Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics

Does sexual rehabilitation work for gay and bisexual prostate cancer patients? Acceptability, feasibility, and efficacy results from the Restore-2 randomized controlled trial

PURPOSE

Sexual minority prostate cancer patients have worse health-related quality of life outcomes than heterosexual patients. We conducted the first study to test whether sexual and urinary rehabilitation tailored for sexual minority patients was acceptable, feasible, and efficacious at improving their sexual and urinary function.

METHODS

Restore-2 was a 24-month randomized controlled trial of an online biopsychobehavioral rehabilitation study for sexual minority men treated for prostate cancer experiencing sexual and/or urinary problems. Participants were 401 US sexual minority men treated for prostate cancer and experiencing sexual and/or urinary problems at baseline. Intervention components included phosphodiesterase-5 inhibitors, sexual aids, a pelvic floor exercise regimen and video, a guide to good gay sex following treatment, and coaching. Quality of life assessments were completed at baseline, 3, 6, 12, 18, and 24 months.

RESULTS

We confirmed good acceptability and feasibility, but only minimal improvement was observed over time and no differences were found between treatment and control arms.

CONCLUSIONS

We found no evidence that the intervention improved sexual or urinary outcomes for participants. However, we confirmed excellent acceptability and feasibility for a sexual rehabilitation program tailored to sexual minority participants. In addition, participants reported enduring usage and acceptability of sexual aids (including vacuum pump, anal dilators, and penile constriction rings) as well as masturbation and pelvic floor exercises to accommodate their sexual challenges.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual "accommodation," rather than "rehabilitation," may be a more accurate and realistic goal for this population. Patients should be provided sexual aids to help accommodate their sexual and urinary challenges.

TRIAL REGISTRATION

This study was retrospectively registered with ClinicalTrials.gov, study number: NCT03923582; date: 22/04/2019.

Functional outcomes and health-related quality of life following penile cancer surgery: a comprehensive review

INTRODUCTION

Organ-sparing surgery (OSS) in penile cancer management aspires to maintain organ form and function and preserve health-related quality of life (HRQoL), yet there is a lack of integrated evidence exploring these outcomes.

OBJECTIVES

The aim sought to review HRQoL, functional, aesthetic, and psychological outcomes following OSS or radical penectomy for penile cancer.

METHODS

A systematic review of MEDLINE and Cochrane databases included studies reporting on function (sexual, urinary or sensory), genital appearance or HRQoL/psychological well-being following surgical treatment of primary penile cancer. English-language reports (2000-2022), incorporating patient-reported or objective clinical outcome measures, were eligible. Studies of nonsurgical treatment strategies and those in the context of metastatic disease were excluded. Data were compiled and analyzed.

RESULTS

Twenty-six studies were included. Sexual function was the most studied outcome (754 pooled respondents; 19 studies), most frequently with the original 15-item and abridged 5-item International Index of Erectile Function. Preservation of erectile function following OSS is generally described, with some reduction in overall sexual satisfaction cited. Heterogeneous assessment of voiding function with little preoperative evaluation render interstudy comparison difficult. Most patients appear able to void from a standing position following OSS, with spraying the most common symptom. Maintenance of some sensory function is described with both split-thickness skin grafting and urethral glanduloplasty following radical glansectomy. Limited studies suggest reasonable patient satisfaction with genital cosmesis post-OSS. A negative impact on HRQoL is described in most studies following penile cancer surgery, variably correlated with aggressiveness of penile surgery and addition of lymphadenectomy. Anxiety, depression, and reduced self-esteem have been reported in penile cancer survivors. Relationship well-being varies, with some survivors reporting this to be unchanged.

CONCLUSION

OSS can preserve elements of sexual, urinary, and sensory function, supporting advantages over radical penectomy for eligible patients. However, a comprehensive understanding remains limited due to small, heterogeneous patient cohorts, challenges in obtaining premorbid data, and variability in outcome measures. Standardization of patient-reported outcomes following OSS is desirable.

