madman
Super Moderator
Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel (2022)
Daniela Wittmann, Ph.D., MSW Akanksha Mehta, MD, Eilis McCaughan, Ph.D., RN, Martha Faraday, Ph.D., Ashley Duby, MS, Andrew Matthew, Ph.D., Luca Incrocci, MD, Arthur Burnett, MD, Christian J. Nelson, Ph.D., Stacy Elliott, MD, Bridget F. Koontz, MD, Sharon L. Bober, Ph.D., Deborah McLeod, Ph.D., Paolo Capogrosso, MD, Tet Yap, MD, Celestia Higano, MD, Stacy Loeb, MD, Emily Capellari, MLIS, Michael Glode, MD, Heather Goltz, Ph.D., MSW, Doug Howell, Michael Kirby, MD, Nelson Bennett, MD, Landon Trost, MD, Phillip Odiyo Ouma, MS, Run Wang, MD, Carolyn Salter, MD, Ted A. Skolarus, MD, MPH,1, John McPhail, Susan McPhail, Jan Brandon, Laurel L. Northouse, Ph.D., RN, Kellie Paich, MPH, Craig E. Pollack, MD, MHS, Jen Shifferd, MPT, Kim Erickson, PT, and John P. Mulhall, MD
ABSTRACT
Background: Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strains their relationships.
Aim: We convened an international panel with the aim of developing guidelines that will inform clinicians, patients, and partners about the impact of prostate cancer therapies (PCT) on patients’ and partners’ sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.
Methods: The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995−2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment. Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).
Outcomes: Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.
Results: The guidelines account for patients’ cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on a literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.
Clinical Implications: The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.
Strengths & Limitations: The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. A limitation is a variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.
Conclusion: The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation, and outline areas for future research.
INTRODUCTION
Sexual dysfunction is the most commonly reported health-related quality of life outcome following therapies for prostate cancer, affecting men, partners, and their relationships. Sexual health care should therefore be central to prostate cancer survivorship care.
National origin, ethnicity, and race affect perspectives on gender roles, sexual orientation, relationships, health beliefs, disparities in access to healthcare, and uptake of healthcare offered. Help-seeking may be impeded by men’s culture-driven discomfort about discussing sexual side-effects of treatment − a topic considered embarrassing and intensely private.1
These guidelines were created, based on a biopsychosocial model of sexuality2 (Figure 1) and 6 guiding principles: (1) The healthcare provider plays an active role in routinely addressing sexual concerns in prostate cancer survivorship. (2) Sexuality and sexual recovery are multi-dimensional. (3) As a part of a new sexual paradigm in survivorship, grief and mourning have been shown to play an important role in couples’ recovery of sexual intimacy, despite sexual dysfunction.3 (4) Men rarely return to baseline sexual function after prostate cancer therapy. (5) Including the partner in sexual health counseling, if both partners agree, is preferable when men are partnered. (6) Support by a multidisciplinary team of healthcare providers is needed to best support men and their partners who desire to recover sexual intimacy after prostate cancer therapy.
Guidelines Statements
Counseling Patients and Partners about the Impact of PCT on the Biopsychosocial Aspects of Sexuality
1. A clinician-initiated discussion should be conducted with the patient and the partner (if partnered and culturally appropriate), about realistic expectations of the impact of PCT on the patient’s sexual function, the partner’s sexual experience, and the couple's sexual relationship. The clinician should promote openness and inclusivity, consider cultural context, and tailor counseling to the specific needs of patients who are heterosexual, gay, bisexual (GBM), identify as men who have sex with men (MSM), transgender women, and gender non-conforming individuals. (Strong Recommendation; Evidence Strength Grade C)
2. Patients and partners should be advised that biopsychosocial treatment for sexual problems can mitigate sexual dysfunctions and lead to the recovery of sexual intimacy. (Strong Recommendation; Evidence Strength Grade C)
3. Patients and partners should be advised that psychological distress, including grief and mourning about sexual losses, resulting from the sexual side-effects of PCT, can be experienced after PCT, and that distress can be mitigated with appropriate biopsychosocial rehabilitation strategies. (Moderate Recommendation; Evidence Strength Grade C)
Counseling Patients on the Impact of Individual Prostate Cancer Therapies on Sexual Function
4. Patients and partners should be counseled that all PCTs may result in the patient’s short-term and long-term erectile dysfunction (ED). (Strong Recommendation; Evidence Strength Grade B)
5. Patients and partners should be counseled that patients treated with radical prostatectomy have different trajectories of sexual function decline and potential recovery compared to patients treated with radiotherapy. (Moderate Recommendation; Evidence Strength Grade C)
