How you manage the symptoms of advanced prostate cancer and the side effects of treatment has a major impact on your quality of life. The diagnosis alone can create fear, anxiety or depression for some men. Learning what to expect from both the disease and the treatment options can give you a sense of control and confidence in making the decisions ahead. Ask your doctor or nurse to explain instructions and any medical terms that are unclear to you. Seek help as soon as you feel you are having trouble coping with the illness. Resources and support services at your hospital and in the community can provide assistance. In addition to friends and family, social workers, support groups, counseling, and mental health services can help you feel that you are not alone when you are stressed or overwhelmed.

Although you may not experience symptoms of advanced prostate cancer, some side effects are common to both prostate cancer and its treatments. The symptoms that occur most frequently include:

Urinary problems (pain or burning when urinating, blood in the urine, or decreased force of your urinary stream)
Erectile dysfunction (difficulty having an erection, impotence)
Pain or discomfort in your pelvic area, spine, hips, ribs, or other bones
Bowel problems may also occur during or after treatment, and hormone therapy and chemotherapy are associated with side effects as well.

Urinary Problems

Both prostate cancer and its treatments can result in urinary problems, such as burning with urination, weak urinary stream, blood in the urine, and incontinence (inability to control urination). There are three basic types of urinary incontinence:

Stress incontinence: You leak urine when you cough, sneeze, laugh, or rise from a sitting position.
Urge incontinence: You are unable to get to the bathroom in time.
Overflow incontinence: You don’t empty your bladder completely when you urinate.

In rare cases, the prostate tumor may press on the urethra (the tube that carries urine out from the bladder), restricting or even blocking the flow of urine and causing pain and enlargement of the bladder. Some degree of incontinence is likely after radiation therapy, cryotherapy, and radical prostatectomy if the muscles or nerves that control the release of urine are damaged. Incontinence may disappear in a few weeks or months, but for some men it may take several years for incontinence to resolve or it may be a lasting problem.

Managing Urinary Problems

There are a variety of options available to help manage urinary problems:

Medications that improve urinary flow, such as tamsulosin (Flomax) and tolterodine (Detrol).
Medications that calm an irritated bladder, including terazosin (Hytrin) and solifenacin (Vesicare).
Kegel exercises, which involve contracting and relaxing the muscles of the pelvis, helping you to maintain better control of urination.
Devices to collect urine or stop leakage, such as a condom catheter, which fits over the penis and drains urine into a storage bag, or a penile clamp, which stops urine leakage with a V-shaped foam cushion that presses on the urethra.
Injection of collagen into the urethra, which narrows the passageway for urine.
Surgical procedure to provide support to the urethra and relieve pressure on the bladder.
Talk with your doctor about specific treatments that might benefit you, depending on the particular urinary problem or type of incontinence you have.

Erectile Dysfunction (Impotence)

Erectile dysfunction or impotence is the inability to have and sustain an erection. Both prostatectomy and radiation therapy can cause impotence and sterility if damage occurs to veins or nerves that help achieve and/or maintain an erection. Because these nerves and blood vessels are delicate, they can be damaged even if treatment is given with great care. ADT often causes impotence and loss of sexual desire by eliminating testosterone. Impotence may be temporary or long-lasting. If you want to be able to father children, you may wish to consider use of a sperm bank before treatment.

The emotional impact of impotence can be very important, causing feelings of anger, sadness, frustration, or lack of confidence. Often, men with impotence will avoid sexual contact, causing their partner to feel rejected or inadequate. But couples can achieve intimacy and express affection in ways other than sexual intercourse by touching, caressing, massaging, holding, hugging, and kissing. You may consider seeking sex therapy treatment as a couple or alone.

Managing Erectile Dysfunction

Your sexuality doesn’t have to be limited to an erection, but your doctor can suggest a number of ways to improve your ability to have an erection, including:

Medicines for erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). NOTE: These drugs are not safe for men who take nitrates or alpha-blockers.
Penile injections
Vacuum erection devices
Penile implants
Urethral suppositories

Pain

Men sometimes feel they shouldn’t complain about pain, that they should just be brave and bear it. But pain is a stress on your body and can affect your immune system and its disease-fighting factors. Not only can pain hurt your spirit, it can interfere with your recovery. If you are in pain, you may feel:

Angry
Anxious
Depressed
Worried
Lonely
Tired

Controlling pain is part of your cancer treatment. Numerous medicines are available for a wide range of pain, from mild to severe. Don’t “save” pain medication for a later time the best way to control pain is to stop it early, or keep it from getting worse. It may be helpful to keep a diary of pain you experience. You might list:

When you take pain medicine
Name and dose of the medicine you take and its effect
Length of time the medicine works for you
Any side effects from the medicine
Other methods that provide relief for your pain
Activity that makes the pain worse or makes it better
Things you’re unable to do because of pain

With advanced prostate cancer, metastases to bones can cause back, pelvis, or hip pain and even fractures (broken bones). As the tumor grows, it may press on tissues around it, causing pain. Back or neck pain may result if a tumor spreads to the spine and presses on the spinal cord. Radiation therapy can help prevent or treat fractures and provide pain relief. Bisphosphonates, a class of drugs commonly used to treat osteoporosis (weakening and thinning of bones), prevent the loss of bone mass and will help prevent bone fractures as well as relieve bone pain. Vitamin D and calcium supplements help support bone strength and are given along with bisphosphonates.

