The side effects of prostate cancer treatments are known to affect bowel, bladder and sexual dysfunction, which in turn may affect long-term quality of life. Quality of life is an important issue for patients with prostate cancer because it is a relatively slow-growing disease with a long life expectancy. Three key complications of treatment will be discussed here - sexual dysfunction, urinary incontinence and fatigue.

Sexual Dysfunction (loss of sex drive and erectile dysfunction)
As prostate cancer is a disease of older males, 50 years and above, and reported that older men were underestimated as likely to be disturbed by post-treatment impotence as younger men. Also, an assumption was made of elderly men who had passed the traditional age of raising a family and therefore less attention was paid to the consequence of impotence.

Support may consist of listening, providing and discussing the treatment options available and clarifying information. For example :

>>	Discuss strategies to improve motivation and erectile function - increase length of foreplay - focus sensations on pleasure or arousing fantasy - practice teasing techniques - use sexually stimulating visuals (e.g., books, tapes)
>>	Review options for maintaining an erection that are available through the urologist such as medication, external devices and penile prosthesis.
>>	Speak to the urologist or refer to a sexual counsellor if appropriate.

It is important that health-care providers feel comfortable discussing sexuality and sexual dysfunction. If they are uncomfortable with their own feelings regarding sexuality, they could impose their own values on the patient and his significant other.

Urinary incontinence
Depending on the severity of the problem, initial treatment at control should include bladder training, habit training or timed voiding, prompted voiding and the use of pharmacologic agents. If all fails, a permanent indwelling catheter or incontinence devices are recommended. Subsequent nursing interventions should include teaching and educating the patient and significant other in the care of the urinary catheter, adaptation of an indwelling catheter in the daily living and observing for signs and symptoms of urinary tract infection and obstruction.

Management of an indwelling urethral catheter:

Prevent infection
	Perform meatal care twice daily with soap and water
	Empty urinary drainage bag when 2/3 full
	Keep catheter drainage bag below the level of the bladder
	Use aseptic technique (swabbing with alcohol swab) when emptying drainage bag and attaching drainage bags. The drainage system should not be disconnected unnecessarily.
	Keep drainage bag off the floor. Attached to a hanger or hook on the side of the patient’s bed or chair. A leg bag is used for patient who is mobile as it is less cumbersome and can be worn under clothing.
	Observe for signs and symptoms of urinary tract infection such as pain, fever, cloudy or foul-smelling urine
Maintain catheter patency
	Keep catheter secured to leg or abdomen at all times
	Keep catheter and tubing straight and free of kinks and tension. The catheter is taped laterally to the upper thigh or abdomen to prevent pressure on the penile-scrotal angle (erosion of tissue at the penile-scrotal angle may develop if tension is applied to the catheter).
Catheter change
	Indwelling urethral catheters are changed at varying intervals and may be left in place for 4-6 weeks depending on the type of material used in the catheter. Collecting tubing and drainage bags are changed every 7 days.

Fatigue
Treatment-related fatigue has been documented in many studies. Jakobsson et al. (1997) conducted a study on 11 men with prostate cancer who had undergone either surgery, hormonal or radiation treatment at a Swedish hospital that focused on functional health status in relation to daily life. The researchers found that fatigue scores the highest as the worst symptom that was affecting the subjects’ daily living compared to other symptoms (pain, dyspnoea, appetite loss etc.). Frequent visits to the toilet thus breaking a good sleep and inadequate rest could also inadvertently contribute to fatigue.

Interventions

	Assess the pattern of fatigue and its effect on the patient’s life-style
	Instruct patient on energy conservation techniques - frequent rest periods - pacing / spacing activities - going to bed early and rising later - nutrition (high calorie / high protein diet)
	Physical exercise has also been shown to reduce fatigue

Pain (related to surgery, bone metastases or advanced disease)Management include:

	Assess location, onset, duration, and severity of pain using a 0-10 scale before and after each dose of breakthrough pain medication
	Medicate with simple analgesics or non-steroid anti-inflammatory drugs, adding a long-acting opioid drug if necessary
	Manage constipation with routine administration of laxative and stool softener
	Teach use of non-pharmacological methods of pain relief (e.g., relaxation, distraction techniques)
	Evaluate effectiveness of pain management regimen

Christine Sek
Nurse Clinician
National Cancer Centre, Singapore