6. Patients and partners should be counseled that after PCT, most patients do not return to their pre-treatment erectile function levels. (Strong Recommendation; Evidence Strength Grade B)
7. Patients and partners should be advised that pre-existing ED is associated with a higher risk of post-treatment ED after radical prostatectomy, regardless of the surgical technique used, and after radiotherapy, regardless of the type of radiation employed. (Strong Recommendation; Evidence Strength Grade B)
8. Patients and partners should be informed there is no clear evidence supporting the advantage of either robotic, laparoscopic, or open radical prostatectomy in terms of post-operative erectile function outcomes. (Moderate Recommendation; Evidence Strength Grade C)
9. Patients and partners should be counseled that both prostatectomy and radiation therapy may be associated with orgasmic pain, decreased sexual desire, anodyspareunia during anal intercourse, and changes in ejaculatory function. Prostatectomy results in immediate and complete loss of ejaculate volume, while radiation therapy is associated with a more gradual decline and variable reduction in ejaculate volume. (Moderate Recommendation; Evidence Strength Grade C)
10. Patients and partners should be counseled that sexual arousal incontinence and climacturia may occur after radical prostatectomy with the potential to recover with the recovery of urinary control. (Strong Recommendation; Evidence Strength Grade C)
11. Patients and partners should be counseled that penile length and girth/volume loss may occur after radical prostatectomy. (Moderate Recommendation, Evidence Strength Grade C)
12. Patients and partners should be informed that radical prostatectomy may be associated with an increased risk of the development of penile curvature (Peyronie’s disease; PD). (Conditional Recommendation, Evidence Strength Grade C)
13. Patients and partners should be counseled regarding the diverse impacts of androgen deprivation therapy (ADT) (as a primary or as an adjuvant ADT) on sexual desire, erectile function, penile girth and length, ejaculatory function, orgasmic function, and couples’ intimacy. (Strong Recommendation; Evidence Strength Grade C)
14. Patients and partners should be counseled that patients treated with combined ADT and radiotherapy are at risk for the cumulative sexual side effects associated with both ADT and radiotherapy. (Strong Recommendation; Evidence Strength Grade C)
15. Prior to undergoing PCT, clinicians should routinely ask prostate cancer patients (regardless of age) and their partners if future fertility is desired. (Moderate Recommendation; Evidence Strength Grade C)
16. Patients interested in future fertility should be counseled that PCT may negatively affect their fertility potential. These patients could consider pre-treatment sperm banking and referral to a reproductive specialist as the availability of assisted reproductive techniques and financial and cultural considerations allow. (Moderate Recommendation; Evidence Strength Grade C).
Assessment of Sexual Dysfunction and Sexual Distress
17. Clinicians should offer screening and assessment prior to PCT and regularly throughout follow-up, tailored to cultural context, sexual orientation, and gender identity. (Clinical Principle)
18. In both pre and post-PCT assessments, clinicians should pay attention to the presence of ED, low sexual satisfaction, low desire, orgasmic dysfunction [including altered orgasmic sensation, lack of orgasm (anorgasmia), painful orgasm (dysorgasmia), and orgasm-associated urinary incontinence (climacturia)], sexual arousal incontinence, changes in penile shape, girth, length or size, anodyspareunia, curvature, couples’ sexual concerns and avoidance or cessation of sexual activity, and couples’ sexual concerns. (Moderate Recommendation; Evidence Strength C)
19. Patients and partners should be counseled that an assessment of the partner’s sexual function can help plan treatment designed to support couples’ recovery of sexual intimacy. (Clinical Principle)
20. Clinicians should use validated Patient Reported Outcome (PRO) measures whenever appropriate and whenever possible to assess patients’ sexual function and possibly partners’ sexual function, as well as sexual distress, based on a clinical assessment of the patients’ and partners’ goals for sexual recovery. (Clinical Principle)
Lifestyle Modification
21. Lifestyle modification should be recommended to patients to optimize their overall health and sexual health, including avoiding smoking, engaging in physical activity, weight loss, increasing consumption of healthful plant-based foods, and reducing consumption of red and processed meat. (Clinical Principle)
Psychosocial Treatment
22. Clinicians should provide education, individualized sexual rehabilitation, and psychosexual support to patients and partners across the entire survivorship continuum, tailored to PCT type, partnership status, cultural, ethnic, and racial context, sexual orientation, and gender identity. (Strong Recommendation; Evidence Strength Grade C)
23. Clinicians should normalize grief as a typical reaction to sexual losses and encourage patients and partners to whom sexual recovery is important to pursue sexual intimacy despite sexual losses. (Strong Recommendation; Evidence Strength Grade C)
