Sexual rehabilitation with intracavernous alprostadil after radical prostatectomy: Outcomes from a nursing program

Introduction and objectives: Erectile dysfunction (ED) is a common complication after radical prostatectomy that affects quality of life. There are several therapeutic options, including intracavernous alprostadil injections (IAI). However, no specific recommendations have been made on the optimal rehabilitation strategy. In this study we evaluated a sexual rehabilitation program (SRP) with IAI for patients with ED after radical prostatectomy, assessing the rate of compliance and reasons for dropout.Methods: The sexual rehabilitation program (SRP) was offered to all patients who underwent radical prostatectomy from 1 January 2010 to 31 December 2019. The first consultations were performed by a urology specialist nurse, explaining the IAI procedure and possible complications. The program was considered successful when the patients achieved autonomy in the drug preparation with a good injection technique. A medical consultation was performed at 6 months evaluating the IAI usage and adverse events. In case of dropout, a questionnaire about reasons for dropout was performed. The primary endpoint was the rate of compliance and dropout of the program. Secondary endpoints were the reasons for dropout and adverse events. Results: 340 patients underwent radical prostatectomy at our institution, and 123 patients accepted to participate in the rehabilitation program. A total of 96 patients (78%) successfully completed the SRP, and at 6 months 60 (62.5%) still used IAI. Concerning the reasons for dropping out, the most frequent were the need of injectable therapy and pain. Regarding complications, 17 patients (13.8%) reported pain related to the injection and 1 patient (0.8%) had a priapism, managed with conservative treatment. Conclusions: Management of post-radical prostatectomy ED by a nursing program achieved good rates of patients’ self-injection accomplishment and treatment compliance. Close monitoring for dose adjustment and management of post-injection penile pain is required during the follow-up.

A sexual rehabilitation intervention for women with gynaecological cancer receiving radiotherapy (SPARC study): design of a multicentre randomized controlled trial

Background Sexual problems are frequently reported after treatment with radiotherapy (RT) for gynaecological cancer (GC), in particular after combined external beam radiotherapy and brachytherapy (EBRT+BT). Studies demonstrate that psychosexual support should include cognitive behavioural interventions and involvement of the patient’s partner, if available. Therefore, we developed a nurse-led sexual rehabilitation intervention, including these key components. The intervention was previously pilot-tested and results demonstrated that this intervention improves women’s sexual functioning and increases dilator compliance. The objective of the current study is to investigate the (cost-)effectiveness of the intervention compared to optimal care as usual (CAU). We expect that women who receive the intervention will report a statistically significant greater improvement in sexual functioning and – for women who receive EBRT+BT – higher compliance with dilator use, from baseline to 12 months post-RT than women who receive optimal care as usual (CAU). Methods/design The intervention is evaluated in the SPARC (Sexual rehabilitation Programme After Radiotherapy for gynaecological Cancer) study, a multicentre, randomized controlled trial (RCT). The primary endpoint is sexual functioning. Secondary outcomes include body image, fear of sexual activity, sexual-, treatment-related- and psychological distress, health-related quality of life and relationship satisfaction. A cost-effectiveness analysis (CEA) will be conducted in which the costs of the intervention will be related to shifts in other health care costs and the impact on patient outcome. The study sample will consist of 220 women with GC treated with RT in specialized GC treatment centres (N = 10). Participants are randomized to either the intervention- or CAU control group (1:1), and within each centre stratified by type of radiotherapy (EBRT+BT vs. EBRT only) and having a partner (yes/no). All women complete questionnaires at baseline (T1) and at 1, 3, 6, and 12 months post-RT (T2, T3, T4 and T5, respectively). Discussion There is a need to improve sexual functioning after RT for GC. This RCT will provide evidence about the (cost-)effectiveness of a nurse-led sexual rehabilitation intervention. If proven effective, the intervention will be a much needed addition to care offered to GC survivors and will result in improved quality of life. Trial registration ClinicalTrials.gov, NCT03611517. Registered 2 August 2018.