Sexual characteristics of patients with prostate cancer seen for radiation treatment

Background

Prostate cancer was estimated to be the second most diagnosed cancer and the fifth leading cause of cancer mortality among men, with an estimated 1.4 million new cases and 375,000 deaths globally in 2020. There are significant changes in sexual activities and subsequent changes in quality of life associated with the diagnosis and treatment of prostate cancer. Sexual problems experienced by prostate cancer patients include erectile dysfunction, reduced sexual desire, reduced sexual function, problems with ejaculation, as well as problems with orgasm, and these could occur before and/or after treatment. This study aims to highlight the sexual characteristics of prostate cancer patients, which would help identify altered sexuality that might require intervention by healthcare providers.

Method

All patients who presented with pathologically diagnosed, organ-confined prostate cancer referred for high-dose-rate brachytherapy were approached for participation in the study. An interviewer-administered questionnaire was administered to the consenting patients.

Results

A total of 56 patients gave consent for the study out of 60. All the patients were married, with 5 (8.9%) having multiple wives. Only ten respondents (17.9%) reported having other sexual partners besides their wives. More than half of the patients (34) (60.7%) started having sexual intercourse between the ages of 18 and 20. Many patients claimed that the diagnosis of prostate cancer had affected their sexual lives. About half of the respondents (44.6%) believed that their partners were less satisfied with their sexual performance, as evidenced by the loss of partners (5.4%), partners refusing sexual advances (14.3%), partners complaints (10.7%), and partners' reduced inclination to ask for sex (33.9%). One patient expressed fears of passing the disease to their partners.

Conclusion

The management of prostate cancer should include sex therapy and rehabilitation in couples from the point of diagnosis to maintain sexual function as close as possible to that in the general population in order to maintain an improved quality of life.

Experiences of sexual well-being interventions in males affected by genitourinary cancers and their partners: an integrative systematic review

PURPOSE

Sexual well-being has been identified as an unmet supportive care need among many individuals with genitourinary (GU) cancers. Little is known about the experiences of using sexual well-being interventions among men and their partners.

METHODS

This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and followed a systematic review protocol. Data extraction and methodological quality appraisal were performed, and a narrative synthesis was conducted.

RESULTS

A total of 21 publications (reporting on 18 studies) were included: six randomised control trials, seven cross-sectional studies, three qualitative studies, and five mixed methods studies. Sexual well-being interventions comprised medical/pharmacological and psychological support, including counselling and group discussion facilitation. The interventions were delivered using various modes: face-to-face, web-based/online, or telephone. Several themes emerged and included broadly: (1) communication with patient/partner and healthcare professionals, (2) educational and informational needs, and (3) timing and/or delivery of the interventions.

CONCLUSION

Sexual well-being concerns for men and their partners were evident from diagnosis and into survivorship. Participants benefited from interventions but many articulated difficulties with initiating the topic due to embarrassment and limited access to interventions in cancer services. Noteworthy, all studies were only representative of men diagnosed with prostate cancer, underscoring a significant gap in other GU cancer patient groups where sexual dysfunction is a prominent consequence of treatment.

IMPLICATIONS FOR CANCER SURVIVORS

This systematic review provides valuable new insights to inform future models of sexual well-being recovery interventions for patients and partners with prostate cancer, but further research is urgently needed in other GU cancer populations.

Developing a Patient-Centered Model of Prostate Cancer Care: Patient Satisfaction With a Survivorship Program Embedded in Urologic-Oncologic Care

OBJECTIVE

To evaluate patients' and partners' satisfaction with a prostate cancer survivorship program embedded in urologic-oncologic care. As a part of quality improvement activity, we developed a patient and partner-centered, biopsychosocial support program for men and partners coping with the urinary and sexual side-effects of surgical treatment for prostate cancer. The program became a part of usual care for all prostate cancer patients.

METHODS

Patients who saw both an advanced practice provider and a sex therapist between August 1, 2018 and July 31, 2019 were eligible. Surveys packets were sent to 146 patients with surveys included for partners (N = 292). We used descriptive statistics to characterize participant responses.

RESULTS

Responses were received from 88 patients and 70 partners (56% response rate for the group). Patients and partners reported very high or fairly high satisfaction with the rehabilitation activities of the program (86-97% and 90%-100%, respectively); 91% of patients and 84% of partners thought having pre-operative education and post-operative rehabilitation was a good or fairly good idea; 83% of patients and 79% of partners would very much or somewhat recommend the program to a friend who was considering surgical treatment for prostate cancer.

