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Seminars in Oncology Nursing, Vol 24, No 2 (May), 2008: pp 102-114

OBJECTIVES:
To provide an overview of the challenges in sexuality men face when they have been diagnosed and treated for various types of cancer.

DATA SOURCES:
Review and research articles, abstracts, books, electronic databases, clinical experience.

CONCLUSIONS:
An in-depth assessment of sexual needs and issues specic to men includes physical and psychosocial problems related to sexuality. Interventions include psychosocial sexual interventions, coping strategies, communication strengthening exercises, or alternative sexual techniques that will assist if physical functioning is diminished. Various medical, surgical, or pharmacologic approaches are available.

ALTERATIONS OF SEXUAL FUNCTION IN MEN WITH CANCER

MICHAEL E. GALBRAITH AND FRANCES CRIGHTON
VER 10 million people in the United States alone have survived cancer, and approximately 45% of those survivors are men. The numbers of survivors are expected to markedly increase over the next several decades as people continue to live longer.1,2 However, each year more men are diagnosed with cancer than women (approximately 745,180 men vs 692,000 women) and men have a higher annual death rate (approximately 294,120 men vs 271,630 women).2 As in other chronic illnesses, cancer and its treatment-related sequela place a burden on the physical, emotional, intimate, and relational resources of the man, his partner, and family. Communication and intimacy can be interrupted as couples who become survivors of cancer are faced with physical and psychological consequences of diagnosis and treatment.3-5 This in turn can place additional stressors on health and well-being. This is especially the case for older adults, in that over half of all cancers occur in people over 65.6 In addition, recent ndings suggest that older couples do not differ substantially from younger couples in their sexual activity and interest.7 Consequently, the impact of cancer on sexuality for men is an issue of concern across the life span. The purpose of this article is to provide an overview of the sexual challenges men face when they are diagnosed and treated for various types of cancer. It will demonstrate that men do not experience these challenges in isolation; rather, they often have these experiences in the context of current or future relationships. Cancer treatment-related sequelae specic to men will be discussed. The importance of an in-dept assessment of sexual needs and issues specic to men will be outlined, and various treatment approaches will be identied.

IMPLICATIONS FOR NURSING PRACTICE:

Although it is recognized that male sexuality in the cancer arena has been overlooked in the past, nurses have the opportunity to change this trend in the clinical setting and improve sexual health care delivery for men.

KEYWORDS:
Cancer, males, sexuality, interventions

Michael E Galbraith, RN, PhD: Associate Professor, School of Nursing, University of Colorado Denver, Aurora, CO. Frances Crighton, RN, PhD: Tony Grampas Urological Oncology Program, University of Colorado Hospital, Aurora, CO. Address correspondence to Michael Galbraith, RN, PhD, School of Nursing, University of Colorado-Denver C288-18, Education 2 North, Room 4314, 13120 E. 19th Ave, PO Box 6511, Aurora, CO 80045; e-mail: Michael.Galbraith@UCHSC.edu

CONTEXT OF SEXUALITY FOR MEN WITH CANCER

2008 Elsevier Inc. All rights reserved.

0749-2081/08/2402-$30.00/0 doi:10.1016/j.soncn.2008.02.010

t is clear that cancer affects both members of the couple, not just the patient. This impact on partners and the dyadic relationship is reected in a growing body of literature.5,8-14 It has been shown that men and women tend to respond differently to

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the stress of a cancer diagnosis.9,15-17 However, even successful treatment can alter the quality of the couples relationship.18 Some researchers have noted partners of patients with cancer experience more psychological distress than their cancer-affected mate.5,19-22 However, survivors themselves also report frustrations with their relationship and that they nd it difcult to share emotions and concerns with their partner.5,23 Fewer than half of men who experienced some form of sexual dysfunction related to treatment believed their partner supported them in their efforts to nd help.24 It is important to note that for some couples who are cancer survivors, stressful relationships and an unsupportive partner tend to increase distress and thus lead to avoidant coping behaviors.25 However, being part of a strong, positive, safe, committed, and supportive relational dyad buffers against psychological distress for patients with cancer.26,27 There is a need to implement evidence-based strategies that emphasize couple-focused educational approaches that target communication and intimacy. This in turn promotes couples supporting each other during the process of diagnosis, treatment, and into survivorship.25,27-31 This includes intra-couple communication, information about intimacy issues, and education related to managing treatment-related sexual challenges.32

