MANAGING LONG-TERM POST-TREATMENT SEQUELAE

Nursing interventions can improve the long-term health status and quality of life of patients who have undergone treatment for cancer. Nurses play a vital role in providing direct care and education and in helping patients cope more effectively with post-treatment sequalae such as psychological distress, chemotherapy long-term effects, urinary problems, and bowel dysfunction.

Psychological Distress

For many patients and families, cancer is a fatal disease that always involves pain, suffering, debilitation, and emaciation, and patients typically experience varying levels of psychological distress. Left unaddressed, serious anxiety, depression, or other types of psychological distress may leave cancer survivors unable to tend to their needs.

Each person’s post-treatment experience is different. Some will struggle with negative emotional reactions, and others say that they have a renewed positive outlook on life because of the cancer. Cancer survivors often have reactions such as:

  • Fear of recurrence
  • Anger
  • Guilt
  • Depression
  • Anxiety
  • Feeling alone
  • Concerns about family and finances
  • Changes in body image and sexuality
  • Loss of control and independence

Fear of recurrence is the most common emotional difficulty that people say they have after completing cancer treatment. A certain amount of anxiety is normal, but for some it can become debilitating.

Patients require support in managing various sources and levels of distress. Nurses must assess patients for psychological distress over the entire course of the patient’s cancer experience, including assessing for positive or maladaptive coping behaviors, interpersonal communications, and evidence of the need for additional psychosocial support or interventions, such as referral for professional counseling. Basic steps the nurse can take include:

  • Assessing and screening for signs of anxiety
  • Ensuring open communication in an environment that is appropriate for a discussion about psychological concerns
  • Preparing to refer patients to mental health specialists or support services as deemed appropriate
  • Remaining knowledgeable about current evidence-based principles

Approaches that have been shown to be helpful for managing anxiety and distress include:

  • Cognitive behavioral therapy
  • Mindfulness-based stress reduction, including acceptance and commitment therapy
  • Self-management
  • Exercise
  • Antianxiety or antidepressant medications

Support groups have also been shown to be helpful. While the logistics of organizing them can be challenging, the growth of online support groups for survivors of diverse cancer types and treatments has made these resources accessible for many more people.

The nurse also helps strengthen patient and family confidence to explore preferences for issues related to end-of-life care, such as withdrawal of active disease treatment, desire for the use of life-support measures, and symptom management (Hinkle & Cheever, 2018; NCI, 2020).

Alopecia

Most people undergoing chemotherapy experience loss of hair (alopecia) that tends to begin 1 to 2 months into treatment. How much hair is lost depends on the medication and dose. Most people with see some thin hair growth a few weeks following treatment cessation. Real hair may begin to grow back within 1 to 2 months. Research finds, however, that people also experience permanent hair loss.

Although healthcare providers may view hair loss as a minor issue, for many patients it is a major assault on their body image, challenging their self-esteem and resulting in psychological distress. Alopecia is a symbol to nearly everyone around the patient that they have cancer, and both men and women indicate that hair loss is one of the side effects they dread the most. Men are concerned about loss of hair on the head as well as other areas of the body, such as the chest. Men may be especially concerned about how this will affect them in their workplace.

The nurse can provide information about steps to minimize frustration and anxiety associated with hair loss. A helpful intervention might include preparing for hair loss before any has occurred by cutting it shorter. Coworkers may become used to seeing a shorter style, so when hair loss occurs it will not be so dramatic.

Because hair loss can occur in clumps, a buzz cut might be considered. With a buzz cut, however, the person should be prepared for the potential reactions of others. A newly shaved head may not be a problem in public, where this style has been adopted by many men, but in social, family, and work circles, the look may evoke questions and concerns.

After treatment ends, means to help coax the regrowth of hair include:

  • Massaging the scalp with fingertips, which increases blood circulation to the scalp
  • Using over-the-counter topical remedy for hair regrowth (after consulting with one’s healthcare provider)
  • Using a gentle, moisturizing shampoo

Hair may not look or feel the same as it was prior to therapy until up to a year and a half after treatment ends (Cancer and Careers, 2021; Mayo Clinic, 2021c; Hinkle & Cheever, 2018).

Urinary Problems

Treatment for prostate cancer can result in urinary problems, including incontinence and retention. The five years following a prostatectomy are associated with worse incontinence compared to other forms of treatment, regardless of cancer risk group. Those receiving brachytherapy have a more difficult time with urinary and bowel symptoms during the first year (Hoffman et al., 2020).

