Erectile Dysfunction and Urinary Incontinence After Prostate Cancer Treatment

Disparities in the Delivery of Prostate Cancer Survivorship Care in the USA: A Claims-based Analysis of Urinary Adverse Events and Erectile Dysfunction Among Prostate Cancer Survivors

Background and objective

Incidence rates for prostate cancer (PCa) diagnosis and mortality are higher for Black men. It is unknown whether similar disparities exist in survivorship care. We assessed the delivery and quality of survivorship care for Black men undergoing PCa therapy in terms of the burden of and treatment for urinary adverse events (UAEs) and erectile dysfunction (ED).

Methods

We queried Optum Clinformatics data for all patients diagnosed with PCa from January 1, 2002 to December 31, 2017 and identified those who underwent primary PCa treatment. Index cohorts were identified in each year and followed longitudinally until 2017. Data for UAE diagnoses, UAE treatments, and ED treatments were analyzed in index cohorts. Cox proportional-hazards regression models were used to examine associations of race with UAE diagnosis, UAE treatment, and ED treatment.

Key findings and limitations

We identified 146, 216 patients with a PCa diagnosis during the study period, of whom 55, 149 underwent primary PCa treatment. In the primary treatment group, 32.7% developed a UAE and 28.2% underwent UAE treatment. The most common UAEs were urinary incontinence (11%), ureteral obstruction/stricture (4.5%), bladder neck contracture (4.5%), and urethral stricture (3.7%). The most common UAE treatments were cystoscopy (13%), suprapubic tube placement (6%), and urethral dilation (5%). Overall, UAE diagnosis rates were higher for Black patients, who had significantly higher risk of urethral obstruction, rectourethral fistula, urinary incontinence, cystitis, urinary obstruction, and ureteral fistula. Overall, UAE treatment rates were lower for Black patients, who had significantly higher risk of fecal diversion and/or rectourethral fistula repair (adjusted hazard ratio [aHR] 1.71, 95% confidence interval [CI] 1.04-2.79). Regarding ED treatments, Black patients had higher risk of penile prosthesis placement (aHR 1.591, 95% CI 1.26-2.00) and intracavernosal injection (aHR 1.215, 95% CI 1.08-1.37).

Conclusions and clinical implications

Despite a high UAE burden, treatment rates were low in a cohort with health insurance. Black patients had a higher UAE burden and lower UAE treatment rates. Multilevel interventions are needed to address this stark disparity. ED treatment rates were higher for Black patients.

Patient summary

We reviewed data for patients treated for prostate cancer (PCa) and found that 32.7% were diagnosed with a urinary adverse event (UAE) following their PCa treatment. The overall treatment rate for these UAEs was 28.2%. Analysis by race showed that the UAE diagnosis rate was higher for Black patients, who were also more likely to receive treatment for erectile dysfunction.

Association Between Statin Exposure and Incidence and Prognosis of Prostate Cancer: A Meta-analysis Based on Observational Studies

It is widely thought that statins have huge therapeutic potential against prostate cancer (PCA). This study aimed to investigate the effect of statin exposure on PCA incidence and prognosis. PubMed, Web of Science, Embase, and Cochrane databases were searched for observational studies on the association between statin exposure and PCA from inception until July 2022. The primary endpoints were the incidence of PCA and the survival rate. A total of 21 studies were included in this meta-analysis. The pooled estimates showed that exposure to hydrophilic statins was not associated with the incidence of PCA (odds ratio [OR]=0.94, 95% CI=0.88-1.01, P =0.075), while the incidence of PCA was significantly decreased in populations exposed to lipophilic statins compared with the nonexposed group (OR=0.94, 95% CI=0.90-0.98, P =0.001), mainly in Western countries (OR=0.94, 95% CI=0.91-0.98, P =0.006). Subgroup analysis showed that simvastatin (OR=0.83, 95% CI=0.71-0.97, P =0.016) effectively reduced the incidence of PCA. The prognosis of PCA in patients exposed to both hydrophilic (hazard ratio [HR]=0.57, 95% CI=0.49-0.66, P <0.001) and lipophilic (HR=0.65, 95% CI=0.58-0.73, P <0.001) statins were better than in the nonexposed group, and this improvement was more significant in the East than in Western countries. This study demonstrates that statins can reduce the incidence of PCA and improve prognosis, and are affected by population region and statin properties (hydrophilic and lipophilic).

An overview of the history, current strategies, and potential future treatment approaches in erectile dysfunction: a comprehensive review

INTRODUCTION

Erectile dysfunction (ED) is one of the most common urologic problems in men worldwide, with an approximately high incidence rate, significantly affecting patients' quality of life and their sexual partners.

