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Furdoon here and it's all new to me!

User
Posted 22 Sep 2019 at 15:06

Hi Guys.

I have recently been diagnosed with prostate cancer with a Gleason 8, a T2 and N0. leaning towards radiation as not surgery... Think long term effect on sexual function is less... though I accept longer treatment time... Any thoughts....?

User
Posted 22 Sep 2019 at 22:50

Hi,

We often have this debate and without all the evidence you could say if sexual function is your main priority there is a good chance radiation might be a better option.  With an op there is a lot of hit and miss with nerve sparing. I've read that there is a risk of sexual deterioration over a couple of years with radiotherapy but don't know how probable it is.  There are a lot of 'mights', 'perhaps', 'probables' and 'ifs' about the above.

I preferred the op and would still, but sexual performance was much lower in my priorities. I just wanted it gone asap.  All the best.

 

User
Posted 23 Sep 2019 at 08:50
One thing to be aware with RT is that the HT that accompanies it will completely take away your libido, so although the sexual function remains, the desire will be completely absent for the two years (or however long it may be) that you're on HT.

I'm on the RT/HT road myself (started HT in Aug 2018, had my RT in Feb/Mar 2019) and it's been a reasonably smooth experience. No side-effects that are too bad.

Best wishes,

Chris

User
Posted 23 Sep 2019 at 09:51

I'm sure I've written this before, but I can't find it in searching...

When comparing treatments for sexual function, these are things you might think of...

For radical prostatecomy (RP), a significant factor is if you have nerve sparing or not. This will depend how close the cancer is to the rear and lower surfaces of the prostate where the neurovascular bundles run along the surface, and carry nerves that generate erections. If these can't be saved, you won't be able to have natural erections. The surgeon will be able to give an idea before the operation, but they won't know for sure until they are doing the operation. After the operation, erections won't work, but if the nerves are saved, erections will come back typically between 6 months and 2 years later in around 60% of cases. Erections often aren't as powerful, particularly in the case of partial nerve sparing, and this might be a significant issue in the case of anal sex. PDE5 inhibitor drugs can help (cialis, viagra, etc) by amplifying the effect of the working nerves, but won't work in the case of no working nerves. Your GP can supply these generally at a maximum of 1 a week under current guidelines. In the case of loss of nerves or failure to recover after nerve sparing, there are some other options. Vasodilator drugs such as Caverinject and Muse pellets work for most people but can be painful in some cases. Vacuum pump with cock rings is another possibility, but less satisfactory and probably not for anal sex. Implants can work well, and can either be semi-rigid permanently erect or inflatable. They are particularly suitable for people who had ED before treatment, and can get them back to a better place than they started. They have a small infection risk, and if that happens, it's a disaster with no options anymore. RP will also shorten your penis. When your prostate is removed, around 5-6cm of urethra through the middle come out with it, and to join the urethra back to the bladder, the bladder is pulled down and the urethrea is pulled inwards towards it, so you might lose around 3cm erect length, depending how large your prostate is and how much the bladder will pull down into the space. There's a risk for urinary continence too. You will probably be incontinent afterwards but this usually comes back - your brain has to relearn to use the external urinary sphincter for primary continence, rather than the internal urinary sphincter which is removed with the prostate. RP is quite a major operation even when done keyhole, and will leave you recovering for several months afterwards.

There are different types of radiotherapy (RT). External Beam RT (EBRT) is perhaps the best known, but you might be a candidate for seed brachytherapy (internal radiotherapy, where radioactive seeds are inserted into the prostate which work slowly over a year until their radioactivity has decayed away). RT is much less of an assault on your body than RP. Many people continue working throughout EBRT, and Brachy might just require a week or two to recover (longer for a manual job). RT is almost always given with hormone therapy (HT) because the two together have much better outcomes - you are hitting the cancer with two things at once. HT is usually given for 18-36 months with EBRT, but sometimes for as little as 3 months with seed brachy - it will depend on your case and the protocols in use at your treatment centre. The RT and HT both have their own side effects. RT will upset the bowel and bladder during treatment and for up to 6 weeks afterwards, but usually gets better. Some people do have permanent changes such as urgency and slight incontinence as these side effects don't always completely go away afterwards, but they usually do. RT doesn't normally cause any erection problems at the time, but has potential long term side effects, which can include a very slow loss of erections years later (in around 30-40% of cases), and there's a very small risk of the RT causing bladder or bowel cancer very many years later, which is slight concern for younger patients. HT has a long list of potential side effects while you are on it (although no one gets all of them), but they mostly go when you come off HT. Reduction (and in some cases complete loss) of libido is one of them, and that may make it difficult to get erections, although the mechanics still works fine, and it can impact relationships - both partners need to be prepared and understand what's happening. It is important that you do continue to have regular erections though, as a period without them will damage the erectile tissue in the penis, resulting in shorter and less solid erections when you come off hormone therapy, but with regular erections, this is completely avoidable.

Anyway, these are some things to ponder, but I would not disagree with your leaning towards RT.

Edited by member 23 Sep 2019 at 19:13  | Reason: Not specified

User
Posted 23 Sep 2019 at 13:44
Hi,

I know you've asked specifically about the impact on sex. But it's worth bearing in mind that with surgery you get a much clearer idea about the grade of your cancer i.e. whether the staging is correct and whether there's been any further spread.

I was diagnosed as G9 T2 with possible T3 before surgery and upgraded to T3B N1 based on the post-surgery pathology report. Something which might be more relevant with higher grade Gleason Scores.

