Designing better support programs for couples with sexual issues after prostate surgery

[Wendy_Winnall]

 It’s an unfortunate reality that prostate surgery can be bad for your sex life. Men and their partners need better support to help them deal with changes to sex after this surgery. A new Australian study has compared two different methods of delivering support to help couples with problems having sex after surgery. This research is essential for designing support services that actually work and make a difference for these couples.

Problems with sex after prostate surgery

Most men have problems with sex in the short term after prostate surgery. Unfortunately, sexual function does not return to normal for many of these men in the long term. Some of the ongoing issues faced by men and their partners are: loss of sexual desire, reduced erections and penis size, problems with organisms and leakage of urine during sex. Unsurprisingly these changes can cause problems with intimacy between couples and harm masculine self-esteem.

Damage caused by prostate surgery

One of the issues men face after surgery is reduced erections. This can happen due to damage caused during the surgery. Damage to the nerves and blood supply to the penis, and damage to the supporting tissue in the area, can cause erectile dysfunction. The nerves connecting to the penis are very close to the prostate gland, so surgery in this area can easily affect them. Even if nerve-sparing surgery is performed, the nerves need to be separated from the prostate in order to remove the gland. This can cause damage through bruising and inflammation.

Another type of damage that can affect erections is believed to result from the penis being inactive. This causes a lack of blood and oxygen supply to the organ, from the absence of regular erections. Clinicians working in the field of sexual health generally believe that regular erections are necessary, whether they are used for sex or not. Erections bring fresh blood to the penis, supplying it with oxygen. It’s thought that without this regular supply of oxygen, the penis tissue suffers damage such as scar tissue formation. This can become worse over time, and also lead to loss of length.

Having sex after surgery

Many men who have prostate surgery will go on to regain sexual function. But this often requires some kind of assistant. Assistance can come from sexual aids such as vacuum pumps. There are also medical aids such as the drugs Viagra, Cialis and Levitra to help achieve erections. Injections of Alprostadil also help many men to form erections. Other “natural” supplements claim to help achieve erections. However there is some risk associated with these supplements. Some men choose to have penile implant surgery for long-term problems, allowing them to achieve erections.

Despite various medical approaches to improving couples’ ability to have sex after prostate surgery, problems having sex remain a big issue for many couples. Even for men who can achieve erections, there are other issues that may detract from their sexual satisfaction, such as difficulty having orgasms and urine leakage. These issues are not well-addressed by health workers. Research has also shown that the partners of these men are rarely part of the discussion with healthcare workers.

Support services for men with sexual problems after prostate surgery

There are support services available for men and their partners coping with sexual problems after prostate surgery. Men can go to their doctors, prostate cancer specialist nurses and other health professionals such as sexiologists and sex therapists. Men and their partners might also find informal help from peers who are going through similar issues. Prostate cancer support groups and online groups, such as PCFA’s Online Community can help link people with others facing the same problems. Some couples even find that talking to staff at their local sex shop can help them discover helpful options, such as sex toys, of which they were previously unaware.

Australian research into sexual support for couples affected by prostate surgery

Despite the support that is available, sexual issues remain a major problem for many men after prostate surgery. Clearly, more support is needed for these men and their partners.

It’s important that the support offered to these men is evidence-based. Otherwise it could be a waste of time for everyone. To ask what types of support programs actually work for these couples, researchers test programs and use surveys to find out if they’ve made a difference.

Assessing sexual support programs is an important facet of prostate cancer survivorship research. Research like this is undertaken by expert survivorship researcher Prof Suzanne Chambers. Working at the Menzies Health Institute Queensland, Prof Chambers put together a national and international team of experts to test Australian support programs in high quality, long-term trials.

Prof Chambers has led an Australian study that tested two different types of support for people with sexual problems. The study specifically tested support for couples, offering help with sexual issues after prostate surgery.

The aim of her study was to ask if these support programs improve sexual problems faced by these couples. The researchers particularly looked at effects on sexual function, sexual satisfaction, marital satisfaction, masculine self-esteem and use of sexual aids.

