Mr Jas Kalsi, Consultant Urologist and Male Fertility Expert at Cromwell Hospital discusses erectile dysfunction (ED) in prostate cancer patients and the treatments available at Cromwell Hospital.

Each year about 1.3 million men are diagnosed with prostate cancer worldwide, which represents about 13% of all cancers diagnosed in men. In the UK, prostate cancer is the most common cancer in men, with over 56 000 new cases diagnosed in 2018.

Risk factors for prostate cancer include increasing age, a family history of the disease in a first-degree relative, a BMI (Body Mass Index) and ethnicity—one in four black men will be diagnosed with prostate cancer in their lifetime in England, twice the risk of white men (one in eight).

Radical treatments for prostate cancer include:

  • removal of the prostate gland (radical prostatectomy)
  • external beam radiotherapy- This treatment is normally given as a number of short, daily treatments in a radiotherapy department.
  • radiation therapy (brachytherapy): It is a local treatment and treats only a specific part of your body.
  • high-intensity focused ultrasound (HiFU) : It is a cancer treatment that aims to kill cancer cells with high frequency sound waves.
  • Androgen Deprivation Therapy (ADT): This treatment aims to reduce male hormones levels (androgen) in the body or prevent them from promoting the growth of prostate cancer cells.

Active surveillance is also offered as an option to men with low-risk, and sometimes intermediate-risk, localised prostate cancer.

While effective in prolonging survival, these treatments commonly induce erectile dysfunction (ED). The UK-wide Life After Prostate Cancer Diagnosis (LAPCD) study, examining patient-reported outcomes of over 30 000 prostate cancer survivors at 18–42 months after diagnosis, reported that 81% of patients described their overall sexual function as poor or very poor.

Typically, (ED), accompanied by gradual structural changes in the penis, can develop immediately after or slowly over a few months. In addition, androgen deprivation may also cause loss of sexual interest, as well as more general symptoms such as fatigue, low mood, weight gain and decreased muscle mass. ED has been linked to loss of self-esteem and depression and can significantly impair quality of life for both men and their partners.

A wide range of treatments are available for the management of ED, including:

  • oral phosphodiesterase type 5 inhibitors: this is a type of drug that can affect blood flow and how cells communicate in the body. It helps increase blood flow to the penis during sexual arousal.
  • intra-cavernosal injections (ICI): injections that help treat ED by improving blood flow to the penis.
  • intraurethral suppositories or ointment (alprostadil): medications that treat ED by increasing blood flow to the penis to achieve and maintain erection.
  • vacuum erection devices (VED): an external pump that a man with ED can use to get and maintain an erection.
  • penile implants: men with ED can acquire an erection with the help of penile implants, which are devices placed inside the penis.

Despite the known risk of ED after treatment and the availability of treatment options, ED remains an under-reported and often undertreated condition. The LAPCD study reported that only 44% of men were offered intervention(s) to help with sexual function, such as medications, devices or specialist services. 

UK guidelines are now available to support the management of ED in patients with prostate cancer after prostate surgery or radiotherapy.

These guidelines emphasise the importance of proactive early sexual rehabilitation after a prostatectomy under the care of a specialist andrologist. They also support the need for patient education and pharmacological intervention to minimise treatment-induced penile changes.