Biopsies cause physical harm that affects Erectile Function but the mechanism is still not clear.
Some trials back in 2005 identified the problem and this was confirmed statistically in 2009 (eg Fujita K et al. Serial prostate biopsies are associated with an increased risk of erectile dysfunction in men with prostate cancer on active surveillance.
J Urol (Dec) 2009;182(6):2664-9 and 2010 (eg Palumbo F et al. A prospective study on patient’s erectile function following transrectal ultrasound guided prostate biopsy. Arch Ital Urol Androl (Dec) 2010;82(4):265-8.
It has been confirmed more recently by Murray KS et al. (A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy. BJU Int. (Aug) 2015;116(2):190-5.) They concluded that “The exact cause of this effect is yet to be determined.”
The various trials found that the deterioration in erectile function (EF) was not related to the prostate cancer itself but could have other explanations including not only anatomical damage but also psychological effects such as the PC diagnosis following the biopsies.
If it is anatomical (such as nerve damage) this would show as a greater reduction in EF with more core biopsies such as 12, 20 or more. This was implied in the 2009 study by Fujita et al who noted that “Multivariable analysis for biopsy number, age, prostate volume and prostate specific antigen showed that only biopsy number was associated with decreasing Sexual Health Inventory for Men score (p = 0.02).”
As you probably know the 5-item Sexual Health Inventory for Men (SHIM) mentioned by Fujita is essentially the same as a 5-item version of the International Index of Erectile Dysfunction (IIEF-5) that is in turn an abridgment of the 15-element International Index of Erectile Dysfunction (IIEF-15).
Your suspicion that multiple core biopsies as part of active surveillance would cause an increase in erectile dysfunction is supported by the evidence, as Fujita et al found that only the number of biopsies carried out was associated with decrease erectile function.
Don Benjamin – Cancer Information Support Society
ED Induced by Prostate Biopsy Likely ‘Underestimated’
Nick Mulcahy, October 01, 2015
The various degrees of erectile dysfunction (ED) that occur after prostate biopsy with a needle through the rectum wall have “probably been underestimated,” according to new research.
A new study showed a “significant decrease” in the erectile function score of most men after biopsy, and the drop was independent of age, cancer diagnosis, and previous biopsy status, report the study authors, led by Katie Murray, MD, from the University of Kansas Medical Center in Kansas City.
Although ED was recognized as a complication of prostate biopsy as early as 2001, it has not been well-established by data, unlike potential adverse events such as hematuria, pain, voiding dysfunction, and infection.
In their prospective study, Dr Murray and her team used a standard test — the International Index of Erectile Function (IIEF-5) — to evaluate 220 men with elevated levels of prostate-specific antigen (PSA) who underwent a transrectal-ultrasonography-guided prostate biopsy.
In the study cohort, median IIEF-5 score was significantly lower 1 week after biopsy than at baseline (15.5 vs 18.2; P < .001). And the score remained significantly lower at 4 weeks (17.3 vs 18.4; P = .008) and 12 weeks (16.9 vs 18.4; P = .004).
The team does not, however, say that the needle caused physical damage in this nerve-intensive area that led to ED. “The exact cause of this effect is yet to be determined,” they write.
The study was published in the August issue of BJU International.
“Psychological stress” likely contributes to the ED, writes Brian Helfand, MD, from the University of Chicago, in an accompanying editorial. The men in this study who had a benign biopsy had a fairly quick return to baseline in terms of their erectile function (after 1 week, as a group), even though some men reported lower scores for up to 3 weeks.
Dr Helfand points out that a study he was involved in showed that a diagnosis of prostate cancer “can influence a man’s erectile function after prostate biopsy” (BJU Int. 2013;111:38-43).
The literature on this subject is mixed, with some studies finding and some not finding that biopsy induces ED, he adds. Nevertheless, Dr Helfand suggests that “patients should be counseled on the possibility of relatively short-term (‘acute’) changes in erectile function.” Dr Murray and her team say the same thing.
This single-group study could have been stronger in terms of its evidence, said Clint Bahler, MD, from Indiana University in Indianapolis, who was not involved in the study but was asked to comment on the findings.
“They should have followed another group of [healthy] men with elevated PSA who did not get biopsy to compare, for instance,” he told Medscape Medical News.
Like Dr Helfand, Dr Bahler pointed out that men who had a benign biopsy (67% of the group) had relatively transient ED, compared with those who had cancer detected.
For the patients who did not get a diagnosis of prostate cancer, median IIEF-5 score was lower only at the 1-week follow-up (P < .001). But for those with prostate cancer detected, the median score was lower at 1 week (P < .001) and at 12 weeks (P = .001) after biopsy.
Notably, there is no detailed breakout of scores for the benign group. “They should give us the scores for the benign group, but these are censored, which is suspicious,” said Dr Bahler.