24. Clinicians should include the partner, if both the patient and partner agree, and provide support for couples coping with the sexual side-effects of PCT both directly and through referral for psychosexual treatment. (Strong Recommendation, Evidence Strength Grade C)
25. Clinicians should support GBM, MSM, transgender women, and gender non-conforming patients and their partners with information relevant to their sexual experience, and guide them towards meaningful support resources. (Expert Opinion)
26. Clinicians should refer patients, partners, and couples for whom education and support are insufficient for specialty psychosexual treatment. (Clinical Principle)
27. Clinicians should make patients and partners aware of group interventions and digital health/telemedicine methodologies that can increase access to sexual health support in prostate cancer survivorship. (Moderate Recommendation, Evidence Strength Grade C)
Treatment of Sexual Dysfunctions
28. Clinicians should consider nerve-sparing surgical treatment options, when available and oncologically safe, irrespective of baseline ED. (Moderate Recommendation; Evidence Strength Grade C)
29. Clinicians should define the intent and goals of penile rehabilitation strategies on an individualized basis, including preservation of penile length, maintenance of corporal tissue quality, and early patient engagement in sexual recovery. Penile rehabilitation should not be equated with treatment for the recovery of unassisted erectile function. (Clinical Principle)
30. Clinicians should counsel patients that the use of phosphodiesterase type 5 inhibitors (PDE5i) for penile rehabilitation in the early post-prostatectomy period (up to 45 days post-surgery) does not improve rates of unassisted and PDE5i-assisted erectile function recovery at 12 months compared to placebo. (Strong Recommendation; Evidence Strength Grade C)
31. Clinicians should advise patients there is limited evidence to determine the benefit of non-PDE5i approaches for penile rehabilitation in order to promote recovery of erectile function. (Moderate Recommendation, Evidence Strength Grade C)
32. Patients and partners should be counseled that there is insufficient evidence to definitively support penile rehabilitation with PDE5 inhibitors for the prevention of penile volume loss. (Conditional Recommendation, Evidence Strength Grade C)
33. Clinicians should counsel patients that there is insufficient evidence to fully determine the benefit of PDE5i use after radiation therapy as a strategy for penile rehabilitation. (Conditional Recommendation, Evidence Strength C)
34. Clinicians should support patients’ use of pro-erectile aids, as well as a non-penetrative sexual activity if they wish to continue to engage in sexual activity. (Strong Recommendation; Evidence Strength Grade C)
35. Clinicians should discuss all available erectile function treatment options with patients following all PCT modalities, including PDE5i, intraurethral suppositories, intracavernosal injections (ICI), vacuum erection devices (VED), penile traction therapy, and penile implants. Clinicians should tailor recommendations based on patient preference, efficacy, and phase of erectile function recovery. This discussion should address the benefits, risks, and contraindications associated with each option, as well as patient and partner goals. (Clinical Principle)
36. Clinicians should inform patients with persistent ED after completion of PCT about the potential benefits and risks of penile implant surgery. (Moderate Recommendation; Evidence Strength Grade C)
37. If identified, altered orgasmic sensation, difficulty reaching orgasm, or anorgasmia can be managed using a biopsychosocial approach. (Expert Opinion)
38. Persistent, bothersome dysorgasmia may be treated using alpha-adrenergic blockers. (Moderate Recommendation, Evidence Strength Grade C)
39. Patients and partners should be counseled regarding management strategies for bothersome sexual incontinence (including sexual arousal incontinence and climacturia), including psychological reframing. (Clinical Principle)
40. Patients should be counseled that there are insufficient data regarding the efficacy of pelvic-floor rehabilitation, penile tension loop, a male sling operation, or placement of an artificial urinary sphincter for the management of sexual incontinence (including sexual arousal incontinence and climacturia). (Conditional Recommendation, Evidence Strength C)
41. Clinicians may discuss the risk and benefits of testosterone therapy to improve low sexual desire in hypogonadal men following PCT. (Moderate Recommendation, Evidence Strength Grade C)
42. Clinicians should counsel patients that there are inadequate data to quantify the risks vs benefits regarding testosterone therapy to treat low sexual desire in men with treated, or active, non-metastatic prostate cancer. (Conditional Recommendation, Evidence Strength C)
Lifestyle Modification Strategies
43. Clinicians should inform patients and partners about the importance and benefits of exercise for sexual health and as a component of medical management related to ADT. (Moderate Recommendation; Evidence Strength Grade C)
A Summary of Guidelines Statement
Figure 3 is an at-a-glance summary of the guidelines. Guidelines statements are organized to suggest a pathway for a systematic approach to providing sexual health care to patients with prostate cancer and their partners.
