Complications
Your Organisational Guidance
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Recommendations nationales de bonne pratique pour la prise en charge du cancer localisé de la prostate: première partiePublished by: KCELast published: 2014Nationale praktijkrichtlijn voor de aanpak van gelokaliseerde prostaatkanker: deel 1Published by: KCELast published: 2014Caused by an irritation of the mucosal lining of the urethra.
May be treated with non-steroidal anti-inflammatory (NSAIDs) drugs or phenazopyridine.
Caused by an irritation of the lining of the bladder and bladder neck.
May be treated with alpha-blockers.
Radiotherapy and radical prostatectomy are associated with urinary incontinence; rates of urinary incontinence are higher following surgery than radiation.[186][392]
After radiotherapy, urinary incontinence may be caused by an irritation of the lining of the bladder and urethral sphincter. Bladder spasms result in urge incontinence, which may be treated with conservative therapy (e.g., bladder retraining, pelvic floor muscle training, behavioural therapy) or with pharmacotherapy (e.g., anticholinergic drugs or a beta-3 agonist).[393]
After surgery, urinary incontinence may be caused by damage to the pelvic floor muscles or damage to the urethral sphincter. Incontinence following surgery usually improves over time, and most men achieve continence within a year.[394] There is a lack of good-quality evidence for conservative treatments, such as pelvic floor muscle training, electrical or magnetic stimulation, and lifestyle modifications.[395][396] However, pelvic floor muscle exercises (Kegel exercises) may be effective to strengthen the pelvic floor.
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[Evidence B] Guidelines recommend pelvic floor muscle exercises or pelvic floor muscle training, which should be started in the early post-operative period.[394][397] A preoperative pelvic floor muscle training programme may be beneficial to promote early recovery.[394][398]
For patients who continue to have bothersome stress urinary incontinence despite conservative therapy at 1 year after treatment, surgery (e.g., to implant an artificial urinary sphincter, male sling, or adjustable balloon device) may be considered.[394]
Caused by an irritation of the lining of the bladder.
Caused by an irritation of the lining of the bladder and bladder neck.
Overall prevalence decreases with duration of follow-up.[399]
Caused by a temporary loss of the mucosal lining of the rectal wall.
May be treated with a low-residue diet designed to avoid gastrointestinal inflammation, and antidiarrhoeals.
Mild rectal bleeding is common 1-3 years after radiotherapy.[399]
The risk of severe bleeding is low. It appears similar to haemorrhoidal bleeding and is caused by neovascularisation and telangiectasia formation in the rectal mucosa.
Caution should be taken when colonoscopy reveals an abnormality in the rectal wall in a patient with a history of radiotherapy. Multiple biopsies of the anterior rectal wall may result in fistula formation.
Androgen deprivation therapy (ADT) promotes weight gain, decreases insulin sensitivity, and adversely alters lipid profiles. It may be associated with a greater incidence of diabetes and stroke; increased incidence of cardiovascular disease has not been consistently demonstrated.[417][418] The increased risk of cardiovascular disease and stroke may be limited to men with drug-induced androgen deprivation and not those treated with surgical castration.[410][419][420] The benefits of ADT should be weighed against potential harms. The optimal strategy to mitigate the adverse metabolic effects of ADT is unknown.[421]
A systematic review and meta-analysis found that, based on limited evidence, exercise may benefit some markers of cardiometabolic health (e.g., diastolic blood pressure, fasting blood glucose, C-reactive protein, whole-body lean mass, appendicular lean mass, whole-body fat mass, whole-body fat percentage, trunk fat mass), but not others (e.g., systolic blood pressure, blood lipid metabolism).[422]
The American Society of Clinical Oncology has published guidance regarding exercise, diet, and weight management during cancer treatment.[423]
When dysuria or urinary obstructive symptoms occur more than 6 months after radiotherapy (more commonly after brachytherapy), they may be caused by urethral stricture.
