Do female sexologists have male patients

Male sexuality in cancer. A guide from the Cancer League for patients and their partners

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1 Male Sexuality in Cancer A cancer league's guide for patients and their partners

2 Imprint _Publisher of the Swiss Cancer League Effingerstrasse 40 Postfach Bern Telephone Fax _Special advice (alphabetical) Philippe Glemarec (Oncology Care, Lausanne); Dr. med. France Laurencet (medical oncology, Geneva); Dr. med. Willy Pasini (psychiatry, sexology, Geneva); Dr. med. Mark Wisard (urology and sexology, CHUV, Lausanne); Dr. med. Abderrahim Zouhair (Radiation Oncology, Lausanne) _Texts Evelyne Huber, Susanne Lanz, Alexia Stantchev _Translation Sylvia Müller, sm-communications, Winterthur _Editor Susanne Lanz, Swiss Cancer League, Bern _Illustrations Willi R. Hess, scientific draftsman, Bern _Photos ImagePoint AG, Zurich _Design Wassmer Graphic Design, Langnau ie _Druck Ast & Jakob, Vetsch AG, Köniz This brochure is also available in French and Italian. Contents Editorial 5 Cancer leaves its mark 6 Male sexuality 8 Male body and eros 9 Erection, ejaculation and orgasm 12 Relationship and sexuality 14 No fixed rules and norms 14 Cancer and partnership 14 Change as a life's work 17 Frequently asked questions about cancer, sexuality and fatherhood 19 The most common Problems 25 Listlessness 25 Erectile dysfunction 27 Ejaculation disorders 1 Injury to erogenous zones Chronic fatigue 4 Pain 4 Changes in body image 5 Urinary incontinence 7 A word for your partner 39 Epilogue 41 Glossary 43 Appendix Swiss Cancer League, Bern This brochure was produced with the support of Schering (Switzerland) AG can be realized. KLS / / 8000 D / 1029 Male sexuality in cancer

3 Dear Reader, You have probably had the painful experience of how much cancer can affect all areas of life. After the initial shock of the diagnosis, the treatment takes up a large part of your life energy. Everyday life changes, including that of your partner and relatives. Uncertainty and worries, but also complaints such as tiredness, physical changes and pain, put a strain on you and your partnership. In addition, there are manifest or feared effects on sexual potency and fertility. The need for attention, recognition and tenderness is of course retained or even intensified. The desire for sexual relationships, on the other hand, can be dampened by the physical and emotional strain and only gradually return after the therapy has been completed. This often leads to difficulties, because many people find it difficult to talk about their sexual feelings. Sometimes they just don't have the right language for it. Questions and fears about sexuality often remain a taboo. This brochure invites you to talk to your partner and, if this is difficult for you, to seek professional help. The brochure shows the most common cancer-related impairments in the area of ​​sexuality and suggests possible solutions. However, one or the other can often only be achieved with professional support and advice that is personally tailored to you. Since sexuality is experienced and assessed very individually and encompasses a broad spectrum, hardly all of the questions and answers dealt with here are of interest to you. Simply choose the topics that concern and interest you. We hope that you will be able to experience your everyday life and your partnership as happy again despite illness. With best wishes, Your Cancer League The brochure is based on the heterosexual couple relationship. However, many recommendations can also serve homosexual couples. 4 Male Sexuality in Cancer Male Sexuality in Cancer 5