PSYCHOLOGICAL AND PHYSIOLOGICAL IMPACT OF CANCER TREATMENT ON MENS SEXUALITY

he various kinds of treatment and approaches to manage a cancer diagnoses impact men and their sexual health-related quality of life (QOL). It is important to acknowledge that men often receive more than one treatment for their cancer diagnosis and, consequently, may face multiple challenges and treatment-related sequelae The examples discussed below reect the primary concerns regarding sexuality men and their partners may face with a particular treatment approach and how it will impact this complex and multifaceted aspect of their sexuality.33

Surgery A number of cancers men face have a surgical component. Depending on the type of surgery and area of the body affected, multiple issues can arise ranging from erectile dysfunction (ED) to

body image and self-esteem alterations. These complications arise out of impaired vascular supply or enervation to the pelvic and sexual organs that can occur. Additionally, pelvic organs may be removed or altered surgically, which can also affect hormonal balance.34 In particular, surgeries that involve colorectal resection often damage the pelvic nerve that contributes to increased rates of impotence, changes in ejaculation patterns, body image problems, decreased desire, and over all decrease in health-related QOL (HRQOL).35,36 Depending on the size and location of the tumor, autonomic pelvic nerve-sparing procedures have been used with a moderate degree of success,37 with sexual functioning returning to its preoperative level within 1 year for most men. However, Mauer et al38 noted that men with colorectal cancer experienced a reduction in sexual interest, sexual activity, ability to have intercourse, and the ability to achieve orgasm regardless of the type of surgical procedure. It is interesting to note that men who have had various types of surgeries for colorectal cancer report more sexual problems and distress related to sexual functioning than is reported by women who have received similar kinds of treatment for a similar diagnosis.38,39 Radical cystectomy for carcinoma of the bladder often leads to erectile, ejaculatory, and fertility dysfunction for men.40,41 This type of surgery results in urinary diversion, which can substantially impact body image, sexual desire, and feelings of sexual competency, even if erectile function is retained. Although there are differences in HRQOL among the different surgical treatment approaches, urinary control plays an important role in how men perceive how much they are bothered by the treatment and its sequelae.42 The impact of surgery for prostate cancer on mens sexuality has been discussed extensively.43-46 It has been well documented that surgical procedures substantially impact sexual functioning and sexual HRQOL. There have been advances in nerve-sparing techniques, laparoscopic procedures, and robotic-assisted approaches that have lessened the rates of ED and other complications. Yet men are still faced with treatment-related sequelae from these approaches to prostate cancer treatment.47 Penile cancer is a relatively rare but devastating form of cancer specic to men, which is often treated with surgery. However, despite challenges with body image issues and sexual functioning, men reported they continued be interested in maintaining an active sex life.48

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Radiation A number of cancer diagnoses for men have radiation as a component of their treatment. Radiation therapy can negatively impact a mans ability to achieve and sustain erections even though sensation may not be altered. The corporal nerve is not typically damaged by radiation; however, scar tissue can be formed within the pelvic bed vasculature. Consequently, atherosclerosis can be accelerated that impair erectile functioning.34,49 Radiation may also cause side effects such as fatigue, nausea, and diarrhea, which can have a negative effect on libido and sexual functioning.50 Unfortunately, these late effects from radiation can take up to 2 to 5 years to manifest.51 One of the cancers that involves extensive radiation is head and neck cancer. There are often additional treatment modalities used, and together these treatment regimens can have a long-lasting impact on body image and sexuality for men. Monga et al52 explored the impact of radiation treatment on the sexual QOL in patients with head and neck cancer and reported that even though study participants felt they were disgured, most remained interested in sexual expression. However, they also reported higher levels of sexual distress when compared with a normative matched group who did not have cancer.52 Other studies have indicated that even though the general HRQOL for those who have been treated for head and neck cancer deteriorates initially after treatment, it slowly recovers during the rst year following treatment. However, sexual performance and satisfaction did not improve over the same time period.53 Cancers impact on mens sexuality has been addressed the most extensively for men with prostate cancer. While there are a number of different treatments for prostate cancer, similar numbers of men receive either some type of surgery or radiation. Radiation treatment for prostate cancer includes photon external-beam radiation, brachytherapy, transperineal implantation of radioactive iodine-125 seeds, proton-beam radiation, or conformal external beam radiation.54-56 Treatmentrelated sequelae range from ED, loss of desire, dissatisfaction with orgasms, and overall decline in HRQOL.57,58 Men treated with radiation therapy for prostate cancer have reported that even up to 2 years after treatment, sexual dysfunction impacted the overall quality of their lives on many dimensions beyond the specic challenges to their sexual functioning. The men felt that inti-