OBJECTIVES

Due to the association of this disorder with essential diseases such as cardiovascular disease and diabetes, its prevention and treatment are vital for overall human physiologic and psychological health. Along with reviewing the history of treatment and current methods, we seek new approaches to curb this issue in the future.

METHODS

In this review, investigations were based on the focus of each section's content or conducted on an ad hoc basis. Searches were performed in Scopus and PubMed.

RESULTS

In recent years, many treatments for ED have been reported besides oral administration of phosphodiesterase 5 inhibitors such as sildenafil and tadalafil (approved by the Food and Drug Administration). Common oral medications, intracavernous injections, herbal therapies (eg, herbal phosphodiesterase 5 inhibitors), and topical/transdermal medications are routine ED treatment approaches. Moreover, some novel medications are innovative candidates for completing ED's treatment protocols: stem cell injection, low-intensity extracorporeal shock wave therapy, platelet-rich plasma injection, gene therapy, amniotic fluid matrices, rho-kinase inhibitors, melanocortin receptor antagonists, maxi-K channel activators (ie, large-conductance calcium-activated potassium channels), guanylate cyclase activators, and nitric oxide donors.

CONCLUSION

Due to the importance of this complicated problem in men's society, a faster course of treatment trends toward new methods is needed to increase efficiency. Combining the mentioned treatments and attentively examining their efficacy through programmed clinical trials can be a big step toward solving this global problem.

Curcumin slow-release membrane promotes erectile function and penile rehabilitation in a rat model of cavernous nerve injury

Male erectile dysfunction (ED) caused by cavernous nerve injury is a common complication of pelvic surgery, radiotherapy, transurethral surgery or other operations. However, clinical treatment for iatrogenic or traumatic male ED is difficult and not satisfactory. Many studies have shown that curcumin can promote the repair and regeneration of peripheral nerves; however, whether curcumin can rescue cavernous nerve injury is unknown, and the poor bioavailability of curcumin limits its application in vivo. Hence, the study was conducted. A curved slow-release membrane was produced, and the properties were examined. In addition, the effects of the curcumin slow-release membrane on cavernous nerve-injured SD rats were studied. We found that polylactic acid-glycolic acid-polyethylene glycol (PLGA-PEG) can be used as a good carrier material for curcumin, and curcumin-loaded PLGA-PEG membranes can effectively rescue the cavernous nerve in SD rats, restore the continuity of the cavernous nerve, and increase the expression of nNOS mRNA and proteins in penile tissue, which can improve the penile erectile function of injured SD rats, reduce the degree of penile tissue fibrosis, and effectively promote penis rehabilitation. The curcumin slow-release membrane is proposed to be a new therapeutic approach for penile rehabilitation of cavernous nerve injury.

Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications

Transrectal ultrasound (TRUS) has been an invaluable tool in the assessment of prostate size, anatomy and aiding in prostate cancer (PCa) diagnosis for decades. Emerging techniques warrant an investigation into the efficacy of TRUS, how it compares to new techniques, and options to increase the accuracy of prostate cancer diagnosis. Currently, TRUS is used to guide both transrectal and transperineal biopsy approaches with similar cancer detection rates, but lower rates of infection have been reported with the transperineal approach, while lower rates of urinary retention are often reported with the transrectal approach. Multiparametric MRI has substantial benefits for prostate cancer diagnosis and triage such as lesion location, grading, and can be combined with TRUS to perform fusion biopsies targeting specific lesions. Micro-ultrasound generates higher resolution images that traditional ultrasound and has been shown effective at diagnosing PCa, giving it the potential to become a future standard of care. Finally, high-intensity focused ultrasound focal therapy administered via TRUS has been shown to offer safe and effective short-term oncological control for localized disease with low morbidity, and the precise nature makes it a viable option for salvage and repeat therapy.

The Interplay between Vascular Function and Sexual Health in Prostate Cancer: The Potential Benefits of Exercise Training

Prostate cancer and its associated treatments can cause significant and lasting morbidities, such as cardiovascular and sexual dysfunctions. Various interventions have attempted to prevent or mitigate these dysfunctions. This review summarises the available evidence on the effects of exercise training on markers of cardiovascular disease (as assessed via vascular health outcomes) and sexual health in this prevalent cancer population. Current studies predominantly report blood pressure outcomes as a marker of vascular health, as well as various questionnaires assessing sexual health parameters, in men on active treatment (i.e., hormone or radiation therapies) or post-treatment. Preliminary evidence suggests that exercise interventions may elicit improvements in sexual function, but not blood pressure, in these populations. Future studies in more advanced and varied prostate cancer populations (i.e., those on chemotherapies or immunotherapies, or undergoing active surveillance) are required to ascertain the duration, intensity and frequency of exercise that optimises the effects of exercise training on cardiovascular and sexual dysfunctions (and their relationship) in men during and following treatment for prostate cancer.

