Development of UK recommendations on treatment for post-surgical erectile dysfunction

Sexual Dysfunction in Prostate Cancer Patients According to Disease Stage and Treatment Modality

AIMS

To investigate physical and psychological sexual dysfunction (SD) in prostate cancer (PCa) patients, according to disease stage and treatment modality.

MATERIALS AND METHODS

Participants diagnosed with PCa completed an online survey reporting sexual side effects across 13 domains, the importance of sexual function, and their support needs. Disease stage and treatment data were collected to identify variations in experience. Results were analysed descriptively and with chi-squared significance testing.

RESULTS

Six hundred fifty-four participants diagnosed with localised (66.1%), locally advanced (25.1%), and advanced (8.9%) PCa responded to the survey. Their disease management included radical prostatectomy (RP; 49.7%), radiotherapy (RT; 45.9%), and androgen deprivation therapy (ADT; 43.6%). More than 98% reported new-onset post-treatment sexual problems. The most common physical dysfunctions were erectile dysfunction (ED; 91.0%), ejaculatory disturbance (82.9%), and anatomical penile change (70.0%). The most common psychosexual dysfunctions were loss of sexual confidence (76.2%), loss of sex drive (67.1%), and loss of self-esteem (57.1%). Participants diagnosed with advanced disease were significantly more likely to report SD than participants with localised or locally advanced disease in 5 of 13 domains (p < .05). Participants whose treatment included a combination of RP, RT, and ADT were most likely to report SD in 7 of 13 domains. Overall, 78.3% of participants said sexual activity was important to them, with 61.8% placing sexual problems in their top three current concerns. Furthermore, 78.3% wanted to discuss sexual problems with a healthcare professional, with most wishing to focus on ED, loss of sexual confidence, and low libido.

CONCLUSION

SD is a common, wide-ranging, and distressing side effect of treatment, and PCa survivors place a high level of importance on sexual recovery. Those with advanced disease are among the worst affected and report high levels of psychosexual problems. Holistic rehabilitation strategies addressing a broad range of side effects would benefit all, but particularly those treated with permanent ADT.

Male pediatric, adolescent, and young adult reproductive survivorship

As pediatric, adolescent, and young adult cancer survival rates increase, emphasis is placed on reducing late effects, including reproductive complications and potential impact to fertility. Male survivors are at risk of abnormalities in sperm, hormone deficiencies, and sexual dysfunction. This can impact one's progression into puberty and ability to have a biological child and impacts quality of life following treatment. Access to reproductive care is important and requires patient assessment and appropriate referral to reproductive specialists. This review addresses reproductive complications associated with therapy, standard-of-care testing, and therapeutic interventions. The psychologic impact on psychosexual functioning is also addressed.

Efficacy, Use, and Acceptability of a Web-Based Self-management Intervention Designed to Maximize Sexual Well-being in Men Living With Prostate Cancer: Single-Arm Experimental Study

BACKGROUND

Sexual dysfunction is a frequent side effect associated with different prostate cancer treatment approaches. It can have a substantial impact on men and their partners and is associated with increased psychological morbidity. Despite this, sexual concerns are often not adequately addressed in routine practice. Evidence-based web-based interventions have the potential to provide ongoing information and sexual well-being support throughout all stages of care.

OBJECTIVE

The aim of this study is to examine the efficacy of a web-based self-management intervention designed to maximize sexual well-being in men living with prostate cancer and explore user perspectives on usability and acceptability.

METHODS

We used a single-arm study design, and participants were provided with access to the 5-step intervention for a period of 3 months. The intervention content was tailored based on responses to brief screening questions on treatment type, relationship status, and sexual orientation. Efficacy was assessed by using two-tailed, paired sample t tests for comparing the mean differences between pre- and postintervention measurements for exploring the participants' self-reported knowledge and understanding, sexual satisfaction, and comfort in discussing sexual issues. Usability and acceptability were determined based on the program use data and a postintervention survey for exploring perceived usefulness.