Urinary incontinence as a result of cancer treatment may be short- or long-term. It can be uncomfortable, frustrating, and embarrassing for the patient to cope with. The highest rate of occurrence is during the first month following treatment. Stress and urge incontinence are common, with stress incontinence being the most common. Some men with severe stress incontinence have nearly constant urine loss (total incontinence).

Urinary incontinence usually improves with time. Most men start to see an improvement 1 to 6 months after treatment. Other men are incontinent for a year or more, and some men never fully recover, even if they have treatments to help their incontinence.

Nursing intervention has been shown to have significant beneficial effects on urinary function at 3 and 6 months after discharge. The nurse can encourage the person to take steps to prevent incontinence, improve continence, anticipate leakage, and cope with lack of complete control.

Most often, the first treatment recommended for regaining bladder control is bladder retraining, a type of behavioral therapy that helps the person regain control over urination. Bladder control retraining gradually teaches the person to hold urine for longer and longer periods of time by scheduling bathroom visits; performing Kegel’s exercises to strengthen the muscles used to start and stop the flow of urine; and biofeedback therapy, a form of pelvic floor muscle physical rehabilitation that uses a small electronic device to help the patient learn to control urine.

Management options depend on how much urine is being leaked, and they include:

  • Absorbent pads and pants (washable and disposable)
  • Bed protectors
  • Urinary sheaths and drainage bags
  • Bed protectors
  • Handheld urinals to allow quick access for urge incontinence or frequency
  • Penile clamps (If using a penile clamp, the patient is informed that it is an uncomfortable option and that the clamp must be opened at least every two hours to allow blood to flow back into the penis.)
  • Carrying extra clothing in case of urinary accidents, which improves confidence when restroom access is limited
  • Maintaining a healthy weight (Extra weight can put pressure on the bladder and the muscles that support it.)
  • Avoiding foods that can irritate the bladder, such as dairy products, citrus fruits, sugar, chocolate, soda, tea, and vinegar
  • Quitting smoking (Nicotine can irritate the bladder and cause the person to cough and leak urine.)
  • Increasing voiding frequency and avoiding positions that encourage the urge to void

It is important to let the patient know that regaining urinary control is a gradual process; he may continue to “dribble,” but this should gradually diminish, usually within one year (Hinkle & Cheever, 2018; Wang et al., 2018; PCUK, 2021a; ASCO, 2021c).

MEDICATIONS

Antispasmodic medications may be prescribed to decrease involuntary bladder contractions, improve urinary flow, and control urgency, pain, and leakage. Commonly prescribed medications include:

  • Tamsulosin (Flomax)
  • Terazosin (Hytrin)
  • Tolterodine (Detrol, Detrol LA)
  • Solifenacin (VESIcare)
  • Oxybutynin (Ditropan, Ditropan XL)

Another medical treatment option is to temporarily paralyze the bladder muscle with botulinum toxin (Botox, Dysport). This medication is injected into the bladder muscle to help muscles relax, thereby giving the patient more time to get to the bathroom when feeling the need to urinate. Most people obtain symptom relief quickly, in as short as a few days. The treatment results last about six months, and repeat injections can be given. One possible side effect is urinary retention (Mayo Clinic, 2019a).

Patients are educated about the benefits and harms of each medication and when to contact their provider due to side effects. These may include:

  • Severe stomach pain or constipation
  • Blurred vision, tunnel vision, eye pain, or seeing halos around lights
  • Decreased urination and anuria
  • Dysuria
  • Dehydration symptoms
  • Dry mouth, constipation, and confusion (more likely in older adults)
  • Chest pain
  • Hallucinations
  • Cardiac irregularities
    (Mayo Clinic, 2020b)

NONSURGICAL INVASIVE PROCEDURES

Nonsurgical invasive procedures for incontinence include collagen injections, percutaneous posterior tibial nerve stimulator, and sacral neuromodulation.

Collagen Injections

Collagen injections are a minimally invasive procedure to add bulk to the urinary sphincter, creating a seal that stops urine from leaking by thickening the urinary sphincter. This may be the best option as a temporary measure or as an option for men who are unwilling or unfit to undergo invasive surgery. Success may diminish over time as bulking agents are absorbed into the body (Gill, 2018).

Percutaneous Posterior Tibial Nerve Stimulator (PTNS)

PTNS is a procedure in which a small electrode is passed through the skin of the ankle near the tibial nerve. The electrode is connected to a pulse stimulator outside the body. The stimulator sends pulses to the electrode to stimulate the tibial nerve, which then travels to the nerve roots in the spine to block abnormal signals from the bladder and prevent bladder spasms.