CONCLUSION

Embedding a patient and partner-centered prostate cancer survivorship support program in oncologic care can positively impact patients' and partners' engagement in and satisfaction with post-operative rehabilitation.

Sexual rehabilitation recommendations for prostate cancer survivors and their partners from a biopsychosocial Prostate Cancer Supportive Care Program

PURPOSE

This study aimed to highlight the biopsychosocial recommendations provided to prostate cancer survivors and their partners during sexual rehabilitation.

METHODS

Retrospective analysis of a prospectively maintained patient database was conducted for visits between 2013 and 2019. The sexual health rehabilitation action plan (SHRAP) is a standardized 29-item list of biopsychosocial recommendations. The frequency of biopsychosocial recommendations provided to patients via their SHRAPs was assessed.

RESULTS

Among 913 patients, across 2671 appointments, nearly 74% of patients underwent radical prostatectomy. Other treatments included combination therapy (surgery, radiation, and/or androgen deprivation therapy (ADT)) (13%), radiation (external beam radiation or brachytherapy) (5%), and active surveillance (2%). Each patient had a median of 2 (SD 2.06) appointments and received a mean of 10.0 (SD 3.9) recommendations at each visit. Educational recommendations (penile rehabilitation, orgasmic guidelines, and climacturia management) were provided in 84% of visits followed by psychosexual recommendations (pleasure-focused, dedicated time, simmering, sexual aids, and sensate focus) in 71% of all appointments. The top recommendations (total n, frequency of recommendation) were penile rehabilitation (2253, 84%), pleasure-focus (1887, 71%), phosphodiesterase inhibitors (1655, 62%), clinical counselor (1603, 60%), vacuum erectile device (1418, 53%) and intracavernosal injections (1383, 52%).

CONCLUSIONS

Biopsychosocial programs are evolving to be a key part of prostate cancer survivorship. This study's insight suggests that prostate cancer survivors require education around their sexual consequences and psychosexual counseling alongside proven biomedical strategies for erectile dysfunction.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivorship programs should integrate educational and psychosocial strategies alongside biological strategies for prostate cancer survivors and their partners.

Incorporating the Principles of Sex Therapy into Urologic Care

Urologic conditions and their treatments can have a significant impact on patients' sexual functioning and sexual health. Although urologists address sexual dysfunction within their scope of practice, sexual health conversations occur rarely and focus narrowly on physiologic sexual function. The sex therapy perspective considers biologic, psychological, relationship, and cultural aspects of sexuality. We propose that urologists benefit from taking this perspective when performing sexual health assessment. Urologists are not required to provide sex therapy but can optimize their patient's sexual well-being by taking a holistic perspective on sex and offering informational resources and referral to colleagues with complementary sexual health expertise.

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.

Clinic Utilization and Characteristics of Patients Accessing a Prostate Cancer Supportive Care Program's Sexual Rehabilitation Clinic

Prostate cancer (PC) treatment leads to impairment of sexual function. The Prostate Cancer Supportive Care (PCSC) Program's Sexual Rehabilitation clinic (SRC) assists patients and their partners with sexual recovery using a biopsychosocial approach to rehabilitation. This study characterizes patients seen in the SRC between July 2013-1 July 2019. Data was retrospectively abstracted from clinic records. In total, 965 patients were seen over 3391 appointments during the study period. Median age (standard deviation (SD)) was 66 years (SD = 7.1), 82.0% were partnered, yet 81.7% attended appointments alone. 88.0% were treated with surgery, 5.1% with brachytherapy, 3.7% with external beam radiation (EBRT), 1.8% with combined brachytherapy and EBRT, and 1.4% with androgen deprivation therapy. In total, 708 patients (73.4%) attended ≥1 follow-up appointment. Median time (SD) between end of prostate cancer treatment to first SRC appointment was 270 days (range 0-7766). The mean (SD) self-reported overall sexual satisfaction (extracted from International Index of Erectile Function-5 (IIEF-5)) significantly increased both with erectile aids (1.69 (SD = 1.52) to 2.26 (SD = 1.66), p < 0.001, n = 148) and without erectile aids (1.71 (SD = 1.44) to 2.35 (SD = 1.57), p < 0.001, n = 235). This study provides guidance for further investigation to refine treatment, wait-times, support, and/or resource offerings in this type of program.