Clinician Education and Training
44. Clinicians should undergo sexual health education in interprofessional groups using case-based/reflective learning approaches, adopting a biopsychosocial lens, and incorporating attention to ethnic and racial diversity and to sexual minorities. (Strong Recommendation; Evidence Strength Grade C)
Healthcare Programs and Systems
45. Providers and healthcare systems should develop culturally appropriate materials for counseling patients and their partners regarding the impact of PCT on sexual health. (Moderate Recommendation; Evidence Strength Grade C)
46. Patient education programs about sexual recovery after PCT should be tailored to reflect local cultural influences, based on resources available in that region, the conceptualization of sexual recovery, and of the priorities in that region. (Expert Opinion)
47. All insurance providers should cover the treatment of sexual dysfunctions secondary to PCT in order to validate this clinically important aspect of prostate cancer care and to reduce disparities in access to care. (Clinical Principle)
Future Directions
There is a growing body of evidence to validate the concept that sexual health support is critical to the well-being of patients with prostate cancer and their partners, however, most research has been conducted in Europe and in English-speaking countries where research resources are more available and attitudes towards prostate cancer and sexuality are relatively similar. Funding sources should be identified to promote research in low and middle-income countries on cultural, ethnic, and racial groups’ attitudes toward sexuality, sexual practices, and preferences for support. Similarly, funding sources should be identified to promote research on sexual and gender minorities, such as men who have sex with men, trans women, and gender non-conforming patients.
The most significant gap in the treatment of physiologic sexual dysfunction is the lack of evidence demonstrating convincingly that penile rehabilitation protocols improve the recovery of erectile function. Animal models have not translated well into human recovery. At this time, the value of penile rehabilitation is largely psychological because it engages men and their partners in sexual recovery early. More research is needed to advance this area of survivorship care
Treatment for erectile dysfunction following prostate cancer treatment is supported by well-established evidence. The major gap in care is the uncertainty about the acceptability of erectile dysfunction treatments in cultural and ethnic groups, given the stigma associated with sexual dysfunction. Locally based research can answer questions about the acceptability of sexual aids.
Psychosocial support for the use of pro-erectile treatments is now evidence-based but is not implemented in the majority of prostate cancer treatment settings. Attentiveness to partners’ needs and interventions for couples are just emerging. Interventions tailored to sexual orientation and gender identity remain undeveloped. More research into the needs and preferences of these populations is needed so that relevant interventions can be developed and tested.
Lack of clinician competence to provide sexual health care is an ongoing barrier. Education to address patients’ and partners’ sexual health concerns and rehabilitation must become an integrated part of multidisciplinary professional training for clinicians who care for prostate cancer patients.
Addressing perceived cost will be key moving forward, as healthcare institutions claim cost is the primary barrier to patients’ obtaining sexual aids and to embedding a fully trained specialist in psychosexual care in oncology treatment programs. Moreover, culturally appropriate methods for providing integrated sexual health care should be investigated.
Finally: advocacy directed at providers, institutions, and governments is needed to secure funding for research to answer questions about the psychosexual needs and resources relevant to patients and partners in low and middle-income countries. Evidence-based clinical care in prostate cancer survivorship can only grow if it becomes a societal priority. Given the considerable prevalence of prostate cancer globally, support of men and partners’ efforts to recover sexual intimacy after prostate cancer treatment represents a metric of quality of prostate cancer care.