RESULTS

A total of 109 participants were recruited for this study. Significant postintervention improvements at follow-up were observed in the total scores (out of 20) from the survey (mean 12.23/20 points, SD 2.46 vs mean 13.62/20, SD 2.31; t₈₈=9.570; P=.001) as well as in individual item scores on the extent to which the participants agreed that they had sufficient information to manage the impact that prostate cancer had on their sex life (mean 2.31/4 points, SD 0.86 vs mean 2.57/4, SD 0.85; t₈₈=3.660; P=.001) and had the potential to have a satisfying sex life following treatment (mean 2.38/4 points, SD 0.79 vs mean 3.17/4, SD 0.78; t₈₈=7.643; P=.001). The median number of intervention sessions was 3 (range 1-11), and intervention sessions had a median duration of 22 minutes (range 8-77). Acceptable usability scores were reported, with the highest result observed for the question on the extent to which the intervention provided relevant information.

CONCLUSIONS

This study provides evidence on the efficacy of a tailored web-based intervention for maximizing sexual well-being in men living with prostate cancer. The results indicate that the intervention may improve one's self-perceived knowledge and understanding of how to manage sexual issues and increase self-efficacy or the belief that a satisfactory sex life could be achieved following treatment. The findings will be used to refine the intervention content before testing as part of a larger longitudinal study for examining its effectiveness.

Sexual aspects of shared decision making and prehabilitation in men diagnosed with prostate cancer

This article addresses sexual aspects of two related HCP-roles in the period between a diagnosis of prostate cancer (PC) and the start of treatment. First, the 'lovemap-perspective' is used to fine-tune the process of shared decision making. Then sexual prehabilitation is explored in detail, in the belief that better sexual function before starting treatment is more likely to lead to better post-treatment outcomes. Recommendations will be shared on further development of sexual prehabilitation approaches.

Psychosocial contributors to patients' and partners' postprostate cancer sexual recovery: 10 evidence-based and practical considerations

Sexual recovery after prostate cancer (PCa) treatment is challenging. When expectations are that erectile response will quickly return to baseline, patients can often struggle when this does not happen. Further difficulty is experienced when patients encounter physical, psychological, and relational barriers to sexual adjustment. Drawing on the psychosocial research literature and on 15 years of clinical experience counseling PCa patients about sexual recovery, this paper outlines considerations for clinical practice. Suggestions include broadening the target for successful outcomes after Pca treatment beyond erectile function to include sexual distress and other sources of sexual concern. Clinicians are urged to consider individual differences such as the larger context of the patient, including their values and preferences, their treatment goals, and their relationship situation and status, in order to promote successful sexual adaptation. When introducing treatment approaches, the role of grief and loss should be assessed, and patients should be supported to foster realistic expectations about the recovery process. Suggestions for how to introduce various sexual strategies to patients are also offered, including ways to support patients in making and sustaining behavioral changes associated with sexual intervention. Clinicians are offered suggestions to promote patients' sexual flexibility, prevent long periods of sexual inactivity, and help patients to identify various sexual motivators. Consideration of these psychological, relational, and social factors are all likely to help facilitate better sexual outcomes for PCa patients.

PDE-5i Management of Erectile Dysfunction After Rectal Surgery: A Systematic Review Focusing on Treatment Efficacy

Erectile dysfunction (ED) is one of the main functional complications of surgical resections of the rectum due to rectal cancers or inflammatory bowel disease (IBD). The present systematic review aimed at revising ED management strategies applied after rectal resections and their efficacy in terms of improvement of the International Index of Erectile Function (IIEF) score. A literature search was conducted on Medline, EMBASE, Scopus, and Cochrane databases by two independent reviewers following the PRISMA guidelines. Randomized and nonrandomized controlled trials (RCTs, NRCTs), case-control studies, and case series evaluating medical or surgical therapies for ED diagnosed after rectal surgery for both benign and malignant pathologies were eligible for inclusion.

Out of 1028 articles initially identified, only five met the inclusion criteria: two RCTs comparing oral phosphodiesterase type-5 inhibitor (PDE-5i) versus placebo; one NRCT comparing PDE-5i versus PDE-5i + vacuum erection devices (VEDs) versus control; and two before-after studies on PDE-5i. A total of 253 (82.7%) rectal cancer patients and 53 (17.3%) IBD patients were included. Based on two RCTs, PDE-5i significantly improved IIEF compared to placebo at 3 months (SMD = 1.07; 95% CI [0.65, 1.48]; p < .00001; I² = 39%). Improved IIEF was also reported with PDE-5i + VED at 12 months. There is a paucity of articles in the literature that specifically assess efficacy of ED treatments after rectal surgery. Many alternative treatment strategies to PDE-5is remain to be investigated. Future studies should implement standardized preoperative, postoperative, and follow-up sexual function assessment in patients undergoing rectal resections.

