Various anticancer treatments, especially those directed toward the pelvis, can damage blood vessels and reduce circulation of blood to the penis and/or damage the autonomic nervous system, resulting in higher rates of erectile dysfunction in survivors than in the general population. In addition, hormonal therapy can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for male sexual problems, namely erectile dysfunction.

Abstract

Various anticancer treatments, especially those directed toward the pelvis, can damage blood vessels and reduce circulation of blood to the penis and/or damage the autonomic nervous system, resulting in higher rates of erectile dysfunction in survivors than in the general population. In addition, hormonal therapy can contribute to sexual problems, as can depression and anxiety, which are common in cancer survivors. This section of the NCCN Guidelines for Survivorship provides screening, evaluation, and treatment recommendations for male sexual problems, namely erectile dysfunction.

NCCN Categories of Evidence and Consensus

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.

Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

Overview

Cancer treatment, especially hormonal therapy and therapy directed toward the pelvis, can often impair sexual function. In addition, depression and anxiety, which are common in survivors, can contribute to sexual problems. Thus, sexual dysfunction is common in survivors and can cause increased distress and have a significant negative impact on quality of life.1-5 Nonetheless, sexual function is often not discussed with survivors.6,7 Reasons for this include a lack of training of health care professionals, discomfort of providers with the topic, and insufficient time during visits for discussion.1 However, effective strategies for treating both female and male sexual dysfunction exist,8-11 making these discussions a critical part of survivorship care.

Male Aspects of Sexual Dysfunction

The NIH Consensus Conference on Impotence defined impotence, or male erectile dysfunction (ED), as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.”12 In fact, impotence and ED are not synonymous. Impotence can involve problems of sexual desire, orgasm, or ejaculation, which are not necessarily linked with achieving or maintaining an erection.13

ED occurs frequently in the general population and increases with age.14 In one community-based study, 33% of men aged at least 75 years reported moderate or worse ED.15 ED is also very common in male cancer survivors. Anticancer treatment modalities used in a variety of cancers have the potential to damage blood vessels, leading to a reduction in blood circulation to the penis, and/or damage to the autonomic nervous system. Thus, higher rates of ED are seen in cancer survivors than in the general population. The prevalence of ED in male survivors of colorectal cancer has been reported to range from 45% to 75%,2,16,17 and it has been reported in up to 90% of prostate cancer survivors.18-22

F1NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Male), Version 1.2013

Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 3; 10.6004/jnccn.2014.0037

F2NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Male), Version 1.2013

Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 3; 10.6004/jnccn.2014.0037

In 2005, the American Urological Association (AUA) published a guideline on the management of ED; it was reviewed and confirmed as still valid by the AUA in 2011.13 Using a consensus-based approach with the AUA guideline as a guide, the NCCN Survivorship Panel concluded that (1) informed patient and physician decision-making is the standard for guiding treatment decisions for ED treatment; and (2) a psychological overlay frequently exists in patients with ED and may be even more pronounced in the face of cancer survivorship. Endocrine disorders are also an important consideration in the cause of ED. Although sex therapy and the diagnosis and treatment of endocrine disorders are important management issues, these are beyond the scope of these guidelines and are therefore not addressed in depth.

Evaluation and Assessment for Male Sexual Function

Male cancer survivors should be asked about their sexual function at regular intervals. Patients should be asked about their sexual functioning before they received the cancer diagnosis, and their perceptions regarding the impact of cancer treatment on their sexual functioning and intimacy. A quantitative questionnaire such as the Sexual Health Inventory for Men can be considered to help identify patients who might benefit from treatment of ED.14

Patients with concerns about their sexual function should undergo a more thorough evaluation, including screening for possible psychosocial problems (ie, anxiety, depression, relationship issues, drug or alcohol use) that can contribute to sexual dysfunction. Identifying prescription and over-the-counter medications (especially hormone therapy or opioids) that could be a contributing factor is also important. A focused physical examination can also be helpful and should include examination of the chest (for gynecomastia), abdomen, phallus, scrotum/testicles, and cord structures.