macy with their partners, everyday interactions with other women, sexual fantasy life, and their own perceptions of masculinity had been negatively affected by the treatment-related sequelae.59 One of the key issues for men who have received radiation therapy is that the effects may not be evident for months to years following treatment.60 However, there is emerging support that brachytherapy may result in lower incidences of overall sexual dysfunction. Chemotherapy Chemotherapy affects mens sexuality in part because gonadal tissue is particularly sensitive to the alkylating agents used in many treatment regimens. The level of gonadal dysfunction is dependent on the type and amount of chemotherapy administered.61,62 In addition, other side effects such as fatigue, nausea, and pallor may impair sexual desire and body image. Chemotherapeutic agents also impact fertility by reducing sperm count or contributing to testicular atrophy.34 High-dose chemotherapy in preparation for hematopoietic stem cell transplant is recognized to negatively inuence sexuality for men.61,62 Problems ranged from difculty achieving and maintaining erections to changes in the intensity and frequency of orgasms.63 Men also faced challenges with sexual function following bone marrow transplantation. The most common problem reported was a lack of interest in sexual activities.64 At the same time, the men also reported more depression and increased concern over their physical appearance. It is important to note that in both studies most men indicated they felt they had not received sufcient information related to how the treatment was going to impact their sexuality. In addition, they indicated they had not been provided with adequate resources to manage the side effects of treatment.63,64 Chemotherapy for testicular cancer also affects sexuality. However, progress is being made toward improving survival, HRQOL, fertility, and sexual functioning. Some men who received chemotherapy for testicular cancer reported that sexual QOL and fertility were not signicant issues for them.65,66 However, for most, challenges still exist. In a study that investigated the long-term impact on sexuality in those receiving cisplatin, etoposide, and bleomycin, it was determined that overall impact on sexual functioning is substantial.67 However, within 1 year, the

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chemotherapy-induced morbidity improved and participants experienced penile rigidity in response to visual erotic stimulation. Alterations in sexual functioning reported by testicular cancer patients may stem from psychological issues rather than physiological impairments because men undergoing this type of treatment can feel particularly vulnerable because of having been diagnosed and treated for a life-threatening and sexuality-threatening disease.68,69 Hormone Therapy Hormone therapy for prostate cancer is intended to reduce or eliminate circulating androgens to reduce prostate cancer cell growth. This is accomplished through chemical or surgical castration. It is used most commonly for later-stage prostate cancers with the hope of slowing the progression of metastatic disease, although it has been used in early stage prostate cancer to reduce plasma testosterone levels before radiation treatment is initiated.70-72 However, because androgens also facilitate sexual desire and performance, the majority of men receiving this treatment report a profound decrease in their sexual QOL.50 Additionally, hormone deprivation for men can produce loss of bone mineral density, changes in body composition, moodiness, depression, and anxious feelings while potentially exacerbating hypertension, diabetes, and coronary artery disease.73,74 Research related to how men respond to the impact of hormone treatment is limited. However, in one report, a group of men who had been treated with androgen-deprivation therapy indicated they felt they were unprepared for the side effects from treatment, which included gynecomastia, hot ashes, ED, and loss of libido, The men also indicated they felt like they were on the fence between feeling like men yet having symptom experiences typically associated with being a women.75 The ndings from this study emphasize the potential complexity of both the physiological and psychological side effects from hormone deprivation therapy. Palliative Care Sexuality is often overlooked in end-of-life care for men with terminal cancer. Although relatively little research exists in this area, there are a number of points for the nurse to consider when dealing with sexuality issues for men who are at the end

of their lives. It has been suggested that sexuality as a core component of life continues into a patients end-of-life trajectory, particularly for those who are interested and able to participate.76,77 Some patients have described the ability to be sexually expressive and intimate with a partner as their basic human need and right even up to the moment of death. Though some care providers, both professional and informal, may nd it challenging to acknowledge the sexual needs of the dying patient, there are a number of considerations to keep in mind when caring for a man at the end of his life, regardless of the type of treatment he has received or the site of the primary cancer.78 Often the patient and his partner are concerned with the lack of privacy in the care environment. In addition, there may be a number of physical symptoms impacting sexual interest and expression that need to be addressed such as fatigue, pain, nausea and vomiting, dyspnea, neuropathies, mobility, and limited range of motion. These physical symptoms are often accompanied by psychological challenges such as body image issues, anxiety, and depression. Consequently, an accepting attitude and open communication are essential between the patient, his partner, and the health care providers, regardless of the type of environment in which the end of life is being experienced. Overall, it is clear the diagnoses of cancer and its subsequent treatment impacts a large number of men. More specically, it is also clear that cancer treatments have a profound impact on mens sexuality. At the same time, it is important to remember this does not happen to just the individual; rather, it happens to him in the context of the relationships he is in currently or will be in the future.

