Managing Prostate Cancer

The two side effects of prostate cancer treatment that concern men the most are urinary incontinence and erectile dysfunction. As treatments for prostate cancer improve, these complications will become less common. When they do occur, however, there are effective ways to alleviate them.

This section discusses:

• Urinary incontinence
• Erectile dysfunction

Urinary incontinence

Because surgery or radiation therapy may irritate the urethra or bladder or damage the urinary sphincter muscles that contract to prevent urine from flowing out of the bladder, some degree of incontinence is common immediately after treatment.

A number of methods can be used to reduce incontinence:

• Lifestyle measures: Simple changes in behavior can be helpful. A high-calorie diet and lack of exercise can lead to obesity, which increases pressure on the bladder and exacerbates incontinence. Because constipation can also worsen symptoms, it is important to eat high-fiber foods, such as leafy green vegetables, fruits, whole grains, and legumes. Caffeine and alcohol consumption should be limited since they increase frequency of urination. If nighttime urination is a problem, avoid consuming liquids several hours before bedtime.
• Kegel exercises: Kegel exercises are performed by squeezing and relaxing the pelvic floor muscles that support the bladder and surround the urethra. By strengthening these muscles, bladder control may improve. To locate the pelvic floor muscles, try slowing or stopping the flow of urine midstream.
• Collagen injections: Collagen can be injected around the bladder neck to add bulk and provide increased resistance to urine flow during times of physical strain. However, repeat injections often are needed because collagen is a naturally occurring protein and is broken down by the body.
• Artificial sphincter implantation: In this procedure, a doughnut-shaped rubber cuff is implanted around the urethra. The cuff is filled with fluid and is connected by a thin tube to a bulb implanted in the scrotum. In turn, the bulb is connected to a reservoir within the abdomen. The fluid in the cuff creates pressure around the urethra to hold urine inside the bladder. When the urge to urinate is felt, squeezing the bulb transfers fluid from the cuff to the reservoir and deflates the cuff for three minutes so urine can drain through the urethra. Afterward, the cuff automatically refills with fluid and urine flow is again impeded.
• Absorbent products: Wearing absorbent pads or undergarments is the most common way to manage incontinence. Typically used right after surgery, these products are effective for minor to severe incontinence.
• Penile clamps: These devices, which compress the penis to prevent urine from leaking, are an option for severe incontinence. Penile clamps are not recommended immediately after treatment because they prevent the development of muscle control that is needed to regain urinary continence.
• External collection devices: These condom-like devices can be pulled over the penis and held in place with adhesive, Velcro straps, or elastic bands. A tube drains fluid from the device to a bag secured on the leg. Often used with a penile clamp, these devices should not be used immediately after surgery, because muscle control needed for bladder control will not develop.
• Catheters: A Foley catheter is a small tube that is inserted through the urethra and allows urine to flow continuously from the bladder into a bag after prostate treatment. This option is not recommended for long-term use because it can cause irritation, infection, and, possibly, lack of muscle control.
• Medications: Medication can be used to control mild to moderate incontinence but is not effective for severe cases. Medication such as oxybutynin (Ditropan), tolterodine (Detrol), and propantheline (Pro-Banthine) may reduce urge incontinence by decreasing involuntary bladder contractions. Nasal decongestants, like pseudoephedrine, or the antidepressant imipramine (Tofranil) can reduce stress incontinence by increasing muscle tone in the bladder neck. Because pseudoephedrine is a stimulant that can increase heart rate and blood pressure, it should be used only under a doctor's supervision. The drug also may cause nervousness, restlessness, and insomnia and may have adverse effects in people with asthma or cardiovascular disease.

Erectile dysfunction

Men who must undergo radical prostatectomy or radiation therapy for prostate cancer often fear they will be unable to resume sexual activity after treatment. While these procedures may result in erectile dysfunction, they do not directly affect libido or the ability to achieve orgasm. This is in contrast to hormone therapy, which lowers testosterone and decreases libido.

Treatments for erectile dysfunction include:

• Vacuum pumps: A simple, noninvasive treatment for erectile dysfunction is the vacuum pump—an airtight tube that is placed around the penis before intercourse. The tube is attached to a pump, which withdraws air from the tube and creates a partial vacuum that causes the penis to become engorged with blood. A constricting ring is then placed at the base of the penis to prevent blood from flowing out. Erections last about a half an hour; leaving the constricting ring on for a longer period may be harmful. Vacuum pumps are highly effective devices, but many men find them cumbersome to use.
• Oral medications: Oral drugs are the newest advance in the treatment of erectile dysfunction. Three drugs are currently available: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). All three belong to a class of drugs known as phosphodiesterase type 5 inhibitors. Unlike other therapies for erectile dysfunction, these drugs do not produce erections in the absence of sexual stimulation.
• Vasodilators: Erections can be produced with vasodilators, drugs that widen the blood vessels and allow the penis to become engorged with blood. The most commonly used vasodilator for erectile dysfunction is alprostadil. Other vasodilators include papaverine and phentolamine. Alprostadil can be injected directly into the base of the penis with a needle or inserted into the urethra in pellet form through a delivery system called MUSE. Both approaches have drawbacks. Injections can cause pain, scarring, and priapism—a painful, prolonged erection that must be treated medically. MUSE can cause urethral burning. Using low doses can minimize the risk of such side effects.
• Surgery: Several types of surgically implanted devices can provide erections sufficient for sexual intercourse. In one approach, a semirigid device—a rod-shaped piece of silicone inserted into the penis—is bent downward into the erect position before intercourse; afterward, it is folded upward close to the body. A more commonly used device consists of two hydraulic chambers implanted into the penis and connected to a fluid-filled pump placed in the scrotum. An erection is created by pumping fluid into the chambers.