levels – normal levels are important for recovery of erectile function
    • time it takes for testosterone levels to return to normal after ADT

Pre-treatment recommendations

  • Discuss the impact of treatment on sexual function and rationale for early intervention with the patient and, if they wish, their partner
  • Assess the patient and partner's current sexual function
  • Assess the couple's readiness to engage in an ED rehabilitation programme
  • Assess comorbidities, concurrent medication and lifestyle habits that could affect sexual function
  • Assess baseline testosterone levels

Post-treatment recommendations

  • Discuss the implementation of an ED rehabilitation programme with the man and his partner
  • Assess erectile function and sexual desire

Treatment pathway

Recommended treatment pathway for managing ED after radiotherapy/ADT*


Pre-treatment
  • Assess ED risk factors
  • Assess baseline erectile function
  • Explain sexual side-effects of radiotherapy/ADT
  • Check baseline testosterone
LOW LIBIDO (ADT) ED (RADIOTHERAPY OR BRACHYTHERAPY)
First line
  • Psychosexual therapy and counselling
  • +/- PDE5-I low dose daily + PDE5-I standard dose on demand or PDE5-I on demand only or PDE5-I on demand/daily use for 12 weeks or as long as needed
  • +/- VED 10 min daily
  • Early initiation of PDE5-I
  • PDE5-I low dose daily + PDE5-I standard dose on demand or PDE5-I on demand only or PDE5-I on demand/daily use for 12 weeks or as long as needed
  • +/- VED 10 min daily
  • +/- psychosexual therapy and counselling
  Conservative approaches:
Exercise programme; lifestyle advice; pelvic floor exercises
 
  • Review at three months
  • Specialist ED clinic referral
Second line§ Add ICI/transurethral or topical alprostadil
  Review at three months
Third line Tertiary andrology service for consideration of penile implants
ED=erectile dysfunction; ADT=androgen deprivation therapy; ICI=intra-cavernosal injection; VED=vacuum erection device; PDE5-I=phosphodiesterase type 5 inhibitor
*Algorithm is a collation of survey responses of individual clinical practice
The most effective combination depends on patient and partner needs. Daily and on demand PDE5-I used simultaneously is an off-label recommendation
Psychosexual therapy and counselling provided as an adjunct to biomedical ED management
§Second line onwards usually through referral to specialist ED clinics.

Responsibility for prescribing specific treatments is determined at local service level

Duration of treatment
The decision to stop treatment depends on each patient, as the recovery time differs from man to man. Ideally, a treatment should be given until it's no longer needed

Treatment initiation

  • Initiate treatment (PDE5-I) soon after radiotherapy/starting ADT, no later than 3–6 months

Psychosexual therapy and psychological counselling

  • Enable access to psychosexual therapy or psychological counselling, especially to men on ADT with persistent low desire and individual/couple distress
  • Encourage partner support for the sexual rehabilitation programme through psychosexual therapy or couple counselling as appropriate
  • Encourage the man to schedule regular sexual contact with or without intercourse, to assist the management of low desire

Re-assessment

  • Once ED management is initiated, re-assess treatment response at regular intervals preferably every three months

Treatment duration

  • Try PDE5-I drug/dose combination on at least eight occasions before switching to another drug/dose combination, unless patient reports adverse event warranting an early switch
  • Individualise duration of treatment for each man. Strict time limits are inappropriate in clinical practice
  • The duration of any treatment can range from three months until the man no longer needs treatment

Assessment of erectile function

  • Assess patient's/partner sexual function pre- and post treatment, verbally or using validated sexual questionnaires|

| Routinely available questionnaires include: the International Index of Erectile Function (IIEF); Sexual Health Inventory for Men (SHIM); Female Sexual Function Index (FSFI); Erection Hardness Score (EHS); Self-Esteem And Relationship (SEAR) questionnaire; Sexual Life Quality Questionnaire (mSLQ-QOL); Miller Social Intimacy Scale (MSIS).

  • Offer sexual counselling to men and their partners prior to initiation of ADT/radiotherapy to prepare them for sexual side-effects
  • Discuss sexual rehabilitation programmes with patient and his partner, if possible
  • Discuss lifestyle changes, testosterone levels and exercise programmes with men prior to initiating long-term ADT
  • Check baseline testosterone levels to exclude an existing testosterone deficiency
  • Assess general health, comorbidities and concurrent medication
  • Once ED treatment is started, re-assess patient regularly—at least every three months

Useful sources of information

Professional support

  • Face-to-face and online training for health professionals: visit prostatecanceruk.org/education for further information
  • Free educational resources are available in Macmillan's Learnzone, including 'Sexual Relationships and Cancer', an online module on how to talk to patients about the issues surrounding sexuality and cancer—visit learnzone.org.uk for further information

Patient information and support

References

full guidelines available from...
prostatecanceruk.org/for-health-professionals/guidelines/treating-erectile-dysfunction-after-radical-radiotherapy-and-androgen-deprivation-therapy-adt-for-prostate-cancer

Prostate Cancer UK and Macmillan Cancer Support. Treating erectile dysfunction after radical radiotherapy and androgen deprivation therapy (ADT) for prostate cancer. A quick guide for health professionals: supporting men with erectile dysfunction. January 2015


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