Promoting Sexual Well-being for Men and Their Partners Affected by Prostate Cancer

OBJECTIVE

To present an overview of the issues related to the sexual well-being of people affected by prostate cancer and their partners, and propose ways to manage and address these by oncology nurses and the wider multi-disciplinary team.

DATA SOURCES

Electronic databases such as PubMed and Cinahl were used to retrieve relevant literature published between 2010 and 2020.

CONCLUSION

Sexual well-being in patients with prostate cancer and their partners is multifaceted, comprising physical, emotional, social, and cultural aspects.

IMPLICATIONS FOR NURSING PRACTICE

A combination of pharmacologic and non-pharmacologic interventions, together with enhanced communication, can be successful in providing culturally competent, person-centered care by oncology nurses and the wider multi-disciplinary team.

Using Bionics to Restore Sensation to Reconstructed Breasts

Mastectomy often leads to a complete desensitization of the chest, which in turn can give rise to diminished sexual function and to disembodiment of the breasts. One approach to mitigate the sensory consequences of mastectomy is to leverage technology that has been developed for the restoration of sensation in bionic hands. Specifically, sensors embedded under the skin of the nipple-areolar complex can be used to detect touches. The output of the sensors then drives electrical stimulation of the residual intercostal nerves, delivered through chronically implanted electrode arrays, thereby eliciting tactile sensations experienced on the nipple-areolar complex. The hope is that the bionic breast will restore a woman's sense that her breast belongs to her body so she can experience the pleasure of an embrace and derive the benefit of the sensual touch of her partner.

Sexual Health Recovery For Prostate Cancer Survivors: The Proposed Role Of Acceptance And Mindfulness-Based Interventions

INTRODUCTION

1 in every 7 Canadian men is affected by prostate cancer. Given impressive advances in detection, treatment, and survival rates, there is a considerable focus on survivors' supportive care needs. Among the top unmet supportive care needs for prostate cancer survivors are concerns related to sexual health and intimacy.

AIM

To provide a rationale for introducing mindfulness- and acceptance-based approaches into the role of psychosexual interventions aimed at improving sexual satisfaction among prostate cancer survivors (and their partners).

METHODS

A literature review was performed to examine the prevalence of sexual difficulties after prostate cancer treatment and the efficacy of current pharmacologic and psychological treatment approaches.

MAIN OUTCOME MEASURE

The main outcome measure was focused on sexual satisfaction in prostate cancer survivors.

RESULTS

Current pharmacologic interventions for sexual difficulties after prostate cancer treatment are not fully meeting the needs of prostate cancer survivors and their partners. Conclusions cannot be drawn from existing psychological interventions because of methodologic inconsistencies. Additionally, the focus on erectile function as a measure of treatment effectiveness is likely to instill a greater sense of hopelessness and loss for prostate cancer survivors, which may exacerbate issues around sexual intimacy and satisfaction. An impressive body of evidence supports the role of mindfulness in improving women's sexual functioning and there is preliminary evidence suggesting the efficacy of this approach for improving men's sexual functioning.

CONCLUSION

We propose that psychosexual interventions that prioritize mindfulness and acceptance-based frameworks may help men to tune into sensations while challenging the foci on performance and erections, thereby increasing the potential for improvement to sexual satisfaction among prostate cancer survivors. Bossio JA, Miller F, O'Loughlin JI, et al. Sexual Health Recovery for Prostate Cancer Survivors: The Proposed Role of Acceptance and Mindfulness-Based Interventions. Sex Med Rev 2019;7:627-635.

Finding sexual health aids after cancer: are cancer centers supporting survivors' needs?

PURPOSE

Sexual dysfunction is one of the most prevalent and distressing treatment-related side effects for both male and female cancer survivors. Survivorship care guidelines recommend therapeutic sexual aids to help improve sexual problems. However, little is known about the availability of sexual aids and resources at cancer centers.

METHODS

Twenty-five comprehensive cancer centers affiliated with both the National Cancer Institute and the National Comprehensive Care Network were surveyed using the "mystery shopper" method to determine whether various types of sexual aids were available at the centers. Staffs from cancer center staff retail stores and patient boutiques were queried in separate telephone calls regarding the availability of these aids for and women.

