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Beyond the diagnosis: Navigating sex after prostate therapy

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Handsome Older Man Smiling with Arms CrossedFor most of history, almost all men felt too embarrassed to seek help if they experienced difficulties “behind closed doors.” Unfortunately, this attitude kept men from seeking professional help even if they were only experiencing these problems as a natural side effect of a different and unrelated health problem. Happily, there has been a 180-degree turn in attitudes about sexual performance, and it’s now openly talked about in the same way as any other medical problem is discussed between patients and doctors. This has been especially beneficial in the case of problems resulting from quite two common conditions related to the growth of the prostate gland. Prostate cancer (PCa) and benign prostate hyperplasia (BPH) affect more than half of all men over the age of 50, and the degree of effect grows as they grow older, so increasingly require treatment for the condition. Consequently, they become progressively susceptible to the negative effects that often come from prostate therapy.

More about the prostate gland

  The prostate is a small, muscular gland found only in males. It’s about the size of a walnut and is situated below the bladder, surrounding the urethra (the tube that carries urine out of the body). The prostate’s two main functions are: producing seminal fluid and controlling urination.  It follows that problems in the prostate gland can have a significant impact on many aspects of sexual function. This blog concentrates on how sexual activity can be disrupted by prostate therapy that was called for on account of the two most common prostate problems, and on the possible remedies that are used to treat them. It is easy to lump all diseases associated with the prostate gland in older men into one basket, but this can lead to some confusion. Prostate cancer (PCa) and benign prostate hyperplasia (BPH) appear to be related because of some shared features. The timeframe for developing each disease is roughly the same. The symptoms of the associated disorders resemble each other, and data has shown that there is a strong likelihood that BPH is also present when PCa has been diagnosed. However, doctors have not yet been able to establish whether there is any causal link between the two conditions. Both are very closely associated with aging. For men under the age of 50, only about two in every thousand men will be diagnosed with PCa, but the rate rockets ten-fold, up to two in every hundred for men in their 50s. In the following decades, the rate keeps climbing, to one in 20 (5%) for ages 60 to 69, and 9% for men 70 and older. More than half of all prostate cancers are diagnosed in men over the age of 65. In parallel, the lifetime risk of a man in the 51-60 range developing benign prostate hyperplasia (BPH) has been estimated to be 50%. It increases to 70% in the 61-70 years age group.

What are the main differences between prostate cancer and benign prostate hyperplasia?

BPH and prostate cancer have very different effects in terms of their impact on sexual function and how the selected prostate therapy can, in turn, cause further dysfunctions. In the realm of sexual function, BPH’s main impact is on erectile function and ejaculation. The enlarged prostate physically interferes with blood flow and nerve signals, affecting both erection and ejaculation. PCa’s impact is less direct. Early in the development of the cancer, the malignancy is usually localized, and PCa rarely affects a man’s active sex life. However, as the condition progresses, there are likely to be more aggressive treatments, like surgery and radiation. These can have significant and permanent effects on erection, ejaculation, and desire. In the case of medical treatments for BPH, medicines called 5-alpha-reductase inhibitors like Jalyn, Avodart, Propecia, and Proscar can cause impotence, ejaculation difficulties, reduced libido, and ED in some men. There are also choices for minimally invasive prostate therapy procedures like microwave ablation that can damage nerves, leading to ED and retrograde ejaculation. For cases of PCa the main available treatments are radical prostatectomy and radiation therapy. These types of prostate therapy can severely impact erectile function and ejaculation due to nerve damage. These effects can be permanent and would require additional interventions like implants or medication.

How is prostate cancer diagnosed?

PCa is the second leading cause of cancer death among men in the US, accounting for more than 10% of cancer-related deaths in males and causing 94 deaths every day in the US. In 2023, there were  288,300 new cases and 34,700 deaths. The National Cancer Institute estimates that the average risk across all age groups is 13% (with the incidence increasing with age), and the overall risk of mortality is 2.5%. The only way to definitively diagnose prostate cancer is a biopsy, which doctors routinely order if blood tests show an elevated level of the prostate-specific antigen (PSA). There have been significant changes in the use of routine PSA screening in men aged 70 and older. This is because the potential survival benefits from treatment are statistically minimal, and they do not outweigh the significant adverse effects and health issues that the average man in this age group may experience due to treatment. According to the Prostate Cancer Foundation, “while prostate cancer is relatively common, the good news is that more than 80% of all prostate cancers are detected when the cancer is confined to the prostate or the region around it. Treatment success rates are high compared with many other types of cancer. “The 5-year survival rate for men diagnosed with early-stage prostate cancer in the United States is greater than 99%. In other words, the chance of a man dying from prostate cancer is generally low. However, some aggressive cancers can spread even when they appear to be confined to the prostate. The exact causes of these prostatic diseases is not yet fully understood. Anatomically, BPH arises from the transition zone of the prostate gland. PCa is an adenocarcinoma, which means it arises from epithelial cells located in the peripheral zone of the prostate gland, and only a small percentage come from cells in the transition zone. In only one-fifth of cases do BPH and PCa co-exist in the same prostatic zone. These diseases have a major effect on millions of men’s quality of life and life expectancy.

