Sildenafil citrate may be effective in the management of sexual dysfunction after radiation therapy in some men. In a randomized placebo-controlled, crossover design study (RTOG-0215) of 60 men who had undergone radiation therapy for clinically localized prostate cancer, and who reported erectile dysfunction that began after their radiation therapy, 55% reported successful intercourse after sildenafil versus 18% after placebo (P <.001).[Level of evidence: 1iC]
A prospective community-based cohort of men aged 55 to 74 years treated with radical prostatectomy (N = 1156) or EBRT (N = 435) attempted to compare acute and chronic complications of the two treatment strategies after adjusting for baseline differences in patient characteristics and underlying health. Regarding acute treatment-related morbidity, radical prostatectomy was associated with higher rates of cardiopulmonary complications (5.5% vs. 1.9%) and the need for treatment of urinary strictures (17.4% vs. 7.2%). Radiation therapy was associated with more acute rectal proctitis (18.7% vs. 1.6%). With regard to chronic treatment-related morbidity, radical prostatectomy was associated with more urinary incontinence (9.6% vs. 3.5%) and impotence (80% vs. 62%). Radiation therapy was associated with slightly greater declines in bowel function.
Radiation is also known to be carcinogenic.[72,73] EBRT for prostate cancer is associated with an increased risk of both bladder and rectal cancer. Brachytherapy is associated with bladder cancer.
Impotence is common in the reported case series, ranging from about 47% to 100%. Other major complications include incontinence, urethral sloughing, urinary fistula or stricture, and bladder neck obstruction.
Hormone Therapy Complications
Several different hormonal approaches can benefit men in various stages of prostate cancer. These approaches include bilateral orchiectomy, estrogen therapy, LHRH agonists, antiandrogens, ketoconazole, and aminoglutethimide.
Benefits of bilateral orchiectomy include ease of the procedure, compliance, its immediacy in lowering testosterone levels, and low cost. Disadvantages include psychologic effects, loss of libido, impotence, hot flashes, and osteoporosis.[41,74] (For information on loss of libido and impotence, refer to the Sexuality and Reproductive Issues summary; refer to the PDQ summary on Fever, Sweats, and Hot Flashes.)
Estrogens at a dose of 3 mg per day of diethylstilbestrol will achieve castrate levels of testosterone. Like orchiectomy, estrogens may cause loss of libido and impotence. Gynecomastia may be prevented by low-dose radiation therapy to the breasts. Estrogen is seldom used today because of the risk of serious side effects, including myocardial infarction, cerebrovascular accident, and pulmonary embolism.
In a population-based study within the Veterans Administration system, LHRH agonists were associated with an increased risk of diabetes as well as cardiovascular disease, including coronary heart disease, myocardial infarction, sudden death, and stroke. Bilateral orchiectomy was also associated with an elevated risk of coronary heart disease and myocardial infarction.[75,76,77]