Many men understand that when prostate cancer is caught early, it can be treated effectively, and the primary treatment options for localized disease are all excellent choices. However, many men also have significant concerns about the side effects of these treatments.
The concerns are justified, but there are many misunderstandings about how often side effects occur, how severe they really are and what can be done to manage them and counteract their occurrence.
Many of the side effects that men fear most following local treatment are often less frequent and severe than they might think, thanks to:
- Technical advances in both surgery and radiation therapy
- Researchers persistently seeking new ways to help overcome side effects
- Improvements in treatment delivery
It’s still important to understand how and why these effects occur, and to learn how you can minimize their impact on your daily life.
The broad categories of side effects associated with prostate cancer treatments includes:
- Urinary Dysfunction
- Bowel Dysfunction
- Erectile Dysfunction
- Loss of Fertility
- Side Effects of Hormone Therapy
- Side Effects of Chemotherapy
Depending on the treatment strategy used, some or all of these effects might be present. It’s also important to realize that not all symptoms are normal, and that some require immediate care.
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The below table is an attempt to compare three of these side effects across the different local therapies (NNSRP=non-nerve sparing radical prostatectomy, NSRP=nerve sparing radical prostatectomy, EBRT=external beam radiation therapy, BT=brachytherapy).
Each table shows the proportion of men three years after therapy with sexual dysfunction (left), bowel problems (middle), and urinary incontinence (right).
- Yellow indicates normal function
- Blue indicates mild dysfunction
- Red indicates more severe dysfunction
These figures are shown for men with normal function prior to therapy.
Reproduced from the Journal of Clinical Oncology 2009; 27: 3916-3922.
Of course, exact figures will differ across institutions and surgeons or radiation oncologists. The figures here are only meant to be a guide to help understand these risks over time. The numbers will also differ if there is already dysfunction present prior to surgery or radiation, as the risks of side effects are increased in this setting.
If you have erectile dysfunction before either surgery or radiation, the therapy will not reverse that. In contrast, urinary obstruction symptoms can often improve after surgery and occasionally after radiation. Urinary incontinence can also improve after these local therapies.
Managing Side Effects After Local Therapy (Surgery or Radiation Therapy)
For a comprehensive review of side effects from local therapies, such as surgery and radiation therapy, please refer to the treatment related side effect section (currently on page 11 of this document). This section will discuss how to manage common side effects from surgery and radiation therapy.
Management of Urinary Dysfunction
Because the urinary symptoms following radiation therapy are irritative in nature, 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 irritative bladder 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 this 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.
Management of Bowel Dysfunction
The broad term of bowel dysfunction includes diarrhea or frequent stools; fecal Incontinence or the inability to control bowel movements; and rectal bleeding. Although these side effects are uncommon, they are much more common following external beam radiotherapy than surgery, but as techniques and dose planning strategies improve, these rates have been dropping.
Usually the main treatment for bowel dysfunction is treating the individual symptoms. Anti-diarrheal agents (lomotil, immodium) can be used to help with loose bowel movements. Increasing fiber intake through whole grains, fruits and vegetables, or fiber supplements can also help. Bothersome and persistent rectal bleeding is rare (<3%), but if conservative measures don’t work such as diet changes or steroid suppositories, then laser therapy can be used to stop bleeding in the rectum caused by radiation.
Careful monitoring of the diet to avoid foods that might irritate the gastrointestinal tract is important, but complete elimination of fibrous, bulky foods can lead to constipation and straining, which in turn can make rectal worse.
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 and therefore causing the penis to stay rigid.
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 helping effects of sildenafil and vardenafil last for about 8 hours and tadalafil about 36 hours.
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, and that 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.
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 using a disposable plastic applicator. Like the oral medications, it, too, stimulates blood flow into the penis; an erection typically occurs within 10 minutes after insertion of the pellet, and can last for 30 to 60 minutes. About 40% of men have reported successfully achieving erections after using this drug, but the results are often inconsistent.
Caverject uses the same drug that is in the MUSE pellets, but delivers it via an injection directly into the penis. It takes about 10 minutes to work and lasts for about 30 minutes. Although nearly 90% of men using Caverject reported erections about six months after therapy, most men are not willing to inject themselves regularly, so the treatment is not often used for long periods of time.
For those unwilling or unable to use any form of 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. 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 straightens from being filled with the fluid, it pulls 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.
Fertility Options After Treatment
Despite the best efforts of surgeons and radiation oncologists, it is nearly impossible for a man to retain his ability to father children through sexual intercourse after initial treatment.
For men who wish to father children after treatment for prostate cancer, the best chance for fertility is sperm banking. Semen containing sperm is frozen in liquid nitrogen and, although the cells are technically still alive, all cellular activity ceases. After thawing, up to 50% of sperm will regenerate and can be used for artificial insemination.
As an alternative to banking sperm, extracting sperm directly from the testicles might be an option. After harvesting sperm from testicular tissue, a single microscopic sperm is injected into a single microscopic egg. If an embryo forms, it is implanted into the woman’s uterine wall and allowed to grow.
Although technical advances in assisted reproduction have dramatically improved the conception rates, the success rates for the two procedures combined—sperm extraction followed by injection of the sperm into the egg—is less than 50%.
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Terms to know from this article:
A surgical technique during a prostatectomy where one or both of the neurovascular bundles controlling erections are spared. The utilization of this procedure is governed by the extent of the cancer and the skill of the surgeon.
Surgery to remove the entire prostate. The two types of radical prostatectomy are retropubic prostatectomy and perineal prostatectomy.
External beam radiation
A form of radiation therapy in which the radiation is delivered by a machine pointed at the area to be radiated. May be known as external beam radiation (EBR, XBR), external beam radiation therapy (EBRT, XBRT).
A procedure in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumor. Also called internal radiation, implant radiation, or interstitial radiation therapy.
Inability to control the flow of urine from the bladder (urinary incontinence) or the escape of stool from the rectum (fecal incontinence).
A problem that occurs when treatment affects tissues or organs other than the ones being treated. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.
The tube through which urine leaves the body. It empties urine from the bladder.
An operation to remove part or all of the prostate. Radical (or total) prostatectomy is the removal of the entire prostate and some of the tissue around it.
see benign prostatic hyperplasia