20 Management of different types of sexual dysfunctions caused by ADT 1. Erectile Dysfunction One of the most common sexual dysfunctions associated with ADT is erectile dysfunction (ED). Testosterone plays a vital role in maintaining penile tissue health and regulating the nitric oxide pathway, which is essential for achieving and maintaining erections. The reduction in testosterone levels due to ADT can lead to impaired erectile function, affecting sexual performance and satisfaction. Men who have good erectile function before starting ADT may benet from penile rehabilitation using established medical treatments several times a week to ensure that erectile tissue is oxygenated. Phosphodiesterase-5 Inhibitors Medications such as sildenal, tadalal, and vardenal are commonly used to treat erectile dysfunction in men on ADT. These drugs enhance the effects of nitric oxide, a natural chemical in the body that relaxes muscles in the penis, increasing (12) blood ow and facilitating erections . Intracavernous injections Intracavernous injections (IC) are indicated for those patients who undergo a non-nerve-sparing radical prostatectomy or whose condition fails to respond to PDE-5 inhibitors. Intracavernous agents can be used either individually or as a combination regimen. The most widely studied regimens are currently prostaglandin E1 (PGE1) and a combination of phentolamine, papaverine, and PGE1 (Trimix). Quadrimix (Trimix + atropine) is also available. ICI therapy is effective in 64% to 98% of patients with erectile dysfunction and is associated with an increase in sexual activity, improvement in the quality of erections, and improvements in sexual satisfaction for both the patient and his (13) partner . Vacuum Erection Devices Vacuum erection devices offer an additional option for post–radical prostatectomy patients who fail to have response to PDE-5 inhibitors. They promote engorgement of the penis through negative pressure effects on the corporeal chambers. When used with a venous constriction ring to maintain tumescence, they have proved to be highly effective in providing patients with a minimally invasive, reasonably inexpensive means (13) to obtain an erectio . Penile Implants For patients with severe erectile dysfunction that does not respond to other treatments, penile implants may be considered. These devices are surgically implanted into the penis to enable (12) erections when desire . 2. Decreased Libido Testosterone exerts its effects centrally and peripherally; libido is thought to be effected by testosterone’s role within the central nervous system (CNS). Libido, or sexual drive, is difcult to isolate as there are numerous physiological, environmental, (14) and psychological factors that may inuence it . The suppression of testosterone levels by ADT can lead to a decline in libido, impacting the sexual interest and motivation of patients. Bupropion Some explanations of testosterone’s role on libido are based on increased dopamine release within the CNS. Dopamine may directly inuence libido. Some data support the positive effect of bupropion on sexual desire due to the dopamine agonistic effect and can be considered as a treatment (14) options for low libido . Intermittent Androgen Deprivation Therapy (IAD) IAD has emerged as a treatment option than can improve symptoms and quality of life by allowing the return to sexual function in men with prostate cancer. Compared to continuous ADT, IAD has (15) shown improvements in sexual desire and libido . Psychosexual Support Professional sexual therapy can invoke awareness of sexual fantasies, relying on their potential to trigger sexual desire and arousal. Counselling can also recruit past sexual fantasies and explore expanding erogenous zones. Cognitive reframing of sexual experiences and mindfulness techniques may also be helpful for men on ADT. 3. Orgasmic Dysfunction Orgasm is the brain’s perception and interpretation of the various striated and smooth muscle (accessory glands) contractions and sensory neuronal stimulation in the pelvic region and other erogenous zones. Prostate cancer treatments can remove or radiate the prostate and surrounding bladder neck, seminal vesicles, and vas deferens which may result in altered orgasmic sensation or orgasmic threshold. Psychological and physiological variants such as depression, altered erectile function, and reduced testosterone with ADT can further reduce the chance of reaching (12) and enjoying orgasm . But it is important for patients and their partners to know that men can still achieve orgasm even if their erections are not rm. Physiotherapy Treatments for orgasmic dysfunction may include pelvic oor therapy for general pelvic oor hyperspasticity, but no direct literature exists. Psychosexual support Successful treatment of a patient with orgasmic difculties requires experimentation and openmindedness regarding the use of sexual aids, such UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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