Appreciate that it's not what you asked about, but just something else to consider.

Chris

User
Posted 23 Sep 2019 at 15:44

Chris, you are right that the cancer may be upgraded after a RP, but mostly that only matters after a RP because of the risk of missing some.

If a high risk (G9) patient is being treated by RT, the nodes and seminal vesicles will be treated anyway as though they had cancer even if none was found, so it's likely to wipe out unknown spread in the first treatment. This is done because you can't go back and treat them with more RT later (with a few exceptions).

Conversely, if you have a RP and it's found some things were missed, you then have to have RT too, and end up with side effects of both procedures.

I don't think there is a clear winner.

 

Edited by member 23 Sep 2019 at 15:46  | Reason: Not specified

User
Posted 23 Sep 2019 at 16:19
As a 57 year old you need to be concerned about the long term effects of radiation too.

Generally the older you are and the more advanced or aggressive the the cancer is will make radiation the more suitable choice.

I would argue a G8 T2 is an ideal RP candidate.

Having said all that as my Doc pointed out doing nothing is statistically just as effective as radiation or surgery!

Basically read up and be a fully informed patient!

User
Posted 23 Sep 2019 at 16:25

Hi Furdoon - sorry to hijack the conversation

Andy62

I was lead to believe you don't have to have nerves preserved to achieve erections with Cialis etc. Have I got it wrong? I had RP with nerves spared both sides, 7 weeks post op - no glimmer of activity! Am taking cialis 2.5 mg for penile rehabilitation, but not dared to take higher doses to see if any erection. Cant think of it with ongoing incontinence which is a bummer

Thala

User
Posted 23 Sep 2019 at 17:37

Thala,

You do need nerves for PDE5 inhibitors to give you an erection. The nerve signals cause the generation of nitric oxide (NO) inside the penis, and this causes muscle relaxation that generates blood flow causing the erection. The erection is maintained while nerves continue signalling generation of NO. The NO is continuously broken down by PDE5, so that when the nerves stop signalling for an erection, the NO goes, and the erection is lost.

If you don't generate much NO because not many nerves are working, it will be broken down by PDE5 before it builds up high enough concentration to generate an erection.

This is where the PDE5 inhibitors come in. They prevent the breakdown of the NO, so that with less being generated (due to fewer working nerves), the concentration will still get high enough to generate an erection.

However, with no nerves and hence no NO, no amount of PDE5 inhibitor will generate an erection as there's no NO to start with. As I mentioned above, then you would then need to use vasodilator drugs (such as alprostadil) to generate an erection. These mimic the effect of the NO, so no nerve signal is required.

Note that PDE5 inhibitors have an additional effect too (for which they were originally invented), and that's to increase capillary blood flow. This helps preserve the tissue of the corpus cavernosum (erectile part of the penis) in the absence of erections, and this is what the daily low dose PDE5 inhibitors are aiming to do. A flaccid penis has about 30% blood flow that similar body tissues get, which means it normally runs ischemic (short of oxygen). The body protects it against long term harm by giving you nocturnal erections around 4 times per night during REM sleep. However, with damaged nerves (or if you are on hormone therapy), this protection mechanism doesn't work, and the daily PDE5 inhibitor dose increases the flaccid blood flow to provide some level of work around, even though it's nowhere near enough to generate an erection.

7 weeks is far too soon to be concerned about no response post RP. Also, PDE5 inhibitors (such as Cialis) won't give you an erection unless you are suitably aroused, because it needs some NO to be produced by nerves. If you've been told to try higher dose to achieve an erection, go ahead and try (20mg is the normal "event" dose, but less will be needed if you are on a daily low dose).

Conversely, the vasodilator drugs (for use with no working nerves) will give you an erection aroused or not, and it won't go away just because you stop being aroused at the end of sex either - you have to wait until the drug wears off.

Edited by member 23 Sep 2019 at 17:37  | Reason: Not specified

User
Posted 23 Sep 2019 at 18:04
Thala

7 weeks in is way to early to be worrying about either!

User
Posted 23 Sep 2019 at 19:45
Thanks Andy for the informative answer.

Francij1 - thank you , 7 weeks is too early indeed, but makes you feel better when someone says so!

User
Posted 26 Sep 2019 at 22:17
Hi All of you. Many thanks for all the information you have taken the time to provide. I don't think 'watch and see' is for me. Today I met the team and I have elected to go for radiation and hormone treatment. The oncologist has put me on 2 weeks of tablets to be followed by injection. I have the option of monthly or 3 monthly injection... Any views on this? The radiation therapy will commence in Jan for 4 weeks then continue with injections for upto 18 months...
User
Posted 26 Sep 2019 at 22:29

People usually have the 3-monthly ones, as being more convenient (and I suspect cheaper). Sometimes you get a monthly as the first one, just in case you're allergic to it (although I never heard of that happening).

User
Posted 27 Sep 2019 at 03:03
Not so much about being allergic to it as finding the side effects intolerable and having to wait 3 months to get it out of the system. Seems sensible to have the monthly one the first time and then go to the 3 monthly dose if they are willing to do that?
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 30 Sep 2019 at 17:45
Thanks again folks.... Start taking the tablets tomorrow.... the start on the treatment journey.... which so many of you have been on or I am joining on that road... Good luck to us all ; )
User
Posted 30 Sep 2019 at 19:41
What are you taking? 50mg bicalutimide?

Best wishes,

Chris

 
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