4 Cancer leaves its mark Sexuality is shaped by numerous mechanisms that are in a delicate balance with one another. On the one hand, certain organs and body parts, the nervous system and hormones control our sexuality; on the other hand, our impressions, feelings and thoughts play a decisive role. Cancer and cancer treatments can seriously disrupt this subtle interaction and thus also affect sexuality. Sexual behavior is individually different and can take on an infinite number of facets and forms. It is not only controlled by highly complex biological processes, but also shaped by cultural and family influences, experiences and ideas. Emotional stress A diagnosis of cancer changes life fundamentally. Much of what was previously valid suddenly seems to be called into question. Illness and treatment can take all of your attention for a while, leaving your thoughts almost exclusively around it. Added to this are the fear for their own health and sometimes for their own life, and worries about the future of relatives. The associated insecurity can wane sexual interest. Many sufferers report that they lost all interest in sexual relationships during treatment and beyond. In this phase, it can also make perfect sense to mobilize all your strengths to cope with the disease. Physical Effects The physical effects of cancer can temporarily or permanently limit sexual opportunities. The extent of the impairment depends on the type of cancer and the therapy:> A sexual organ can be directly affected, e.g. B. in prostate or testicular cancer (see brochures on p. 49). > Other tumors in the pelvic region (e.g. in the bladder, in the intestine) can also affect the neighboring genital organs and impair sex life; z. B. if nerves or vessels are damaged during an operation or radiation (see also p. 11 Nervous system). > Chemotherapy with cytostatic drugs (drugs that interfere with cell division and thus block cell growth) also damage healthy body cells that, like cancer cells, divide rapidly. These include blood, mucous membrane and hair cells. This can also disrupt the formation of sperm. The effects vary depending on the type of drug, combination, and dosage. However, the healthy cells usually recover and with time the fertility returns. With high-dose chemotherapy, the risk of permanent fertility is increased. > Something similar happens with radiation. In spite of a precise orientation, healthy cells are always temporarily affected. Whole-body irradiation (e.g. before a stem cell transplant) increases the risk of permanent fertility. > Hormonal changes also affect sexuality. (Anti-) hormone therapies are sometimes used to block the growth of hormone-dependent tumor cells (for example in prostate cancer). There are different methods for this, which have different effects. > Other influences caused by side effects of therapy such as B. hair loss, skin problems, tiredness etc. have a rather indirect effect. Self-confidence can be shaken and sexual responsiveness can be dampened. In addition, scars, an artificial body outlet (stoma) or a urinary catheter can change sexual activity. Questions create clarity In any case, it is important that you discuss your individual situation with your doctor, if possible before the treatment. Depending on the type of tumor, other medical specialties are involved (urology, gastroenterology, visceral surgery, oncology, radio-oncology, etc.). Do not hesitate to ask all the questions that concern you in this context. It can be helpful if you write down your questions beforehand and take the slip with you to the doctor. 6 Male Sexuality in Cancer Male Sexuality in Cancer 7

5 Male sexuality By sexuality we mean everything that, in the broadest sense, is related to our sexuality and the associated ideas, behaviors, emotions, physical and psychological reactions. Various organs and organ systems as well as biological processes are involved. Sexual pleasure (libido, appetite) is a reaction to sensory perceptions, touch and body contact and to feelings about a certain person, perhaps only present in the imagination. This triggers sexual arousal. In response to these stimuli, the man usually responds with an erection (see page 12). Organs in the male pelvis a testes b epididymis c spermatic duct d bladder e seminal vesicles f prostate g vascular / nerve bundle (neurovascular bundle) h pelvic floor (supports the external sphincter of the urethra) i penis k penile cavernous body (corpus cavernosum) l urethral erectile tissue (corpus spongiosum) Urethra n pubic bone o rectum or rectum p anus male body and eros The illustrations on these pages are primarily limited to the external and internal sexual organs of men. The interaction of these and other organs can be affected by cancer and cancer treatments; the sexual possibilities are thereby changed to a greater or lesser extent. The impairments vary depending on age, affected organ and therapy; they are partly temporary, partly permanent. Cancer and cancer treatment can also leave traces on other parts of the body or disrupt systems such as nerve or hormone control and thus affect sexual function. The interrelationships can perhaps be better understood with the aid of the graphic representations. 8 Male Sexuality in Cancer Male Sexuality in Cancer 9

6 1 Hypothalamus 2 Pituitary gland 3 Adrenal glands 4 Vascular / nerve bundles (stylized) 5 Testes The hormonal system In the human body, various glands produce a multitude of hormones with different functions. This also includes the hormones that control and influence sexual and reproductive functions. The top “control center” for this is the hypothalamus or the pituitary gland in the center of the head (see illustration on the left). In men, sex hormones (androgens), including testosterone, are produced in the testicles (gonads), where the sperm cells are also produced. Testosterone is also produced in small amounts in the adrenal glands. In addition, the male body (especially the fatty tissue) also produces a small amount of female sex hormones (estrogens). During puberty, testosterone stimulates the growth and development of the genital organs and the secondary sexual characteristics. So it promotes the male physique, beard growth, the growth of armpit and pubic hair and the development of a deep voice. In adulthood, testosterone is important, among other things, for the maintenance of these secondary sexual characteristics and for sperm production. Testosterone deficiency Without testosterone, fertility is lost. The influence on libido (sexual desire), on the other hand, varies from person to person in adult men. Lack of testosterone can lead to sexual listlessness; But it doesn't always have to be that way: some men remain sexually irritable and active, even with a markedly reduced testosterone level. It sometimes (also psychologically) plays a role whether the testosterone level has naturally decreased, i.e. due to age, or whether it is brought about abruptly and “forcibly”. The removal of both testicles is particularly drastic. This is very rarely the case with testicular cancer, as usually only one testicle is affected. In the case of hormone-dependent prostate cancer, a possible form that is difficult to cope with psychologically is to slow down cancer growth for a certain period of time. Every man has the right to reject this therapy proposal and, for example, to opt for drug-based hormone suppression (see Appendix: Prostate Cancer Brochure). The various possibilities and limits should be carefully weighed with the doctor. The nervous system The nervous system is extremely complex. You can think of it as a control system that harmonizes and coordinates the various functions in our body: both those that we can influence at will, as well as those that are not subject to our will. The control center is in the brain. 10 Male Sexuality in Cancer Male Sexuality in Cancer 11

