NcXHF

LESLIE R. SCHOVER
tinuous ADT in prolonging survival in men who have a rising
PSA after defınitive treatment for local disease, while allowing
somewhat better quality of life. 22 In men with metastatic
disease, mean survival was slightly longer (5.8 vs. 5.1 years)
when continuous ADT was used, but the clinical signifıcance
of the results is not very convincing. 23
Men often remain profoundly hypogonadal for months after
ADT is withdrawn, especially if they are older or have had
several cycles on and off ADT. 22 Not surprisingly, recovery of
quality of life, including sexual function, is correlated with
serum testosterone levels. Typically, about one-half of men
recover better erections when off ADT, but only a minority
remains sexually active after several months. The rate of sexual
inactivity may be even greater for men who have metastatic disease.
24 The structural changes in the erectile tissue of the penis
related to ADT or androgen-blocking drugs may contribute to
men’s discouragement about sexual function. Continuing impairment
of sexual desire and arousability related to central nervous
system effects undoubtedly also play a role. 25
One of the largest prospective trials to measure sexual function
during intermittent ADT was a phase II cohort study of
250 men treated with a combination of flutamide and leuprolide
for 9 months, with subsequent times off treatment over 2
years if the PSA was 4 ng/mL or less. 26 About one-half had
biochemic recurrence after defınitive localized treatment;
others had locally advanced or metastatic disease at diagnosis.
As expected, sexual function already was impaired at
baseline, with 57% reporting erection problems, 47% low desire,
and 46% sexual inactivity. All self-report measures deteriorated
over the 9 months of ADT and only 13% remained
sexually active. During their time off ADT, 52% of men sexually
active at baseline resumed sex and all reported improved
erectile function. However, 9 to 12 months off ADT
was necessary to reach optimal recovery. Although desire for
sex and feeling masculine improved during time off ADT,
these outcomes remained poorer than at baseline. Approximately
15% of men who continued having sex during ADT
reported adequate erections. The authors did not report factors
that may identify the subgroup of men who maintain
fairly normal sex lives during ADT, but the author’s clinical
experience suggests that younger age, a strong desire for sex
at prostate cancer diagnosis, and being in a relationship with
good sexual communication are all good prognostic factors.
INTERVENTIONS TO MAINTAIN SEXUAL
SATISFACTION IN MEN ON ANDROGEN
DEPRIVATION THERAPY
As the anecdote at the beginning of this article suggests, an
important factor in helping men maintain sexual activity and
satisfaction during ADT is to provide positive, although realistic,
expectations. Not all men or their partners have a
strong desire to stay sexually active, especially if ADT that
began after defınitive therapy for localized disease already
impaired erections.
For those who want a sex life, I often cite a classic study
demonstrating that hypogonadal men have more trouble
than men with normal hormone levels in getting subjectively
aroused or achieving erections if they are asked to generate
their own sexual fantasy. 27 However, when shown an erotic
fılm, their arousal and erections are similar to those of eugonadal
men. Thus, it is likely to take both extra physical caressing
and mental sexual stimulation for a man to experience
arousal or to get the best possible erection when on ADT. I
counsel men and their partners to put a priority on time for
intimate touching, rather than waiting for spontaneous desire.
A sensate focus framework helps partners regard sexual
caressing as a time to share intimacy rather than an occasion
to demonstrate sexual performance. 28
Men who begin with good erectile function may benefıt
from penile rehabilitation using medical treatments for erectile
dysfunction, such as oral medication, vacuum erection
devices, or penile injections several times a week to ensure a
regular supply of oxygenated blood to the erectile tissue. 29
The utility of penile rehabilitation during ADT has not been
studied yet in a randomized trial.
Some men are not able to maintain fırm erections even if
they want to be sexually active, and can get subjectively
aroused, because of damage to the smooth muscle and venous
occlusion mechanism in the erectile tissue. This erection
problem is unlikely to be treated successfully with oral,
phosphodiesterase-5 inhibitors, a vacuum erection device, or
penile injection therapy. It may require surgery to implant an
inflatable penile prosthesis. 30 Motivation to have surgery is
often related to the importance sexuality is in a man’s life and
his current relationships status. Men who have sex with men
may need a more rigid erection to achieve anal penetration,
which also could make a penile prosthesis attractive. 31 Some
men switch from preferring to be the partner who penetrates
anally to being the anal receptive partner as a way to get sexual
pleasure despite erectile dysfunction.
With or without fırm and reliable erections, men can still
experience the sensation of orgasm during or after ADT, but
it may require more intense sexual stimulation over a longer
period of time than before. For partners, the effort to help a
man reach orgasm can turn sex from a pleasurable sharing of
intimacy into a work session. I often encourage couples to
incorporate vibrator stimulation into their sexual caressing.
A vibrator provides a different and intense type of sexual
pleasure with less effort than prolonged manual or oral stimulation
of the penis. For men who enjoy vaginal or anal penetration,
vibrators that mimic the sensation are available.
Other options include the Viberect, a medical-grade vibrator
that can vary the frequency and intensity of stimulation, or
high-tech vibrators that provide a range of types of physical sensations.
If partners are open to watching erotic videos during
sex, the extra mental stimulation may help a man to get as
aroused as possible. If the couple fınds that the use of erotic fılms
has a negative effect on their intimacy, the man can watch a
video just before starting sexual activity with a partner.
Since the prostate and seminal vesicles produce the liquid
components of semen, men who have had radical prostatectomy
have dry orgasms that include pleasurable sensations
and muscle contractions, but without semen coming out of
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