Restoring Sexual Function after Lupron/Cancer Treatment

Facts about Prostate Cancer: Prostate cancer is a highly prevalent disease afflicting one in five American men. It is the most commonly diagnosed cancer in men and the second leading cause of cancer death after lung cancer. Treatments for localized prostate cancer include: Observation, Surgery (radical prostatectomy) and Radiation therapy ± androgen ablation. Treatments for advanced prostate cancer: Androgen ablation and Chemotherapy

In 2002, Schover et al published an important manuscript in Cancer 95: (8) 1773 – 1785 entitled: Defining Sexual Outcomes after Treatment for Localized Prostate Cancer. The objective was to identify factors associated with “good sexual outcome” in a large group of survivors of localized prostate cancer. A survey was mailed to 2636 men with prostate cancer by either radiation therapy or radical prostatectomy. A total of 1236 men returned the questionnaire (49%) an average 4.3 years post-treatment. The following results were obtained. At time of diagnosis of prostate cancer, 36% had ED. Within the past 6 months prior to completing questionnaire, 85% now reported ED. Only 13% had reliable firm erections spontaneously and 8% had erections with aid of medical treatment. Men were distressed about loss of desire and trouble having satisfying orgasms as they were about ED. Better sexual outcomes were related to: younger age, absence of medical factors, not having antiandrogen therapy or adjuvant therapy, having a sexually functional partner. In summary, the great majority of men who survive prostate cancer DO NOT achieve a return to functional sexual activity in the years after treatment.

Facts About Lupron, Zoladex: Lupron/Zoladex are synthetic GnRH agents which means that these agents mimic the messages made by the hypothalamus to stimulate the pituitary. Initially there is a burst of LH/FSH and elevation of testosterone; ultimately, there is absent LH/FSH and therefore absent testosterone synthesis. Lupron/Zoladex are very effective agents stopping testicle biosynthesis of testosterone. Blood levels of testosterone fall below the reference values. Example: Pre-Lupron/Zoladex – Testosterone 450 (reference range 300 – 1000). Post-Lupron/Zoladex – Testosterone 50 (reference range 300 – 1000).

Sexual Dysfunctions Observed: Surgery and radiation therapy are associated with erectile dysfunction in 5% to 100% of cases. Surgery can lead to nerve damage to the erection nerve, erection arterial damage and erection tissue scar (fibrosis) damage which leads to venous leakage. Radiation therapy can also lead to ED. The major difference is that radiation does not damage the erection nerve. Radiation therapy may induce erection arterial damage and erectile tissue scar (fibrosis) damage which leads to venous leakage. Androgen deprivation therapy (Lupron/Zoladex) is associated with: 1) erectile dysfunction smooth muscle dysfunction and /or erectile tissue fibrosis damage which leads to venous leakage, 2) hypoactive sexual desire disorder which means no libido/interest and 3) orgasmic dysfunction.

What are the long-term consequences of Lupron/Zoladex on sexual function? What are the long-term consequences of Lupron/Zoladex on overall health? Sex steroid hormones, such as testosterone, induce protein synthesis in the genital tissues. These proteins cause the genitals to: grow, become more sensitive and have more blood vessels. These proteins also act on the brain to have libido and also act on the bones, muscles, skin, mood, etc. Without sex steroids, genital tissues shrink/atrophy, become less sensitive and poorly engorge.

Therapies utilized for men who develop ED after treatment for prostate cancer:

Oral erectogenic agents: Three PDE5 inhibitors are currently available for the management of erectile dysfunction, Viagra, Levitra and Cialis. Physicians and patients should not rely upon one PDE5 inhibitor for all patients with ED all the time. In sexual medicine it is important to recall that patients (and partners) are the ultimate decision makers about their treatment. Health care professionals need to give more complete information and guidance about PDE5 inhibitor therapies to ED patients. If the cause of the ED is disrupted erection nerve integrity, treatment by oral erectogenic agents is often not effective.

MUSE/Intracavernosal therapy: MUSE and Caverject are both FDA approved for ED treatment and are more likely to be effective if the cause of the ED is disrupted erection nerve integrity. Side effects include penile pain and poor efficacy. Other intracavernosal agents may be used when Caverject is either not tolerated or not effective. Such alternative agents include papaverine and phentolamine (bimix) and papaverine, phentolamine and PGE 1 (trimix).

Other: Another option for ED management is the Vacuum Constrictive Device. Finally, if none of the above treatments are effective, consider insertion of the penile implant.

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