7 The nervous system plays a key role in sexual arousal and intercourse. It transmits signal stimuli from the body to the brain and vice versa. These messages are very important for erection and ejaculation. Cancer, cancer operations and treatments can also damage nerve tracts, so that the transmission of stimuli is disturbed. When intervening in the pelvis, it is not always possible to spare all important nerves. In connection with the stiffening of the limbs, the so-called vascular nerve bundle (see Fig. P. 8) is particularly worth mentioning. It runs directly along the bladder, seminal vesicles, prostate, and urethra. Before interventions or irradiation in the pelvic area, ask the surgeon or radiation oncologist which restrictions you may have to expect and how these can be alleviated (see also p. 6). Erection, ejaculation and orgasm Contrary to popular belief, erection, orgasm and ejaculation are three different physical processes that do not necessarily work together. The erection (stiffening of the limbs) When a man is sexually aroused, his brain involuntarily sends out nerve signals. These nerve stimuli flow through the nerve tracts in the spinal cord in the area of ​​the anus, prostate and urethra up to the penis. In the penis they release chemical messenger substances that cause the erectile tissue to swell and the blood vessels to expand. Now the blood shoots into the blood vessels of the limb: the penis erects under this pressure, swells and becomes stiff. The nerve impulses and the resulting chain reaction cannot be deliberately controlled. The erection just happens. It cannot be produced by muscle strength or exertion. On the other hand, it can be made more difficult under the influence of certain drug side effects, damaged nerves, insufficient blood flow (tumescence) or stressful feelings (insecurity, nervousness, fear of failure, stress, grief). Ejaculation (ejaculation) With sustained stimulation, the sexual arousal increases to orgasm (climax), a moment of highest physical and emotional pleasure. Sex organs, pelvic floor, sphincters, etc. contract rhythmically. As a rule, the semen is also expelled (ejaculation, ejaculation). The great tension during the excitement phase is followed by deep relaxation associated with a feeling of satisfaction. Orgasm and ejaculation are not necessarily the same thing. There are orgasms without ejaculation and ejaculations without orgasm. Sometimes, especially after operations in the prostate-bladder area, the seminal fluid is also expelled backwards into the urinary bladder. This phenomenon is called retrograde ejaculation in technical jargon. The semen is then later excreted in the urine. Sensation of pleasure The actual "pleasure organ" is the sexual center in the diencephalon. During orgasm, nerve impulses are sent to the brain from the penis and other erogenous zones; the brain decodes them as sensations of pleasure. The nerves that trigger the sensation of pleasure in the brain are also called "sensitive" nerves. They are fundamentally different from the nerves that send impulses from the brain to the penis and thus control the erection. Conclusion: Even men who no longer have an erection can in most cases still feel pleasure and orgasm. 12 Male Sexuality in Cancer Male Sexuality in Cancer 13