Mitochondrial genome variation and prostate cancer: a review of the mutational landscape and application to clinical management

Prostate cancer is a genetic disease. While next generation sequencing has allowed for the emergence of molecular taxonomy, classification is restricted to the nuclear genome. Mutations within the maternally inherited mitochondrial genome are known to impact cancer pathogenesis, as a result of disturbances in energy metabolism and apoptosis. With a higher mutation rate, limited repair and increased copy number compared to the nuclear genome, the clinical relevance of mitochondrial DNA (mtDNA) variation requires deeper exploration. Here we provide a systematic review of the landscape of prostate cancer associated mtDNA variation. While the jury is still out on the association between inherited mtDNA variation and prostate cancer risk, we collate a total of 749 uniquely reported prostate cancer associated somatic mutations. Support exists for number of somatic events, extent of heteroplasmy, and rate of recurrence of mtDNA mutations, increasing with disease aggression. While, the predicted pathogenic impact for recurrent prostate cancer associated mutations appears negligible, evidence exists for carcinogenic mutations impacting the cytochrome c oxidase complex and regulating metastasis through elevated reactive oxygen species production. Due to a lack of lethal cohort analyses, we provide additional unpublished data for metastatic disease. Discussing the advantages of mtDNA as a prostate cancer biomarker, we provide a review of current progress of including elevated mtDNA levels, of a large somatic deletion, acquired tRNAs mutations, heteroplasmy and total number of somatic events (mutational load). We confirm via meta-analysis a significant association between mtDNA mutational load and pathological staging at diagnosis or surgery (p < 0.0001).

Effect of Eischens Yoga During Radiation Therapy on Prostate Cancer Patient Symptoms and Quality of Life: A Randomized Phase II Trial

PURPOSE

A randomized phase II study was performed to measure the potential therapeutic effects of yoga on fatigue, erectile dysfunction, urinary incontinence, and overall quality of life (QOL) in prostate cancer (PCa) patients undergoing external beam radiation therapy (RT).

METHODS AND MATERIALS

The participants were randomized to yoga and no-yoga cohorts (1:1). Twice-weekly yoga interventions were offered throughout the 6- to 9-week courses of RT. Comparisons of standardized assessments were performed between the 2 cohorts for the primary endpoint of fatigue and the secondary endpoints of erectile dysfunction, urinary incontinence, and QOL before, during, and after RT.

RESULTS

From October 2014 to January 2016, 68 eligible PCa patients underwent informed consent and agreed to participate in the study. Of the 68 patients, 18 withdrew early, mostly because of treatment schedule-related time constraints, resulting in 22 and 28 patients in the yoga and no-yoga groups, respectively. Throughout treatment, those in the yoga arm reported less fatigue than those in the control arm, with global fatigue, effect of fatigue, and severity of fatigue subscales showing statistically significant interactions (P<.0001). The sexual health scores (International Index of Erectile Function Questionnaire) also displayed a statistically significant interaction (P=.0333). The International Prostate Symptom Score revealed a statistically significant effect of time (P<.0001) but no significant effect of treatment (P=.1022). The QOL measures had mixed results, with yoga having a significant time by treatment effect on the emotional, physical, and social scores but not on functional scores.

CONCLUSIONS

A structured yoga intervention of twice-weekly classes during a course of RT was associated with a significant reduction in pre-existing and RT-related fatigue and urinary and sexual dysfunction in PCa patients.

Yoga Intervention for Patients With Prostate Cancer Undergoing External Beam Radiation Therapy: A Pilot Feasibility Study

PURPOSE

Studies have demonstrated beneficial health effects from yoga interventions in cancer patients, but predominantly in breast cancer. Research on its role in alleviating prostate cancer (PC) patients' side effects has been lacking. Our primary goal was to determine the feasibility of recruiting PC patients on a clinical trial of yoga while they underwent external beam radiation therapy (RT).

METHODS

Twice-weekly yoga interventions were offered throughout the RT course (6-9 weeks). Baseline demographic information was collected. Feasibility was declared if 15 of the first 75 eligible PC patients approached (20%) were successfully accrued and completed the intervention. Additional end points included standardized assessments of fatigue, erectile dysfunction (ED), urinary incontinence (UI), and quality of life (QOL) at time points before, during, and after RT.

