What are the treatment options for anejaculation in patients with prostate cancer?

Treatment Options for Anejaculation in Prostate Cancer Patients

Anejaculation after prostate cancer treatment is largely permanent and has no effective medical reversal, so management focuses on pre-treatment counseling, psychological support, and addressing coexisting sexual dysfunctions rather than restoring ejaculatory function. 1

Understanding the Problem

Anejaculation is extremely common after prostate cancer treatment, affecting 11-72% of men after radiation therapy (increasing from 16% at 1 year to 89% at 5 years) and nearly all men after radical prostatectomy. 1, 2 The condition results from radiation-induced small vessel obliteration, endarteritis, and progressive fibrosis affecting the seminal vesicles, vas deferens, and prostatic ducts—a relentless process that worsens over time. 1

Risk Factors to Identify

• Older age at treatment increases anejaculation risk 1, 2
• Concurrent androgen deprivation therapy (ADT) significantly elevates risk 1, 2
• Radiation dose >100 Gy predicts higher rates 2
• Smaller prostate size at treatment correlates with increased risk 2

Pre-Treatment Counseling (Critical First Step)

Explicit counseling about permanent anejaculation must occur before any prostate cancer treatment. 1 This is mandated by both American Cancer Society and AUA/GURS/SUFU guidelines. 1

Key Counseling Points

• Ejaculate will be absent despite preserved orgasm ability—men can still achieve climax 1, 3
• The condition is permanent—do not assume patients understand this without explicit discussion 1
• Sperm banking must be discussed before treatment for men of reproductive age 1
• Anejaculation is distinct from erectile dysfunction—these are separate issues requiring different approaches 1

Management Approach

1. Psychological and Counseling Support

Open discussion about body image changes is essential, with referral to supportive counseling when patients express distress. 1 The psychological impact can be profound, particularly for men who have sex with men (MSM), who report anejaculation as especially distressing and may need to explore new modes of sexual expression. 4

• Refer to sex therapy or couples counseling for persistent distress 3
• Proactively ask about sexual function during routine follow-up—many men will not volunteer this information 1
• Address loss of identity and relationship concerns that commonly accompany this change 4

2. Manage Coexisting Erectile Dysfunction

Erectile dysfunction commonly coexists with anejaculation and should be pursued aggressively. 1

First-Line Treatment: PDE-5 Inhibitors

• Prescribe sildenafil, vardenafil, or tadalafil as first-line therapy with efficacy rates of 73-88% 3, 5
• Start conservatively with on-demand dosing and titrate to maximum dose if needed 3
• Daily low-dose PDE-5 inhibitors can also be effective for penile rehabilitation 3
• Contraindicated with oral nitrates due to dangerous blood pressure drops 3

Additional Interventions

• Testosterone therapy if morning testosterone <300 ng/dL—but contraindicated in men on active surveillance or ADT 3
• Pelvic floor physical therapy may improve sexual function in prostate cancer survivors 3
• Refer to urology for persistent dysfunction to discuss vacuum devices, intraurethral suppositories, or penile prosthesis 3

3. Address Orgasm Quality Issues

PDE-5 inhibitors can be used for problems with orgasm intensity or difficulty achieving climax. 3, 5

• Vibratory therapy may reduce problems with orgasm 3, 5
• SSRIs (paroxetine, sertraline, citalopram, fluoxetine) dosed daily or clomipramine on-demand may help with orgasm-related issues, though these are typically used for premature ejaculation in the general population 3

4. Lifestyle Modifications

Recommend smoking cessation, weight loss, increased physical activity, and reduced alcohol consumption—these improve sexual function in men generally. 3

Critical Clinical Pitfalls to Avoid

• Do not conflate anejaculation with erectile dysfunction—these require different management strategies though they often coexist 1
• Do not dismiss the psychological impact—loss of ejaculation can be profoundly distressing 1, 4
• Do not wait for patients to bring up sexual concerns—proactive questioning is essential 1
• Do not use apomorphine—it has limited efficacy and significant side effects compared to PDE-5 inhibitors 5

Special Population Considerations

For men who have sex with men, anejaculation has unique impacts on sexual practices and identity. 4 These patients may experience heteronormative biases in healthcare and require providers who understand their specific sexual practices and relationship dynamics. 4