The treatments for prostate cancer are all associated with varying degrees of side effects. When evaluating treatments to decide which one(s) may be most effective and also suitable for your preferences and lifestyle, one factor that drives that decision is the side effects associated with each treatment approach.
Hormone therapy consists primarily of antiandrogens and luteinizing hormone, releasing hormone (LH-RH) agonists, and in some cases, surgical removal of the testicles (orchiectomy). Estrogen therapy is rarely used.
- Breast pain and enlargement: Antiandrogens, estrogen, and orchiectomy may result in sensitive and/or painful nipples and/or an increase in breast tissue.
- Cardiovascular events: Continuous estrogen therapy is associated with blood clots, stroke, and other cardiovascular risks.
- Cholesterol changes: Antiandrogens can lower “good” cholesterol (high-density lipoprotein—HDL) when combined with LH-RH treatment. LH-RH treatment alone can significantly increase triglycerides.
- Diarrhea and/or constipation: Antiandrogens can cause these side effects.
- Erectile dysfunction/loss of libido: Antiandrogens, LH-RH agonists, and orchiectomy are associated with erectile dysfunction, while LH-RH agonists can also reduce libido.
- Fatigue: Antiandrogens, LH-RH agonists, and estrogen can all cause fatigue.
- Hair and skin changes: Antiandrogens and LH-RH agonists are associated with hair growth on the head, hair loss on the rest of the body, and dry skin.
- Hot flashes: Antiandrogens, LH-RH agonists, and orchiectomy are associated with hot flashes.
- Osteoporosis: Antiandrogens, LH-RH agonists, and orchiectomy contribute to bone loss. Other factors include a man’s bone health before therapy, the length of hormone therapy, and fracture history.
- Penis/scrotum shrinkage: Any reduction in testosterone can reduce the size of the penis and scrotum.
- Weight and/or belly fat gain: Antiandrogens and LH-RH agonists can contribute to these side effects.
EBRT can cause side effects that occur within 90 days after receiving radiation treatment (acute side effects) or more than 90 days after radiation treatment (late side effects). The most common acute side effects include:
- Bowel changes: Diarrhea, abdominal cramping, rectal pain, rectal bleeding, and feeling the need to have a bowel movement
- Edema: Rare, but may affect the legs, scrotum, or penis.
- Rectal and urinary irritation: The effects from conformal EBRT are typically less severe.
- Skin irritation: The most sensitive areas are the perineum and the fold under the buttocks.
- Urinary symptoms: Urinary urgency, hesitancy, and increased urination during the night as well as urinary incontinence.
The side effects can differ depending on which radioactive seeds are implanted. Palladium, for example, typically causes urinary symptoms earlier because it releases high energy sooner than iodine.
- Difficulty or an inability to urinate; occurs in 7 to 25 percent of men
- Urinary symptoms: Urinary retention, frequent urination
- Urinary incontinence: Occurs in less than 1 percent of men
- Rectal ulceration and bleeding: Seen in less than 5 percent of patients
- Narrowing of the urethra: Caused by the formation of scar tissue, and occurs in 5 to 12 percent of men.
- Erectile dysfunction: Occurs in as many as 40 to 60 percent of men
- PSA increase: Temporary and benign increase in some men
The most common side effects are:
Black, tarry stools
Painful or difficult urination
Shortness of breath
Sores, ulcers on the lips or in the mouth
Unusual bleeding or bruising
Unusual weakness or tiredness
Less common or rare side effects include:
Difficulty walking (rare)
Loss of consciousness (rare)
Numbness or tingling in the fingers or toes
Pain in the lower back or side accompanied by fever or chills
Rapid or slow heartbeat
Swelling of the eyelids
Swelling of the tongue or face (rare)
The side effects generally are the same for all types of the procedure: retropubic prostatectomy, perineal prostatectomy, laparoscopic prostatectomy, and robot-assisted laparoscopic prostatectomy. The percentage and/or severity of the side effects associated with each type of surgery can vary.
- Anesthesia-related side effects: For general anesthesia, common side effects may include nausea, vomiting, and scratchy throat. When epidural anesthesia is used, potential side effects include lowered blood pressure and impaired movement of the legs.
- Bladder neck contracture: Occurs in 3 to 5 percent of prostatectomies. (Ellsworth) Signs and symptoms of bladder neck contracture include straining to urinate and a decreased stream. A complication of treatment for bladder neck contracture is urinary incontinence.
- Bleeding and blood transfusion: Blood loss tends to be less with both laparoscopic and robot-assisted prostatectomies compared with retropubic prostatectomy. A 2010 study found that 0.8 percent of men who underwent robotic laparoscopic prostatectomy needed a transfusion compared with 3.4 percent of those who underwent open prostatectomy. (Kordan)
- Death: The risk of dying from a prostatectomy is about 0.5 percent.
- Deep venous thrombosis: Occurs in less than 10 percent of prostatectomy patients. Less often a piece of the clot breaks away and travels to the heart and lungs, resulting in life-threatening pulmonary embolus.
