Dude, Where’s My Erection? (Part II)

Dude, Where’s My Erection? (Part II): Pharmacologic Options for Managing Erection Challenges After Cancer

Warning: Mature Content

Disclaimer: This information is not a substitute for medical care. Always inform your healthcare team of any concerning symptoms you are experiencing, and consult with your healthcare provider before starting new treatments, therapies, or health routines.

Welcome to Part II of a three-part conversation exploring the cancer and erection connection (turns out, there was so much good stuff to share that I had to extend the series!). As we dug into the nitty gritty of what erections actually are and how they work back in Part I, it became clear that there are several steps in the process that are vulnerable to the impacts of cancer and its treatments. Next on the agenda is what to do about it!

Options can be categorized into medical, mechanical, and mindful management strategies. Here in Part II, we will be diving into some of the pharmacologic approaches that cancer survivors have found helpful. In the next (and final) part of the series, we will focus on various non-pharmacological ways to support erections, including a discussion of some mechanical aids and mindful strategies available to help maximize your sexual experiences.

Quick note: My soapbox spiel about the terminology around penises and erections from Part I also pertains to Parts II and III, but I’ll spare you my speech as long as you promise that you’ve taken the message to heart—capiche?

Alright, we will move on then to the land of erectile possibilities!

Erection-Enhancing Medications

There are a few options for prescription erectile medications that can treat erection problems.

Prescription medications come in either an oral pill that acts systemically to affect erection response, or in the form that gets administered locally to the penis and has a direct effect on the tissue involved in erections. Some of these may be used in an erectile rehabilitation routine (which we will chat more about in Part III).

Oral Medications

Phosphodiesterase-5 (PDE5) inhibitors are a class of medicines that can improve erections for some people experiencing difficulties, and are often recommended for cancer survivors (2,9), including the AYA population (8, 10).

If you thought the physiology lesson ended in Part I, nope! In order to understand how these medications work, I think it’s helpful to know some specifics about the chemicals involved in the erection process. One important player is nitric oxide. This chemical relaxes the tissues of the corpora cavernosa and promotes the action of another erection-promoting chemical, cyclic guanosine monophosphate (cGMP), to help dilate the blood vessels of the penis and increase the blood flow (4). In the normal erection process, cGMP is eventually broken down by the enzyme phosphodiesterase-5 (PDE5). However, if the action of the PDE5 enzyme is inhibited (like with these medicines), then cGMP is allowed to stay active longer and continue to exert its vasodilating effects on the erectile blood vessels and tissues.

The most famous PDE5 inhibitor is sildenafil (brand name Viagra), but there are several other medicines available as well (vardenafil, avanafil, and others). All are considered basically equal when it comes to effectiveness and safety, as well as side effect tolerability (3,7). They differ in how quickly they take effect (onset) and how long their effect lasts (duration), as well as cost (7). Most are dosed on-demand, meaning that you take a dose a certain amount of time before sexual activity. This typically requires planning for sexual encounters and making sure the medicine has had enough time to take effect. However, tadalafil is a PDE5 inhibitor that can be taken daily, allowing more sexual spontaneity.

A few things about PDE5 inhibitors. First, they do not cause spontaneous erections. I repeat, simply taking a pill will not cause an erection. Instead, the medication impacts the complex physiologic chemistry that occurs in response to sexual stimulation. So, it’s not like you take a pill and then 30 minutes later you automatically have an erection. It’s more like, you take a pill and then 30 minutes later the potential to achieve and keep an erection is increased, should you happen to find yourself in a sexy situation.

Also, these are systemic medications. This means that their vasodilating effects can occur in other parts of the body as well. This vasodilation is what causes side effects like flushing, headache, nasal congestion, heartburn, and upset stomach (7). Vasodilation can also lead to lower blood pressures and dizziness. As with any medication, it is important to understand when PDE5 inhibitors might be contraindicated, what potential interactions there might be with other medicines you are taking, and what symptoms would require immediate attention if you do take one of these drugs (7). Your provider or pharmacist can help you answer any questions you have and help you determine if this is a good option for you.

