The Management of Sexuality and Incontinence in Advanced Prostate Cancer Presentation - Inge Van Oort

September 24, 2019

Inge van Oort presented the topic of managing sexuality and incontinence issues in patients with advanced prostate cancer at the Advanced Prostate Cancer Consensus Conference (APCCC 2019). When assessing sexual symptoms she references the EAU guidelines on sexual activity and the percentage of prostate cancer patients that will receive androgen deprivation therapy (ADT) at some point in the disease trajectory. She highlights several side effects of hormonal treatment including a reduction in both libido and the ability to gain and maintain erections as well as urinary symptoms, therefore concluding it is imperative that partners be included in treatment decisions due to the impact on the patient’s quality of life.


Inge van Oort, MD, Ph.D., Radboud Institute for Molecular Life Sciences, Nijmegen, Netherlands 

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Inge van Oort: Well, thank you. I hope you enjoyed lunch. Of course, I also want to thank Aurelius and Silke, to ask me. I hope not just because I'm a female, but because I'm a urologist. So, I'm an oncological urologist, one of the few here around. I'm from Nijmegen, but I live in Arnhem. This is also the Rhine, but then in Arnhem. So, I have conflicts of interest and several of them are the reason I gave this talk.

So now for something entirely different, sexuality and incontinence. Well, let's start with the guidelines. Yesterday, I told the chair of the EAU Guidelines I was giving this talk and he was like, "This is not part of this meeting." Well, let's see. What do the guidelines say? Not a lot. Maybe that's why he said it. Sexual function, it is mentioned and it only says, "The management of acquired Erectile Dysfunction is mostly, non-specific." What are we doing with that?

Well, then we look at the recommendations. Okay, now we get somewhere. Androgen deprivation, exercise. Good. Then about weight, about smoking. Then, not on the part of ADT, but on the part of T1-T3, then it mentions incontinence and sexuality, but only after radical treatment. So still nothing, nothing on ADT.

Well, then start with the urinary problems. So how many symptoms, how many people in all prostate cancer patients have urinary symptoms? Then, I mean everybody who's from active surveillance to the radical treatment, but also on ADT. Then we see around 18% have frequency and around 13% have, at least once a day, a leak. There are small differences in reporting of urinary symptoms by stage.

But men who underwent surgery, sorry urologists, reported higher level of urinary incontinence. Almost one in four leaked at least once a day, and one in three used one or more pads a day. Then you have those nice pictures saying, "Incontinence after Prostate Cancer," with a smiling man. Well, that's not true. I never see them smile. So, having a prostatectomy gives more urinary problems than starting hormones. So medical oncologist, you're off the hook.

But what about sexuality problems? 50% of prostate cancer patients treated, will receive ADT at some point. Castrate levels of testosterone have a dramatic impact of quality of life of the patient. It also significantly affects the intimate partners of the patients, who often experience more distress than the patients themselves.

So the problems, how many do have the problems? Again, all prostate cancer patients, all around have 80% loss of erections, loss of ability to reach orgasm, and loss of overall sexual function. If you look by stage, then we see 75% with localized, 90% with locally advanced, and almost up to 100% with advanced cancer. So it is a big problem.

Men on ADT experience a number of sexual side effects. Patient and partners are negatively affected by ED. Patients report being especially distressed by a decrease in sexual thoughts, and their response to visual and tactile prompts. So, their libido is off. This gives different reaction by patients. Some remain troubled by the loss of erections. Others are relieved that the loss of erections is associated with the loss of libido. But still, many men want a functional erection for the benefit of their partners. Though patients often find it very difficult to discuss.

Improvement of ED can improve their sense of masculinity and self-esteem, but that's not the only part. The reduced libido gives also withdrawal of emotional and physical intimacy and can lead to significant partner distress. Their partners describe even more distress than the patients. They often want to talk about the ADT-associated changes, while patients want to minimize the issues. The partners may be also be less attractive to their partners, while he's on ADT.

This denial appears to be common way to cope, but is detrimental to prostate cancer patients in the long term. These conflict in coping methods lead to isolation of either or both partners, the loss of hope of satisfying sexual encounters, and subsequently, loss of intimacy. That can even be more destructive than loss of sex.

Psychological distress of the female partners predict the ultimate health of the male patient. Partners should be, therefore, included in the treatment decision and consent process, and provide adequate and appropriate support. In case you have a couple with complex sexual and relationship issues, please advise them to go to a psychologist or relationship counselor or a sexologist or sexual medicine specialist.

Then about male patients. Most of the literature, and there was not a lot, but most of the literature on the partner problems is on heterosexual couples. But the physiological changes due to prostate cancer treatments, seems to have a bigger impact on sex life of homosexual couples. Homosexual couples, after radical prostatectomy, have a lower health-related quality of life, a lower male self-image, and more psychological problems. So, we clinicians should not automatically assume that our patient is heterosexual. We also should not only being open to, but also proactively informing about the relationship and sexual activity, in order to subsequently be able to adequate assess and advice.

But how good are we in guiding our patient and partners? Well, not good. 60% were not offered medication to aid or improve erections. It's so easy to do that. Almost 80% were not offered devices. There are devices to help. And 85% were not offered specialist service to help sex life. And then patients who are offered at least one of three intervention, according to treatment group, then you see in surgery, we do. In radiotherapy, we're getting worse. And if they on ADT, we don't do it.

So, we aren't doing that well, and that has to change. We need more attention for sexuality problems in patients with hormonal treatment, because not only overall survival, but also quality of life is important for these patients. We have to start talking on the effects on sexuality and intimacy problems, both for the female and male partners, during consultation. We have to offer medication, we have to offer devices and specialist. Otherwise, just send them to specialist. For your urinary problems of your patients, just consult your urologist medical oncology. Trust me, I'm a urologist. And I'd like to thank you.