Prostate Cancer
Radioactive Prostate Seed Implant Therapy—
Possible Side Effects and Complications
Side effects of radioactive prostate seed implant therapy
vary widely from one patient to the next. Long-term complications are uncommon.
Possible Side Effects
- Perineal Symptoms
Most patients
experience tenderness in the perineum for several days following
the implant. Bruising and discoloration can extend into the scrotum.
This should not be alarming. The perineal discomfort is usually
mild to moderate and can be managed with Tylenol, Aleve or ibuprofen.
These medications are okay to take after an implant.
- Urinary Symptoms
In the first 24 to 48 hours after the implant, there
may be moderate to severe burning on urination and the urinary
stream may be very weak. About 5 percent of the patients find
it impossible to urinate at night and must return to the hospital
emergency room for placement of a Foley catheter. If urinary
blockage occurs during the day, please contact your urologist. He
or she may be available to place a catheter in their office.
- For
several weeks or months after the implant patients may experience
urinary urgency, frequency and irritation. These symptoms
can be mild, moderate or severe and tend to be worse at night.
Initially, most men find that they get up at night to urinate
two to four times more than they did before the implant.
Men who have burning on urination usually report that this
discomfort is felt on the tip of the penis. This is not the
result of any injury to the penis, but rather these sensations
are being referred to the penis from the prostate.
- Medications
called alpha-blockers (Flomax, Hytrin or Carduria) are particularly
helpful in relieving these symptoms. These medications help
the prostate to relax, allowing the urine to pass more freely
through the swollen and inflamed gland. Anti-inflammatory
medications such as Aleve or ibuprofen can also be very helpful.
Occasionally, there is bladder irritation. In that case,
patients may benefit from Pyridium, which numbs the bladder.
- Urinary
urgency can be rather severe for a month or two after the
implant, and if not careful, an accident might occur. In
order to avoid urinary leakage it is best to set-up a schedule
and void every hour while awake. Severe urgency is often
triggered by standing up or touching water. So be prepared
to rush to the bathroom in those situations. Be prepared
to quickly find a bathroom when you hop out of the car. If
you have been sitting in a meeting at work for more than
an hour, be prepared to rush to the bathroom when you stand
up. Never pass up the opportunity to use the men’s
room.
- The
urinary symptoms can last for many months. They tend to last
longer with I-125 seeds than with Pd-103 seeds. However,
at some point, usually six to eight weeks after the implant,
the symptoms will begin to improve. By three months, most
men who have a Pd-103 prostate seed implant, will say that
their urinary function is 90 percent back to normal, and
that they are getting up at night one extra time or the same
number of times as they did before the implant. Urinary burning
may last only a few days, however, as the radiation dose
builds up in the prostate, the burning sometimes returns
between the third and sixth week after the procedure. If
this is the case, the burning usually resolves by three months.
The last symptom to go away is the weak stream. The strength
of the stream is usually pretty good by three months, but
it may take another couple of months for the stream to fully
return to normal. Alpha-blockers are usually discontinued
between the third and fourth month. Occasionally the urinary
stream never fully recovers and patients may stay on long-term
alpha-blocker medication.
- The
most common urinary complaint is frequent urination at night,
which can significantly interfere with sleep. Patients report
that they will get up many times to urinate, but that the
stream is weak and that they cannot empty their bladder.
This will cause them to get up again soon thereafter. Sometimes
patients are unable to get their stream started for five
to ten minutes. Infrequently patients have severe burning
and say that urination feels like they are “peeing
through razor blades.” Alpha-blockers
are very helpful for nighttime symptoms, and unless a patient
is instructed otherwise, it is best to take these medications
about one hour after dinner. It is also helpful to avoid
fluids in the evening to reduce urination frequency during
the night.
- Rectal Symptoms
Some patients occasionally experience
rectal urgency, frequency, discomfort or bleeding. Bleeding
is more likely to occur in patients with hemorrhoids. Ointments
or suppositories can help with these symptoms. These symptoms
are usually mild.