Daniela Wittmann, Ph.D., MSW Akanksha Mehta, MD, Eilis McCaughan, Ph.D., RN, Martha Faraday, Ph.D., Ashley Duby, MS, Andrew Matthew, Ph.D., Luca Incrocci, MD, Arthur Burnett, MD, Christian J. Nelson, Ph.D., Stacy Elliott, MD, Bridget F. Koontz, MD, Sharon L. Bober, Ph.D., Deborah McLeod, Ph.D., Paolo Capogrosso, MD, Tet Yap, MD, Celestia Higano, MD, Stacy Loeb, MD, Emily Capellari, MLIS, Michael Glode, MD, Heather Goltz, Ph.D., MSW, Doug Howell, Michael Kirby, MD, Nelson Bennett, MD, Landon Trost, MD, Phillip Odiyo Ouma, MS, Run Wang, MD, Carolyn Salter, MD, Ted A. Skolarus, MD, MPH,1, John McPhail, Susan McPhail, Jan Brandon, Laurel L. Northouse, Ph.D., RN, Kellie Paich, MPH, Craig E. Pollack, MD, MHS, Jen Shifferd, MPT, Kim Erickson, PT, and John P. Mulhall, MD
ABSTRACT
Background: Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strains their relationships.
Aim: We convened an international panel with the aim of developing guidelines that will inform clinicians, patients, and partners about the impact of prostate cancer therapies (PCT) on patients’ and partners’ sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.
Methods: The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995−2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment. Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).
Outcomes: Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.
Results: The guidelines account for patients’ cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on a literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.
Clinical Implications: The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.
Strengths & Limitations: The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. A limitation is a variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.
Conclusion: The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation, and outline areas for future research.
INTRODUCTION
Sexual dysfunction is the most commonly reported health-related quality of life outcome following therapies for prostate cancer, affecting men, partners, and their relationships. Sexual health care should therefore be central to prostate cancer survivorship care.
National origin, ethnicity, and race affect perspectives on gender roles, sexual orientation, relationships, health beliefs, disparities in access to healthcare, and uptake of healthcare offered. Help-seeking may be impeded by men’s culture-driven discomfort about discussing sexual side-effects of treatment − a topic considered embarrassing and intensely private.1
These guidelines were created, based on a biopsychosocial model of sexuality2 (Figure 1) and 6 guiding principles: (1) The healthcare provider plays an active role in routinely addressing sexual concerns in prostate cancer survivorship. (2) Sexuality and sexual recovery are multi-dimensional. (3) As a part of a new sexual paradigm in survivorship, grief and mourning have been shown to play an important role in couples’ recovery of sexual intimacy, despite sexual dysfunction.3 (4) Men rarely return to baseline sexual function after prostate cancer therapy. (5) Including the partner in sexual health counseling, if both partners agree, is preferable when men are partnered. (6) Support by a multidisciplinary team of healthcare providers is needed to best support men and their partners who desire to recover sexual intimacy after prostate cancer therapy.
Guidelines Statements
Counseling Patients and Partners about the Impact of PCT on the Biopsychosocial Aspects of Sexuality
1. A clinician-initiated discussion should be conducted with the patient and the partner (if partnered and culturally appropriate), about realistic expectations of the impact of PCT on the patient’s sexual function, the partner’s sexual experience, and the couple's sexual relationship. The clinician should promote openness and inclusivity, consider cultural context, and tailor counseling to the specific needs of patients who are heterosexual, gay, bisexual (GBM), identify as men who have sex with men (MSM), transgender women, and gender non-conforming individuals. (Strong Recommendation; Evidence Strength Grade C)
2. Patients and partners should be advised that biopsychosocial treatment for sexual problems can mitigate sexual dysfunctions and lead to the recovery of sexual intimacy. (Strong Recommendation; Evidence Strength Grade C)
3. Patients and partners should be advised that psychological distress, including grief and mourning about sexual losses, resulting from the sexual side-effects of PCT, can be experienced after PCT, and that distress can be mitigated with appropriate biopsychosocial rehabilitation strategies. (Moderate Recommendation; Evidence Strength Grade C)
Counseling Patients on the Impact of Individual Prostate Cancer Therapies on Sexual Function
4. Patients and partners should be counseled that all PCTs may result in the patient’s short-term and long-term erectile dysfunction (ED). (Strong Recommendation; Evidence Strength Grade B)
5. Patients and partners should be counseled that patients treated with radical prostatectomy have different trajectories of sexual function decline and potential recovery compared to patients treated with radiotherapy. (Moderate Recommendation; Evidence Strength Grade C)