There have been no major side effects reported with the use of PTNS, and patients describe the sensation during treatment as pulsing or tingling in the foot. Each PTNS treatment takes about 30 minutes, and the patient is required to commit to 12 weekly follow-up sessions with their provider at the beginning, and then monthly thereafter to sustain improvements (PCUK, 2021a; University of Colorado, 2021).

Sacral Neuromodulation (SNS)

When other treatments fail or cannot be tolerated, sacral nerve stimulation may be an option. The sacral nerve is involved in controlling bladder, bowel, and pelvic floor muscles. The SNS procedure entails implanting a small pacemaker-like device in the fleshy part of the buttocks, with a thin wire extending into the area near the sacral nerve through which low voltage pulses are delivered. The procedure is performed in the hospital under light anesthesia. The device’s battery last about five years and requires surgery to replace (NYU Langone, 2021).

SURGERY

Surgical options may be considered if the patient continues to experience incontinence 6 to 12 months after treatment and when other methods have been unsuccessful. Surgical procedures include an internal male sling, artificial urinary sphincter, or adjustable balloons.

Internal Male Sling

This device is a synthetic mesh-like tape that is placed around the urethral bulb, compressing and moving the urethra into a new position to increase pressure on the urethra to keep it closed and to stop urine from leaking. The procedure requires surgery under general anesthesia in order to fit the sling. This procedure may be an option for patients who leak a moderate amount of urine (two to three pads per day) one year after treatment for prostate cancer. The sling may not work as well if the patient was treated with radiation therapy, however.

Side effects of this procedure may include:

  • Pain in the first three months following the procedure
  • Infection (causing about 1 in 10 men to have the sling removed)
  • Problems with urine retention (not very common)
    (PCUK, 2021a)
Artificial Urinary Sphincter

Considered the gold standard of therapy for severe urinary incontinence following prostate cancer surgery, an artificial urinary sphincter involves surgery under general anesthesia to fit a small device that consists of:

  • A fluid-filled cuff that fits around the urethra
  • A balloon in front of the bladder
  • A pump implanted in the scrotum
Artificial urinary sphincter for treating urinary incontinence following prostate cancer surgery

(Source: Blausen Medical, 2014.)

The cuff presses the urethra closed to prevent urine leakage, allowing the patient to control when he urinates. To urinate, the patient squeezes the pump in the scrotum, which moves the fluid out of the cuff and into the balloon. When the cuff is empty, the urethra opens and urine is allowed to pass through. After a short delay, the fluid flows back into the cuff to press the urethra closed again.

Postoperatively, it may take 4 to 6 weeks to heal, during which time the pump cannot be activated, and additional adjustment surgeries may be necessary.

This procedure is usually done only for men who are still incontinent at least 6 months following their treatment for cancer. Risks for this procedure include infection, erosion of tissue around the implants, and breakage of parts of the device. Some men will need another operation to fix problems, and some men may need their device removed (PCUK, 2021a).

Adjustable Balloons

Adjustable balloons involve surgery to place two small fluid-filled balloons around the urethra. The balloons press on the urethra to stop urine leakage, but the patient should still be able to urinate when he chooses. Each balloon contains fluid and is attached to a device (port) placed in the scrotum. The physician can use these ports to make the balloons bigger or smaller at any time in order to increase or decrease pressure on the urethra.

Risks include infection, shrinking, or moving of the balloons. Balloons are an option for incontinence lasting more than six months after surgery, but they are not an option for those who have had radiotherapy (PCUK, 2021a).

Bowel Dysfunction

Bowel dysfunction following prostate cancer treatments may include diarrhea, frequent stools, fecal incontinence, and rectal bleeding. Altered bowel function is not common (<1%) in men following prostatectomy. In rare cases of locally advanced prostate cancer where the cancer has invaded the rectum, surgery may result in rectal damage (PCF, 2021e).

Radiation therapy can cause significant damage to the rectum, leading to symptoms such as:

  • Diarrhea
  • Increased flatulence
  • Urgency
  • Feeling that bowels have not emptied properly
  • Pain in the abdomen or rectum
  • Bleeding from the rectum (rare)
  • Thick and stringy mucus discharge
    (PCUK, 2021b)

During radiation therapy the patient may experience softer stools and, occasionally, diarrhea (<10% of men). These symptoms typically resolve within a few weeks following completion of radiation therapy. Rarely, however, symptoms can persist (or even begin) months to years after treatment ends. After two years, about 20% of men report having persistent diarrhea a few times each week, while rectal bleeding can increase from 5% immediately after treatment to 25% after 2 years.

