From the Guidelines
Erectile dysfunction (ED) is extremely common in patients undergoing androgen deprivation therapy (ADT) for prostate cancer, affecting approximately 70-95% of men, as reported in the most recent study 1. This high incidence is directly related to the mechanism of action of ADT, which works by dramatically reducing testosterone levels in the body. Since testosterone is essential for normal erectile function, its suppression inevitably leads to ED in most patients. The onset of ED typically occurs within the first few months of starting ADT and often persists throughout treatment. The severity of ED can vary based on several factors including the patient's age, baseline erectile function before treatment, type of ADT used (whether LHRH agonists like leuprolide or antagonists like degarelix), and whether ADT is used alone or in combination with other treatments. Unlike some ADT side effects that may improve with time, ED typically persists as long as hormonal therapy continues.
Treatment Options
Treatment options for ADT-induced ED include:
- PDE5 inhibitors (sildenafil, tadalafil)
- Vacuum erection devices
- Intracavernosal injections
- Penile implants Though these interventions have lower success rates in ADT patients compared to men with ED from other causes due to the profound hormonal suppression, as noted in 1. Additionally, testosterone therapy may relieve symptoms of ED, problems with ejaculation, or problems with orgasm for survivors with hypogonadism, but should not be used if contraindicated by the primary oncologic diagnosis, such as prostate cancer on active surveillance or prostate cancer on ADT 1. Lifestyle modifications, such as smoking cessation, weight loss, increasing physical activity, and avoiding excess alcohol consumption, can also improve erectile and sexual function, as suggested by 1. Referrals to specialists, including psychotherapy, sexual/couples counseling, urology, or sexual health specialists, may be necessary for comprehensive treatment of sexual dysfunction, as recommended in 1.
From the Research
Incidence of Erectile Dysfunction with ADT Treatment in Prostate Cancer
- The incidence of erectile dysfunction (ED) in patients undergoing androgen deprivation therapy (ADT) for prostate cancer is a significant concern, with studies indicating a variable degree of ED in these patients 2.
- A study published in 2008 found that 57 (14.4%) patients reported ED after ADT induction, with 40 (70%) reporting new-onset ED and 17 (30%) reporting ED before ADT 2.
- Another study published in 2015 confirmed that RT/ADT for prostate cancer can significantly impair erectile function, with many men achieving erections through PDE5-I use, while others require combined management incorporating exercise, lifestyle modifications, psychosexual counseling, and other erectile aids 3.
- The true incidence of ED after prostate cancer therapy is unknown, but proposed pathophysiological mechanisms of ED include neurovascular injury, local inflammatory changes, and damage to nearby supporting structures 4.
Factors Associated with ED after ADT
- Age <70 years and the absence of diabetes mellitus (DM) were associated with reporting ED after ADT induction 2.
- Testosterone plays a crucial role in regulating sexual desire, and ADT has been shown to result in a five to sixfold increased risk of reduced libido and a threefold increased risk of ED 5.
Management of ED after ADT
- Successful outcomes are possible with multimodal therapy, including medical therapy, such as phosphodiesterase-5 inhibitor monotherapy, and surgical options 2.
- Penile rehabilitation aims to help men regain the ability to achieve erections sufficient for satisfactory sexual intercourse during rehabilitation from prostate cancer treatment 4.
- Current management strategies for erectile function rehabilitation predominantly relate to patients who have had radical prostatectomy, and options include phosphodiesterase type 5 inhibitors, intracavernosal injection of vasoactive agents, vacuum erection devices, and penile implants 4.
- A study published in 2021 found that clinicians were less likely to discuss sexual dysfunction, take baseline assessments, refer to a specialist clinic, or offer rehabilitation when dealing with patients with advanced disease 6.