Early management of side effects has been shown to help patients live longer, better lives.
It is very important that you communicate with your doctors about the side effects that you are experiencing as you undergo treatment. Ongoing and proactive communication will enable your doctor to manage your side effects as early as possible to prevent worsening or development of downstream complications.
Management of Urinary Dysfunction
Because the urinary symptoms following radiation therapy stem from irritation of the tissues, drugs that improve urinary flow are commonly used. Tamsulosin (Flomax), terazosin (Hytrin), and other alpha-blockers are typically instituted in all men following radiation therapy for at least a few weeks, and are gradually withdrawn as symptoms improve. Anticholinergic medications like tolterodine (Detrol) or solifenacin (Vesicare) can help treat bladder irritation symptoms as well.
In cases of persistent urinary incontinence, the least invasive procedure consists of an injection of collagen into the urethra. This tightens the passageway, making it more difficult for urine to leak through. Although over 50% of men stay dry with this procedure, the effects only last for a short time.
Longer-lasting results are seen with surgical procedures. In one-type of procedure, a sling made from silicone or, more rarely, human tissue is slipped under the urethra and anchored to the muscle or bone, relieving the urethra from pressure buildup in the abdomen as urine accumulates in the bladder.
The sling results in urinary function improvements in about 70% of men after prostatectomy, although only about half of those reported being completely dry after four years. Following radiation therapy, only 30% of men showed an improvement, with even fewer men reporting being completely dry after four years.
Management of Erectile Dysfunction
When a man is sexually aroused, the erectile nerves running alongside the penis stimulate the muscles to relax, allowing blood to rush in. At the same time, tiny valves at the base of the penis lock shut, preventing the blood from flowing back out. The backup of blood results in an erection.
The oral medications for erectile dysfunction, sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra), relax the muscles in the penis, allowing blood to rapidly flow in. On average, the drugs take about an hour to begin working; the erection-boosting effects of sildenafil and vardenafil last for about 8 hours; tadalafil lasts about 36 hours. About 75% of men who undergo nerve-sparing prostatectomy or more precise forms of radiation therapy have reported successfully achieving erections after using these drugs.
However, these drugs are not for everyone. Many men with angina or other heart problems take medications that contain nitrates to help the blood flow better to the heart. All three agents used for erectile dysfunction can affect the way that the nitrates work—and cause blood pressure to drop to dangerously low levels. They can also interfere with alpha-blockers, drugs that are commonly used in men with the noncancerous growth of the prostate known as BPH, which are often used in men following certain types of radiotherapy, particularly brachytherapy.
In addition to the oral medications, there are a number of alternative treatments that might be helpful to men with erectile dysfunction.
Alprostadil (MUSE®) is a medicated pellet about half the size of a grain of rice that is inserted into the urethra through the opening at the tip of the penis. Like oral medications, it also stimulates blood flow into the penis. About 40% of men have reported successfully achieving erections after using this drug, but the results are often inconsistent.
Alprostadil (CaverJect®) uses the same drug that is in the MUSE pellets, but is delivered via an injection directly into the penis. Although nearly 90% of men using CaverJect reported erections about 6 months after therapy, many men aren’t comfortable injecting themselves regularly, so the treatment is often used only after other approaches have not worked.
For those unwilling or unable to use medication to help improve erectile function, there are still a number of choices.
The vacuum constriction device, or vacuum pump, creates an erection mechanically, by forcing blood into the penis using a vacuum seal. Because the blood starts to flow back out once the vacuum seal is broken, a rubber ring is rolled onto the base of the penis, constricting it sufficiently so that the blood does not escape. About 80% of men find this device successful, but it, too, has a high drop-out rate.
Note that the constriction ring at the base of the penis is effectively cutting off fresh circulation. Because of this effect, it is crucial that the ring be removed immediately after intercourse, or the tissue can be damaged due to lack of flowing oxygen. (See When to Seek Help for more information.)
The final option for treating erectile dysfunction is the surgically inserted penile implant, which mimics the natural function of the penis. With the three-piece implant, a narrow flexible plastic tube is inserted along the length of the penis, a small balloon-like structure filled with fluid is attached to the abdominal wall, and a release button is inserted into the testicle. The penis remains flaccid until an erection is desired, at which point the release button is pressed and fluid from the balloon rushes into the plastic tube. As the tube fills with fluid, it straightens, pulling the penis up with it, creating an erection.
Assuming the mechanics are working correctly, it is by definition 100% effective, and about 70% of men remain satisfied with their implants even after 10 years.
Note that the surgical procedure is done under general anesthesia, so this option is not available to men who are not considered good candidates for surgery because of other health reasons.