8 Couple Relationship and Sexuality For most people, sexuality is not only used for procreation and pleasure, but also offers them the opportunity to feel particularly close to another person. For many couples, sex is just one of many expressions of affection and attraction. Just as important for them are trust, mutual respect, tenderness, shared values, shared experiences and other signs of their solidarity. No fixed rules and norms Sometimes we find our own sex life downright mundane compared to what we learn about the sexuality of others in the media. Depending on the phase of life and personal feelings, sexuality has a different status in a person's life. In the case of a major disease like cancer, sexual activity is often stopped for a certain period of time or it takes a back seat. When the spirits gradually return after the end of the treatment, the desire for sexual get-togethers grows again. In the meantime, don't put any pressure on yourself: there are no norms as to how often or how sexual encounters should take place. So you can take your time and maybe use this time to talk to your partner about wishes and possibilities.Sexuality can be lived and experienced in many ways. Genital intercourse can or does not have to be part of it. Eroticism often arises in the rather quiet spaces in between, where two people attract and get close, touch, caress or massage each other. Cancer and partnership Cancer can throw some of the things that have given you security up to now, including the habits and rituals of your partnership and your sexual get-togethers. Some things in life have to be changed, new plans have to be forged. Perhaps you are dependent on outside help because your performance is limited. This also changes the roles within your family and partnership. Sometimes smoldering problems that existed before the disease now come to the fore. In other cases, however, going through the illness and the treatments together can also strengthen the relationship. Perceiving our own needs We often have certain expectations: For example, we long for more tenderness, for a very specific touch or just want attention, but we do not communicate this. Many a wish remains unfulfilled. The questions interspersed in this brochure can help you to become clear about your situation and your own needs and then to share them with your partner. You will find that you have nothing to lose and that it is beneficial to learn more about each other. This way, misunderstandings can be cleared out of the way. Also, remember: your partner cannot guess your needs. For example, the desire for tenderness is often confused with the need for sexual intercourse. Talking to Each Other Looking at your potential difficulties and aspirations together and talking about them can reinvigorate your relationship. However, many couples find it difficult to talk about their own sexuality. It may therefore be helpful for you to put your thoughts in order before you speak them out. Questions to Ask Yourself What was it like before the illness? > Was I satisfied with our sexuality? > How often have we been together? > What did I like and what didn't I like? > How important was sexuality to us before the illness? And now? > Have we talked about our sexuality before? How is it now? 14 Male Sexuality in Cancer Male Sexuality in Cancer 15

9 How is it today? > What do I find attractive, erotic about myself? > Do I trust my partner? Am I afraid of possible rejection? > What scares me? > What hurts me? What is good for me? Which are my pleasure zones? Have they been changed by the disease? > What do I feel like doing? What do I need for a satisfying sexuality? > What is preventing me from feeling lust and joy? How do we relate to each other? > What holds us together? Tenderness, sex, our children, everyday life together, friendship, care, security ...? > What's going on in my partner? What fears or fears does she possibly have? > What does my partner want? Did i ask her? Can i ask you > If reticence or distance is noticeable in our relationship: is this actually due to the illness? > Do we have a common language for sex? Which? Is it more factual (link)? More childlike (Pfifli)? More vulgar (tail)? Anyone who speaks openly about their wishes and tries to fulfill them will usually find a satisfactory solution. Many couples also report that the more intensive mutual exchange has enriched their relationship. Maintaining the relationship A couple relationship is like a plant: it needs to be nurtured and cared for so that it flourishes. Especially when "it" doesn't really work anymore, other forms of togetherness can bridge the difficulties, perhaps even help to overcome them. It can be exciting and erotic to encounter each other again in everyday life instead of focusing exclusively on the sexual act. Every relationship that is healthy at its core can be consciously revitalized: through small attentions, mutual surprises, shared experiences, things that create closeness. Your relationship will be strengthened by any get-together where you feel comfortable with and perceive each other. Couples therapists even recommend making an appointment every now and then, like when you and your partner did not live together. Change as a life's work Losses and changes are part of our life. We cannot avoid them. As painful as this sometimes seems, in retrospect, many people report that unpleasant changes were ultimately also an opportunity and opened up new perspectives for them. At the time of cancer diagnosis and treatment, however, the threat inevitably comes first. It often takes many individual steps to learn to live with uncertainty, steps that can be accompanied by numerous emotions. They range from anger (why me?) To denial (that's none of my business) to self-accusation (if I had acted differently). Ambiguities, unspoken things and also relationship problems may now show up more clearly than before the illness. It is important that you face this process of processing and allow yourself to feel. Rejection, anger, and sadness are normal, healthy reactions. Questions to ask yourself> What has changed? > What do I no longer want? What do I want instead? > Am I ready for something new? Do I want my partnership to develop further? To what extent does this also affect our sexuality? Time heals Most wounds close over time. Perhaps, however, certain changes are indicated and need getting used to, some temporary, others permanent. Professional accompaniment is recommended if you cannot find the way to a happy sexual relationship again and if you have difficulties with your partner or cannot talk to her about it as a result. 16 Male Sexuality in Cancer Male Sexuality in Cancer 17