SEXUAL ASSESSMENT

exuality and intimacy questions are frequently omitted by the provider taking the health history of the male cancer patient for various reasons.79-81 These reasons include clinic appointment time schedule, the providers lack of recognition of the importance of sexual function related to the mans HRQOL, and the providers comfort level in discussing sexual and intimacy issues. Some do not bring up the issue of sexuality because the average patient appointment time frequently is too short to address all of the treatment issues and conduct a thorough physical examination. Providers avoid topics they determine are

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not critical to the mans care and may require extra time. In addition, many oncologists are not comfortable with discussing sexual function.80 Providers may also avoid assessing sexuality because they lack knowledge of interventions to help men if problems are identied. In addition, they may feel the men are more concerned with their cancer diagnosis than their sexuality.79 Others have suggested providers may feel they are invading the privacy of the patients in asking personal questions about sexual functions, erections, and relationship issues.81 In addition, there may be concerns about differences in age, ethnicity, socioeconomic factor, and religious orientation between the provider and patient. Many providers, and in particular non-genitourinary oncologists, usually wait for the man or his partner to raise questions related to sexual dysfunction; however, there are advantages to addressing sexual issues.80 These include letting the patient know that sexuality is an important aspect of HRQOL and part of the total health of men and their partners. It would also link sexuality with health and would encourage men to maintain normal relationships, social functioning, and other activities during treatment and recovery from cancer. Various assessment models are identied in the literature that can help to guide sexual assessment. Katz82 identied three models and described their use in conducting a sexual assessment: the PLISSIT, BETTER, and ALARM models. These models are discussed in depth in the article on sexual assessment elsewhere in this issue, and are recognized for assisting the cancer care provider with the initial sexual assessment. However, they do not address specic questions that allow the provider to plan the intervention. DiMeo83 outlined three assessment categories and identied assessment questions. These categories include medical history, sexual psychosocial history, and questions related to the quality and frequency of erections. Other providers suggest that sexual assessment questions be included in the initial health self-assessment completed by the patient.79 The models and various sexual assessment criteria can be used by clinicians to develop skills in taking a sexual assessment. In an ideal clinic situation, the provider introduces the subject of sexual health to the patient as a way of letting the male cancer patient know sexuality is an important part of normal health. It also conveys that the provider is concerned about his sexual health as it relates to his cancer treatment. The oncologist can be encour-

aged to introduce the oncology nurse, who can follow-up with the man and his partner to focus on sexual health issues. Guide for the Sexual Assessment Just about all male cancer patients will experience some form of alteration in sexual function. Depending on the diagnosis and treatment, men may experience severe sexual problems. Cancer diagnoses known to cause severe sexual problems among men are head and neck, hematologic, lung, colorectal, and genitourinary cancers. In addition, men receiving palliative care also report substantial issues with sexual expression. There is some argument that the initial assessment appointment should come at the beginning of treatment before sexual side effects have occurred. If this approach is followed, there is the possibility that at this stage of cancer diagnosis, men and their partners are more concerned with their mortality. Consequently, sexual issues may not be as important as they are later in the treatment or recovery trajectory. However, among prostate cancer patients where type of treatment has a direct effect on sexual function, an appointment with the oncology nurse to discuss potential sexual side effects and possible treatments during the treatment decision phase may help men make their treatment decisions. If possible, the patient should be encouraged to include his partner in the appointment because sexuality involves both him and his partner. It is recognized that at least an hour should be allowed for the assessment and introduction of sexual interventions. The man should complete a health history including medications, psychosocial relationships, emotional impact of cancer diagnosis, other health problems, prior surgical procedures, and sexual function history before the appointment. This format is generally less threatening to men and allows them to answer the questions at home where they have more time and fewer interruptions. The oncology nurse can then focus on the answers given to specic questions and easily obtain clarication of the extent of the mans concerns about sexual side effects. Because the man is a known cancer patient, and the oncology nurse has an understanding of the various problems that occur with particular types of cancer, the assessment can be more focused. A shorter amount of time can be spent on past medication and medical history, which allows for more time to be spent on