Rectal pain and bleeding can also develop even months to years after completing radiation treatment. This may be related to scar tissue that does not stretch as well as normal tissue and can tear and bleed with bowel movements or with hard stools (PCUK, 2021b; Johns Hopkins Medicine, 2021c).

There are few, if any, treatment options for bowel dysfunction following radiation therapy. Laser therapy can be of some help in stopping rectal bleeding. Antidiarrheal agents, such as over-the-counter medicines (Kaopectate, Imodium, Lomotil), can be recommended to help with loose bowel movements, as well as increasing fiber intake through whole grains, fruits and vegetables, or fiber supplements.

Other helpful measures include:

  • Eating five to six small meals a day instead of three large meals
  • Eating foods at room temperature (very hot and cold foods can irritate the bowels)
  • Eating slowly so as to swallow less air
  • Avoiding very spicy, fried, greasy, or fatty foods
  • Avoiding most milk products if sensitive to them
  • Avoiding foods that cause increased flatus (e.g., cabbage, broccoli, cauliflower)
  • Drinking at least 8 to 10 glasses of water each day
  • Limiting caffeine, which can irritate the bowel and cause fluid loss
  • Reducing or eliminating alcohol and tobacco
  • Not chewing gum
  • Decreasing and managing stress
  • Taking over-the-counter stool softeners
    (PCUK, 2021b)
BOWEL PROBLEMS AND ANAL SEX

If the patient is a receptive partner during anal sex, then bowel problems after radiotherapy may be a particularly difficult issue. It is important to discuss a patient’s sexual preferences in order to provide the most appropriate and helpful support, guidance, education, and counseling. For those who have bowel problems or a sensitive anus following radiation therapy, it may be recommended that they wait until these have settled before engaging in anal sex (PCUK, 2021c).

Sexual Dysfunction

There are four main components of sexual dysfunction that may be affected by prostate treatment:

  • A decline in libido (sex drive) is most common in those who have received hormone therapy. Even though the patient may still obtain an erection, it is more difficult when there is less interest in sexual activity. Libido normally returns once the testosterone level normalizes after treatment is completed. For many patients and their partners, this can be a major concern, and couples counseling should be considered when it is causing stress in the relationship.
  • Mechanical ability is the ability to achieve a firm erection and is controlled by nerves and vessels closely associated with the prostate and structures near the penis. Mechanical ability is most affected by surgery or radiation therapy.
  • Orgasm/climax may be difficult to achieve after treatment, especially in the presence of low libido or when erections are not firm enough. Discomfort with orgasm may be experienced initially after treatment; it is transient and should resolve. Men will continue to have the pleasurable sensation of orgasm without ejaculation.
  • Ejaculate will be minimal or absent after treatment. The prostate and seminal vesicles that produce ejaculate are removed and/or irradiated during treatment. This results in minimal to no ejaculate.
    (PCF, 2021f)

PREVALANCE OF SEXUAL DYSFUNCTION

The most common side effects following prostate cancer treatment are sexual dysfunction related to the inability to get or sustain an erection, decreased libido, and fatigue. Erectile dysfunction (ED) remains the most common side effect after treatment. About 60% of men report having erectile dysfunction 18 months after surgery, and fewer than 30% have erections firm enough for intercourse after 5 years (AECM, 2021).

Studies have shown that approximately 50% of men who had the ability to have an erection prior to surgery will maintain this ability long-term as a result of “nerve sparing” prostatectomy. In those with high-risk cancer, however, it is often more difficult to spare the nerves, as the tumor may have spread outside the prostate capsule. Erectile function is then lower than average.

Radiation therapy has less impact on erectile function in the first 5 to 10 years after treatment compared with surgery, and approximately 70% of men who have baseline erectile function before treatment will keep that ability after treatment. The rate of erectile function decline in those who received radiation therapy, however, is slower than with surgery, and 15 years after treatment, the rates are similar to those who underwent surgery (PCF, 2021f).

Men given androgen deprivation therapy (ADT) have the worst rates of sexual dysfunction since irreversible damage may occur to the erectile tissue in the penis. Serum testosterone requires 9 to 12 months off ADT to recover; however, about one half of men do not recover the ability to achieve an erection. This is difficult to treat except with penile prosthesis implant surgery. Although ADT is harmful to sexual function, many patients do maintain an interest in sexual activity. One factor that has been found to play a role is keeping an emotional connection with a partner (Fode et al., 2020).