10 Frequently Asked Questions about Cancer, Sexuality, Fatherhood Counseling Services It can be easier to talk about certain problems instead of pausing to think about them. If it is difficult for you, it is advisable to first talk to someone you trust from your treatment team or your family doctor. If necessary, specific specialist advice (e.g. urologist, sexologist, couple counseling) can be recommended or prescribed. Your cantonal cancer league or a self-help organization can also be contact points. If you prefer to remain anonymous, the cancer hotline, online advice or an internet forum might be an option for you (see appendix). You do not need to hide behind the scientific or discreet terms that are partly used in this brochure. Just talk the way you naturally like to talk about sex. Approval of costs You may be able to clarify your concerns to your satisfaction after just a few hours of consultation and recognize new perspectives for yourself and your relationship. Before doing this, however, you should obtain a confirmation of the costs from your health insurance company or ask your doctor or the cancer association in your region to do this for you. The insurance benefit depends, among other things, on your type of insurance and on whether the offer of your choice is recognized by your health insurance company. The questions and answers listed here can hardly satisfy all needs, the individual requirements are too different for individual people. Do not hesitate to contact your doctor and treatment team if you have any questions or concerns. Other contact points could also be helpful for you (see appendix). Is Cancer Contagious? No, cancer itself is not contagious, either through sexual contact or otherwise. The cancer cells cannot be transmitted through body contact, neither through kisses with tongue nor through vaginal, oral or anal sex. However, cancer can be more common in certain families. The cancer league brochure “Familial Cancer Risks” (see appendix) goes into more detail. Can you get cancer from certain sexual practices? So far, no direct causes have been proven. The kebs cells themselves are not transferable. However, frequent unprotected sexual intercourse with different partners increases the risk of a viral infection (hepatitis, herpes, papillomavirus, HIV). Such infections can lead to the development of cancer over time. For example, infection with the hepatitis virus can promote the development of liver cancer. Or certain types of papillomavirus (they are transmitted by men) can be involved in the development of cervical cancer in women. Am I radioactive after exposure? What is the risk to my environment? There are different types of radiation, each with different consequences. Your radiation oncologist will discuss with you exactly what measures may need to be taken. When irradiated from the outside, the rays are directed through the skin (percutaneously) and the tissue onto the tumor. In this case nothing remains of the rays in the body; They are therefore not radioactive. For some tumor diseases, radiation from the inside (brachytherapy) is now also carried out. The radioactive sources are located directly in the tumor or in its vicinity or in the affected area. 18 Male sexuality in cancer Male sexuality in cancer 19

11 organ (e.g. in the prostate or in the rectum). Depending on the dosage, a stay in hospital may be necessary for reasons of radiation protection. After outpatient radiation treatment (or after leaving the hospital) there is no radiation risk for the environment, not even during sexual contact. In radioimmunotherapy, radioactive substances (radiopharmaceuticals) are administered so that they "dock" to the cancer cells and destroy them. Excess substances that are not absorbed by the tissue are usually excreted with the urine. Depending on the situation, the therapy is carried out on an outpatient basis or in a hospital. In order to rule out any risk to the environment, you must observe certain protective and precautionary measures for a short period of time. For example, you shouldn't carry young children around for hours; But you can hug and kiss her without further ado. You should use condoms during intercourse for about a week. You must safely prevent conception for about six months. Your doctor will give you precise information about the measures you need to take. You can find more about radiation therapy and how to deal with side effects in the Cancer League brochure “Radio-Oncology” (see appendix). Can sex make my illness worse? That should hardly be the case. On the contrary: A satisfying sex life increases self-esteem, stimulates the immune system, has a stress-reducing effect and gives energy and joy of life. Are there reasons to forego sex anyway? > If you have had an operation in the pelvic area, you must refrain from sexual intercourse until everything has healed. This also applies to irritation or inflammation in the pelvic area after irradiation. > After chemotherapy, the number of blood platelets (thrombocytes), which regulate blood clotting, can drop sharply, which increases the risk of bleeding. If this applies to you, you should only practice "soft sex" without penetration. Your doctor will do regular blood tests during chemotherapy and tell you what this means for you. Is anal intercourse (not) a problem? Anal intercourse generally carries an increased risk of bleeding, injury and infection, which can be exacerbated by cancer. This is especially true if the number of blood platelets (thrombocytes) or white blood cells (leukocytes) is too low after cancer therapy. The rule is: Always use condoms and lubricants and temporarily avoid certain sexual practices. You should speak to your doctor beforehand about the possible risks and side effects of certain sexual practices. How at risk is my partnership if I want or have to forego sexual intercourse? Love and partnership go far beyond genital intercourse. Even during illness, there are countless ways to express affection and togetherness other than through sex. However, unspoken guesses or fears about what your partner might be feeling or thinking are of little help. If you are concerned with this, speaking directly to you can bring you clarity. The questions interspersed in this brochure can help you clarify your mutual expectations. I didn't have a partner before my illness. Now my chances are falling even more. Such fears are understandable, even if there are many men who have only met their heart partner during or after an illness. Life crises often lead to opportunities that one never dared to dream of before. Many sufferers report that they have dealt more with themselves and what matters in life during the illness, and that they have become more self-confident as a result. This confidence also helps in building a new relationship. Please discuss all questions about conception and contraception with your doctor before starting treatment. Insist even if they shouldn't bring up the topic on their own. 20 Male Sexuality in Cancer Male Sexuality in Cancer 21