Development of a conceptual framework to improve sexual wellbeing communication in routine prostate cancer care

OBJECTIVE

To systematically develop a framework to improve sexual wellbeing communication in routine prostate cancer care.

METHODS

The Theoretical Domains Framework was used to guide a multi-phase process used to identify components of the framework based on evidence reviews, semi-structured interviews and stakeholder workshops. 'Think-aloud' testing was used to explore usability, potential barriers and other factors relevant to implementation.

RESULTS

A conceptual communication framework consisting of 'Engagement' (E), 'Assessment' (A), information and 'Support' (S) and 'Sign-posting' (Si) sections was developed. The framework emphasises routine engagement to normalise sexual concerns, brief, non-sensitive assessment, personalised advice based on treatment type and relationship status, and a mechanism for referral to additional support or self-management resources in the form of a patient and partner handout. Usability testing identified strategies to promote implementation.

CONCLUSIONS

The proposed framework is appropriate for use in routine practice and appears to be acceptable to patients, partners and healthcare professionals. Its use may help address gaps in sexual wellbeing support for men and partners living with prostate cancer. Further work will be conducted evaluating an online engagement tool, modelled on the framework.

PRACTICE IMPLICATIONS

The EASSi framework can facilitate and structure sexual wellbeing conversations and ensure fundamental but individualised support is provided routinely in prostate cancer care.

Management of erectile dysfunction after prostate cancer treatment: cross-sectional surveys of the perceptions and experiences of patients and healthcare professionals in the UK

OBJECTIVES

Erectile dysfunction (ED) is known to be a common consequence of radical treatment for prostate cancer (PCa) but is often under-reported and undertreated. This study aimed to explore how ED in patients with PCa is managed in real-life clinical practice, from the perspective of patients and healthcare professionals (HCPs).

DESIGN AND SETTING

This is a UK-wide cross-sectional survey of men with ED after treatment for PCa which covered assessment and discussion of erectile function, provision of supportive care and satisfaction with management. Parallel surveys of primary and secondary HCPs were also conducted.

RESULTS

Responses were received from 546 men with ED after PCa treatment, 167 primary (general practitioners and practice nurses) and 94 secondary care HCPs (urologists and urology clinical nurse specialists). Survey findings revealed inadequate management of ED in primary care, particularly underprescribing of effective management options. A fifth of men (21%) were not offered any ED management, and a similar proportion (23%) were not satisfied with the way HCPs addressed their ED concerns. There was poor communication between HCPs and men, including failure to initiate discussions about ED and/or involve partners, with 12% of men not told that ED was a risk factor of PCa treatment. These issues seemed to reflect poor access to effective ED management or services and lack of primary HCP confidence in managing ED, as well as confusion over the roles and responsibilities among both HCPs and men.

CONCLUSIONS

This study confirms the need for better support for men from HCPs and more tailored and timely access to effective ED management after treatment for PCa. A clearly defined pathway is required for the discussion and management of ED, starting from the planning stage of PCa treatment. Improved adherence to ED management guidelines and better education and training for primary care HCPs are areas of priority.

Canadian consensus algorithm for erectile rehabilitation following prostate cancer treatment

INTRODUCTION

The present descriptive analysis carried out by a pan-Canadian panel of expert healthcare practitioners (HCPs) summarizes best practices for erectile rehabilitation following prostate cancer (PCa) treatment. This algorithm was designed to support an online sexual health and rehabilitation e-clinic (SHARe-Clinic), which provides biomedical guidance and supportive care to Canadian men recovering from PCa treatment. The implications of the algorithm may be used inform clinical practice in community settings.

METHODS

Men's sexual health experts convened for the TrueNTH Sexual Health and Rehabilitation Initiative Consensus Meeting to address concerns regarding erectile dysfunction (ED) therapy and management following treatment for PCa. The meeting brought together experts from across Canada for a discussion of current practices, latest evidence-based literature review, and patient interviews.

RESULTS

An algorithm for ED treatment following PCa treatment is presented that accounts for treatment received (surgery or radiation), degree of nerve-sparing, and level of pro-erectile treatment invasiveness based on patient and partner values. This algorithm provides an approach from both a biomedical and psychosocial focus that is tailored to the patient/partner presentation. Regular sexual activity is recommended, and the importance of partner involvement in the treatment decision-making process is highlighted, including the management of partner sexual concerns.