RESULTS

Of the 25 centers contacted, 23 (92%) responded about aids for men, and 22 (88%) responded about aids for women. Eighty-seven percent of the centers reported having no sexual aids available for men, and 72% of centers reported having no aids available for women. The most common advice given to mystery shoppers was a suggestion to use the internet. Only one center had numerous aids/resources for both men and women.

CONCLUSIONS

The large majority of cancer centers reported having no sexual aids or other sexual health resources available for men or women.

IMPLICATIONS FOR CANCER SURVIVORS

Results underscore the widespread lack of resources to promote sexual health rehabilitation at major cancer centers, both for male and female survivors.

Male Sexual Desire: An Overview of Biological, Psychological, Sexual, Relational, and Cultural Factors Influencing Desire

INTRODUCTION

The literature showed the need for a better understanding of the male sexual response, which has historically been considered as simpler and more mechanistic compared with that in women.

AIM

To examine the literature on biopsychosocial factors associated with the level of sexual desire in men and discuss some interesting directions for future research.

METHODS

A systematic literature review was conducted.

MAIN OUTCOME MEASURES

169 articles published in Google Scholar, Web of Science, Scopus, EBSCO, and Cochrane Library about male sexual desire and related biopsychosocial factors.

RESULTS

We found a lack of multidimensional studies on male sexual desire. Most existing research has focused on hypoactive sexual desire disorder in coupled heterosexual men. Biological factors play important roles in the level of sexual desire, but they are insufficient to explain the male sexual response. Psychological, relational, and sexual factors (eg depression, anxiety, emotions, attraction, conflicts, communication, sexual functioning, distress, satisfaction) are involved in the development/maintenance of lack of sexual interest in men. Cultural influence is also relevant, with cognitive factors linked to gender roles and sexual scripts of masculinity identified as important predictors of low sexual desire.

CONCLUSION

Male sexual desire is characterized by an interplay among biological, psychological, sexual, relational, and cultural elements. This interplay merits further study to better understand how sexual desire works and how treatments for low sexual interest could be improved. Nimbi FM,Tripodi F, Rossi R, et al. Male Sexual Desire: An Overview of Biological, Psychological, Sexual, Relational, and Cultural Factors Influencing Desire. Sex Med Rev 2020;8:59-91.

Scandinavian Prostate Cancer Patients' Sexual Problems and Satisfaction With Their Sex Life Following Anti-Cancer Treatment

INTRODUCTION

Active prostate cancer treatment is often associated with significant adverse physiological and psychological effects including significant sexual problems. Most studied among these sexual problems is erectile dysfunction while related sexual bothers such as overall sexual function and satisfaction with one's sex life are much less studied.

AIM

To investigate problems related to erectile functioning, orgasmic ability, sexual function, and satisfaction with one's sex life among a cohort of Scandinavian prostate cancer patients age 40 years and older who were sexually active prior to their diagnosis of prostatic cancer.

METHODS

The survey study used a cross-sectional design and a mixed recruitment procedure. Patients were recruited through the prostate cancer patient advocate organizations in Denmark, Norway, and Sweden (Scandinavia). The final sample included 1,707 prostate cancer patients. For analyses, participants were stratified into 4 groups according to their total treatment burden.

OUTCOMES

Outcomes included subjective reporting of erectile functioning, orgasm, and sexual functioning, and satisfaction with one's sex life.

RESULTS

The study found that the prevalence of erectile dysfunction and problems related to orgasm and overall sexual function ranged from 72-92% across prostatic cancer treatment groups. Conversely, this range was 61-69% among the respondents who had not undergone prostatic cancer treatment. Across treatment groups, a minority of patients (<15%) reported being satisfied with their sex lives. After socio-demographic variables were controlled for, patients who did not receive prostatic cancer treatment were 3.75 times more likely than those in the reference group to not report sexual function problems.

CONCLUSION

Among older prostate cancer patients, who at their time of diagnose were sexually active, sexual satisfaction is low and prevalence rates of sexual problems is high, thus underlining the strong clinical need to address sexual problems and satisfaction among this cohort of patients in order to promote sexual health and well-being following active cancer treatments. Martin Hald G, Dahl Pind M, Borre M, et al. Scandinavian Prostate Cancer Patients' Sexual Problems and Satisfaction With Their Sex Life Following Anti-Cancer Treatment. Sex Med 2018;6:210-216.