12 Perhaps you fear rejection as soon as you tell a new acquaintance about your illness. Perhaps you are physically in a bad state and you feel inhibited about showing yourself naked. Or your sexual options are limited. It cannot be ruled out that someone will react cautiously as soon as he or she learns about your illness. Often the other person gets frightened at first and has to get used to the thought. What seems like a “rejection” mostly arises from one's own fears and insecurity. In a relationship worthy of the label, such concerns should quickly subside. As a new relationship begins to deepen, in time you should start talking about your illness as well. There are always suitable opportunities. If you can accept your own limitations and deal with them naturally and naturally, this will also be easier for a partner. In the case of physical impairment or limitation, however, it would be unnecessary for both of you if you only talked about it the first time you went to bed or if "it" became visible. Is paternity still possible? Depending on the phase and age of your life, you may be concerned with the question of whether you will be able to father a child later. There is no general answer to this question, as the effects of cancer and cancer treatments vary from person to person. Sometimes they reduce fertility, sometimes lead to temporary and sometimes permanent sterility. Therefore, the topic should be on the table before the start of treatment if possible. So do not be afraid to ask your surgeon, urologist, oncologist, radio-oncologist, family doctor, etc. about it. Under what conditions can I become a father despite being treated for cancer? All reproductive organs must be kept functional, this usually also applies to the ability to erect and ejaculate. You also need adequate sperm production (quantitatively and qualitatively). Only your doctor can give you more detailed information about your situation. Are there ways of maintaining fertility? Thanks to improved surgical and treatment techniques and thanks to early detection, sterility is becoming increasingly rare after cancer. Nevertheless, it cannot be ruled out. Even if you are not (yet) concerned with the question of paternity, it is important to clarify the question before starting treatment. This makes it possible at best to freeze sperm (cryopreservation) before the sperm formation is damaged by any therapy. The process is simple: the sperm is obtained through masturbation and placed in a sperm bank, for which you usually have to pay an annual fee. This enables you to become a father through artificial insemination even years later. If there is no erection and / or ejaculation, sperm can be obtained through a small surgical procedure. One speaks of testicular sperm extraction (TESE). Sperm cells are taken from the testicles or epididymis. If you ejaculate inwards into the bladder (retrograde), the semen can be removed from the urine. When is the right time for paternity? Radio and chemotherapy can temporarily damage semen formation. There is, therefore, some risk of deformity for a child conceived during these therapies and for a period of time thereafter. You should therefore wait even after the treatment has ended. How long it is likely to take for semen formation to return to normal depends on the therapies. Your doctor will inform you accordingly.If your partner became pregnant by you before the start of treatment, there is no risk to the child-to-be or to your partner. Cancer is not contagious. Do we have to use contraception during treatment? Yes. All classic and safe contraceptive methods are suitable for this. If your partner is using contraception, you should still protect yourself and your partner with condoms for the entire duration of treatment and for a certain time thereafter; because during chemotherapy the sperm can always contain traces of the medication. 22 Male Sexuality in Cancer Male Sexuality in Cancer 23

13 The most common problems Depending on the type of cancer, depending on the stage, and depending on the treatment, different problems can arise. We'll go into the most common ones here. There are no magic recipes for sexuality and the relationship between two people. What some find pleasant may turn out to be useless or even annoying for others. The following suggestions are just a few of the things that can inspire you and your partner. Listlessness Sexual desire and behavior is very different from person to person, regardless of illness. In the case of cancer and the symptoms associated with it, it is normal and it often happens that someone is hardly interested in sexual relationships and hardly reacts to erotic stimuli. During treatment and during a stay in hospital, many of those affected have the feeling that their body has been lost or that it is only the subject of medical and hygienic activities. For therapy or examinations, one is always half-naked in front of strangers. This hurts one's privacy and can lead to someone not wanting to be touched for a while afterwards. Over time, this kind of inner defense disappears again. Possible causes> Mental stress due to the illness: worries, fears, general malaise> Tiredness and exhaustion ("Fatigue"; see p. 34)> Pain (see p. 34)> The various treatments> Changes in body image (see p. 35 )> Changes in the hormonal balance Irradiation in the pelvic area, certain chemotherapy, (anti-) hormone therapies or medication against nausea (antiemetics) can temporarily or permanently lower the testosterone level. If both testicles are surgically removed, testosterone production is practically complete (see p. 10 hormone system). 24 Male Sexuality in Cancer Male Sexuality in Cancer 25