ADDRESSING THE PATIENT’S SEXUAL ISSUES

Sexual issues may become a concern to the patient soon after or within the weeks to months following treatment, requiring assessment and open discussion with the patient about these issues and how they can be managed. Many patients and their partners report that they were not informed about sexual side effects before treatment, or, if they were informed, that they didn’t retain enough to fully understand them (Dubin et al., 2020).

Body image, self-esteem, sexual dysfunction, and intimacy are difficult topics for patients and their partners, and this affects their willingness to openly discuss them. Nurses must be knowledgeable and comfortable with the topic, including religious implications, cultural norms, gender differences, and sexual preferences. The nurse’s awareness and proactive role in addressing concerns can greatly affect the patient’s quality of life and psychosocial well-being.

Sexual issues should be addressed early in the treatment process, and a sexual assessment will identify a baseline against which post-treatment changes can be measured. Along with the assessment, the nurse provides education regarding long-term effects on sexuality (Grier, 2018).

Within the multidisciplinary team, nurses especially play a key role in the presentation of sexual health counseling. However, healthcare provider assessment of patients’ sexual health is often superficial. It is a difficult and delicate topic for many, but it is imperative to assess patients in a matter-of-fact and sensitive manner. Barriers to effective communication reported by nurses have included:

  • Conflict with the nurse’s personal values and beliefs
  • Lack of education in effectively communicating about the topic
  • Nurse’s feelings of discomfort with sexual topics viewed as “taboo”
  • Fears about the patient’s reaction
  • Feeling that this component of health is not necessary or pertinent to patient care
  • Negative attitudes and beliefs of nurses toward LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning, and others) individuals

Other studies have found that when confronted by patients’ sexual problems, nurses felt ill-prepared to develop a care plan for them, expressing concerns that their education regarding sexual health pertained only to contraception, maternal health, reproduction, fertility, and sexually transmitted infections—all generally concerns of younger individuals. Often older adults’ sexuality is ignored due to the misconception that they no longer participate in sexual activity.

The PLISSIT model is one tool developed to assist nurses and other healthcare professionals in addressing patients’ sexuality issues. This tool provides four levels of intervention that should take place in a private, quiet environment that ensures patient comfort.

PLISSIT MODEL
(Culp, 2020; Agochukwu & Wittman, 2019)
P Permission Give the patient permission to talk about feelings and ask questions.
L
I
Limited
Information
Offer limited or basic information and resource materials to dispel myths and provide facts.
S S Specific
Suggestions
Suggest guidance on possible management options for the patient’s specific problems; this requires a deeper level of expertise on the part of the nurse.
I
T
Intensive
Therapy
Identify need for further support/therapy and make appropriate referrals.

ADDRESSING LOSS OF LIBIDO

Libido plays a major role in many individual’s concept of manhood. Before prostate cancer treatment, a patient may have experienced a number of triggers that resulted in sexual desire and arousal:

  • Sight: Seeing someone or something that “turns them on”
  • Sound: Certain sounds or sex talk
  • Fantasy: Using the imagination to think about sexual experiences
  • Memory: Recalling prior sexual experiences
  • Smells: Certain smells associated with past sexual experiences
  • Words: Reading about sexual encounters
  • Touch: Certain forms of touching

After prostate cancer treatment, however, men may lose their capacity to respond to any and all of these triggers, leading to feelings of loss, disappointment, frustration, anger, and shame. Couples may respond negatively when their pre-cancer treatment sexual activities are no longer accessible, and very often men withdraw emotionally and physically from their partners, resulting in high levels of stress.

When providing support for the patient who is experiencing this loss, it must be stressed that regaining one’s libido takes time, effort, and new experiences in order to reprogram mind and body to experience arousal in completely different ways than before. It is important to encourage the patient to talk with his partner about how he is feeling.

It is also helpful to talk about ways to enjoy a fulfilling sexual relationship without performing the act of intercourse. Hugging, cuddling, and kissing can be comforting and assist in relaxation, and touching in a nonsexual way can demonstrate dedication to the relationship. Some men find that feeling relaxed and having these other types of physical contact can gradually result in becoming aroused.

Patient education also includes information about support groups as valuable ways to meet people who are sharing the same experiences and who may have suggestions to share on how to manage issues around sexuality. It may also be helpful to refer the patient and his partner to a counselor or therapist, either separately or together, for specialized assistance (Island Sexual Health, 2021; Cancer Research UK, 2019).

TREATMENT STRATEGIES FOR ED

Treatment strategies for erectile dysfunction include oral and injectable medications, urethral suppositories, penile implants, and negative-pressure vacuum devices.

