Management of erectile dysfunction in men treated with androgen deprivation therapy

Abstract

A 55-year-old man presented to his GP with worsening pain in his left hip. The pain was present during the night as well as in the day. A plain radiograph of the hip demonstrated a sclerotic lesion suspicious of a metastatic deposit. Subsequent investigations revealed a prostate-specific antigen (PSA) of 200ng/ml. Similarly, sclerotic lesions were noted in the right hip and ischium. Prostatic biopsies confirmed Gleason 4+3 adenocarcinoma of the prostate and he was entered into the STAMPEDE trial. He was randomised to receive luteinising hormone-releasing hormone agonist therapy alone, so was commenced on goserelin injections. Bicalutamide was given at the beginning of therapy to prevent tumour flare. Six months later, his PSA had fallen to 0.6ng/ml with a serum testosterone <0.4ng/dl. During a clinic appointment he complained of loss of libido and difficulty maintaining erections adequate for sexual intercourse. He was commenced on tadalafil (Cialis) tablets twice a week as first-line treatment. THE CASEE rectile dysfunction (ED) is the persistent inability to attain and maintain a penile erection satisfactory for sexual intercourse. ED is increasingly common with advancing age, but is even more pronounced in men with prostate cancer who receive androgen deprivation therapy (ADT). Reported rates of impotence in this group range from 50 to 100 per cent.The aetiology of ED in men with prostate cancer is often mixed. Vascular and/or neurological damage at prostatectomy or following radical radiotherapy explains some of the incidence, but even without these treatments, such as in this case, erectile problems are common. Hormonal, neurological, vascular and psychological factors contribute to a greater or lesser degree in different individuals. EFFECTS OF ANDROGEN DEPLETIONAndrogen deprivation therapy, by definition, causes sustained suppression of serum In this series, the authors present cases of men being treated with androgen deprivation therapy, and highlight their management to prevent and treat associated toxicities. This second article will consider the management of erectile dysfunction.

Erectile Dysfunction: A Primer for in Office Management

“…This includes, and is not limited to, reduction in response to endogenous vasodilators, altering compliance of corpus cavernosum and resulting in dysfunction of the veno-occlusive mechanism important in erectile function [45]. Intermittent ADT, as opposed to continuous ADT, may be used in the right clinical setting and this may help alleviate sexual dysfunction [46]. The treatment algorithm for such patients remains similar with conservative and medical treatment options trialed initially; however, early specialist referral may be warranted.…”

Managing erectile dysfunction after prostate cancer treatment

“…Androgen‐deprivation therapy (ADT) describes a systemic treatment used to lower testicular androgen levels and includes luteinising hormone‐releasing hormone (LHRH) agonists ( eg goserelin), LHRH antagonists ( eg degarelix) and anti‐androgens ( eg bicalutamide). ADT lowers testosterone levels in the body, which in turn can lead to decreased arousal and libido 24 . ADT also causes structural changes to the penis, decreased penile length and testicular size; 25 these changes make it more difficult to achieve and maintain an erection.…”

Non-pharmacological and non-surgical strategies to promote sexual recovery for men with erectile dysfunction

“…Indeed, all major treatments for localized prostate cancer increase the risk of ED ( 41 - 43 ). In addition, many prostate cancer patients receive androgen deprivation therapy, which reduces libido substantially ( 35 , 44 , 45 ). Indirectly, but inevitably, the diminished sexual function and desire of patients affect their partners.…”