Urinary stricture may occur more acutely after surgery.
In patients who receive radiation or undergo surgery, erectile dysfunction may be caused by damage to either the penile bulb or the neurovascular bundle.
Radiotherapy produces a vasculopathy and compromised blood supply that may be overcome with a phosphodiesterase-5 (PDE5) inhibitor (e.g., sildenafil, tadalafil). The onset of erectile dysfunction following radiation is rarely before 6 months. A randomised trial showed no benefit to the administration of tadalafil during radiation in preventing erectile dysfunction.[400]
In patients who undergo surgery and suffer damage to the neurovascular bundles resulting in erectile dysfunction, PDE5 inhibitors are unlikely to hasten recovery of erectile function. Evidence suggests that penile rehabilitation strategies consisting of scheduled (i.e., daily) use of PDE5 inhibitors following surgery may result in similar self‐reported erections and erectile function as non-scheduled and on-demand use.[401]
In one cohort study, men who underwent surgery for unfavourable-risk disease reported worse sexual function at 5 years compared with those who received radiotherapy combined with androgen deprivation therapy.[186]
Hormone-induced erectile dysfunction is caused by a decreased level of testosterone. The effect of finasteride on sexual functioning is minimal for most men and should not impact the decision to prescribe or take finasteride.[402]
Rapid loss of bone mineral density is a common complication of androgen deprivation therapy (ADT), increasing the risk of osteoporosis and fractures.[147] Risk assessment for treatment-related bone loss, using the Fracture Risk Assessment Tool (FRAX®), is recommended for all patients starting ADT.[3] Dual-energy x-ray absorptiometry (DXA) scan should be performed for patients at increased risk based on FRAX® assessment.[148] University of Sheffield: FRAX tool Opens in new window DXA scan should be repeated every 1-2 years for patients taking ADT; treat osteoporosis according to guidelines.
All patients receiving ADT should be given lifestyle advice to reduce the risk of osteoporosis (e.g., smoking cessation, reducing alcohol intake, diet and exercise, calcium and vitamin D supplementation).[3]
Denosumab or a bisphosphonate is recommended to reduce the risk of skeletal complications in patients with treatment-related bone loss receiving ADT.[3][403][404]
Denosumab or zoledronic acid are recommended to prevent skeletal-related events (e.g., bone fracture, spinal cord compression) in patients with castration-resistant disease who have bone metastases.[3][405]
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Denosumab is preferred to zoledronic acid due to its superior efficacy.[3][406] Other bisphosphonates can be considered if denosumab and zoledronic acid are unsuitable or unavailable.[407]
Caused by hormone alterations as a result of androgen deprivation therapy with luteinising hormone-releasing hormone (LHRH) antagonists and agonists.[410]
Medroxyprogesterone effectively reduces hot flushes in men undergoing androgen suppression for prostate cancer, and may be the preferred treatment.[411] One guideline recommends paroxetine or clonidine (but not gabapentin) in preference to no treatment for men with prostate cancer who experience drug-induced hot flashes (low-quality/very low-quality evidence).[412][Evidence C]
Acute haematuria may be caused by urinary tract infection, radiation cystitis, tumour retraction, or bleeding diathesis.
Acute bleeding after a brachytherapy implant may be managed initially with bladder irrigation.
For late and/or persistent bleeding, urinary tract infection should first be ruled out. Pentoxifylline and vitamin E may be tried for 3-12 months. Hyperbaric oxygen is reserved for refractory bleeding.
Caused by an acute swelling of the prostate gland that results in obstruction.
May be treated with non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids.
If complete obstruction is present, then a Foley catheter should be placed. Acute urinary retention is more common after brachytherapy, and is rare during or after external beam radiotherapy.
Presents as rectal pain and/or painful bowel movements. Caused by inflammation of the muscle of the rectal wall or anus.
May be treated with corticosteroid suppositories.
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