People recruited to the trial were 189 heterosexual couples. The man in each couple had recent surgery for localised prostate cancer. Couples were randomly divided into three groups: 1) peer-led support 2) nurse counselling and 3) usual care. Usual care was used as a comparison to the two support models. The study asked if the support models led to improvements above usual care. It also allowed a comparison of the two support models to each other.

Interventions for couples affected by prostate surgery

Both intervention types used phone support/counselling in 6 to 8 sessions. This included skills training in couple communication and coping. DVDs were provided to couples with a tip sheet. Both members of the couple attended the call sessions with conversations occurring over speakerphone.

Nurse counselling support  was delivered by two experienced prostate cancer nurse counsellors, who received additional training. Couples selected their own goals that they wanted to achieve. They were guided with information about prostate cancer, menopause, sexuality, expressing affection, non-demanding sexual touch, how age affects sexuality and medical treatments for erection problems.

Peer support support  was delivered by men who had prostate surgery over 12 months ago. These peers received training lectures and workshops that covered communication skills, adjustment to cancer, managing treatment effects and sexuality. The peer support intervention was couples-based and aimed for empathic mutual support and education. Components included education about prostate cancer diagnosis, common experiences with surgery and recovery, managing side effects, improving communication between the couple and with health professionals, maintaining intimacy in relationships and managing erection problems managing.

The two support programs were compared to each and other and to a control group of couples who had “usual care”. The researchers used a number of validated surveys to test the success of the two programs. They asked whether the programs decreased unmet sexual needs or led to improvements in sexual function and satisfaction, marital satisfaction, masculine self-esteem and use of sexual aids. This was a 5-year study. The researchers surveyed men each year for 5 years, to ask about the long-term benefits from these support programs.

The results of the study produced one very clear finding, and a number of less clear implications. The study clearly showed that long-term use of medical treatments for erection problems was greatly enhanced by the nurse-led and the peer support. The main treatments used were tablets to induce erections. Over 80% of the men in the supported programs were long-term users of these treatments.

The study results indicated that the additional support helped the men to maintain their use of these treatments. This may be important for long-term penile rehabilitation. Long-term use of treatments to keep erections going for 2 years is believed by some clinicians to be necessary for penile rehabilitation.

There were other results from the study that paint a less-clear picture. The study showed some complex patterns of differences across the groups. The reasons for some of these differences are difficult to interpret. For example, men in the nurse-led group had a greater masculine self-esteem than men in the peer group. But this difference was only seen at 2 years and 5 years after surgery. In some cases, results were better in the group who had usual care, not the support from peers or nurses.

Some effects were different for males and females. For instance, women in the peer support group reported better sexual function and satisfaction than women in the other groups (at 2 and 3 years after surgery). But these benefits were not reported by the men in the peer group.  

Prof Chambers states that this study “highlights that when a couple is facing the challenge of a prostate cancer diagnosis, they each often will cope differently, and may need different types of support. Both peer and nurse support are different and equally important sources of help and advice”.

Overall this study has shown the nurse-led and peer support can improve men’s long-term use of medical sexual aids. This will hopefully be useful in promoting penile rehabilitation – a long-term program. Aside from this finding, the mixed results from the other surveys indicate that other benefits could be gained from this type of support program, but that the support models are not currently optimised to fulfil these needs. More research is needed to design and test such programs.

Fortunately, more research has been funded. Prof Chambers research group have welcomed a new Research Fellow at the University of Technology, Sydney. Dr Anna Green is taking on this project within the Centre for Research Excellence in Prostate Cancer Survivorship.

Designing better support programs

Designing health support programs that work is difficult. Health promotion programs work well if they are good quality, underpinned by sound theory and evidence, and are objectively assessed during their development. Support programs can be done poorly, and often are. They are put together based on vague ideas of what might work, and little attempt is made to assess whether they are actually making a difference to anyone. High quality survivorship research like this trial is essential for ensuring that a support program fulfils its needs, and actually makes a measurable, positive difference to people who need support. This research has shown that the two support models can improve use of medical sexual aids during couple’s support. But more research and development is necessary before we have a program that robustly improves sexual function, masculine self-esteem, marital satisfaction and reduces unmet sexual needs and improve.