Introduction

Sexual difficulties are a common and distressing side effect of prostate cancer and its treatment. Patients who experience sexual dysfunction (e.g., erectile dysfunction (ED), loss of sexual desire, or both) after having a prostatectomy or undergoing radiation or hormone therapy may also struggle with the psychological and relational ramifications of this change. For example, they may experience a loss of self-confidence regarding their body image and sexual performance and/or worry about not being able to satisfy their sexual partner(s).

Currently, many providers address cancer-related sexual dysfunction with medications such as phosphodiesterase type-5 inhibitors (PDE5i). Although these oral medications can be helpful for treating ED, there are many factors at play when it comes to sexual dysfunction, so a multidisciplinary approach to care may produce better results.  

Exercise is one element of a comprehensive treatment plan that may be beneficial to cancer patients. Past research has indicated that consistent exercise can decrease anxiety, depression, and fatigue while improving physical functioning and quality of life. Recent studies show that exercise may also have a positive impact on cancer patients’ sexual function.

Methods

On July 13, 2021, researchers conducted a systematic review of randomized controlled trials (RCTs) that examined the sexual function of prostate cancer patients engaging in exercise as part (or all) of their treatment plan. They used the PICOS (population, intervention, comparison, outcomes, and study method) model to determine the eligibility of each study. For the purposes of this literature review, the inclusion criteria were outlined as follows:

• Population: Adult prostate cancer patients (≥18 y), treated and untreated
• Intervention: Exercise interventions (at least 1 supervised session) alone or in combination with other supportive interventions. Swallowing, jaw, and breathing exercises were excluded, as well as exercise that was prescribed in combination with medications or erection aids.
• Comparison: Usual care, wait-list or another form of exercise interventions
• Outcomes: Sexual function (including quality of life questionnaires if they have a specific sexual function subscale)
• Study Design: RCTs with at least 15 participants published in the English language

Results

The literature search yielded 15,081 articles. After removing the duplicates, the researchers were left with 6,254 articles. All but 22 of these articles were excluded for not meeting the PICOS criteria. Ten of the remaining 22 studies involved an exercise-only intervention, four included exercise as part of a multimodal intervention, and eight involved pelvic floor muscle exercises.

In nine of the 22 studies, there were “significant between-group differences in sexual activity and sexual function, including libido/major interest in sex, erectile function, and erection frequency in favor of the intervention group (IG) [over the control group]” (Reimer et al., 2021). Six of the nine RCTs that showed favorable outcomes for the IG were exercise-only interventions such as yoga and supervised aerobic, resistance, and flexibility exercises during radiotherapy and androgen deprivation therapy (ADT). One of the RCTs was a multimodal intervention in which participants restricted their calories and completed supervised walking and stretching, and two were pelvic floor muscle exercise interventions.

The participants’ sexual function was assessed through a variety of validated questionnaires including the International Index of Erectile Function (IIEF), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire – Prostate Cancer Module (EORTC QLQ-PR25), and the Expanded Prostate Cancer Index Composite (EPIC). As such, the outcomes varied greatly across the 22 included studies in terms of measured values.

Discussion & Conclusion

Although some of the studies included in this literature review indicated positive results of exercise on the sexual function of prostate cancer patients, further research should be done to expand on these findings and determine appropriate exercise interventions for a prostate cancer treatment plan.

The authors acknowledge that a limitation of this review is the variety of exercise interventions and study designs used across the RCTs. Due to the diverse nature of the studies, it is impossible to draw overarching conclusions about the impact of exercise on the sexual function of patients.

They concluded: “While preliminary data suggests that certain exercise interventions for prostate cancer patients may improve sexual dysfunction, the evidence remains inconclusive and it is not yet possible to provide evidence-based exercise recommendations. Only few studies to date assessed sexual dysfunction as a primary endpoint and used comprehensive assessment methods. Further randomized controlled trials involving sexual dysfunction as a primary outcome and more comprehensive assessment tools are needed to confirm the rehabilitative and preventive effects of exercise on sexual dysfunction in prostate cancer patients.”

Resources:

• Reimer, N., Zopf, E.M., Böwe, R., & Baumann, F.T. (2021). Effects of Exercise on Sexual Dysfunction in Patients With Prostate Cancer – A Systematic Review. The Journal of Sexual Medicine, 18(11), 1899-1914. DOI: https://doi.org/10.1016/j.jsxm.2021.09.001