Sex and the prostate Lorraine Grover Psychosexual nurse specialist The London Clinic and The Prostate Centre, London. BMI Shelburne Hospital, Bucks. National Institute for Health and Clinical Excellence (NICE) Prostate Cancer. February 2008. Treatment and care should take into account men s individual needs and preferences. Healthcare professionals should ensure men and their partners have early and ongoing access to specialist psychosexual and erectile dysfunction services www.nice.org.uk Before starting treatment Treatment may result in: - altered physical appearance - altered sexual experience - possible loss of sexual function, ejaculation and fertility NICE Guidelines February 2008. WHO declaration - sexual health There exist fundamental rights for the individual, including the right to sexual health and a capacity to enjoy and control sexual and reproductive behavior in accordance with a social personal ethic freedom from fear, shame, guilt, false beliefs and other factors inhibiting sexual response and impairing sexual relationships freedom from organic disorders, disease and deficiencies that interfere with sexual and reproductive function Jardin A, Wagner G, Khoury S, et al, editors. 1st International Consultation on Erectile Dysfunction, 1 3 July 1999, Paris, France. p 1. 1
Why talk about sex? Psychological well being as well as physical well being gives an holistic approach Self esteem Good sex usually takes place within the context of a good relationship B. Zilbergeld, 1999. Environment Set the scene Posters Sexual Advice Association Leaflets - Macmillan, Sex and diabetes, Sex and the heart Books Referral details Relate, COSRT. Promote sexual health Components of a normal erection ED and lifestyle factors Alcohol 1,2 Drugs/substance use 2 Smoking 1 3 Obesity 4 1. Feldman HA, Goldstein I, Hatzichristou DG, et al. J Urol. 1994;151:54 61. 2. Benet AE, Melman A. Urol Clin North Am. 1995;22:699 709. 3. Mannino DM, Klevens RM, Flanders WD. Am J Epidemiol. 1994;140:1003 1008. 4. Blanker MH, Bohnen AM, Groeneveld FPMJ, et al. J Am Geriatr Soc. 2001;49:436 442. 2
How does ED affect lives Self Esteem Impact even if not in a relationship Relationship change 1:10 people keep any sexual contact. (Riley and Riley. Int Journal Clinical Practice 2000) Intimacy Encourage partner to consultation When clinicians describe treatment for prostate cancer the patient may be given a list of negative side effects rather than positive outcome Listen to the patient and treat his or her experience and not just the diagnosis Ignorance about what to do is a major barrier to communication Penile rehabilitation Testosterone deficiency Lack of desire and erectile function Lack of strength and vigour Decrease muscle mass and bone density Changes Relationship +/- Senses Intimacy Body image Communication Isolation Anger, bereavement 3
Hope is extended that every erectile problem can be simply treated with the right medication. This promotes a kind of magical thinking that precludes any awareness of the development and maintenance of erectile problems. It removes the man s emotions and his intimate relationship from his sexual response Weeks and Gambescia 2000. Current management options Lifestyle change Psychosexual therapy Oral pharmacological therapy Intraurethral / Intracavernosal therapy Vacuum device Implant surgery Combination therapy 4
Schedule 2 Diabetes Multiple Sclerosis Spinal Cord Injury Prostate Cancer Men who have had their prostate removed Severe pelvic injury Radical pelvic surgery SLS selected list scheme Poliomyelitis Men treated for kidney failure(transplant and dialysis) Single gene neurological disease Spina bifida Parkinson s disease Extreme distress Phosphodiesterase type V inhibitors (PDE5) Sildenafil citrate (Viagra), 25 mg, 50 mg and 100 mg Tadalafil (Cialis) 10 mg and 20 mg, 5mg and 2.5mg Vardenafil (Levitra) 5 mg 10 mg and 20 mg. Orodispersible tablets 10mg Sexual stimulation No use of nitrates Natural erection, spontaneity Patient choice Viagra Sexual stimulation No nitrate use Cialis Sexual Stimulation No nitrate use Levitra Sexual Stimulation No nitrate use 4 h window 24-36 h window 4-6 h window Intraurethral therapy (MUSE) Side effect profile: visual disturbance Food interaction Side effect profile: back pain, myalgia No food interaction Side effect profile: no visual disturbance No food interaction 5
Intracavernosal therapy Vacuum devices Alprostadil (Caverject incl. dual chamber) Implantable prostheses What is psychosexual therapy? Helps to address assumptions about the sexual arousal response Education health issues partner s response Creates a language and focuses on clear, helpful communication patterns Cognitive restructuring Provides and sets goals for patients using behavioural tasks sensate focus, etc. Focused and short term 6
Techniques New chapter! Dispel myths and misconceptions expectations normal sexual response cycle Self Focus Sensate focus Intimacy: non genital, genital, intercourse ban Communication: talk, touch. Tasks in privacy of home Self focus Know body better to share Communication Relaxation Kegal exercises Masturbation and intercourse ban Sensate focus Exercises to acquire and increase sensual and sexual awareness of own and partner s body Non sexual Sexual Start of specific treatment if necessary Mutual agreement to finish 7
Thinking out of the box Sexual aids vibrators strap ons Masturbation lubrication Vacuum constriction device Vaginal dilators/fingers/vibrators Vaginal lubrication Clothing, scarves, textures, ostomy bag covers Lubricants Outcome Change balance of relationship inform patient/partner of this exacerbate difficulties Improve communication fears, dislikes, enjoyment managing expectations Achieve satisfactory sexual activity Refer if necessary to appropriate clinician 8
One minute left.. Hand on the door Oh doctor / nurse, by the way DO NOT let go of this Patient will feel supported and return Summary Health professionals have vital role in supporting patient/partner own awareness Management to include identification of organic cause(s), sexuality and relationship issues of the couple Flexibility of treatment options that may include pharmacological, psychosexual and relationship support Follow up Tips for a short consultation Make sure that the patient/partner feels valued and that the problem is important In my experience Discuss expectations of treatment Provide literature plus diary safe websites self-administered questionnaires Address discussion between patient and partner Book follow-up appointments Involve the practice nurse, have referral pathways to others for multidisciplinary team. References www.cosrt.org.uk (College of sexual and realtionship therapy) www.sexualadviceassociation.co.uk (Sexual Advice Association) www.relate.org.uk Erectile dysfunction. Integrating couple therapy, sex therapy and medical treatment. Weeks and Gambescia 2000 The new male sexuality. Zilbergeld 1999 Healthy sex. Stoppard 1998 Sex therapy a practical guide. Hawton 1985 Sleeping with ED Lehmann & Kirby 2008 Intimacy & sexuality for cancer patients and their partners. Brandenburg, Grover & Quinn 2010 9
Contact details Lorraine Grover Psychosexual nurse specialist www.lorrainegrover.com The Erection Connection Mobile: 07899991665 10