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problems specically related to a particular type of cancer diagnosis. Specic topics to discuss with a male cancer patient with a particular type of cancer are outlined in Table 1. Begin the assessment by afrming for the couple that sexuality is a critical part of HRQOL and treatment options are available. They need to be reassured the oncology nurse can help them nd interventions that will assist toward solving their sexual challenges. This information generally puts the couple at ease with the subject of sexuality, and they begin to share their experiences and knowledge with sex and will ask additional questions. The focus for the oncology nurse is to put the patient at ease with the topic of sexuality. Terms used are extremely important. Avoid terms that the patient or his partner could misinterpret. Avoid the term impotency as it indicates inadequacy and can impact the mans self esteem. It is important to maintain eye contact with both the patient and his partner and to encourage both members of the couples to participate in the as-

sessment. Let the couple know that sexual dysfunction is a normal part of cancer and cancer treatments and what they are feeling and experiencing is shared by other male cancer patients. Most male cancer patients have a decrease in libido either because of fatigue or result of medication. Knowing their experience is not abnormal and shared by others can put the couples mind at ease and they will be able to relax.79 After the initial introduction and explanation of the procedures to be followed during the assessment, the oncology nurse can clarify what medications the patient is taking and other risk factors might be present. Special attention can be given to the mans specic type of cancer and areas of concern. Limit the health assessment to approximately 10 to 14 minutes so more time can be spent on determining how the cancer diagnoses and treatment has impacted the couples sexuality. Time management is important to allow enough time for taking the assessment and introduction of the interventions and answering questions.79

TABLE 1.
Sexual History Topic Guide82 Assessment Criteria Prescription and non-prescription drugs Questions Antihypertensives Nitrates Pain medication Antidepressants, anxiolytics, and tranquilizers Chemotherapy agents Anti-androgenics Recreational drugs Herbals and vitamins Diabetes Heart history, cardiovascular problems Neurological illness (Parkinson, Multiple Sclerosis) Prior trauma (spinal cord injury, penile injury) Genitourinary cancer surgery, laminectomy, cardiac surgery Problems with depression; anxiety; sleep disturbance; worry about nances, role responsibility, disgurement Feelings of inadequacy, low self-esteem, fear of rejection Number and age of children Relationship with partner Before cancer quality of erections Changes in partner relationship after the diagnosis of cancer Sexual desire Nocturnal erections Ability to have and maintain an erection for self-pleasure and/or partner penetration Ability to experience orgasm with or without erection Ejaculation Xerostomia, difculty breathing, presence of tracheostomy, or gastric tube, colostomy, pain, fatigue, rash and dry skin, use of protected sex if in treatment, risk of low blood counts

Past medical history

Past surgery history Psychosocial history

Sexual history

Other questions

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Special attention should be given to the specic problems male cancer patients with the following cancer diagnoses may be experiencing. For example, men with head and neck cancers may have experienced ED because of disguring surgery that may have led to withdrawal, social isolation, and loss of self-esteem. Some head and neck patients require a tracheotomy and suffer from xerostomia and difculty breathing. Head and neck patients may also experience sexual arousal problems because of loss of voice or the ability to use their mouth or tongue.84 Men with lung cancer are living longer with new targeted therapies and/or chemotherapy in combination with surgery and/or radiation therapy. These patients in particular experience deconditioning symptoms such as a reduction in performance status, shortness of breath, peripheral neuritis, and fatigue.85 Men hospitalized for hematologic cancers reported signicant sexual problems with desire, excitation, and orgasm. In addition, this patient population reports changes in sexual self-image and fear of sexual relations with their partner because they fear infection.86 The incidence of sexual dysfunction among colorectal male cancer patients may be high depending on the type of surgery they received. Among men who require an abdominoperineal resection, ED is related to neurovascular bundle trauma.84 Patients who require a colostomy have specic concerns regarding odor, loss of dignity, privacy, and loss of independence. Any one or all of these responses to treatment can impact the patients sexual function.87 Men in palliative care have additional issues with pain, anorexia, chronic nausea, asthenia, and shortness of breath.89 Men requiring treatment for genitourinary cancers experience some degree of sexual dysfunction depending on the type and site of cancer. Testicular cancer patients tend to be younger and can have concerns with fertility. The clinician should determine the patients desire to bank sperm before beginning treatment. Additional assessment questions should focus on sexual desire, arousal, and ejaculation.88 Men treated for bladder cancer with cystoprostatectomy can also have disruption of their neurovascular bundles. In addition, they can have issues related to urinary diversion that may require self catheterization or ileal conduit care. These men should be asked questions concerning problems with urinary leakage and use of appliances for incontinence.84 Assessment questions for the patient with penile cancer, particularly after he has had a partial penectomy,