CONCLUSIONS

The algorithm proposed by expert consensus considers important factors like the type of PCa treatment, the timeline of erectile recovery, and patient values, with the goal of becoming a nationwide standard for erectile rehabilitation following PCa treatment.

Erectile dysfunction after radical prostatectomy: prevalence, medical treatments, and psychosocial interventions

PURPOSE OF REVIEW

This review will discuss erectile dysfunction in prostate cancer patients following radical prostatectomy . It will focus on the prevalence and current treatments for erectile dysfunction as well as the emotional impact of erectile dysfunction and the current psychosocial interventions designed to help patients cope with this side effect.

RECENT FINDINGS

Although there is a large discrepancy in prevalence rates of erectile dysfunction after radical prostatectomy, several recent studies have cited rates as high as 85%. The concept of 'penile rehabilitation' is now the standard of practice to treat erectile dysfunction following radical prostatectomy. However, many men avoid seeking help or utilizing erectile dysfunction treatments. This avoidance is related to the shame, frustration, and distress many men with erectile dysfunction and their partners experience. Recent psychosocial interventions have been developed to facilitate the use of treatments and help men cope with erectile dysfunction. These interventions have shown initial promise, however, continued intervention development is needed to reduce distress and improve long-term erectile function outcomes.

SUMMARY

Erectile dysfunction is a significant problem following prostate cancer surgery. Although there are effective medical treatments, the development of psychosocial interventions should continue to evolve to maximize the assistance we can give to men and their partners.

Intimacy after prostate cancer: A brief couples' workshop is associated with improvements in relationship satisfaction

OBJECTIVE

Prostate cancer (PCa) treatments often leave men with erectile dysfunction (ED). Even when ED treatments are effective in restoring men's ability to have an erection sufficient for intercourse, couples continue to struggle sexually. Effective treatments to help couples recover sexually are needed.

METHOD

PCa patients and partners (N = 59 couples) attending a one-time couples' intimacy workshop, participated in an evaluation. The workshop, offered eight times over a 2-year period, emphasized a couples-based approach to treatment that enhances direct communication about sexuality and implementation of sexual recovery strategies that are consistent with the couple's values. Couples completed pre and post questionnaires (at baseline and 2 months later) assessing the primary outcome of relationship adjustment (Revised Dyadic Adjustment Scale) and secondary outcome of sexual function (Sexual Function Questionnaire). T-tests were employed to examine pre-post changes in scores. A small qualitative sub-study was conducted on the use of a Commitment to Change goal-setting exercise, completed during the workshop.

RESULTS

Results provide insight into the specific nature of improvements. Patients and partners showed improvements in relationship satisfaction. Improvements with small-to-medium effect sizes were observed for patients and partners sexual function; however, after adjusting for multiple comparisons, these changes were no longer statistically significant. The specific goals set by couples, and their achievement status, are presented.

CONCLUSIONS

The workshop offers a comprehensive, one-session intervention to help couples implement a treatment plan to promote sexual recovery after PCa treatment. Given the observed improvements, progression to a randomized control trial is warranted. Copyright © 2016 John Wiley & Sons, Ltd.

The Circle of Lifestyle and Erectile Dysfunction

INTRODUCTION

Erectile dysfunction (ED) has been significantly associated with many chronic conditions including obesity, the metabolic syndrome, hypogonadism, diabetes mellitus, cardiovascular disease (CVD), lower urinary tract symptoms, and psychiatric/psychological disorders. ED is also a well-established predictor of CVD.

AIM

This review will focus on the association of ED with cardiovascular, metabolic, and cognitive conditions and discuss the effects of managing lifestyle factors in order to reduce the burden of ED and consequently outcomes in patients with chronic conditions.

METHODS

A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1990.

MAIN OUTCOME MEASURES

Main outcome measures were improvements in sexual function.

RESULTS

A total of 59 reviews on the topic were evaluated.

CONCLUSIONS

Targeting several lifestyle factors associated with CVD/metabolic/cognitive disorders, e.g., smoking, alcohol consumption, obesity, and physical activity, can have significant benefits, leading to an improvement in ED as well as testosterone levels and consequently CVD. Kirby M. The circle of lifestyle and erectile dysfunction. Sex Med Rev 2015;3:169-182.