Dr Helfand, Dr Bahler, and the investigators all suspect that longer-term ED might be related to a host of factors, including stress, a diagnosis of cancer, and age.
As Dr Murray’s team puts it, “the exact mechanism of this decline in IIEF-5 score for these patients is most likely multifactorial in nature and many factors — including psychogenic causes, fear of results, anxiety related to biopsy, and even anatomical considerations including nerve damage and hematoma — have potential in being related.”
At baseline, the average age was 64 years, and ED status was reported as nonexistent by 39% of the men, as mild by 22%, as mild to moderate by 15%, as moderate by 10%, and as severe by 14%.
Age appears to play a role in how men do in terms of their erections after undergoing prostate biopsy, the investigators report.
For men younger than 60 years, median IIEF-5 score was lower only at the 1-week follow-up (P = .015). But for men 60 years and older, scores were lower at 1 week (P < .001), 4 weeks (P = .024), and 12 weeks (P = .005).
The investigators also used the International Prostate Symptom Score (IPSS) questionnaire to evaluate the men. They focused on data related to lower urinary tract symptoms, and found that there was a significant change at weeks 1 and 4, but not at week 12. In other words, in this cohort of men, symptoms, on average, improved by week 12.
The study authors, Dr Helfand, and Dr Bahler have disclosed no relevant financial relationships.
BJU Int. 2015;116:164, 190-195. Editorial, Abstract
The only alternative to ultrasound and DCE-MRI diagnosis is global biopsies – 24 to 50 cores. The studies are back on prostate biopsies. It is extremely damaging to the organ and highly likely to spread cancer and if there was no cancer before then ripping 50 bits of flesh from your prostate certainly may cause all types of problems, bleeding infection and inflammation….and metastases will surely be spread by blood and the lymph system if you do have some cancer.
The studies are definite…..
From Dr. Gerald Chodak, for Medscape.
“At the 2013 American Society of Clinical Oncology Annual Meeting, a very provocative paper was presented by Boniol and associates. They analyzed the 120-day mortality rates in men who participated in the PLCO (Prostate, Lung, Colorectal, and Ovarian) screening trial, and the results were somewhat disturbing. They observed that at 120 days, the death rate was 1.3 per 1000 biopsies done in men without cancer, and was higher — 3.5 per 1000 men — in those who had a positive biopsy for cancer.
“This is somewhat consistent with a previous analysis of the European Randomized Study of Screening for Prostate Cancer. That study resulted in a net conclusion that the harms outweighed the benefits. It’s important to understand how this occurs. If someone dies prematurely from a biopsy at an average age of 62, he may have lost about 13 years from his life expectancy. On the other hand, for those men who are avoiding a cancer death as a result of screening, which we know is about 1 per 1000 men screened in 12 years, they may gain only a few years of added life expectancy from the time they would have died of something else.
“We know from breast cancer screening that the average increase in life expectancy is only about 2.3 years. We now total up the number of men who die from a biopsy and don’t have cancer and the men who die from a biopsy and do have cancer, and we also factor in the number of men who die as a consequence of treatment, which we believe to be about 0.2% of men who undergo a radical prostatectomy. The total average number of years of life expectancy lost, at best, is similar to what you gain from saving lives, but it is probably less than that.
“In other words, the net impact is that you lose years of life expectancy in a population that gets tested. Some might argue that you might have a younger group of men who are healthier and they have a lower rate of dying; it’s not clear why these deaths occurred. Most of the deaths are likely to be due to infection, but we don’t know for sure. The bottom line here is that we can’t ignore this complication, and the impact it has on overall life expectancy, when we try to evaluate the net benefits and harms of screening for this disease.
“There is no doubt that many people are going to find this added piece of information even more difficult to accept, but the fact is that, in a well-done study with a full analysis of good data, these are the mortality rates that were observed. They further shift the net balance toward harms over benefits from screening for this disease. I look forward to your comments. Thank you.”
It is obvious that slowly developing cancer never becomes a problem until some other major factor is introduced into our lives, eg, great stress, overweight, cessation of exercise, poor diet, depression, accidents, advancing age-related diminishing of the immune function. OR some surgeon deciding to disturb the sleeping cancer by taking multiple core biopsies – the norm is 24 cores – bound to inflame the gland, release cancer cells to grow elsewhere and give you serious metastasised PCa. Mammograms and biopsies do the same thing to women who have a small cancer (not going to kill them) that is spread by either biopsy needles, or the mechanical crushing of the cancer envelope while squashing the breast (especially small breasts) between mammography plates!
Remember in 1935 Upton Sinclair summed up the problem you are facing very neatly when he wrote “It is difficult to get a man to understand something when his salary depends on not understanding it.”