Prostate cancer is an issue that I come across not infrequently in life and in my work. This is perhaps not surprising, as it is the second most common cancer worldwide (Barsouk et al., 2020; Nanton et al., 2009) and it impacts many couples’ relationships.
It is the most common non-skin malignancy in men. About 90% of prostate cancers are confined to the prostate and adjacent tissues, and prognosis is usually quite good. 50% of men diagnosed with prostate cancer do not require definitive therapy. Management of localized prostate cancer consists primarily of surgery, radiation, or active surveillance. For the remaining 10% of cases with metastatic disease, the disease is generally incurable. Prostate cancer is often seen as easily ‘treatable’. This fact however fails to take into account the effect it has on the couple and their relationship.
Prostate cancer has been referred to as the ‘couple’s disease’ because the illness and treatment affect both the patient and their partner and can become a serious quality-of-life issue. I prefer to refer to is as the couple’s dis-ease. Couples who are survivors of prostate cancer are more often than not faced with interruptions in their intimate relationships, communication, and overall quality of life. In my experience the educational and psychological resources available for these couples are poor. In addition the lack of counselling professionals, experienced both in treating sexual dysfunction and psycho-oncology, as well as poor insurance coverage for mental health services (particularly for sex therapy), are further barriers to disseminating counselling interventions. Survivors and their partners often express anger, disappointment, loss, and sadness as a result of their experiences with the treatment of prostate cancer and the lack of information available prior to and after treatment. Searching through the literature it becomes clear that erectile dysfunction after prostate cancer treatment has been widely studied. However research on sexual recovery of men and couples or understanding it in a cultural context is thin on the ground. Much more research is required in this area. Particularly in the area of men’s and couples coping strategies.
Very few of these studies define sexuality or sex in its border sense of the word. On the whole sex equals erections and penetration. Because of this narrow medical model definition, sex has become performance-based and a rule governed activity. But the reality is that sex encompasses much more. One of the major tasks of the affected partner/partners is to discover and go in search of what the ‘much more’ could be for them. There is no right or wrong. The Eskimos have over 80 distinctions and descriptors for what we refer to as ‘snow’. Challenging yourself/selves to find your own distinctions and descriptors will change your physical, psychological and spiritual reality.
Patients appear to expect little physician help when it comes to sex. Urologists too do not focus on the emotional or spiritual aspects of your sexuality. Asking for help in sexual matters is often seen as neither easy for the person who asks or for the person from whom help is sought. The majority of people still consider sexual activity a private matter and can feel awkward discussing sexual difficulties (though this is also cultural), even the couple. The best place to go for assistance is probably a Sexual Therapist, Psychologist or Psychotherapist with an understanding of sexual rehabilitation. Traditional masculine attitudes about sex can and do inhibit help-seeking. Approximately only 59% of men with erectile dysfunction due to prostate cancer treatment seek medical help and they are more likely to seek erectogenic treatments after prostatectomy than after radiation therapy. Few men actually try treatments and tend to discontinue them early. Effective help seeking actually depends on the willingness to acknowledge problems and convey them to others.
In a study by Bokhour (2001) men confirmed the substantial effect of sexual dysfunction on the quality of their lives in the quality of their sexual intimacy; in their everyday interactions with women; in their sexual imagining and fantasy life; and in their own perceptions of their masculinity. So erectile problems were found to affect men in both their intimate and nonintimate lives, including how they saw themselves as sexual beings. Research shows that men tend to deal with these difficulties through ‘disguise, diversion, and avoidance strategies applied in social interactions, and through self-redefining, self-distancing, and self-solacing cognitive tactics’.
Impact on the Couple:
Upon hearing a diagnosis of prostate cancer the couple have to deal with three major fears: the fear that the partner will die, the fear of erectile dysfunction and the fear of incontinency. Many men and their partners develop sexual dysfunction in response to erectile dysfunction. This is not assisted by the fact that couples are often not told of the consequences of prostate cancer treatment in terms of their future sexual relationship. On top of this, there is little or no instruction on intimacy or relationship building with sexual rehabilitation prescriptions. Men and women report different needs for intimacy and guidance about recovery from treatment and the trajectory for coping may well be different for the partners. Consequently the way in which couples talk about cancer-related concerns as well as the degree to which one or both partners avoid talking about cancer-related concerns can either facilitate or reduce relationship intimacy and the impact of psychological distress. After all the sexual dysfunction is the couple’s issue, not the man’s alone. Improved knowledge and communication about sexuality in middle and older age is a necessary goal of successful recovery for both partners. For some couples, poor communication and sexual dysfunction have predated prostate cancer, this too stifles recovery. Non communication would suggest that those couples who do not share and communicate about these issues are at increased risk of a poor adjustment to prostrate cancer.
