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Maintaining sexual intimacy on androgen deprivation therapy

PCFA_OC_Manager
Community Manager
Community Manager
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One of the most significant side effects of androgen deprivation therapy (ADT) is related to sexual function. ADT blocks the production and effect of testosterone through various mechanisms (discussed in previous blogs). The main impact of reduced testosterone is low libido (reduced desire for sexual activity). However, it has also been demonstrated that low testosterone may affect erectile function both within the penis and the spinal cord. Corona et al have reviewed the medical literature to explain some of the mechanisms for these adverse treatment effects and have proposed some methods of establishing intimacy.

Laboratory findings

Based on research from the penis of rabbits the researchers were able to show that testosterone is essential for relaxation of the arteries and the sudden rush of blood into the cavernosal arteries to achieve an erection. Results also showed that without testosterone even the potent medications (PDE5 inhibitors [PDE5i]) such as sildenafil (Viagra) or tadalafil (Cialis) would be ineffective. They showed that this is not only due to the negative effect of testosterone deprivation on biochemical signalling but also to the structural modification of penile architecture with a decrease in blood vessel muscle and an increase in scarring fibrous tissue, limiting penile blood flow.

Clinical findings

Using positive emission tomography PET and functional MRI scans researchers have shown that testosterone acts in various areas of the brain responsible for regulating sexual behaviours such as the hypothalamus and limbic system. In men who had reduced testosterone levels who were given testosterone supplementation imaging studies showed increased blood flow in the above-mentioned areas with an improvement in sexual symptoms.

Other potential explanations for erectile dysfunction related to ADT are due to the lower number of night-time erections that occur naturally during sleep. This may lead to structural modifications of the penis. ADT can also have negative metabolic effects which can lead to atherosclerosis and vascular disease, reducing the blood flow to penile vessels.

Despite the importance of testosterone, it is important to recognise that sexual function is the result of a complex interplay between relational, organic and intrapsychic factors. In ancient Rome women were able to engage in sexual intercourse with men who had their testicles removed/born without testicles (eunuchs) without the risk of procreation. The testicles are the major site of testosterone production. Some testosterone is also produced in the adrenal gland. This demonstrates that erections are still possible without testosterone in highly motivated individuals. Studies in men with low testosterone who were shown explicit erotic film content were still able to achieve an erection even if it took twice the time to occur. Motivators for sexual activity are mainly related to a more satisfactory couple relationship. The couple should be open to experience sex in new ways where sexual intimacy rather than penetrative intercourse might become the basis of the sexual encounter.

Treatment implications: Minimising the effects of ADT

Intermittent ADT (discussed in a previous research blog) is a treatment approach for eligible patients where treatment is stopped for a period of time with careful monitoring of PSA, clinical exam, symptoms, and imaging studies to avoid disease progression. The rationale for this approach is that patients can take a holiday from side effects such as sexual dysfunction as well as others such as hot flushes and metabolic effects.

For those patients who have good erectile function prior to surgery or radiation and then start ADT, studies have shown that penile rehabilitation with PDE5i may show a beneficial response initially but at 24 months of follow up this response is much lower. To improve the success of this treatment strategy, PDE5i should be combined with vacuum erection devices or penile injections.

Sex therapy

Educational and sexological approaches are essential steps for guaranteeing the best outcomes in all sexual problems. This can be achieved through collaboration with GPs, psychologists, sexologists, andrologists and oncologists. It is important to realise that multiple problems can influence couple fitness. Body feminization related to ADT may include hot flushes, gynaecomastia, loss of muscle mass, genital shrinkage with sexual dysfunction, mood disturbances and can affect patient and partner self-esteem and psychological well-being. Patients and partners therefore need to be prepared and informed. Open communication is crucial to explore expectations and personal experiences. Couples should be adequately informed that the orgasm sensation could be still experienced, even in the absence of firm erections, so that penetrative intercourse is not considered essential to remaining sexually active. In the presence or not of firm erections, patients and their partners should be informed that ADT increases the threshold for triggering the orgasm experience, so a more intense sexual stimulation over a longer period is required. The use of sexual toys or erotic videos can be of value if the couples are open to such experimentation.

An adequate educational program and intervention is beneficial to mitigate the decline in sexual intimacy in men undergoing ADT and allows couples to maintain more successful and satisfactory sexual activity. Finally, the inclusion of a sexual partner in the educational process enhances outcomes and continuation of sexual activity.

Reference

Corona G, Filippi S, Comelio P et al. Sexual function in men undergoing androgen deprivation therapy. Nature: Int. J Impot Res 2021; 33:439-447


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About the Author

Kalli Spencer

MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)

Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.

Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.


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