Oral Medications

PDE5 inhibitors are the first line of treatment for erectile dysfunction. These drugs relax smooth muscle, causing blood to flow into the penis. They are taken 30 to 60 minutes orally before intercourse. An erection can last 1 hour, and stimulation is required to achieve erection. Complications include priapism (a persistent abnormal erection). These medications include:

  • Sildenafil (Viagra)
  • Vardenafil (Levitral)
  • Tadalafil (Cialis)
  • Avanafil (Stendra)

Most men taking these medications are not bothered by side effects. When they occur, however, they can include:

  • Flushing
  • Headache
  • Indigestion
  • Visual changes, such as blue tinge, vision sensitivity to light, or blurred vision
  • Stuffy or runny nose
  • Back pain

All four medications listed above may sometimes cause priapism. If a person experiences an erection that lasts for more than 4 hours, they should seek medical attention to avoid lasting damage.

In rare cases, these drugs can cause serious side effects including sudden loss of vision in one or both eyes or sudden hearing loss. In these instances, the person should be told to stop taking the drug immediately and contact their provider.

These medications are contraindicated for use in those who:

  • Take nitrate drugs such as nitroglycerine, isosorbide mononitrate, and dinitrate
  • Have hypotension or uncontrolled hypertension
  • Have severe liver disease
  • Have kidney disease requiring dialysis
    (Mayo Clinic, 2021c; Hinkle & Cheever, 2018)
Injectable Medications

Peripheral vasodilators are generally prescribed only if oral ED medications are ineffective or not well tolerated. These medications are self-administered injections into the penis and exert their effect directly on the smooth muscle of the corpora cavernosa. They include:

  • Alprostadil (Caverject, Edex), also available in urethral suppository form
  • Papaverine
  • Phentolamine

An erection should follow within 5 to 15 minutes; however, some men may need sexual foreplay to achieve an erection. Erection can last up to 1 hour. These medications may also be given in combination form, including BiMix (papaverine and phentolamine) and Trimix (all three medications) (Hinkle & Cheever, 2018; Kim, 2020; Honig, 2019).

Penile Implants

Two general types of penile implants are available: 1) a malleable, noninflatable, semirigid rod and 2) an inflatable, hydraulic prothesis.

The semirigid rod is made of soft silicone. It is surgically implanted into the corpus cavernosum of the penis, and healing takes up to 3 weeks. Semirigid rod implants result in a permanent semi-erection but can be bent into a position that is not noticeable.

The inflatable prosthesis simulates natural erections and natural flaccidity. This prosthesis involves a 1- to 2-hour procedure in which inflatable cylinders are implanted inside the shaft of the penis, a fluid reservoir is implanted under the abdominal wall (depending on the type of device), and a pump is implanted inside the scrotum. When the patient desires an erection, the pump is squeezed and fluid is sent to cylinders in the penis, creating an erection. Saline returns from the penile receptacle to the reservoir.

Inflatable prosthesis for treatment of ED

Inflatable penile implant inserted into the corpus cavernosum of the penis. (Source: Hovhannes Karapetyan / Wikimedia Commons, Creative Commons License BY-SA 4.0.)

Complications following implantation may include infection, erosion of the prosthesis through the skin, and persistent pain necessitating removal. Ongoing counseling is normally necessary to help the patient and his partner adapt to the prosthesis (Hinkle & Cheever, 2018; Mayo Clinic, 2019b).

Vacuum Devices

Negative-pressure vacuum devices induce an erection using a plastic cylinder placed over the flaccid penis and a hand- or battery-powered pump to apply negative pressure. A constriction band is then placed around the base of the penis to maintain the erection.

Advantages for use of this device include less risk of side effects or complications than any other erectile dysfunction treatments. It is noninvasive and can be used along with other treatments. However, it is cumbersome to use before intercourse, and some men experience a feeling of trapped semen, making ejaculation painful. Patients must be cautioned that the constriction band must not be left in place for more than 1 hour in order to prevent penile injury (Hinkle & Cheever, 2018; Mayo Clinic, 2020c).

CASE

Deion is a 45-year-old man who has returned to the oncology clinic for his six-month follow-up visit after being treated for prostate cancer. He is meeting with Richard, the oncology nurse, to discuss how he has been doing and to address any concerns he might have.

Richard: “It’s good to see you, Deion. Tell me how you’ve been getting along since we last saw you?”

Deion (smiling): “Oh, I’m doing great. I’m pretty much back to my old self.”

Richard: “Are you eating well? Sleeping well? Pain-free?”

Deion (enthusiastically): “Oh, yes. I’m doing really well!”

