Patients facing treatment for prostate cancer expect to be warned of certain dismal side effects: erectile dysfunction and incontinence, for instance. But a new study suggests men should be warned of another possible complication: a shorter penis.
The new report found that a small number of men enrolled in a prostate cancer study complained to their doctors that their penises seemed shorter following treatment (though no actual measurements were taken). Some of the men reported that even this perception of a shortened penis interfered with their intimate, emotional relationships and caused them to regret the type of treatment they chose.
Prostate cancer is the second most common cancer in men, with about 241,740 new cases diagnosed last year, according to the American Cancer Society. Obviously prostate cancer can be serious: it's the second leading cause of cancer death (behind lung cancer) in American men.
But most men diagnosed with prostate cancer will live — and live with the short- and long-term implications of the type of treatment they choose to undergo. While the problems of erectile dysfunction and incontinence are widely known as possible side effects, few studies have been done on treatment-related penile shortening. But doctors say it can and does happen — though it's rarely discussed with patients.
In the current study, which was based on surveys completed by physicians treating 948 men with recurrent cancer, a total of 25 patients (2.63%) complained of a shorter penis. Complaints were most common in men who underwent surgery to have their prostate removed (19 of 510 men) and those treated with male hormone-blocking drugs combined with radiation therapy (6 of 225 men), researchers report. None of the men on radiation therapy alone complained of this particular problem.
These numbers are clearly small; but researchers say the phenomenon, due to its intimate nature, is likely underreported. The takeaway from this study, they say, is that the possibility of a slightly shorter penis after treatment should be made clear to patients as they consider their therapeutic options; a frank discussion upfront might minimize later regret. "Physicians should discuss the possibility of this rarely mentioned side effect with their patients to help them make more informed treatment choices," the study, published in the medical journal Urology, concludes.
Lead author Paul L. Nguyen, M.D., a radiation oncologist at Dana-Farber Cancer Institute and Brigham and Women’s Cancer Center in Boston, said the novelty of the work is that it shows how even the perception of a shorter penis can profoundly impact a man's quality of life and lead to regret. "Some people might think this is frivolous — who cares about a slightly shortened penis — but it really does affect people's lives," he said in an interview. "If guys [in the study] had this bad result they were much more likely to regret the path they chose. This is important to talk about up front when people are making their decisions."
Shortened penises are not a widely investigated phenomenon, Nguyen notes. But in the few published measurement studies, the shortening is on average about one centimeter, he said. There are several theories on what might account for this: in surgery, cutting out a chunk of the prostate may lead to some loss of length, Nguyen said. When it comes to combined radiation and hormone therapy, he said there could be some shrinking or fibrosis of the prostate or erectile tissue that makes it firmer and less elastic.
A 32-year-old man who didn't have cancer, but noticed his penis was shorter after urethroplasty, surgery to repair an injury or defect of the urethra, expressed his shock and disappointment that he was never informed of this possible side effect. Writing in an online support forum, MedHelp, the man reflected what is likely a common reaction:
I specifically asked my doctors before the surgery multiple times about possible complications and cosmetic outcomes and never once was possible penile shortening mentioned. Stroke, heart attack and death were mentioned as risks during surgery and failure, recurrence, and ED were mentioned as possible side effects of the procedure. Also, scars at the incision site, of course...
Erectile length probably shouldn't matter if the surgery is otherwise successful, but I would've preferred at the very least a warning about the risk of shortening — even if temporary — so I could've at least psychologically prepared for the possibility or perhaps opted for another treatment.
Dr. Sharon Bober, a clinical psychologist and director of Dana-Farber's Sexual Health Program who was not involved in the study, has counseled men with shortened penises after cancer treatment. She has this message: Don't give up hope. Even if there is an actual, measurable shortening, she says, it can often be reversed. "If you're getting blood flowing, if you're stretching the tissue and if you're reducing atrophy and reducing the fibrotic process of radiation, you're going to some degree address the shortening," Bober said. "There may be some penile shortening in the short term that can be addressed in the long term with penile rehab."
Bober added that the psychological impact of any real or perceived penile shortening should also be addressed. "When you notice that any part of your body is no longer the same as it was it has a profound impact on body image and self confidence," she said, "but that doesn't mean you can no longer give a partner pleasure or get pleasure. Even if you do notice your penis is a half-inch or centimeter shorter — maybe you can fix it, maybe you can't - but that modest loss of length may not be a deal-breaker in terms of sexual satisfaction. It's probably not as big a deal to your partner as you think."
The key, she says is to prepare men for this possible side effect: "If somebody's not prepared for the change, it feels very distressing because they had no idea — and it's yet another way you feel embarrassed, different," she said.
A 67-year-old man who was recently treated for prostate cancer at Dana-Farber said his penis size didn't change after surgery, radiation or hormone treatment. But he did says that for many men, "the side effects of prostate cancer treatment usually involve some kind of impediments to former sexual performance...and this will create all sorts of anxieties and problems. There's the natural, "My goodness, what's happening?" that pretty much all men go through and maybe that includes all sorts of questioning: "Am I shorter or am I this or that." But in addition, he said: "There's likely a subset of people who have pre-existing issues with penile length and after they have prostate treatment, these penile length issues might become even more pronounced."
Here are a few more details of the study, via press release:
Twenty-five men (2.63 percent of the group) complained of smaller penises after treatment – 3.73 percent for surgery, 2.67 percent for radiotherapy plus androgen deprivation therapy (ADT), and 0% for radiotherapy alone. Radiotherapy included both radiation administered by an external x-ray machine, and brachytherapy – the implantation of radioactive seeds directly into the prostate.
There were no direct measurements of penis size either before or after treatment, said the researchers. Nor did the patients’ physicians specifically ask about this side effect; the issue was brought up by patients in conversations with their doctors. For this and other reasons, the authors of the new study suggest that the problem is likely more common than reported in the survey.
The study’s subjects were men enrolled in a registry called COMPARE that collects data on patients whose prostate cancer shows signs of recurring after initial treatment. Of the 948 men in the study, 22 percent were younger than 60 and the majority were in their 60s, 70s and 80s. Just over half – 54 percent – had undergone surgery to remove their cancerous prostate, while 24 percent received radiation therapy combined with hormone-blocking treatment, and 22 percent had radiation therapy alone.
Luc Cormier, M.D., with the Department of Urology, at Dijon University Hospital in France wrote an accompanying editorial comment noting, wisely, that the whole notion of “'penile length' is decidedly complex," and fraught with imprecision. (What, exactly, and when are you measuring, anyway?) Still, he wrote, despite some of the shortcomings of this study which relied on both physician and patient surveys: "Penile length trouble is often discussed in clinical practice, and physician should be aware of the necessity of informing patients of the possible risk."
Readers, have you faced prostate cancer treatment and been warned of these possible side effects? Do you feel like you got full disclosure on potential problems stemming from treatment? Tell us your stories.
This program aired on January 4, 2013. The audio for this program is not available.