Can prostate cancer cause erectile dysfunction (ED) and benign prostatic hyperplasia (BPH)?

Prostate Cancer's Relationship to Erectile Dysfunction and BPH

Prostate cancer itself does not cause benign prostatic hyperplasia (BPH), but it is a significant cause of erectile dysfunction (ED), particularly through its treatments rather than the disease itself. 1

Relationship Between Prostate Cancer and Erectile Dysfunction

Direct Effects of Prostate Cancer on Sexual Function

• Prostate cancer itself may contribute to sexual dysfunction, though the primary impact comes from treatments rather than the disease 1
• Many men already have sexual problems at diagnosis, with at least one-third experiencing sexual issues before treatment begins 2
• Even men on active surveillance for prostate cancer have higher rates of sexual problems than age-matched peers without cancer 2

Treatment-Related Erectile Dysfunction

• All localized treatments for prostate cancer significantly increase the prevalence of sexual dysfunction 2

• Surgical treatments (radical prostatectomy):

  • ED rates range from 60% to 90% one or more years following surgery 1
  • Nerve-sparing procedures may preserve function in some men, though selection bias may affect reported outcomes 1
  • The rapid effect on erectile function may improve with time in some patients 1

• Radiation therapy:

  • ED rates range from 0% to 85% at one year and later post-treatment 1
  • Unlike surgery, ED from radiation is typically delayed in onset, occurring 6-36 months after treatment 1
  • Three-dimensional conformal techniques appear to result in better preservation of erectile function 1
  • ED worsens gradually due to local neurovascular changes 1

• Androgen deprivation therapy (ADT):

  • Causes the most severe sexual dysfunction among prostate cancer treatments 2
  • Even after just 3-4 months, desire for sex decreases and irreversible damage may occur to erectile tissue 2
  • Approximately 50% of men experience permanent ED even if ADT is discontinued 2
  • Combining radiation with ADT further increases the negative impact on erectile function 1

Relationship Between Prostate Cancer and BPH

Coexistence Rather Than Causation

• Prostate cancer does not cause BPH; they are distinct conditions that frequently coexist due to similar age distribution 3, 4
• Carcinoma of the prostate causes many symptoms similar to BPH, making differential diagnosis important 5
• Before initiating treatment for BPH, prostate cancer should be ruled out as these conditions frequently co-exist 5

Medication Patterns and Relationships

• Men with prostate cancer show higher prescription rates for BPH medications before diagnosis, suggesting increased surveillance among men with lower urinary tract symptoms 6
• After prostate cancer diagnosis, there is a significant increase in prescriptions for ED medications, particularly among men with localized disease, reflecting treatment-related sexual dysfunction 6

Management of ED in Prostate Cancer Patients

Assessment and First-Line Treatment

• All patients with ED after prostate cancer treatment should undergo assessment to identify any correctable risk factors 7
• PDE-5 inhibitors (sildenafil, vardenafil, tadalafil) are typically first-line therapy if no contraindications exist 1, 8
• Response rates to PDE-5 inhibitors vary by treatment type:
  • 70% effectiveness in post-radiation patients 7
  • 40-50% effectiveness in post-surgical patients 7

Second-Line Options

• For patients who don't respond to PDE-5 inhibitors, options include:
  • Intraurethral dissolvable prostaglandin pellets 1
  • Intracavernosal prostaglandin injections 1
  • Vacuum erection devices 1
  • Combination therapy (e.g., PDE-5 inhibitors with vacuum devices) 1, 8
• Penile prosthesis surgery may be considered when other treatments fail 7, 2

Special Considerations and Complications

Psychological Impact

• Sexual dysfunction significantly affects quality of life for prostate cancer survivors 1
• Partners should be included in survivorship care as they are often distressed after diagnosis and treatment 1
• Men who don't regain erectile function may benefit from discussing body image concerns with healthcare providers 1

Treatment-Specific Complications

• Surgery complications include penile shortening and anejaculation (orgasm without ejaculation) 1
• Radiation may cause gradual decline in function due to vascular changes 1
• ADT can cause atrophy of erectile tissue, making treatment more challenging 2

Multidisciplinary Approach

• Sexual recovery is most effective with a multidisciplinary approach involving urologists, mental health professionals, and other specialists 1
• Couples may need support with recovery or acceptance of changes in their sexual relationship 1
• Interventions to enhance emotional intimacy and sexual function have shown success, particularly for couples with fewer psychological resources 1