Vaginal Dilator Use to Promote Sexual Wellbeing After Radiotherapy in Gynaecological Cancer Survivors: A Prospective Observational Study

Background: Since continuing advances in radiotherapy technology broaden the role of radiotherapy in the treatment of gynaecologic malignancies, the use of vaginal dilators has been introduced in order to mitigate the risk of vaginal stenosis. The main aims of this study were to investigate the vaginal dilator use efficacy in the treatment of radiation-induced vaginal stenosis and the vaginal dilator effect on sexual quality of life. Methods: We studied fifty-three patients with endometrial or cervical cancer. The participants were treated with radical or adjuvant external beam radiotherapy and/or brachytherapy. They were routinely examined at four time points post-radiotherapy when also they were asked to fill in a validated sexual function-vaginal changes questionnaire. A p-value less than 0.05 was considered statistically significant. Results: The vaginal stenosis grading score was decreased and the size of the vaginal dilator comfortably insertable was gradually increased throughout the year of vaginal dilator use while radiation-induced vaginal and sexual symptoms were improved throughout the year of VD use. All patients with initial grade 3 showed vaginal stenosis of grade 2 after 12 months of vaginal dilator use and 65.8% of the patients with grade 2 initial vaginal stenosis demonstrated final vaginal stenosis grade 1 while 77.8% of the participants with initial 1st size of vaginal dilators reached the 3rd vaginal dilator size after 12 months. Starting time of dilator therapy <= 3 months after the end of radiotherapy was associated with a significant decrease in vaginal stenosis. Additionally, there was an overall upward trend regarding patients’ satisfaction with their sexual life. Conclusion: Endometrial and cervical cancer survivors should be encouraged to use vaginal dilators for the treatment of vaginal stenosis and sexual rehabilitation after radiotherapy.

Vaginal Dilator Use to Promote Sexual Wellbeing After Radiotherapy in Gynaecological Cancer Survivors: A Prospective Observational Study

Background: Since continuing advances in radiotherapy technology broaden the role of radiotherapy in the treatment of gynaecologic malignancies, the use of vaginal dilators has been introduced in order to mitigate the risk of vaginal stenosis. The main aims of this study were to investigate the vaginal dilator use efficacy in the treatment of radiation-induced vaginal stenosis and the vaginal dilator effect on sexual quality of life. Methods: We studied fifty-three patients with endometrial or cervical cancer. The participants were treated with radical or adjuvant external beam radiotherapy and/or brachytherapy. They were routinely examined at four time points post-radiotherapy when also they were asked to fill in a validated sexual function-vaginal changes questionnaire. A p-value less than 0.05 was considered statistically significant. Results: The vaginal stenosis grading score was decreased and the size of the vaginal dilator comfortably insertable was gradually increased throughout the year of vaginal dilator use while radiation-induced vaginal and sexual symptoms were improved throughout the year of VD use. All patients with initial grade 3 showed vaginal stenosis of grade 2 after 12 months of vaginal dilator use and 65.8% of the patients with grade 2 initial vaginal stenosis demonstrated final vaginal stenosis grade 1 while 77.8% of the participants with initial 1st size of vaginal dilators reached the 3rd vaginal dilator size after 12 months. Starting time of dilator therapy <= 3 months after the end of radiotherapy was associated with a significant decrease in vaginal stenosis. Additionally, there was an overall upward trend regarding patients’ satisfaction with their sexual life. Conclusion: Endometrial and cervical cancer survivors should be encouraged to use vaginal dilators for the treatment of vaginal stenosis and sexual rehabilitation after radiotherapy.

Couples Coping with Prostate Cancer: Women and Men (Re)Negotiating Discourse of Gender, Sexuality and Intimate Relationships

This dissertation project investigates the ways in which men and their female partners navigate discourses of sex, gender, and relationships as they cope with recovery from prostate cancer and engage in penile/sexual rehabilitation. Study I involves a discourse analysis of online patient information sources for prostate cancer-related penile/sexual rehabilitation with a focus on how sex, erections, gender, patients, and relationships are depicted. Study II involves discourse analysis of in-depth interviews with prostate cancer survivors, female partners of men with prostate cancer, and couples, to explore the social norms and collective meanings they adopt when speaking about sex, their identity as a man/woman, recovery, and relationships. Analyses also explore discursive points of connection and discordance between the two studies. Penile rehabilitation is positioned in both studies as a medical imperative through close alignment with scientific empiricism. Sexual side effects (e.g., changes in erections) are framed in biomedical and mechanical terms, and penile rehabilitation is presented as a scientific and effective solution. Both Study I and Study II convey that one’s health and recovery are largely individual responsibilities. Ideal patients are framed as entrepreneurial, responsible, and informed in Study I, and Study II participants largely adopt these discourses. Online information sources situate sexuality within the realm of health and medicine so that changes in erections are positioned as medical issues best resolved using the expertise of medical specialists. The findings from Study II, however, challenge a purely biomedical or health-focused approach to erections. Many patients emphasize the relational and psychological aspects of sex and the inability of pro-erectile interventions to adequately address the injuries caused by prostate cancer treatment. Online materials from Study I reinforce narrowly defined views of masculinity/femininity and (hetero)sexuality. Masculinity and femininity are framed as complementary and distinct opposites, and intercourse is positioned as an essential sexual practice. Many participants frame prostate cancer as a major disruption to successful gender performance and to the sexual status quo. A number of participants resist medicalized/healthisized discourses of sex, and hegemonic masculine subjectivities. They espouse alternative definitions of what it means to be a lover and man/woman. Implications and recommendations are discussed.