6. Patients and partners should be counseled that after PCT, most patients do not return to their pre-treatment erectile function levels. (Strong Recommendation; Evidence Strength Grade B)
7. Patients and partners should be advised that pre-existing ED is associated with a higher risk of post-treatment ED after radical prostatectomy, regardless of the surgical technique used, and after radiotherapy, regardless of the type of radiation employed. (Strong Recommendation; Evidence Strength Grade B)
8. Patients and partners should be informed there is no clear evidence supporting the advantage of either robotic, laparoscopic, or open radical prostatectomy in terms of post-operative erectile function outcomes. (Moderate Recommendation; Evidence Strength Grade C)
9. Patients and partners should be counseled that both prostatectomy and radiation therapy may be associated with orgasmic pain, decreased sexual desire, anodyspareunia during anal intercourse, and changes in ejaculatory function. Prostatectomy results in immediate and complete loss of ejaculate volume, while radiation therapy is associated with a more gradual decline and variable reduction in ejaculate volume. (Moderate Recommendation; Evidence Strength Grade C)
10. Patients and partners should be counseled that sexual arousal incontinence and climacturia may occur after radical prostatectomy with the potential to recover with the recovery of urinary control. (Strong Recommendation; Evidence Strength Grade C)
11. Patients and partners should be counseled that penile length and girth/volume loss may occur after radical prostatectomy. (Moderate Recommendation, Evidence Strength Grade C)
12. Patients and partners should be informed that radical prostatectomy may be associated with an increased risk of the development of penile curvature (Peyronie’s disease; PD). (Conditional Recommendation, Evidence Strength Grade C)
13. Patients and partners should be counseled regarding the diverse impacts of androgen deprivation therapy (ADT) (as a primary or as an adjuvant ADT) on sexual desire, erectile function, penile girth and length, ejaculatory function, orgasmic function, and couples’ intimacy. (Strong Recommendation; Evidence Strength Grade C)
14. Patients and partners should be counseled that patients treated with combined ADT and radiotherapy are at risk for the cumulative sexual side effects associated with both ADT and radiotherapy. (Strong Recommendation; Evidence Strength Grade C)
15. Prior to undergoing PCT, clinicians should routinely ask prostate cancer patients (regardless of age) and their partners if future fertility is desired. (Moderate Recommendation; Evidence Strength Grade C)
16. Patients interested in future fertility should be counseled that PCT may negatively affect their fertility potential. These patients could consider pre-treatment sperm banking and referral to a reproductive specialist as the availability of assisted reproductive techniques and financial and cultural considerations allow. (Moderate Recommendation; Evidence Strength Grade C).
Assessment of Sexual Dysfunction and Sexual Distress
17. Clinicians should offer screening and assessment prior to PCT and regularly throughout follow-up, tailored to cultural context, sexual orientation, and gender identity. (Clinical Principle)
18. In both pre and post-PCT assessments, clinicians should pay attention to the presence of ED, low sexual satisfaction, low desire, orgasmic dysfunction [including altered orgasmic sensation, lack of orgasm (anorgasmia), painful orgasm (dysorgasmia), and orgasm-associated urinary incontinence (climacturia)], sexual arousal incontinence, changes in penile shape, girth, length or size, anodyspareunia, curvature, couples’ sexual concerns and avoidance or cessation of sexual activity, and couples’ sexual concerns. (Moderate Recommendation; Evidence Strength C)
19. Patients and partners should be counseled that an assessment of the partner’s sexual function can help plan treatment designed to support couples’ recovery of sexual intimacy. (Clinical Principle)
20. Clinicians should use validated Patient Reported Outcome (PRO) measures whenever appropriate and whenever possible to assess patients’ sexual function and possibly partners’ sexual function, as well as sexual distress, based on a clinical assessment of the patients’ and partners’ goals for sexual recovery. (Clinical Principle)
Lifestyle Modification
21. Lifestyle modification should be recommended to patients to optimize their overall health and sexual health, including avoiding smoking, engaging in physical activity, weight loss, increasing consumption of healthful plant-based foods, and reducing consumption of red and processed meat. (Clinical Principle)
Psychosocial Treatment
22. Clinicians should provide education, individualized sexual rehabilitation, and psychosexual support to patients and partners across the entire survivorship continuum, tailored to PCT type, partnership status, cultural, ethnic, and racial context, sexual orientation, and gender identity. (Strong Recommendation; Evidence Strength Grade C)
23. Clinicians should normalize grief as a typical reaction to sexual losses and encourage patients and partners to whom sexual recovery is important to pursue sexual intimacy despite sexual losses. (Strong Recommendation; Evidence Strength Grade C)