- Erectile dysfunction: The incidence of erectile dysfunction after prostatectomy may be as high as 88 percent. (Korfage) Other research shows that more than 75 percent of men had erectile dysfunction as long as 92 months after prostatectomy. (Meyer) More on ED after Prostate Surgery
- Hernia: In one study of retropubic prostatectomy, the incidence of hernia was 21 percent, with 82 percent occurring within two years of surgery. (Ichioka) A study of laparoscopic prostatectomy found an 8.3 percent incidence of hernia. (Yoshimime)
- Infection: Infections can occur at incision sites (cellulitis), as an abscess under the skin or deep in the pelvis, or a urinary tract infection. Skin infections can usually be treated with an antibiotic, while abscesses need to be drained. Urinary tract infections typically are related to use of a catheter. The risk of a urinary tract infection increases the longer the catheter is in place.
- Penis shrinkage: If the nerves that run along the prostate are damaged during surgery, there can be a small change in the width and/or length of the penis. One clinical study reported that 63 percent of men who did not use a penile vacuum device after prostatectomy experienced penis shrinkage. (Raina)
- Rectal injury: Damage to the rectum occurs in less than 2 percent of retropubic and perineal prostatectomies. If the injury is small a physician can repair it; if it is large, a temporary colostomy may be necessary.
- Retrograde ejaculation: Men have a 40 to 90 percent chance of experiencing retrograde ejaculation after prostatectomy.
- Sterility: A prostatectomy causes sterility because semen and sperm cells are not ejaculated through the penis to the outside.
- Urinary incontinence: Most men experience some urinary incontinence for several weeks or longer after prostatectomy, but then it resolves for most within a few months. A report in Urology noted that only 7 percent of men had urinary incontinence 18 months after prostatectomy. (Walsh 2000) In a more recent study, 10 percent of men who underwent retropubic prostatectomy had urinary incontinence at 12 months versus 8 percent who had laparoscopic prostatectomy. (Grossi)
- Peyronies disease: The development of a curve in the penis
Reference: Kordon Y et al. Comparison of transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy. BJI Intl 2010 Oct; 106(7): 1036-40
Dr. John Mulhall from Sloan-Kettering Discusses How Cancer Treatments Can Cause Erectile Dysfunction
Men who have had radiation treatment to the prostate are more likely to experience side effects.
- Erectile dysfunction: Several studies report erectile dysfunction to be nearly 90 percent one year after cryosurgery. (Han, Hubosky, Polascik) An experimental procedure called focal cryoablation may be helpful in reducing the chances of erectile dysfunction. (Singh 2010)
- Rectal pain: Occurs in about 2.6 percent
- Swelling: This may occur in the perineum area where the needles are inserted and is usually temporary.
- Urinary incontinence: Rates range from 2 to 7 percent
- Urethral fistula: Seen in 0 to 2 percent
- Urethral sloughing: The passage of dead tissue left over from damage to the urethra from cryosurgery occurs in 2 to 6 percent of patients. (Han, Hubosky, Polascik)
Because HIFU is still a relatively new treatment, there are only a few studies of the impact of HIFU on erectile function and other side effects it may cause. One of those studies was published in the September 2010 issue of Journal of Sexual Medicine. Investigators found that 36 months after undergoing HIFU, 65.5 percent of men had regained erectile function. They also reported no significant change in penis size at 36 months when compared with the size before HIFU. (Li) Over a mean of 41 months, 20 percent of men in another study had urinary incontinence associated with HIFU and an erectile dysfunction rate of 77 percent. (Ripert)
Information about side effects can be gleaned from a variety of other studies conducted over the decade. In one, bladder obstruction was reported to range from 3.6 to 24.5 percent (Blana), while another noted that urinary incontinence occurred in 0.6 to 16 percent of men who underwent HIFU. (Chaussy 2003) Erectile dysfunction may occur in the range of 20 to 49.8 percent of men according to another study, which is lower than other studies. (Mearini 2010) Side effects are more common among men who undergo HIFU as “salvage” treatment (meaning it is done after previous surgery or radiation treatment) than they are among men who have HIFU as their first treatment.
Some of the other side effects attributed to HIFU include pain and/or swelling in the rectum or scrotum area, prostatitis, blood in the urine, blood in the semen or ejaculation fluid, difficulty with urination, urinary tract infections, retrograde ejaculation, urethral stricture or bladder neck contracture (narrowing of the urethra from the bladder to the outside of the body), injury to the rectal wall and/or a rectal fistula (a hole in the rectum), and bowel incontinence.
Dr Addie Wotten from the Australian Prostate Cancer Institute talks about dealing with depression and prostate cancer as well as sexual intimacy after treatment
Blana A et al. Eight years experience with high intensity focused ultrasonography for treatment of localized prostate cancer. Urology 2008; 72:1329-33
Chaussy C, Thuroff S. The status of high-intensity focused ultrasound in the treatment of localized prostate cancer and the impact of a combined resection. Curr Urol Rep 2003; 4:248-52
Li LY et al. Comparison of penile size and erectile function after high-intensity focused ultrasound and targeted cryoablation for localized prostate cancer: a prospective pilot study. J Sex Med 2010 Sep; 7(9): 3135-42
Mearini L, Porena M. Transrectal high-intensity focused ultrasound for the treatment of prostate cancer: past, present, and future. Indian J Urol 2010 Jan-Mar; 26(1): 4-11
Ripert T et al. Transrectal high-intensity focused ultrasound (HIFU) treatment of localized prostate cancer: review of technical incidents and morbidity after 5 years of use. Prostate Cancer Prostatic Dis 2010 Jun; 13(2): 132-37