How is prostate cancer treated?

Generally, the earlier the cancer is caught and treated, the more likely the patient will remain disease-free. Many men with “low-risk” tumors (which are the most common type of prostate cancer), as well as some men with intermediate-risk disease, can safely undergo active surveillance. This means patients are closely monitored without immediate treatment (or treatment-related side effects), while preserving their long-term survival chance if the cancer becomes aggressive enough to require treatment. The options for local or systemic prostate therapy include the following:
  • Hormone therapy, which deprives cancer cells of hormones they need to proliferate
  • Chemotherapy uses strong drugs to kill cancer cells throughout the body. Its advantage is that it can halt or slow cancer progression beyond the prostate and so is used mostly in more advanced cases.
  • Radical prostatectomy is a targeted approach that aims to eliminate or control cancer within the prostate gland. Its possible advantages are that by focusing on the prostate it  minimizes the possible impact on other body parts. For early stages of prostate cancer, local therapy offers a chance for a complete cure.
  • Radiation therapy aims to kill prostate cancer cells by using high-energy lasers or brachytherapy (radioactive seeds implanted in the patient’s body)
  • Microwaves and radiofrequency ablation
  • Urethral stents

What effects can prostate therapy have on sexual performance?

All of the available options can have an impact on sexual function, including reduced sexual desire (lowered libido), erectile dysfunction, premature ejaculation or difficulty achieving orgasm. Additional downsides are diarrhea, nausea, or bowel urgency. The options that involve intervention (surgery, radiation, ablation or stents) might require short-term pain management but the more significant longer-term effects come from the likelihood that they can damage the nerves responsible for erection and ejaculation, leading to ED or retrograde ejaculation.
  • Urethral stents can irritate the penis and affect arousal. 
  • Open prostatectomy and transurethral resection of the prostate (TURP) carries the highest risk of ED and retrograde ejaculation due to potential nerve damage.

Analyzing quality of life (QoL) after prostate therapy for hyperplasia or cancer

Recently, a study was published in the journal Cancer that focused on how diets can influence many factors in the quality of life experienced by men who have been diagnosed with prostate cancer. The study involved 3500 men with a median age of 68, almost half of whom had undergone radical prostatectomy (surgical intervention to remove the prostate gland), and 35% had undergone radiation as the primary therapy. Across the five QoL domains (sexual, urinary irritation/obstruction, urinary incontinence, bowel, and hormonal/vitality), the sexual function domain in the study population recorded the highest dissatisfaction scores (in other words, the lowest QoL).  This study was a follow-up to an earlier one conducted in 2022 that was focused purely on the association of diet and erectile dysfunction (ED). The conclusion of that one was that diet does have an influence on whether mature men (in the age range 40 to 75) and that a plant-based diet low in dairy and meat but rich in fruits, vegetables, grains, and nuts can improve sexual performance.

Maintaining a healthy sex life if you are being treated for benign prostate hyperplasia (BPH) or prostate cancer.

At least the men who are being treated for prostate conditions should not experience some of the social and psychological barriers that for so long have prevented men from seeking assistance when they develop problems relating to sexual performance. There are now far more potent treatments for conditions that arise from prostate diseases, such as erectile dysfunction (ED), lower libido, and problems with ejaculation. These provide options for a non-invasive treatment that, in some cases, do not even require a doctor’s prescription because they work from outside the body and can have no biological effect. As we wrote a few months back, questions about treatment for sexual dysfunction make up a big portion of the queries we get from customers. Since erectile dysfunction is a major consequence of treatment for prostate gland disorders, the bulk of our responses refer to the well-known medications that have been around for nearly 15 years, which are all based on the same form of oral medication called phosphodiesterase 5 (PDE-5) inhibitors. The popular examples of these are Viagra (sildenafil), Cialis (tadalafil), and Levitra (vardenafil). They offer the same benefits and carry similar risks since they are all built on the same basic molecule. More recently, a topical gel called Eroxon Stimugel that works from the outside has revolutionized the path for treating ED. It simply requires a few drops of gel to be rubbed into the tip of the penis and reliably induces a firm erection within 10-15 minutes. This compares very favorably with the way PDE-5 meds work because they take longer to produce the erection, and that makes sexual activity less spontaneous. Until now, there have been no medications that can help with premature ejaculation, which is a prominent side effect of treatments for prostate enlargement and cancer. Recently, we started supplying the Stud 100 topical desensitizer spray. Lidocaine spray is absorbed into the skin of the penis immediately, and it reaches a full numbing effect within 10 to 15 minutes and maintains desensitization for up to two hours. This allows for fully spontaneous sex with reduced anxiety that comes from premature orgasm. In addition to Eroxon Stimugel and Stud 100, which can be purchased without a doctor’s prescription, we now offer single-strength forms of Viagra and Cialis in over-the-counter packs.
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