24. Clinicians should include the partner, if both the patient and partner agree, and provide support for couples coping with the sexual side-effects of PCT both directly and through referral for psychosexual treatment. (Strong Recommendation, Evidence Strength Grade C)
25. Clinicians should support GBM, MSM, transgender women, and gender non-conforming patients and their partners with information relevant to their sexual experience, and guide them towards meaningful support resources. (Expert Opinion)
26. Clinicians should refer patients, partners, and couples for whom education and support are insufficient for specialty psychosexual treatment. (Clinical Principle)
27. Clinicians should make patients and partners aware of group interventions and digital health/telemedicine methodologies that can increase access to sexual health support in prostate cancer survivorship. (Moderate Recommendation, Evidence Strength Grade C)
Treatment of Sexual Dysfunctions
28. Clinicians should consider nerve-sparing surgical treatment options, when available and oncologically safe, irrespective of baseline ED. (Moderate Recommendation; Evidence Strength Grade C)
29. Clinicians should define the intent and goals of penile rehabilitation strategies on an individualized basis, including preservation of penile length, maintenance of corporal tissue quality, and early patient engagement in sexual recovery. Penile rehabilitation should not be equated with treatment for the recovery of unassisted erectile function. (Clinical Principle)
30. Clinicians should counsel patients that the use of phosphodiesterase type 5 inhibitors (PDE5i) for penile rehabilitation in the early post-prostatectomy period (up to 45 days post-surgery) does not improve rates of unassisted and PDE5i-assisted erectile function recovery at 12 months compared to placebo. (Strong Recommendation; Evidence Strength Grade C)
31. Clinicians should advise patients there is limited evidence to determine the benefit of non-PDE5i approaches for penile rehabilitation in order to promote recovery of erectile function. (Moderate Recommendation, Evidence Strength Grade C)
32. Patients and partners should be counseled that there is insufficient evidence to definitively support penile rehabilitation with PDE5 inhibitors for the prevention of penile volume loss. (Conditional Recommendation, Evidence Strength Grade C)
33. Clinicians should counsel patients that there is insufficient evidence to fully determine the benefit of PDE5i use after radiation therapy as a strategy for penile rehabilitation. (Conditional Recommendation, Evidence Strength C)
34. Clinicians should support patients’ use of pro-erectile aids, as well as a non-penetrative sexual activity if they wish to continue to engage in sexual activity. (Strong Recommendation; Evidence Strength Grade C)
35. Clinicians should discuss all available erectile function treatment options with patients following all PCT modalities, including PDE5i, intraurethral suppositories, intracavernosal injections (ICI), vacuum erection devices (VED), penile traction therapy, and penile implants. Clinicians should tailor recommendations based on patient preference, efficacy, and phase of erectile function recovery. This discussion should address the benefits, risks, and contraindications associated with each option, as well as patient and partner goals. (Clinical Principle)
36. Clinicians should inform patients with persistent ED after completion of PCT about the potential benefits and risks of penile implant surgery. (Moderate Recommendation; Evidence Strength Grade C)
37. If identified, altered orgasmic sensation, difficulty reaching orgasm, or anorgasmia can be managed using a biopsychosocial approach. (Expert Opinion)
38. Persistent, bothersome dysorgasmia may be treated using alpha-adrenergic blockers. (Moderate Recommendation, Evidence Strength Grade C)
39. Patients and partners should be counseled regarding management strategies for bothersome sexual incontinence (including sexual arousal incontinence and climacturia), including psychological reframing. (Clinical Principle)
40. Patients should be counseled that there are insufficient data regarding the efficacy of pelvic-floor rehabilitation, penile tension loop, a male sling operation, or placement of an artificial urinary sphincter for the management of sexual incontinence (including sexual arousal incontinence and climacturia). (Conditional Recommendation, Evidence Strength C)
41. Clinicians may discuss the risk and benefits of testosterone therapy to improve low sexual desire in hypogonadal men following PCT. (Moderate Recommendation, Evidence Strength Grade C)
42. Clinicians should counsel patients that there are inadequate data to quantify the risks vs benefits regarding testosterone therapy to treat low sexual desire in men with treated, or active, non-metastatic prostate cancer. (Conditional Recommendation, Evidence Strength C)
Lifestyle Modification Strategies
43. Clinicians should inform patients and partners about the importance and benefits of exercise for sexual health and as a component of medical management related to ADT. (Moderate Recommendation; Evidence Strength Grade C)
A Summary of Guidelines Statement
Figure 3 is an at-a-glance summary of the guidelines. Guidelines statements are organized to suggest a pathway for a systematic approach to providing sexual health care to patients with prostate cancer and their partners.