include inquiries about issues such as penile shorting and ability to achieve penetration. Sexual desire and orgasm are typically maintained by patients with penile cancer, regardless of the presence or absence of their penis. However, the incidence of social isolation is high among penile cancer patients because of body image changes.89 Likewise, they are more likely than other male groups of cancer patients to avoid sexual activities. In those with prostate cancer, the incidence of ED varies depending on the type of treatment. In addition, the sexual function among prostate patients should be assessed before, during, and after prostate cancer treatment. It is important for the oncology nurse to focus on all aspects of the sexual assessment outlined in Table 1, and not just ask questions related specically to ED. In addition, early sexual rehabilitation is important to consider for all prostate cancer patients. During the assessment process, the oncology nurse can observe non-verbal communication that the patient and partner may be exhibiting. Additionally, it is important to note what questions are being asked and what is not being discussed. If, at any point during the assessment the nurse determines that the couple has experienced substantial sexual problems before the diagnosis of cancer, it is important to acknowledge these concerns and ask questions related to these issues. If either the male cancer patient or his partner becomes defensive or accusatory of each other, the nurse should stop the assessment and suggest the couple may need more in-depth sexual counseling. It is also important to let the couple know the nurse will continue to be available to help them with sexual interventions and information at a later date. Additionally, other problems such as loss of self-esteem, anxiety, and withdrawal from family and friends may arise that the nurse can help the couple work through. These problems can generally be discussed with the couple and, with time, support, and help in communication about their mutual sexual desires, their problems can be resolved.

PSYCHO-SOCIAL SEXUAL INTERVENTIONS

nterventions for sexual dysfunction evolve out of the sexual assessment. During the assessment the oncology nurse can determine the couples lifestyle preferences, the nature of their before-cancer sexual relationship, frequency of sexual activity, and relational satisfaction of both

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partners. The sexual intervention model adapted here is a psychosocial education model to assist couples with education in coping, communication, alternate or adapted techniques for sexual expression, management of decreased physical performance abilities, and ED treatment options. Coping As outlined in the assessment criteria, the man experiencing sexual dysfunction may have altered self-esteem, body image changes, disgurement, feel he has lost part of his manhood, and experience anxiety or depression. Cognitive-behavioral techniques may be used to help the man focus on positive aspects of his circumstances. For example, he can focus on the information that others have had success with their treatment for sexual dysfunction, and that he has the support of family and friends, and that he can use self-care strategies to make changes in is life.30 Support group participation with other men experiencing similar problems can also be helpful. Often anxiety and depression can occur among male cancer patients because they have received incorrect information or have irrational fears. Men may misinterpret information given to them by their provider. Sometimes they read literature that has misinformation or are not given accurate facts by wellmeaning friends. Men should be encouraged to discuss their fears of loss, rejection, anxiety, and depression with their oncology nurse and supportive family members.90 While depression and anxiety are common symptoms cancer patients experience, the causes of depression and anxiety are varied and potentially can affect sexual QOL for men. A discussion of these symptoms may bring emotional relief to the male patient; however, medications may still be required to assist the patient if symptoms are not relieved. Communication Poor communication skills of either the male patient or his partner often lead to misunderstanding between the couple. Men experiencing sexual dysfunction may withdraw from sensual contact such as touching, hugging, or kissing for fear of stimulating sexual desire in their partners. He may feel inadequate or unable to participate in any sexual activity. Helping men communicate about sexual needs such as sensual touching, sexual positions, and foreplay activities can improve sexual satisfac-

tion for both members of the dyad and subsequently improve the couples relationships. Communication activities can be accomplished by the couple participating in role playing, followed by debrieng, during a regularly scheduled ofce appointment. The man and his partner can express concerns they might have when trying to talk about sexual problems. The oncology nurse can help both of them achieve a better understanding of their communication problems and potential solutions. This can be accomplished by giving them homework assignments on communication. They can also identify situations when they have difculty discussing certain sexual and intimacy topics. The assignment can also serve as a foundation for discussion with the nurse at the next appointment. Alterations in Sexual Expression or Sexual Techniques The third aspect of the psychosocial education model involves the need to alter some sexual expressions or techniques. These interventions may be needed for head and neck, lung, and colorectal cancer patients. Men with head and neck cancer and lung cancer may experience difculty breathing during intercourse. Techniques suggested to improve breathing problems include instruction in pursed-lip diaphragmatic breathing. Gradually increasing aerobic exercise to regain strength is reported to help male cancer patients.85 Breathing may be assisted by using sitting or standing position during intercourse. If the man has scaring or disgurement because of radical surgery, he may use clothing to cover his scars to enhance his feelings of sexual comfort and condence. In addition, he may choose the spoon position where he lies behind his partner, which may put the patient more at ease with his altered body image. Men with ostomies can change their bags before intercourse, use body lotion to decrease any odor, and wear clothing that make him feel sexually enhanced and condent.84 Management of Decreased Physical Performance Altered physical performance issues are particularly relevant for the men receiving palliative care. The need for closeness and to experience the expression of caring and loving through touching can take precedence over the sexual act of intercourse during this stage of illness.91 The