RESULTS

Between May 2013 and June 2014, 68 eligible PC patients were identified. 23 patients (34%) declined, and 45 (56%) consented to the study. 18 (40%) were voluntarily withdrawn due to treatment conflicts. Of the remaining 27, 12 (30%) participated in ≥50% of classes, and 15 (59%) were evaluable. Severity of fatigue scores demonstrated significant variability, with fatigue increasing by week 4, but then improving over the course of treatment (P = .008). ED, UI, and general QOL scores demonstrated reassuringly stable, albeit not significant trends.

CONCLUSIONS

A structured yoga intervention of twice-weekly classes is feasible for PC patients during a 6- to 9-week course of outpatient radiotherapy. Preliminary results are promising, showing stable measurements in fatigue, sexual health, UI, and general QOL.

Radiation Dose to the Penile Structures and Patient-Reported Sexual Dysfunction in Long-Term Prostate Cancer Survivors

AIM

The involvement of various penile structures in radiotherapy (RT)-induced sexual dysfunction among prostate cancer survivors remains unclear and domains beyond erectile dysfunction such as orgasm, and pain have typically not been considered. The purpose of this study was to investigate sexual dysfunction post-RT for localized prostate cancer and to examine whether radiation dose to different penile structures can explain these symptoms.

METHODS

We investigated sexual dysfunction in two treated prostate cancer cohorts and in one non-pelvic-irradiated cohort, 328 sexually active men part of an unselected, population-based study conducted in 2008. The treated subjects were prescribed primary/salvage external-beam RT to 70 Gy@2.0 Gy/fraction. Absorbed RT doses (Dmean and Dmax ) of the corpora cavernosa (CC), the penile bulb (PB), and the total penile structure (CC + PB) were related to 13 patient-reported symptoms on sexual dysfunction by means of factor analysis (FA) and logistic regression.

RESULTS

Three distinct symptom domains were identified across all cohorts: "erectile dysfunction" (ED, two to five symptoms), "orgasmic dysfunction" (OD, two to four symptoms), and "pain" (two to three symptoms). The strongest predictor for ED symptoms was CC + PB Dmax (P = 0.001-0.03), CC and PB Dmean predicted OD symptoms equally well (P = 0.03 and 0.02-0.05, respectively), and the strongest predictor for pain symptoms was CC + PB Dmean (P = 0.02-0.03).

CONCLUSION

Sexual dysfunction following RT was separated into three main domains with symptoms related to erectile dysfunction, orgasmic dysfunction, and pain. Chances for intact sexual functionality may be increased if dose to the total penile structure can be restricted for these domains in the planning of RT .

Patient-reported sexual toxicity after radiation therapy in long-term prostate cancer survivors

Background:

To present an overview of patient-reported sexual toxicity in sexually active long-term prostate cancer survivors treated with radiation therapy.

Methods:

We used patient-reported outcomes from a study-specific questionnaire surveying symptoms after prostate cancer radiation therapy. Data from 518 men treated at the Sahlgrenska University Hospital in Sweden from 1993 to 2006 were analysed. The men had undergone primary or salvage external beam radiation therapy (EBRT) or EBRT combined with high-dose rate brachytherapy (BT). We also used information from 155 non-treated reference men from the general population with no history of prostate cancer, matched for age and residency.

Results:

Median time from treatment to follow-up was 5 years (range: 1–14 years). Among the 16 investigated symptoms on erectile function, libido, orgasm, and seminal fluid, 9 symptoms in the primary EBRT group and 10 in both the salvage EBRT and the EBRT+BT groups were statistically significantly more prevalent in survivors than in reference men. Erectile dysfunction was influenced by both age and time to follow-up, whereas symptoms relating to orgasm and seminal fluid were influenced by time to follow-up only. Not being sexually active was almost one and a half times as common in survivors as in reference men.

Conclusions:

The presented symptom profiles can help to develop personalized therapy for prostate cancer through a better understanding of which radiation-induced toxicities to be addressed in the clinic and can also assist in identifying suitable interventions for existing symptoms.

Shared Medical Appointments in Cancer Survivorship Care: A Review of the Literature

PURPOSE

The physical and psychological effects of a cancer diagnosis and treatment on an individual may be significant and require appropriate monitoring and management. Furthermore, attention to preventive care and comorbid medical conditions is critical. Innovative approaches are needed to provide quality care to this growing population.