Yet the treatment of prostate cancer can offer the couple an opportunity to re-examine their sexual functioning and propel them toward a better adjustment going forward. A couple’s aim should be sustainable intimacy i.e. physical and emotional intimacy renewal as well as new attitudes (replacing old patterns of thinking) which can positively affect and change not only their sexual experiences but their lives. Understanding that connection and meaning are at the root of both our sexual and spiritual selves, is critical. So successful sexual recovery from prostate cancer treatment can ensue if men and their partners allow each other to grieve the loss of familiar sexuality and explore new, satisfying sexual activity after prostate cancer treatment. This may require freeing oneself of the entrenched internal constructs as you move toward creating an individualized and self-directed sex life. This requires creating an updated concept of sex that is right for both partners as well as broadening your sexual repertoires. The longer you wait to get help or resume sexual activity the larger the barrier becomes to acceptance and change. Both partners have to create a new normal for themselves. This does not require moving away from your core values or sense of morality.
By anticipating that erectile failures are an inevitable part of recovery will also help reduce the chance that a couple abandons initial efforts, treatments and sexual activity all together. Coming to terms with the fact that erectile and sexual dysfunctions (a loss of pleasure and diminution in sexual ability and activity) may be long-term side effect of prostate cancer treatment which can be overcome.
In addition recognizing sexuality as a much larger concept than erectile function is also an important step in reframing prostate cancer’s sexual side effects. Men should be reminded that even without ideal erections, their sexuality remains. Sexual feelings, penile sensitivity, orgasms and partnered intimacy are still available. In order to bounce back from prostate cancer there requires a change in traditional beliefs regarding the importance of erections to men and women’s sexual satisfaction. As well as changes in sexual communication and behaviour by both partners. What is required is ‘less focus on penile rigidity and more on relationship flexibility‘.
Treatment options for prostate cancer are dependant upon on the stage of diagnosis, which can be diagnosed with the help of diagnostic biomarkers such as the PSA test, 4K scores, Prostate MRIs, or a digital rectal examination and biopsy. Then the decision as to the particular choice of treatment must be made: active surveillance, prostatectomy (possibly robot-assisted with the Da Vinci Surgical System) and hormone, radionuclide, radio- or chemotherapy (Barsouk et al., 2020; Hedden, 2018; Nanton et al., 2009). Each prostate-cancer treatment is associated with a distinct pattern of change in quality-of-life domains related to urinary, sexual, bowel, and hormonal function. The side effects often include problems controlling urine flow and erectile disfunction as well as an ‘inability to perform sexually’ (the medical model). The diagnosis of prostate cancer alone can cause sexual dysfunction in some. The side effects of the treatments cause many men to search for what it means to be a man as they are confronted with feelings of embarrassment, ‘loss of manhood’ and the affected sense of masculinity. These changes influence satisfaction with treatment outcomes among patients and their partners. When making your decision regarding treatment do your research thoroughly and together.
Treatments for prostate cancer have varying rates of success. Prostatectomy has been shown to cause erectile dysfunction in 30% to 98% of men (dependant on whether both, one, or neither nerve bundles was spared) and radical prostatectomy results in penile shortening in up to 68% of men. Erectile dysfunction occurs immediately after a prostatectomy with recovery of erection (often partial) taking up to approximately two years. Radiation therapy results in erectile dysfunction in more than 70% of those treated and affects erections gradually as penile tissues, and cavernous nerves are changed by radiation effects, peaking approximately two years after treatment; brachytherapy produces the least amount of sexual deficit but has other side effects such as bleeding and bruising at the radiation site. Hormone ablation therapy has serious consequences: more than 80% of men report loss of erections at 1 year after therapy in addition to profound loss of libido (Katz, A; 2005). Androgen deprivation therapy eliminates erections quickly and decreases libido while generating unpleasant side effects, such as hot flashes, fatigue, and bone fragility. Sexual bother increases post-penile rehabilitation, even in men with “good” erections postoperatively, and can include shame, embarrassment, and a reduction in general life happiness.
If you need to talk about your situation with a professional – contact us: https://milestherapie.com/contact-the-gingko-leaf-for-an-appointment/
Prostate Cancer Treatment (American Website)
Barsouk, A.; Padala, S.A.; Vakiti, A.; Mohammed, A.; Saginala, K.; Thandra, K.C.; Rawla, P.; Barsouk, A. Epidemiology, Staging and Management of Prostate Cancer. Med. Sci. 2020, 8, 28.