Couples Coping with Prostate Cancer: Women and Men (Re)Negotiating Discourse of Gender, Sexuality and Intimate Relationships

This dissertation project investigates the ways in which men and their female partners navigate discourses of sex, gender, and relationships as they cope with recovery from prostate cancer and engage in penile/sexual rehabilitation. Study I involves a discourse analysis of online patient information sources for prostate cancer-related penile/sexual rehabilitation with a focus on how sex, erections, gender, patients, and relationships are depicted. Study II involves discourse analysis of in-depth interviews with prostate cancer survivors, female partners of men with prostate cancer, and couples, to explore the social norms and collective meanings they adopt when speaking about sex, their identity as a man/woman, recovery, and relationships. Analyses also explore discursive points of connection and discordance between the two studies. Penile rehabilitation is positioned in both studies as a medical imperative through close alignment with scientific empiricism. Sexual side effects (e.g., changes in erections) are framed in biomedical and mechanical terms, and penile rehabilitation is presented as a scientific and effective solution. Both Study I and Study II convey that one’s health and recovery are largely individual responsibilities. Ideal patients are framed as entrepreneurial, responsible, and informed in Study I, and Study II participants largely adopt these discourses. Online information sources situate sexuality within the realm of health and medicine so that changes in erections are positioned as medical issues best resolved using the expertise of medical specialists. The findings from Study II, however, challenge a purely biomedical or health-focused approach to erections. Many patients emphasize the relational and psychological aspects of sex and the inability of pro-erectile interventions to adequately address the injuries caused by prostate cancer treatment. Online materials from Study I reinforce narrowly defined views of masculinity/femininity and (hetero)sexuality. Masculinity and femininity are framed as complementary and distinct opposites, and intercourse is positioned as an essential sexual practice. Many participants frame prostate cancer as a major disruption to successful gender performance and to the sexual status quo. A number of participants resist medicalized/healthisized discourses of sex, and hegemonic masculine subjectivities. They espouse alternative definitions of what it means to be a lover and man/woman. Implications and recommendations are discussed.

Is it Worth Starting Sexual Rehabilitation Before Radical Prostatectomy? Results From a Systematic Review of the Literature

Background and Purpose: Sexual dysfunction (SD) is a frequent side effect associated with radical prostatectomy (RP) for prostate cancer (PCa). Some studies have showed the benefit associated with preoperative sexual rehabilitation (prehabilitation) and Enhanced Recovery After Surgery (ERAS) for RP, but no clear clinical recommendations are available yet. Our aim was to conduct a systematic review on sexual prehabilitation prior to RP for patients with a localized PCa and analyze the impact on postoperative sexual health compared with the standard post-operative care.Methods: We performed a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations.Results: Four randomized control trials and one retrospective comparative study were included in the analyses. Three of the five studies showed an improved EF recovery post-RP in the prehabilitation group compared to the standard of care represented by: higher International Index of Erectile Function 5 score (IIEF5) or IIEF score (p &lt; 0.0001) and a higher percentage of patients reporting return of EF based on the Sexual Encounter Profile (SEP) (56 vs. 24%, p = 0.007). Self-confidence, therapeutic alliance, and adherence to treatment were stronger for patients with preoperative consultations (p &lt; 0.05) and EF recovery was better in cases of a higher number of follow-up visits (OR 4–5 visits vs. 1:12.19, p = 0.002).Discussion: Despite heterogenous methods and high risks of bias in this systematic review, starting sexual rehabilitation prior to surgery seems to ensure better EF recovery. This prehabilitation should include information of both the patient and his or her partner, with a closer follow up and the use of a multimodal treatment approach that still remains to be defined and validated (oral medication, vacuum devices, pelvic floor muscle training, etc.).