Richard: “Are you having any problems urinating, like burning or having to go often?”

Deion: “No. Everything seems to be working okay.”

At this point Richard opens up the topic of sexual matters using the PLISSIT model.

Richard (asking permission): “Deion, I want to discuss some matters that might be of concern to you. One in particular is to ask if you’re having any sexual concerns and if you’d like to talk with me about them.”

Deion: “What do you mean?”

Richard: “What I mean is, do you and your partner have any worries or concerns about how things are going sexually?”

Deion (looking at the floor): “Well, as a matter of fact, I can’t get it up anymore, and so it’s not so good.”

Richard: “You haven’t been able to have an erection, is that it?”

Deion: “Yeah. You know, I was told this might happen, but I didn’t really think it would. I don’t feel like a whole man anymore, so … I try not to think about it too much, and I don’t even talk about it anymore. No matter what Felicia and I have tried, nothing works, so we just gave up.”

Richard (providing limited information): “It’s normal to feel sad, frustrated, and angry about this kind of thing. Remember when we first discussed the risks of having surgery, we talked about what side effects might occur and we discussed the fact that there are things that can be done to help with erection problems. Do you remember?”

Deion: “Sure, I remember talking about it, but I didn’t really think that it would happen to me, so I didn’t pay too much attention.”

Richard (offering specific suggestions): “Well, Deion, let me tell you what kinds of treatments are available for men who are having problems getting erections.”

Richard gives Deion a brief description of different treatments for erectile dysfunction and asks Deion if he has any questions or concerns.

Deion pauses and then replies: “Well, I wonder if the little blue pill would work for me. That sounds like the easiest of those choices.”

Richard (offering intensive therapy): “Well, I’ll bring in Dr. Huang, and we’ll see if he thinks that would be a good place to start. I’ll be right back, and we can discuss that option with him then.”

Richard and Dr. Huang enter the room. After a brief examination, Dr. Huang asks how Deion is doing. Dr. Hague says that Richard has informed him of his desire to try an oral medication for his erectile dysfunction. Deion agrees that he would like to give it a try, and so Dr. Huang writes him a prescription for Viagra.

Before the visit ends, Richard also tells Deion that individual and couples counseling is also available, and that if he and Felicia are interested, a referral can be made. Deion says he’ll to talk with his wife and get back to Richard, saying,“It probably would be a good idea.”

Metastatic Cancer Concerns

Prostate cancer commonly metastasizes to bones and less commonly to the lungs, liver, or brain. Men with metastasis may or may not have symptoms depending on the size of the new growth and where the cancer has spread in the body. Learning that the cancer has spread or come back can be a very difficult thing to face and requires supportive care. The treatment options focus on slowing the spread of cancer and relieving pain.

The typical goal of treatment for cancer is a cure, but with metastatic cancer, cure may not be a realistic goal. When cure is not the goal of treatment, the goal becomes to help a person live as well as possible for as long as possible. This involves:

  • Having the fewest possible side effects from the cancer
  • Having the fewest possible side effects from the treatment
  • Having the best quality of life
  • Living as long as possible with the cancer
    (ASCO, 2021d)

Metastatic cancer is usually more difficult to treat. Treatments can control and slow the growth of metastases, but they usually do not go away completely. Treatments may include chemotherapy and other drug therapies, radiation therapy, surgery, and ablation. Supportive or palliative therapies may also be offered in combination with these treatments to help manage or prevent problems caused by the cancer and treatment (CCS, 2021).

MANAGING BONE METASTASIS

The symptoms of bone metastases vary depending on which bones and how many bones are affected. Pain is the most common symptom and usually the first to appear. Bone pain can come and go, it can be constant, and it is often worse at night. Pain may occur in only one area, or it may spread throughout the body. The character of the pain can be sharp or a dull ache. Various medications and treatments can be offered to control pain. Complementary therapies can also bring relief, including acupuncture, acupressure, hypnosis, massage, and relaxation techniques (UM, 2020).

Other indications of bone metastases include fractured bones, most often the ribs, vertebrae, and long bones of the legs. Bone metastases can also result in the following conditions requiring emergency management:

  • Hypercalcemia: Symptoms include constipation, loss of appetite, nausea, urinary frequency, extreme thirst, and confusion.
  • Spinal cord compression: This can be caused by vertebrae damage from bone metastases. Symptoms include loss of balance, weakness or numbness in the legs and sometimes arms, and urinary and bowel incontinence.