Importantly, cardiovascular risk should be estimated for all men with ED, especially those with cardiovascular disease. Cardiovascular disease and ED share risk factors and often coexist.23 Sexual activity is considered equivalent to walking 1 mile in 20 minutes on a flat surface or to climbing 2 flights of stairs in 20 seconds.23 Men who cannot perform these exercises without symptoms are considered to be at high risk for experiencing adverse events associated with sexual activity and should be referred to a cardiologist before treatment for ED.23

Interventions for Male Sexual Dysfunction

Treatment for ED begins with modification of risk factors, such as smoking cessation, weight loss, increasing physical activity, and avoiding excess alcohol consumption. In addition, treatment of psychosocial problems, with referral to sex and couples therapy as appropriate, can often alleviate symptoms of ED.

Oral phosphodiesterase type 5 inhibitors (PDE5is) have been shown to improve the symptoms of ED and be well tolerated.8,10 Many studies have also shown the efficacy and tolerability of PDE5i for treating ED in patients with cancer and survivors.24,25 Importantly, PDE5is are contraindicated in patients taking oral nitrates, because together they can lead to a dangerous decrease in blood pressure.26,27

The timing and dose of PDE5i should be started conservatively, and it should be titrated to maximum dose if needed.13 The patient should be monitored periodically for efficacy, side effects, and any significant change in health status. An adequate trial of PDE5i is defined as at least 5 separate occasions at the maximum dose before reporting it as noneffective, unless the reason for fewer trials is an unacceptable side effect. A different PDE5i can be tried after failure of first-line PDE5i therapy.

If the second PDE5i fails, additional interventions can be considered, with referral to a urologist. These options include second-level interventions, such as intraurethral alprostadil suppositories, intracavernous vasoactive drug injection therapy, and vacuum constriction. A third-level and definitive type of intervention, penile prosthesis implantation, can be considered.13

Individual Disclosures for the NCCN Survivorship Panel

T1

References

  • 1.

    BoberSLVarelaVS. Sexuality in adult cancer survivors: challenges and intervention. J Clin Oncol2012;30:37123719.

  • 2.

    DonovanKAThompsonLMHoffeSE. Sexual function in colorectal cancer survivors. Cancer Control2010;17:4451.

  • 3.

    LaumannEOPaikARosenRC. Sexual dysfunction in the United States: prevalence and predictors. JAMA1999;281:537544.

  • 4.

    MorrealeMK. The impact of cancer on sexual function. Adv Psychosom Med2011;31:7282.

  • 5.

    VomvasDIconomouGSoubasiE. Assessment of sexual function in patients with cancer undergoing radiotherapy—a single centre prospective study. Anticancer Res2012;32:657664.

    • Search Google Scholar
    • Export Citation
  • 6.

    ForbatLWhiteIMarshall-LucetteSKellyD. Discussing the sexual consequences of treatment in radiotherapy and urology consultations with couples affected by prostate cancer. BJU Int2012;109:98103.

    • Search Google Scholar
    • Export Citation
  • 7.

    WhiteIDAllanHFaithfullS. Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?Br J Cancer2011;105:903910.

    • Search Google Scholar
    • Export Citation
  • 8.

    FinkHAMac DonaldRRutksIR. Sildenafil for male erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med2002;162:13491360.

    • Search Google Scholar
    • Export Citation
  • 9.

    GanzPAGreendaleGAPetersenL. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst2000;92:10541064.

    • Search Google Scholar
    • Export Citation
  • 10.

    NehraA. Erectile dysfunction and cardiovascular disease: efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions. Mayo Clin Proc2009;84:139148.

    • Search Google Scholar
    • Export Citation
  • 11.

    MilesCLCandyBJonesL. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database Syst Rev2007:CD005540.

  • 12.

    NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA1993;270:8390.

  • 13.

    The Management of Erectile Dysfunction (2005). American Urological Association Web site. Available at: http://www.auanet.org/education/guidelines/erectile-dysfunction.cfm. Accessed February 9 2014.