Integrative review on the non-invasive management of lower urinary tract symptoms in men following treatments for pelvic malignancies

AIM

To develop a non-invasive management strategy for men with lower urinary tract symptoms (LUTS) after treatment for pelvic cancer, that is suitable for use in a primary healthcare context.

METHODS

PubMed literature searches of LUTS management in this patient group were carried out, together with obtaining a consensus of management strategies from a panel of authors for the management of LUTS from across the UK.

RESULTS

Data from 41 articles were investigated and collated. Clinical experience was sought from authors where there was no clinical evidence. The findings discussed in this paper confirm that LUTS after the cancer treatment can significantly impair men's quality of life. While many men recover from LUTS spontaneously over time, a significant proportion require long-term management. Despite the prevalence of LUTS, there is a lack of consensus on best management. This article offers a comprehensive treatment algorithm to manage patients with LUTS following pelvic cancer treatment.

CONCLUSION

Based on published research literature and clinical experience, recommendations are proposed for the standardisation of management strategies employed for men with LUTS after the pelvic cancer treatment. In addition to implementing the algorithm, understanding the rationale for the type and timing of LUTS management strategies is crucial for clinicians and patients.

Global Quality of Life After Curative Treatment for Prostate Cancer: What Matters? A Study Among Members of the Norwegian Prostate Cancer Patient Association

INTRODUCTION

The purpose of this study was to identify factors that are associated with quality of life (QoL) in relapse-free patients after radical prostatectomy or high-dose radiotherapy with or without hormone treatment.

PATIENTS AND METHODS

A cross-sectional postal survey among members of the Norwegian Prostate Cancer Patient Association was used. We analyzed associations between QoL and general health, "typical" adverse effects (sexual, urinary, and bowel assessed using the Expanded Prostate Cancer Composite items) and psychosocial variables (work ability, family life, social life and/or leisure activities) in univariate and multivariate regression analyses. Statistical significance was defined as P < .01.

RESULTS

Among 612 responders (approximately 50% compliance; median age, 70 years), in univariate analyses QoL was significantly associated with functional aspects and the level of bother within the sexual, urinary, and bowel domains and with general health and psychosocial aspects of daily life. In the multivariate analysis only general health and social life and/or leisure activities remained associated with QoL, with work ability being a third factor in patients younger than 65 years old. Posttreatment worsening of partnership was reported by 12% of the patients.

CONCLUSION

Prostate cancer patients who are to undergo curative treatment should be informed about the risk of reduced function within the sexual, urinary, and bowel domains, but also about these dysfunctions' relation to bother and QoL, considered together with the patients' general health and their preferences as to their social life activities.

Psychosocial perspectives on sexual recovery after prostate cancer treatment

Many therapies for erectile dysfunction (ED) after prostate cancer treatment improve erectile firmness, yet, most couples stop using aids within 1-2 years. Patients and partners who expect immediate and complete success with their first ED treatment can be demoralized when they experience treatment failure, which contributes to reticence to explore other ED aids. Comprehensive patient education should improve sustainability and satisfaction with ED treatments. Pre-emptive and realistic information should be provided to couples about the probability of recovering natural erections. Beginning intervention early and using a couple-based approach is ideal. Recommendations are provided about the timing of ED treatment, the order of aid introduction, and combination therapies. Renegotiation of sexual activity is an essential part of sexual adaptation. From the outset of therapy, couples should be encouraged to broaden their sexual repertoire, incorporate erection-independent sexual activities, and continue to be sexual despite ED and reduced libido.

Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer

AIM

To develop a management strategy (rehabilitation programme) for erectile dysfunction (ED) after radiotherapy (RT) or androgen deprivation therapy (ADT) for prostate cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management in this patient group together with a survey of 28 experts in the management of treatment-induced ED from across the UK were conducted.

RESULTS

Data from 19 articles and completed questionnaires were collated. The findings discussed in this article confirm that RT/ADT for prostate cancer can significantly impair erectile function. While many men achieve erections through PDE5-I use, others need combined management incorporating exercise and lifestyle modifications, psychosexual counselling and other erectile aids. This article offers a comprehensive treatment algorithm to manage patients with ED associated with RT/ADT.

CONCLUSION

Based on published research literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for ED after RT/ADT. In addition to implementing the algorithm, understanding the rationale for the type and timing of ED management strategies is crucial for clinicians, men and their partners.