METHODS

We reviewed the literature evaluating shared medical appointments (SMAs) in noncancer and cancer care settings. Supported by a conceptual framework and adhering to the goals of patient-centered communication, we propose how SMAs may be used in clinical practice to enhance survivorship care.

RESULTS

The literature suggests that SMAs are an effective model in noncancer settings, showing improved blood pressure and health-related quality of life, among others. Although evidence for SMAs in cancer care is limited, there is significant potential for improved patient outcomes and costs. In particular, SMAs may provide an opportunity to address medical and psychological needs while creating a structure for enhanced communication.

CONCLUSION

SMAs may offer an innovative care model for cancer survivors and their providers. Implementation and evaluation of SMAs in the care of cancer survivors is warranted.

Which symptoms come first? Exploration of temporal relationships between cancer-related symptoms over an 18-month period

BACKGROUND

Anxiety, depression, insomnia, fatigue, and pain are frequently reported by cancer patients. These symptoms are highly interrelated. However, few prospective studies have documented the sequence with which symptoms occur during cancer care.

PURPOSE

This longitudinal study explored the temporal relationships between anxiety, depression, insomnia, fatigue, and pain over an 18-month period in a large population-based sample of nonmetastatic cancer patients (N = 828), using structural equation modeling.

METHODS

The patients completed a battery of self-report scales at baseline and 2, 6, 10, 14, and 18 months later.

RESULTS

The relationships between the same symptom at two consecutive assessments showed the highest coefficients (β = 0.29 to 0.78; all ps ≤ 0.05). Cross-loading parameters (β = 0.06 to 0.19; ps ≤ 0.05) revealed that fatigue frequently predicted subsequent depression, insomnia, and pain, whereas anxiety predicted insomnia.

CONCLUSIONS

Fatigue and anxiety appear to constitute important risk factors of other cancer-related symptoms and should be managed appropriately early during the cancer care trajectory.

Patient-reported genitourinary toxicity for long-term prostate cancer survivors treated with radiation therapy

Background:

The objective of this study is to provide comprehensive overviews of patient-reported urinary symptoms for long-term prostate cancer survivors treated with radiation therapy and for untreated, healthy men.

Methods:

We performed a population-based cross-sectional study using a study-specific postal questionnaire assessing symptoms among 1007 men consecutively treated at the Sahlgrenska University Hospital, Göteborg, Sweden from 1993–2006 (primary or salvage external beam radiation therapy (EBRT) or EBRT and high-dose rate brachytherapy). We also randomly recruited 350 non-pelvic-irradiated matched control men from the Swedish Total Population Register. Symptom prevalence and prevalence ratios were computed.

Results:

Survey participation rate was 89% (874/985) for eligible survivors and 73% (243/332) for eligible controls. Median time from treatment to follow-up was 5 years (range, 1–14 years). Among the 21 investigated symptoms reflecting obstruction, frequency, urgency, pain and incontinence, we found significantly higher prevalence compared with controls for 9 symptoms in the EBRT group, 10 in the EBRT+brachytherapy group and 5 in the salvage EBRT group. The prevalence for a majority of the symptoms was stable over time.

Conclusion:

The presented toxicity profiles provide a thorough understanding of patient-reported urinary symptoms that can assist in developing personalised therapy for prostate cancer.

Sexuality and Intimacy After Definitive Treatment and Subsequent Androgen Deprivation Therapy for Prostate Cancer

There are more than 2 million prostate cancer survivors in the United States. Primary therapy with surgery or radiation results in permanent changes in sexual function. More than half of these men are subsequently treated with androgen deprivation therapy (ADT) at some point. The addition of ADT further compromises sexuality, intimacy, and a couple's relationship. This review will highlight the challenges faced by patients and couples and reveal the tremendous need for better education of physicians, patients, and couples as well as for more research in sexuality and intimacy with the goal of improving quality of life for this large population of survivors. Suggestions for clinicians to better help patients and their partners regarding sexuality and intimacy are offered.

Nursing care program for erectile dysfunction after radical prostatectomy

The prevalence of erectile dysfunction (ED) in 114 patients with prostate cancer treated with radical prostatectomy was examined to determine the efficacy of an ED care program in which nurse-provided education plays a fundamental role in the detection and follow-up of ED as well as in treatment compliance. The nursing program consists of four visits during which specific treatment-related information, education and support, active listening, and selection of the treatment best suited to each patient (in consultation with the healthcare team) are provided. One month following bladder catheter removal, 77 of the 114 patients (69%) in the study had ED, with a majority suffering from severe ED. A nursing care program could help minimize ED and enable patients to adapt to their new situation.