    • Search Google Scholar
    • Export Citation
  • 14.

    CappelleriJCRosenRC. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. Int J Impot Res2005;17:307319.

    • Search Google Scholar
    • Export Citation
  • 15.

    MongaMBettencourtRBarrett-ConnorE. Community-based study of erectile dysfunction and sildenafil use: the Rancho Bernardo study. Urology2002;59:753757.

    • Search Google Scholar
    • Export Citation
  • 16.

    EllisRSmithAWilsonS. The prevalence of erectile dysfunction in post-treatment colorectal cancer patients and their interests in seeking treatment: a cross-sectional survey in the west-midlands. J Sex Med2010;7:14881496.

    • Search Google Scholar
    • Export Citation
  • 17.

    HendrenSKO’ConnorBILiuM. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg2005;242:212223.

    • Search Google Scholar
    • Export Citation
  • 18.

    PotoskyALDavisWWHoffmanRM. Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the prostate cancer outcomes study. J Natl Cancer Inst2004;96:13581367.

    • Search Google Scholar
    • Export Citation
  • 19.

    ResnickMJKoyamaTFanKH. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med2013;368:436445.

  • 20.

    SchoverLRFouladiRTWarnekeCL. Defining sexual outcomes after treatment for localized prostate carcinoma. Cancer2002;95:17731785.

  • 21.

    SiegelTMoulJWSpevakM. The development of erectile dysfunction in men treated for prostate cancer. J Urol2001;165:430435.

  • 22.

    StanfordJLFengZHamiltonAS. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA2000;283:354360.

    • Search Google Scholar
    • Export Citation
  • 23.

    NehraAJacksonGMinerM. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc2012;87:766778.

    • Search Google Scholar
    • Export Citation
  • 24.

    HubanksJMUmbreitECKarnesRJMyersRP. Open radical retropubic prostatectomy using high anterior release of the levator fascia and constant haptic feedback in bilateral neurovascular bundle preservation plus early postoperative phosphodiesterase type 5 inhibition: a contemporary series. Eur Urol2012;61:878884.

    • Search Google Scholar
    • Export Citation
  • 25.

    YangLQianSLiuL. Phosphodiesterase-5 inhibitors could be efficacious in the treatment of erectile dysfunction after radiotherapy for prostate cancer: a systematic review and meta-analysis. Urol Int2012;90:339347.

    • Search Google Scholar
    • Export Citation
  • 26.

    KlonerRAHutterAMEmmickJT. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol2003;42:18551860.

  • 27.

    WebbDJFreestoneSAllenMJMuirheadGJ. Sildenafil citrate and blood-pressure-lowering drugs: results of drug interaction studies with an organic nitrate and a calcium antagonist. Am J Cardiol1999;83:21C28C.

    • Search Google Scholar
    • Export Citation

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Figures

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    NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Male), Version 1.2013

    Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

  • View in gallery
    NCCN Clinical Practice Guidelines in Oncology: Survivorship: Sexual Dysfunction (Male), Version 1.2013

    Version 1.2013, 03-08-13 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

References

  • 1.

    BoberSLVarelaVS. Sexuality in adult cancer survivors: challenges and intervention. J Clin Oncol2012;30:37123719.

  • 2.

    DonovanKAThompsonLMHoffeSE. Sexual function in colorectal cancer survivors. Cancer Control2010;17:4451.

  • 3.

    LaumannEOPaikARosenRC. Sexual dysfunction in the United States: prevalence and predictors. JAMA1999;281:537544.

  • 4.

    MorrealeMK. The impact of cancer on sexual function. Adv Psychosom Med2011;31:7282.

  • 5.

    VomvasDIconomouGSoubasiE. Assessment of sexual function in patients with cancer undergoing radiotherapy—a single centre prospective study. Anticancer Res2012;32:657664.

    • Search Google Scholar
    • Export Citation
  • 6.

    ForbatLWhiteIMarshall-LucetteSKellyD. Discussing the sexual consequences of treatment in radiotherapy and urology consultations with couples affected by prostate cancer. BJU Int2012;109:98103.