Nanton, V, Docherty, A; Meystre, C; Dale, J; A pathway: Information and uncertainty along the prostate cancer patient journey, British Journal of Health Psychology; 24 December 2010.
Hedden, L; Pollock, P; Elliot,S; Bossio, J.A.; Development, implementation, and evaluation of a prostate cancer supportive care program. How We Do It. The Journal of Community and Supportive Oncology. Vol 16, No. 6, Nov-Dec 2018.
Molton IR, Siegel SD, Penedo FJ, Dahn JR, Kinsinger D, Traeger LN, Carver CS, Shen BJ, Kumar M, Schneiderman N, Antoni MH. Promoting recovery of sexual functioning after radical prostatectomy with group-based stress management: the role of interpersonal sensitivity. J Psychosom Res. 2008 May;64(5):527-36.
Management of prostate cancer recurrences after radiation therapy-brachytherapy as a salvage option, Gregory W. Allen MD, Andrew R. Howard MD, David F Jarrard MD, Mark A. Ritter MD, PhD. 2007.
Bokhour BG, Clark JA, Inui TS, Silliman RA, Talcott JA. Sexuality after treatment for early prostate cancer: exploring the meanings of “erectile dysfunction”. J Gen Intern Med. 2001 Oct;16(10):649-55.
Canada AL, Neese LE, Sui D, Schover LR. Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Cancer 2005 Dec 15;104(12):2689-700.
Penson DF, McLerran D, Feng Z, Li L, Albertsen PC, Gilliland FD et al. 5-year urinary and sexual outcomes after radical
prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol 2008; 179: S40–S44.
Matthew AG, Goldman A, Trachtenberg J, Robinson J, Horsburgh S, Currie K et al. Sexual dysfunction after radical
prostatectomy: prevalence, treatments, restricted use of treatments and distress. J Urol 2005; 174: 2105–2110.
Navon L, Morag A. Advanced prostate cancer patients’ ways of coping with the hormonal therapy’s effect on
body, sexuality, and spousal ties. Qual Health Res 2003; 13: 1378–1392.
Galbraith ME, Fink R, Wilkins GG. Couples surviving prostate cancer: challenges in their lives and relationships. Semin Oncol Nurs. 2011 Nov;27(4):300-8.
Hollenbeck BK, Dunn RL, Wei JT, Sandler HM, Sanda MG. Sexual health recovery after prostatectomy, external radiation,
or brachytherapy for early stage prostate cancer. Curr Urol Rep 2004; 5: 212–219.
Miranda-Sousa AJ, Davila HH, Lockhart JL, Ordorica RC, Carrion RE. Sexual function after surgery for prostate or
bladder cancer. Cancer Control 2006; 13: 179–187.
Katz A. What happened? Sexual consequences of prostate cancer and its treatment. Can Fam Physician. 2005 Jul;51(7):977-82.
Couper J, Bloch S, Love A, Macvean M, Duchesne GM, Kissane D. Psychosocial adjustment of female partners of men
with prostate cancer: a review of the literature. Psychooncology 2006; 15: 937–953
J. F. Lavery & V. A. Clarke (1999) Prostate cancer: Patients’ and spouses’ coping and marital adjustment, Psychology, Health & Medicine, 4:3, 289-302.
Sex After Prostate Cancer: How To Have Fantastic Sex, More Intimacy, and Relationship Fulfillment After Prostate Treatments, Virgil Beasley Psy.D.
Is there an explaination why incontinence among women gets so much “sanitairy advertisement” in the media and takes a prominent place in the racks of supermarkets and pharmacies and incontinence among men gets hardly any attention at all? .
Yes that’s an interesting question you pose Herman – and its a more complex answer that is required than I can provide here. However incontinence is a common problem among both sexes. But for women there is a sense of it being ‘part and parcel of being a woman’ (as a result of childbearing and parturition, menopause and aging, as well as early socialization). A quick internet search shows that products for men are readily available, but not on the supermarket shelves or at least not in the supermarkets I shop at. Women grow up using sanitary products while male incontinence is often related to illness (poor general health, comorbidities, severe physical limitations, cognitive impairment, stroke, urinary tract infections, prostate diseases, and diabetes). Research would indicate that incontinence is experienced by around 11% of men (though many men fail to request for assistance) and 43% women. The figures for both groups increase with age. Your guess is as good as mine. But perhaps 11% is not a large enough cohort to warrant either the advertising or the stocking of supermarket shelves.
With an increasingly ageing population perhaps our societies should be thinking about this issue with more consideration and thoughtfulness. Good research topic for someone to pick on.