Locally Applied Medications

Alprostadil is another prescription medication that can help with erections (2,7). Unlike PDE5 inhibitors, it is administered directly to the penile tissue and absorbed locally to take effect. This can be accomplished with intracavernosal injections or as an intraurethral suppository. These are often good options for people who cannot take PDE5 inhibitors or if a trial of PDE5 inhibitors did not work (2,3,10). Similar to PDE5 inhibitors, these medications promote erections through the mechanisms of vasodilation, allowing increased blood flow into the erectile tissues of the penis (7). Because they act directly on the erectile tissue and do not rely on intact nerves to have an effect, they may work more reliably than pills and work better for individuals who have nerve damage related to surgery (1).

Intracavernosal injections require learning how to use a very small needle to inject the medicine into the side of the penis. Side effects can include discomfort and development of scar tissue at the injection sites over time with repeated injections. There is also a possibility of priapism, which is an erection that lasts longer than four hours and is considered a medical emergency due to the risk of damage that can occur to the penile tissue (7). Alternatively, the use of an intraurethral suppository requires using an applicator to place a small medicine pellet inside the urethra (where urine and semen leave the body), and massaging the penis for about a minute to distribute the medication into the tissues.

Unlike PDE5 inhibitors, the use of alprostadil locally to penile tissues can cause an erection directly, without any sexual stimulation (7). Like PDE5 inhibitors, these options may be contraindicated for some people, and it is important to understand their potential side effects and any symptoms that would require immediate attention. Again, your provider or pharmacist can assist you in determining whether these may be good options for you.

Testosterone Replacement

The hormone testosterone plays a role in sexual functioning, including desire and arousal, and it helps promote erections by maintaining levels of nitric oxide in the blood stream (4). Because certain cancer treatments can impact the production of testosterone, survivors who are having erection problems should have their testosterone blood levels measured to determine if levels are below normal (10). This is called hypogonadism. Other blood tests may be ordered as well to help determine possible causes or contributing factors to low testosterone and erection problems.

In general, testosterone replacement may improve sexual symptoms for people with testosterone levels below the expected threshold for their age (7,9). And in men with low levels, adding testosterone to the use of a PDE5 inhibitor can improve erection function (7,9). Any treatment plans that include testosterone replacement should be individualized (3). If testosterone replacement is an option you are considering, you should have a thorough discussion with a specialist so that you are able to make an informed choice that’s best for you. Testosterone replacement has the potential to impact fertility (8,10), and this is an important consideration to keep in mind.

Of note, testosterone supplementation for individuals whose levels are already within the normal range is not recommended and does not improve sexual function (6)!

Managing Erection Challenges After Cancer: to be Continued. . .

Pharmacological options sometimes do a really good job of helping people get and keep erections. Unfortunately, they may not work for everyone, and they may not work every time you try them. Or maybe you can’t take these medicines, or you prefer not to. What then?

In Part III, we will talk about some of the non-pharmacological (i.e., non-medicine) based techniques to support erection function in cancer survivors. Between all the possible ways that erection problems can be addressed (medicines, mechanicals, mindfulness, oh my!), it will likely take patience and perseverance to find an option, or some combination of options that feels comfortable and has satisfactory outcomes for you. Remember what I said in Part I about the fact that erections aren’t everything? In Part III, we are going to circle back and put it all together. Stick around!

* * *

JUST SAY NO: Beware of Unproven Remedies

Our society is obsessed with erections, have you noticed? According to advertisers, if you have a penis and it’s not erect, there’s a must-have, all-natural remedy for that! Just send a chunk of change to any of the Get-Hard-Fast companies and in return you’ll receive a discreet package on your doorstep that didn’t require a doctor’s visit or a prescription and is sure to enhance your performance. Whatever that means.

Never mind that these untested remedies are not regulated by the U.S. Food and Drug Administration in the same way that medications are (1,5). Augh, and don’t be fooled by claims about all-natural products. When they say all-natural, what they really want you to hear instead is Healthy! and Safe! But you and I understand “natural” is not synonymous with either being healthy or safe. I mean, cancer is a completely natural result of mutations that occur with cellular replication, yet it doesn’t really have a great safety profile and you won’t see anyone around here standing in line, hoping to score a dose of cancer for its all-natural health benefits. *Insert eyeroll.*

The fact is, manufacturers of these unregulated dietary supplements can pretty much make any claims they want about a product’s effectiveness, without being required to provide proof that their product is safe or that it even actually works. They don’t even have to prove that what they are selling contains the correct dosing or the correct active ingredients it purports to. I’m not kidding! Plus, these products may include unlisted contaminants or ingredients, putting you at risk for ingesting something unsafe for you or something that could interact with other medications you are taking (5).