    • Search Google Scholar
    • Export Citation
  • 7.

    WhiteIDAllanHFaithfullS. Assessment of treatment-induced female sexual morbidity in oncology: is this a part of routine medical follow-up after radical pelvic radiotherapy?Br J Cancer2011;105:903910.

    • Search Google Scholar
    • Export Citation
  • 8.

    FinkHAMac DonaldRRutksIR. Sildenafil for male erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med2002;162:13491360.

    • Search Google Scholar
    • Export Citation
  • 9.

    GanzPAGreendaleGAPetersenL. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst2000;92:10541064.

    • Search Google Scholar
    • Export Citation
  • 10.

    NehraA. Erectile dysfunction and cardiovascular disease: efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions. Mayo Clin Proc2009;84:139148.

    • Search Google Scholar
    • Export Citation
  • 11.

    MilesCLCandyBJonesL. Interventions for sexual dysfunction following treatments for cancer. Cochrane Database Syst Rev2007:CD005540.

  • 12.

    NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA1993;270:8390.

  • 13.

    The Management of Erectile Dysfunction (2005). American Urological Association Web site. Available at: http://www.auanet.org/education/guidelines/erectile-dysfunction.cfm. Accessed February 9 2014.

    • Search Google Scholar
    • Export Citation
  • 14.

    CappelleriJCRosenRC. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. Int J Impot Res2005;17:307319.

    • Search Google Scholar
    • Export Citation
  • 15.

    MongaMBettencourtRBarrett-ConnorE. Community-based study of erectile dysfunction and sildenafil use: the Rancho Bernardo study. Urology2002;59:753757.

    • Search Google Scholar
    • Export Citation
  • 16.

    EllisRSmithAWilsonS. The prevalence of erectile dysfunction in post-treatment colorectal cancer patients and their interests in seeking treatment: a cross-sectional survey in the west-midlands. J Sex Med2010;7:14881496.

    • Search Google Scholar
    • Export Citation
  • 17.

    HendrenSKO’ConnorBILiuM. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg2005;242:212223.

    • Search Google Scholar
    • Export Citation
  • 18.

    PotoskyALDavisWWHoffmanRM. Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the prostate cancer outcomes study. J Natl Cancer Inst2004;96:13581367.

    • Search Google Scholar
    • Export Citation
  • 19.

    ResnickMJKoyamaTFanKH. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med2013;368:436445.

  • 20.

    SchoverLRFouladiRTWarnekeCL. Defining sexual outcomes after treatment for localized prostate carcinoma. Cancer2002;95:17731785.

  • 21.

    SiegelTMoulJWSpevakM. The development of erectile dysfunction in men treated for prostate cancer. J Urol2001;165:430435.

  • 22.

    StanfordJLFengZHamiltonAS. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA2000;283:354360.

    • Search Google Scholar
    • Export Citation
  • 23.

    NehraAJacksonGMinerM. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc2012;87:766778.

    • Search Google Scholar
    • Export Citation
  • 24.

    HubanksJMUmbreitECKarnesRJMyersRP. Open radical retropubic prostatectomy using high anterior release of the levator fascia and constant haptic feedback in bilateral neurovascular bundle preservation plus early postoperative phosphodiesterase type 5 inhibition: a contemporary series. Eur Urol2012;61:878884.

    • Search Google Scholar
    • Export Citation
  • 25.

    YangLQianSLiuL. Phosphodiesterase-5 inhibitors could be efficacious in the treatment of erectile dysfunction after radiotherapy for prostate cancer: a systematic review and meta-analysis. Urol Int2012;90:339347.

    • Search Google Scholar
    • Export Citation
  • 26.

    KlonerRAHutterAMEmmickJT. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol2003;42:18551860.

  • 27.

    WebbDJFreestoneSAllenMJMuirheadGJ. Sildenafil citrate and blood-pressure-lowering drugs: results of drug interaction studies with an organic nitrate and a calcium antagonist. Am J Cardiol1999;83:21C28C.

    • Search Google Scholar
    • Export Citation

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