Clinician Education and Training
44. Clinicians should undergo sexual health education in interprofessional groups using case-based/reflective learning approaches, adopting a biopsychosocial lens, and incorporating attention to ethnic and racial diversity and to sexual minorities. (Strong Recommendation; Evidence Strength Grade C)
Healthcare Programs and Systems
45. Providers and healthcare systems should develop culturally appropriate materials for counseling patients and their partners regarding the impact of PCT on sexual health. (Moderate Recommendation; Evidence Strength Grade C)
46. Patient education programs about sexual recovery after PCT should be tailored to reflect local cultural influences, based on resources available in that region, the conceptualization of sexual recovery, and of the priorities in that region. (Expert Opinion)
47. All insurance providers should cover the treatment of sexual dysfunctions secondary to PCT in order to validate this clinically important aspect of prostate cancer care and to reduce disparities in access to care. (Clinical Principle)
Future Directions
There is a growing body of evidence to validate the concept that sexual health support is critical to the well-being of patients with prostate cancer and their partners, however, most research has been conducted in Europe and in English-speaking countries where research resources are more available and attitudes towards prostate cancer and sexuality are relatively similar. Funding sources should be identified to promote research in low and middle-income countries on cultural, ethnic, and racial groups’ attitudes toward sexuality, sexual practices, and preferences for support. Similarly, funding sources should be identified to promote research on sexual and gender minorities, such as men who have sex with men, trans women, and gender non-conforming patients.
The most significant gap in the treatment of physiologic sexual dysfunction is the lack of evidence demonstrating convincingly that penile rehabilitation protocols improve the recovery of erectile function. Animal models have not translated well into human recovery. At this time, the value of penile rehabilitation is largely psychological because it engages men and their partners in sexual recovery early. More research is needed to advance this area of survivorship care
Treatment for erectile dysfunction following prostate cancer treatment is supported by well-established evidence. The major gap in care is the uncertainty about the acceptability of erectile dysfunction treatments in cultural and ethnic groups, given the stigma associated with sexual dysfunction. Locally based research can answer questions about the acceptability of sexual aids.
Psychosocial support for the use of pro-erectile treatments is now evidence-based but is not implemented in the majority of prostate cancer treatment settings. Attentiveness to partners’ needs and interventions for couples are just emerging. Interventions tailored to sexual orientation and gender identity remain undeveloped. More research into the needs and preferences of these populations is needed so that relevant interventions can be developed and tested.
Lack of clinician competence to provide sexual health care is an ongoing barrier. Education to address patients’ and partners’ sexual health concerns and rehabilitation must become an integrated part of multidisciplinary professional training for clinicians who care for prostate cancer patients.
Addressing perceived cost will be key moving forward, as healthcare institutions claim cost is the primary barrier to patients’ obtaining sexual aids and to embedding a fully trained specialist in psychosexual care in oncology treatment programs. Moreover, culturally appropriate methods for providing integrated sexual health care should be investigated.
Finally: advocacy directed at providers, institutions, and governments is needed to secure funding for research to answer questions about the psychosexual needs and resources relevant to patients and partners in low and middle-income countries. Evidence-based clinical care in prostate cancer survivorship can only grow if it becomes a societal priority. Given the considerable prevalence of prostate cancer globally, support of men and partners’ efforts to recover sexual intimacy after prostate cancer treatment represents a metric of quality of prostate cancer care.