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TABLE 2.
Erectile Dysfunction Treatments82, 92 Treatment PDE-5 Inhibitors Advantages Easy to use High patient satisfaction One time expense Easy to use May be used more than once per day More natural Produces a uniform erection Disadvantages Requires intact neural pathway Contraindicated among patients on nitrates Expensive and may not be covered by insurance Requires skill Pain from the constriction band Less natural Difculty in adjusting the dose Expense Penile burning Priapism Development of injection site plaque Expense Lack of efcacy Local side effects Expense Risk of infection Ination problems Reduced sensation

Vacuum device

Penile injection therapy

Intraurethral alprostadil (Muse)

Easy to use More natural High efcacy Most natural High satisfaction rate Easy to use

Penile prostheses

oncology nurse can help men and their partners understand the changes occurring in this phase of their illness. The partner of the man with endstage cancer can express caring while assisting him with bathing, dressing, or other special cares such as wound care. The male patient may desire, enjoy, and continue to be capable of some form of intercourse; however, the frequency may be decreased because of fatigue and other symptoms. Men often continue to desire emotional connectedness and physical closeness through stroking, hugging, kissing, and meaningful eye contact with their partner.91 The oncology nurses role for the male receiving palliative care is primarily one of coaching the partner in caring for the man with cancer and helping both of them understand the importance of intimacy and wellbeing for the patient. Medical Sexual Interventions Interventions for the male who has erectile dysfunction (ED) associated with sexual dysfunction are outlined by several authors and include penile vacuum devices, penile prostheses, phosphodiesterase (PDE-5) inhibitors such as Viagra (Pzer, Inc, New York, NY), Levitra (Bayer Pharmaceuticals/GlaxoSmithKline; Pittsburg, PA), or Cialis (Eli Lilly and Co, Indianapolis, IN); intraurethral alprostadil; penile injections either with prostaglandin E1 or a bi- or tri-mix of prostaglandin E

1, phentolamine, and paperverine.58,93 The advantages and disadvantages of each of these treatment options are outlined in Table 2. The treatments range from noninvasive and least expensive to most invasive and most expensive. However, most men prefer medications and request one of the PDE-5 inhibitors.58 Men who have had extensive pelvic surgery and lack an intact neural pathway will respond poorly to PDE-5 inhibitors. In addition, PDE-5 inhibitors are contraindicated in men who take nitrates or have cardiac co-morbidities. Men who do not have intact neural pathways will respond better to vacuum device therapy or penile injections. Both of these treatments require patient education before they are prescribed. The vacuum device comes as a two-handed device or a one-handed device with or without battery operation. Men who have dexterity problems or arthritis will nd the battery-operated vacuum devices easier to manage. The vacuum device comes in a case with the vacuum chamber, lubricant jelly, pump mechanism, and several sizes of elastic rings or constriction bands. Prior to use, the constriction band is placed on the outside of the vacuum chamber at the end of the cylinder that goes over the penis. Lubricant is placed around the inside portion of the vacuum chamber that ts over the penis to help create a seal. The pump mechanism is placed at the opposite end of the vacuum chamber. A vacuum is created in the cylinder,

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which draws blood into the penis thereby resulting in an erection for the patient. Once the penis has become fully erect, the constriction band is slipped onto the base of the penis and the vacuum is released and the chamber is removed. Men are then ready for intercourse. Couples can successfully incorporate the vacuum pump into their foreplay activity. The constriction band can stay on up to 30 minutes before it should be removed. Education is needed to help the man and his partner to learn how to apply a sufcient amount of lubricant to the inside of the vacuum chamber opening and to adjust the chamber to the body to create a tight seal and vacuum.92 Many men begin ED treatment with the vacuum device and after several months decide they would like to try penile injection therapy. Men may fear giving themselves an injection in such a sensitive area. However, after the initial injection is given, most men nd the pain from the procedure is minimal and they prefer the erection they experience from the injection once the correct dose is established. A lower dose of the prostaglandin E1 than will ultimately be prescribed is injected initially in the clinic setting. This dose is generally 2.5 to 5 mg of prostaglandin E1. The injection is given at the 2 or 10 oclock position in the base of the penis. Pressure should be held on the site for 5 minutes after the injection has been given to prevent bleeding and to reduce the potential of scaring. The patient will experience an erection in approximately 15 to 20 minutes after the injection. The patients dose will be determined after the assessment of the quality of his erection and length of time the erection is maintained. Men must be informed they will not experience detumescence after intercourse and orgasm and they should be given instructions to seek medical emergency care if the erection lasts 4 hours or longer.91 Adjustment of the patients dose may be challenging. If the patient has trouble maintaining erection, experiences pain, or the cost is prohibitive, he should be switched to a bi-mix or trimix.94 Another way that prostaglandin E1 therapy can be delivered is with an intraurethral pellet (Muse; Vivus Inc., Menlo Park, CA). The pellet is placed in the urethra with a small applicator; it is not used often because of minimal efcacy and the potential for unpleasant side effects from the route of administration. The last and most invasive treatment for ED is the surgical placement of a penile prosthesis. Penile prostheses come in the form of two semi-rigid