14 recommendations> Talk to each other Talk to your partner about your listlessness; this can relieve you and ease the pressure you may be feeling. Perhaps you still feel like an intimate get-together? This can also be done without sexual intercourse. magazines or erotic films into the world of lust. You can also fantasize alone or with your partner about which sexual desires you would like to live out (or maybe not?). Sometimes memories of earlier, particularly beautiful erotic moments also arouse desire. perceived gender when the sexual organs are deliberately not touched for the time being. > Conscious relaxation Emotional and mental stress can paralyze pleasure. If your head is not free for an erotic encounter, you cannot enjoy it either. test he can determine the hormone level. Hormone replacement always has side effects. It comes into question, for example, if the testosterone level falls below the normal norm for your age. In the case of hormone-dependent tumor growth (e.g. prostate cancer), however, the use of hormones is contraindicated. If you find it difficult to talk to each other, a neutral third party can help you organize your thoughts and find the right words. Specialists from your treatment team, the cancer league in your region or, if you would like to remain anonymous, the cancer hotline (see also p. 48) are confronted with such difficulties on a daily basis and can advise you competently. > Analyze displeasure If there are no obvious somatic (physical) reasons, you might find out what exactly is causing you difficulties with the self-questioning on p. 15 ff. > Erotic fantasies It can be stimulating and also funny to find yourself through erotic-> self-stimulation (masturbation) Despite sexual liberation, masturbation is still a taboo in certain circles. Masturbation is a completely natural way of experiencing sexual pleasure and rediscovering or getting to know your own body's reaction. In this way, you can ideally feel more secure and relaxed again with your partner. In sex therapy, masturbation is a recognized "cure" for various disorders. > Partner massages Mutual massage and gentle touching have a very relaxing effect and release some blockages. You can get very close without having intercourse. Sometimes it even becomes more erotic and arousing- Choose from the various options the one that best suits you. For some it is progressive muscle relaxation, for others it is autogenic training or exercise. > Professional massages A specialist not only works intuitively with massages, but also knows how the various muscles, tissues, vessels or nerves are connected to one another. Professional massages can increase your own body awareness with pleasure. That gives strength, energy and self-confidence. > Hormone treatment Whether a possible hormone deficiency can be remedied by administering hormones must be decided together with the doctor. On the basis of blood erectile dysfunction, cancer and cancer treatment, the interplay of physical and mental processes necessary for an erection can temporarily or permanently imbalance (see also p. 12). Erectile dysfunction can occur. For practical reasons, we will deal here with mental and physical causes separately. In fact, they overlap or condition one another. Possible emotional causes> Fear of the disease and its consequences> The feeling of not being able to perform at all> Self-doubt or hurt self-esteem> Fear of failure or pressure to succeed 26 Male sexuality in cancer Male sexuality in cancer 27