And while we’re on the topic of unproven remedies for erection function, I’m just going to continue my PSA by identifying some other treatments that may be advertised to cure erectile dysfunction. These often fall under the umbrella of “regenerative and restorative therapies,” and include stem cell therapy with adipose-derived stem cells (ADSCs), low-intensity shock therapy (LIST), platelet-rich plasma treatments (PRP), and hyperbaric oxygen therapy. Due to a lack of data regarding their safety and efficacy for the purpose of improving erections, these are all currently considered experimental (1,7,9). This means that they should be studied in the context of clinical trials, so we can learn more about them to determine if they have a place in treating erection problems.

So, what I’m saying is, do your research and please, please, please, talk with your provider before starting any over-the-counter dietary supplements or signing up for any cure-all treatments promising things that feel a little too good to be true. It’s important to be skeptical of the hype! I would argue to start where the science is, and enlist your healthcare provider’s input.

REFERENCES AND BIBLIOGRAPHY:

1. American Cancer Society. “Managing Male Sexual Problems Related to Cancer,” (2020). https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fertility-and-sexual-side-effects/sexuality-for-men-with-cancer/sex-problems.html. [Accessed November 26, 2022.]
2. Carter, J., et al. “Interventions to Address Sexual Problems in People with Cancer: American Cancer Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline,” Journal of Clinical Oncology, 36(5), 492–511 (2018). https://doi.org/10.1200/JCO.2017.75.8995. [Accessed March 10, 2023.]
3. Dizon, D. S., & Katz, A. “Overview of Sexual Dysfunction in Male Cancer Survivors,” UpToDate (2022). https://www.uptodate.com/contents/overview-of-sexual-dysfunction-in-male-cancer-survivors. [Accessed November 26, 2022.]
4. Dlugasch, L., & Story, L. Applied Pathophysiology for the Advanced Practice Nurse. Jones & Bartlett Learning, 1st edition (December 11, 2019).
5. Food and Drug Administration. “‘All Natural’ Alternatives for Erectile Dysfunction: A Risky Proposition, (2015). https://www.fda.gov/consumers/consumer-updates/all-natural-alternatives-erectile-dysfunction-risky-proposition. [Accessed February 23, 2023.]
6. Khera, M. “Patient Education: Sexual Problems in Men (Beyond the Basics),” UpToDate (2022). https://www.uptodate.com/contents/sexual-problems-in-men-beyond-the-basics. [Accessed March 6, 2023.]
7. Khera, M. “Treatment of Male Sexual Dysfunction,” UpToDate (2022). https://www.uptodate.com/contents/treatment-of-male-sexual-dysfunction. [Accessed November 26, 2022.]
8. Mitchell, L., Lewin, J., Dirks, J., Wang, K., Tam, S., Katz, A., McCann, B., Lo, K., Laurence, V., Rousset-Jablonski, C., & Gupta, A. “Sexual Health Issues for the Young Adult with Cancer: An International Symposium Held during the First Global Adolescents and Young Adults Cancer Congress” (Edinburgh, United Kingdom), Journal of Adolescent and Young Adult Oncology, 7(2), 153–163 (2018). https://doi.org/10.1089/jayao.2017.0067. [Accessed March 10, 2023.]
9. National Comprehensive Cancer Network. NCCN Guidelines: Survivorship (2018). [Version 1.2022]. https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. [Accessed on December 16, 2022.]
10. Sukhu, T., Ross, S., & Coward, R. M. “Urological Survivorship Issues Among Adolescent Boys and Young Men Who are Cancer Survivors,” Sexual Medicine Reviews, 6(3), 396–409 (2018). https://doi.org/10.1016/j.sxmr.2017.12.007. [Accessed March 10, 2023.]