Treatment options for bone metastases include radiation therapy and bisphosphonates (the gold standard). Cancer cells release proteins that interfere with the normal bone shaping process and stimulate the osteoclasts that break down bone. This results in bone being destroyed faster than it can be rebuilt. Bisphosphonates block osteoclasts and allow bone to again be rebuilt. The most common bisphosphonates used include:

  • Alendronate (Fosamax), a weekly pill
  • Risedronate (Actonel), a weekly or monthly pill
  • Ibandronate (Boniva), a monthly pill or quarterly intravenous (IV) infusion
  • Zoledronic acid (Reclast), an annual IV infusion

Another common osteoporosis medication is denosumab (Prolia, Xgeva). Unrelated to bisphosphonates, denosumab might be used by people who cannot take a bisphosphonate, such as those with reduced renal function. This medication is administered by subcutaneous injection given every six months. This medication may need to be taken indefinitely unless the patient is transitioned to another medication, as research indicates there is a high risk of spinal fractures after stopping the drug (Mayo Clinic, 2021d).

MANAGING LIVER METASTASIS

Liver metastasis is a chronic condition that may result in loss of appetite, pain, ascites, and fatigue.

Loss of appetite can be managed by:

  • Eating small meals and snacks at regular times throughout the day
  • Serving food cold or at room temperature to reduce strong tastes and smells
  • Eating foods high in calories and protein
  • Utilizing commercial nutrition products

Ascites can be the result of blocked lymphatic channels and direct production of fluid into the peritoneal cavity by highly active cancers. Extensive hepatic metastases can also result in portal hypertension (CCS, 2021). Treatments for ascites may include:

  • Diuretics
  • Paracentesis
  • Drainage catheters
  • Vascular shunts
  • Infusion of warmed chemotherapy into the peritoneal cavity
    (LeBlanc & Arnold, 2021)

MANAGING LUNG METASTASIS

Metastatic lung cancer causes dyspnea, which can be the result of:

  • A tumor blocking or narrowing an airway
  • Pressure on structures outside an airway
  • Pleural effusion
  • Anemia
  • Anxiety and stress
  • Hypoxemia

Treatments for patients with lung metastasis include:

  • Oxygen therapy
  • Bronchodilators
  • Anti-anxiety medications
  • Stent placement
  • Thoracentesis for pleural effusion
  • Relaxation and breathing exercise
    (CCS, 2021)

MANAGING BRAIN METASTASES

Metastasis to the brain can result in neurological problems. Depending on which part of the brain is affected, these problems may include:

  • Ataxia
  • Myasthenia
  • Poor balance and coordination
  • Loss of memory and concentration
  • Confusion
  • Changes in mood and behavior
  • Dysarthria
  • Dysphagia
  • Dysphasia
  • Vision problems

Neurological problems can lead to stress and anxiety about losing one’s sense of self as well as independence. Some treatments and supportive therapies can help manage and control these problems, including referral to occupational therapy.

The main focus of treatment for brain metastasis focuses on reducing pain and symptoms resulting from the cancer. Treatments may include:

  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Immunotherapy
  • A combination of treatments

Other treatments might be recommended in different situations (Mayo Clinic, 2020d).

Managing End-Of-Life Care

Talking about end-of-life care can be very difficult for patients and families. At some point, the patient with advanced cancer, their family, and providers may face the decision of whether or not to continue therapy with intent to be cured.

Palliative care can be offered at any stage of illness and is most often associated with advanced disease. Nurses are key members of the palliative team that focuses on maintaining and improving quality of life. Cure is not the goal with palliative care; instead, the goals of palliative care include:

  • Treating and preventing symptoms such as pain, nausea, fatigue, and other physical symptoms resulting from the cancer or its treatment
  • Helping to meet the patient’s emotional and social needs
  • Addressing the patient’s spiritual concerns
  • Addressing practical issues, such as transportation and concerns about finances
  • Providing support for the patient’s family, friends, and caregiver

Palliative treatments can vary and may include medication, nutritional changes, relaxation techniques, and other therapies. The patient may also be given treatments for prostate cancer that are similar to those meant to cure the cancer, including chemotherapy, surgery, and radiation therapy (Zero, 2021b). Men with advanced prostate cancer may receive palliative care for many months or even years.

At some point, hospice care may be required, which is a team-oriented approach to providing pain management and emotional and spiritual support for patients whose life expectancy is 6 months or less. Hospice can be delivered in a hospital, but most hospice care is provided in the patient’s home. Hospice may be indicated when the patient:

  • Presents with distant metastatic disease
  • Shows continual decline despite receiving therapy
  • Refuses to accept further active treatment