15> Stress> Myths and legends about male potency or one's own attitude towards it> Loss of role / image Recommendations The clearer the possible causes are to you, the sooner you can do something about it. Self-questioning (see p. 15 ff.), Conversations with your partner, conversations with a specialist (your doctor, a sex therapist or couples therapist) are the best way to find out what could be the cause. > The erection is often equated with potency (from Latin potentia = power). Find out what makes you feel powerful other than an erection. > Perhaps you would like to be stimulated by your partner differently than before? Have you already told her? > Other sexual practices and a changed attitude towards yourself and your body can relieve you of the pressure of having an erection. The desire to play, a little imagination and humor can work wonders. Anything that is good for you (and your partner) and that makes you happy comes into question: oral stimulation, self-stimulation, a vibrator, etc.> You can also “forbid” yourself to have an erection in order to completely indulge in unintentional pleasurable play and surrender goal. Perhaps you will rediscover laughing and can enjoy each other and have fun with each other and with each other. > Sexual intercourse is possible even without a full erection. With the woman astride the man, the penis is easier to insert with the help of the hands. An orgasm can also occur without an erection or with a partial erection (see p. 12). Possible physical causes> Damaged or cut nerves and / or blood vessels that are important for an erection. This risk is particularly high with surgery or radiation for prostate tumors, but also with bladder and colon cancer. > Too low testosterone level (see p. 10 hormone system)> Damaged penile erectile tissue> Other diseases such as diabetes, high blood pressure, alcohol abuse, depression, etc. or the medication taken against them> Low sexual activity and poor sexual function even before cancer diagnosis Recommendations Important: For sexual clarification There are problems today with reliable investigation methods. If the problem persists, you should definitely consult your doctor before using a sexual enhancer to clarify the exact cause. > It is important that you and your partner talk about erectile dysfunction. Often the "man's silence" causes more problems for a woman than erectile dysfunction per se. > A urologist or, depending on the situation, a sex medicine specialist or therapist can advise you most likely. The various possible solutions must take into account your general health, your specific concerns and your personal preferences. If you are in a committed relationship, your partner should accompany you to such counseling sessions. > Please do not «practice» with the various methods in a quiet room, but get medical advice. > Have the advantages and disadvantages of the respective methods as well as the possible side effects and contraindications explained to you in detail. Medicinal erection aids> Certain drugs cause more blood to flow into the penis or the blood to drain less quickly. This can make an erection possible, even if blood vessels and nerves are injured. An erection is not possible if the nerves are severed. Contrary to popular belief, these are not pleasure pills: if there is no emotional arousal, the drugs will not work. > Substances that dilate blood vessels can also be administered in other ways: Using MUSE (Medicinal Urethral System for Erection): An applicator is used to insert a suppository (urethral rod) into the front of the urethra. The stick dissolves by gently massaging the limb. The substance gets into the erectile tissue and causes an erection after a few minutes. Using SKAT (cavernous body autoinjection therapy): With a very thin needle you can inject the active ingredient into the erectile tissue of the penis yourself. 28 Male Sexuality in Cancer Male Sexuality in Cancer 29

16 That takes some effort. The erection occurs after about 10 to 20 minutes. Vacuum erection pumps They work purely «mechanically». The penis is inserted into a transparent plastic cylinder. A vacuum is generated by means of a pump. This allows blood to flow into the erectile tissue. When the desired erection is achieved, a rubber ring rolled over the penis prevents the blood from flowing back into the body too quickly. It must be removed after 30 minutes at the latest, otherwise the erectile tissue could be damaged. Penile implants They are an option when the erectile tissue is damaged and drug therapy or other procedures are definitely not (any longer) an option. They are surgically implanted and replace or destroy (irretrievably) the erectile tissue. You can choose from> hydraulic erectile tissue implants; they can be stiffened with a pump device and enable a natural-looking erection; > flexible rod prostheses made of silicone. The penis is brought into the desired standing position by hand or bent down again. However, he always feels and appears erect. Penis extensions In rare cases, the penis can be shortened after an operation. An orgasm is still possible. Depending on the situation, an improvement is possible with plastic surgery. An attachable latex prosthesis is an alternative. The prosthesis is placed on the erect penis. Miracle drugs Countless substances that are supposed to promote potency (so-called aphrodisiacs) are touted on the market. Some can have a stimulating effect on tiredness and exhaustion, but that's about it. There are no miracle drugs that have a direct effect on potency. Decision-making support Please consider that a stronger erection or a longer penis is not necessarily more pleasurable for you or your partner. You can have an orgasm yourself without an erection. In addition, many women do not orgasm through vaginal stimulation, but rather through manual and / or oral touch. So you can give your partner pleasure even without an erection. Too much “mechanics” can also dampen love and lust. The following questions may help you and your partner make decisions:> What organic changes have you made? > What options are available for you, both technical and psychological? > Which aids are acceptable to you? > What alternatives are available to you in addition to the erection aids presented here? > To what extent could the different methods contribute to your quality of life? > Is that a win for you as a couple? Risk of long-term reaction Some of the mentioned erection aids can lead to a permanent erection (priapism) if the blood no longer drains. However, this has nothing to do with lust and potency, it is rather uncomfortable and dangerous. In such a case, you should call for medical help after 5 hours at the latest, as otherwise the penile tissue could be seriously damaged. Ejaculation disorders Premature ejaculation (Ejaculatio praecox) Premature or premature ejaculation is defined as an ejaculation that occurs against the will of the man because he cannot feel it coming or cannot hold it back. In itself, however, there is no timely ejaculation. Possible causes> stress, pressure to succeed, worries> erectile dysfunction> prolonged sexual abstinence Recommendations Be sure to discuss the situation with your partner first. If you both think that you are coming too early, you can look for opportunities for change together. There are many ways to be together with pleasure, even without a long erection. 30 Male Sexuality in Cancer Male Sexuality in Cancer 31