rods implanted into the corpus cavernosum of the penis. Another option for a penile prosthesis is the surgical placement of two- or three-part inatable silicon tubes that are combined with a pump and reservoir. When an erection is desired, the pump moves the uid from the reservoir into the tubes, which cause the penis to become rm enough for penetration. When there is no need for an erection, a small valve is pressed by the patient and the uid drains out of the tubes embedded in the penis and back into the reservoir. The reservoir and valve are most commonly placed in the testicular sac. Although patients report the greatest satisfaction with the use of the penile prosthesis, it is one of the most expensive and least frequently used treatment approaches for ED.94 The oncology nurse plays an important role in educating patients about the advantages and disadvantages of all the treatments for ED. Men should be made aware of all of their treatment options and be informed they may want to try several of the treatments before making any nal decisions. The oncology nurse can schedule additional follow-up appointments as needed to help the couple understand their different treatment options. An aspect of patient care frequently omitted with ED treatment is telephone follow-up with the patient after the initial patient education. Telephone contact is extremely important and decreases the patients lack of adherence to ED treatment. Oncology nurses can also help patients with problems they are experiencing with their sexually oriented equipment or dosing of medication. Men may need additional appointment times for clarication of techniques or dosing after they have experimented with equipment or injections in their own home environment. The psychosocial education model helps oncology nurses implement patient education for improvement in patient coping, communication, alterations in sexual expression or techniques, altered physical performance, and ED treatments.

CONCLUSION

ancer impacts mens HRQOL in a number of ways. However, the focus of the preceding discussion has been on how cancer specically affects sexuality for men who have been diagnosed and treated with various types of cancers. Some of the sequelae are more obvious, while other treatment-related side effects are less intuitive. It

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is important to note that the impact of cancer on mens sexual functioning and satisfaction does not happen in a vacuum. Rather, the context for this experience for men is often within their intimate relationships; both current and future. Men receive a variety of treatments for cancer that can impact their sexuality and often they may receive multiple kinds of treatments. Surgical interventions are a treatment of choice for a number of types of cancer such as bladder and colorectal cancer. The surgical procedure itself may interrupt nerve pathways or disturb vascular circulation that in turn directly disrupts sexual functioning. In addition, surgical procedures often leave men with body image issues related to the incision itself or to other body alterations resulting from the treatment. Men who have had radiation treatment often do not experience the direct effects to their sexual functioning, yet, months or years after treatment has been completed, sexual challenges can appear. In addition, men who are being treated with radiation often have other issues that have the potential for impacting sexuality such as fatigue, nausea, and vomiting. Chemotherapy has the potential of affecting sexual functioning for men because of its systemic effect on the body. Studies have shown that men experience changes in sexual functioning when undergoing treatment, yet, they do not feel they have been adequately prepared to anticipate these changes. Research suggests it is important to consider the psychological impact of treatment in addition to the physiological responses of men at risk for challenges to their sexual functioning. Hormonal deprivation therapy is a treatment men may receive for various phases of prostate cancer. While there are promising outcomes for moderating cancer cell growth, there is also a substantial impact on mens sexual function-

ing and self concept. Often men feel that their masculinity is impacted by side effects of hormone therapy. Sexuality at the end of life is not well understood. It is clear that mens sexuality is compromised, yet there are reports that intimacy issues remain relevant for some men as they approach their death. There are many physical concerns that need to be addressed with men and their partners at this stage of the disease. It is imperative that communication be clear and open between the men, their partners, and the health care team. Because cancer and its treatment can have such a profound effect on mens sexuality during all courses of the disease, assessment of issues that are of specic concern to men is critical. However, many clinicians may be uncomfortable talking about sexual issues or may feel they are invading the patients privacy. Yet it is important for health care providers to manage their own discomfort and assess what is important to the patient. Even though the patient has needs related to his sexuality and he may want to express them, he may be hesitating because of a sense that questions and comments related to his sexual needs may not be welcomed. It is important to include the partner if possible when asking direct questions intended to help the patient express his preferences. The oncology nurse can focus on helping the couple improve their coping techniques, patterns of communication, sexual expression, specic techniques, management of decreased performance status, and treatments for ED. Although it is recognized that male sexuality in the cancer arena has been overlooked in the past, oncology nurses have the opportunity to change this trend in the clinical setting and improve sexual heath care delivery for men.

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