Metastases to the liver may cause abdominal pain, and metastases to the lungs can result in a persistent cough and chest pain. Some medical procedures used to diagnose cancer or see how well treatment is working, such as biopsy or bone marrow tests, are painful or cause discomfort. Your doctor and treatment team can help develop a good pain management plan for you that changes to meet your needs.

Bowel Problems

Bowel problems are more common following radiation (EBRT) than any other primary therapy and may include:

Diarrhea
Inability to control bowel movements (fecal incontinence)
Bleeding from the rectum
Dry, red, tender skin at the site of radiation

Although EBRT dosing and techniques continue to improve, the treatment can cause significant damage to the rectum that tends to get worse over time. There are generally fewer bowel problems after brachytherapy, however, and recovery tends to be faster than with EBRT.

Managing Bowel Problems

Antidiarrheal medicines, such as diphenoxylate and atropine (Lomotil) and loperamide (Imodium), help control diarrhea. In addition, it is wise to avoid foods that can irritate the stomach and intestines, such as spicy or greasy foods. Taking fiber supplements or eating more whole grains, fruits, and vegetables can also help by adding bulk to the material in your intestines. Laser therapy may be used to stop rectal bleeding caused by radiation, and special ointments or creams can sooth skin that is tender from radiation treatments.

Side Effects of Hormone Therapy

Although hormone therapy (ADT) is the principal treatment for advanced prostate cancer, it is also known to cause many side effects in addition to impotence and loss of sex drive (Table 1). But many of the side effects are treatable, and most go away once treatment is finished.

Hormone therapy is sometimes given on an intermittent basis in an effort to reduce the side effects (see page 4 for an explanation of an intermittent treatment schedule). It is unclear, however, if this approach is as effective as continuous therapy.

Table 1. Side Effects of Hormone Therapy

Side Effect	Management Options
Hot flashes/flushes	Your doctor may suggest medications such as low doses of estrogen or progesterone.
Osteoporosis	Your doctor may prescribe bisphosphonates to help reverse the effects of osteoporosis and relieve bone pain.
Weight gain, fluid retention, swelling of hands, legs, and feet	Stay active, walk, ride a bike. Limit salt and salty foods. Raise feet when sitting.
Loss of muscle mass	Lift weights, maintain an active lifestyle.
Enlarged and/or tender breasts (gynecomastia)	Your doctor may recommend a single, low dose of radiation before ADT begins.
Fatigue	Take short walks and engage in other physical activity and take short (30-minute) naps.

Side Effects of Chemotherapy

People react differently to chemotherapy, and side effects vary with different treatment combinations and different types of cancer. Although your doctor or nurse will tell you what you may expect from the regimen you will receive, be sure to tell them what side effects you experience. Many side effects are mild, treatable, and will go away after chemotherapy is finished (Table 2).

Table 1. Possible Side Effects and What to do About Them

Hair loss	Be patient — your hair will grow back, but the color or texture may change.
Fatigue (extreme tiredness)/anemia	Get 8 hours sleep every night, take short naps when needed, get some exercise every day, eat and drink well. You may need to eat foods that contain iron.
Numbness/tingling in toes or fingers (neuropathy)	Your doctor may delay or reduce the treatment dose until this side effect resolves.
Low number of white blood cells (infection-fighting cells) Low number of platelets (cells that cause blood to clot in order to stop bleeding)	Your doctor may prescribe pegfi lgrastim (Neulasta), a drug that helps your body build infection-fighting cells. Wash hands often and avoid crowds and people who are sick. Avoid injury and cuts. Don’t use dental fl oss or toothpicks. Wear shoes to protect your feet.
Loss of appetite	Eat 5 or 6 small meals each day instead of 3 large ones. Stay active. Eat foods that are easy to swallow.
Swelling (fluid retention)	Wear loose clothing and shoes that are not too tight. Raise your feet when sitting. Avoid salty foods.
Mouth or lip sores	Use a very soft toothbrush and brush after eating and before bed. Use a mouth rinse of 1 cup warm water, 1/4 teaspoon baking soda, and 1/8 teaspoon salt. Choose soft foods and avoid spicy foods, citrus juices, alcohol, and drinks containing sugar. Avoid smoking.
Nausea (upset stomach) and vomiting	Take your anti-nausea medicine even on days when you feel well. Learn when eating is best for you and wait at least 1 hour after treatment before eating.

Additional Sources of Information

American Cancer Society: www.cancer.org
Sexuality for the Man with Cancer
Prostate Cancer Foundation: www.pcf.gov
When to Seek Help with Treatment Side Effects
Us TOO International Prostate Cancer Education & Support Network: www.ustoo.org
  Post Treatment Issues
  Patient Support Line: 1-800-808-7866 (M-F 9am-5pm)
  Guide to Surviving Prostate Cancer, 2nd ed., By Patrick Walsh