- Sexual Functions
It is not necessary to
abstain from sexual activity, however, a condom should be
used for the first several sexual encounters or for the first
several months to avoid ejaculating a radioactive seed into
another person.
Erectile dysfunction (ED), or difficulty
with erection during sex, may occur immediately after the
implant. This is likely due to bruising of the nerve to erection.
This may recover spontaneously. In the meantime, ED can be
treated very successfully with Viagra, Cialis or Levitra.
Some patients report a mixture of pleasure and pain during
orgasm. Usually the discomfort resolves by three to four
months. The semen is almost always discolored (dark) for
several months due to the presence of old blood. The ejaculatory
ducts may become blocked, and semen production by the prostate
may be impaired, resulting in a marked diminution in the
volume of ejaculatory fluid at the time of orgasm.
- Miscellaneous
Symptoms
Patients usually experience some fatigue. It usually
resolves within three to four months. Blood counts are not
affected by this treatment. There will be no hair loss.
Possible
Complications of Seed Implant Therapy
Complications refer
to long-term or permanent problems. If a complication occurs,
that does not mean that there was an error in the treatment.
Whenever cancer cells are being "killed," normal
healthy cells can be temporarily or permanently damaged.
The same holds true for hormone therapy, external beam radiation
and radical prostatectomy.
- Urinary Incontinence
After the
urinary urgency has resolved, urinary incontinence, the involuntary
loss of urine, is infrequently seen (less than 1 percent
of patients). However, patients who have had a prior transurethral
resection of the prostate (TURP), sometimes called a “roto-rooter
job,” have
an increased risk of incontinence of about 5 percent. Patients
with large TURP defects are not implant candidates. If incontinence
develops following a seed implant, it is usually mild, requiring
no more than one to two pads per day.
- Urinary Structure
About
5 percent of patients develop a urinary stricture or bladder
neck fibrosis. This means that scar tissue has formed, and
has caused narrowing of the urethra, or scarring of that
portion of the bladder, which is near the prostate. This
results in a weak urinary stream, frequent bathroom visits
at night or inability to urinate. Initially the treatment
of choice is alpha-blockers. If the urinary flow is completely
blocked, a temporary catheter is placed. Surgery is not often
required, and should be considered a treatment of last resort.
When surgery is contemplated it is best to wait one year.
The procedures most commonly used are: 1) a “mini-TURP”;
2) a trans-urethralincision of the prostate (TUIP); 3) a
bladder neck incision; or 4) a trans-urethralneedle ablation
(TUNA). Before any surgery is contemplated, the patient’s
urologist should consult with his radiation oncologist. Experience
has shown that in many cases the blockage will resolve by
itself without surgery. The primary risk of these surgical
procedures is permanent and sometimes severe urinary incontinence.
- Rectal Injury
The most common rectal injury is chronic rectal
bleeding. Rectal bleeding may result from pre-existing hemorrhoids,
a rectal cancer, or from fragile blood vessels that form
on the rectal wall as a result of the radiation. These fragile
blood vessels are not dangerous and can usually be treated
successfully with suppositories. If rectal bleeding occurs,
please notify your radiation oncologist. You may need to
see a gastroenterologist (a GI doctor).
- IT
IS OF THE UTMOST IMPORTANCE THAT YOU INFORM YOUR GI DOCTOR
THAT YOU HAVE HAD A PROSTATE SEED IMPLANT. IT IS NOT SAFE
TO HAVE HEMORRHOID SURGERY OR CAUTERY ON YOUR RECTUM. THERE
HAVE BEEN CASES WHERE SUCH PROCEDURES HAVE RESULTED IN SEVERE
RECTAL INJURIES REQUIRING A COLOSTOMY. WE ADVISE YOU TO SHOW
THIS PAGE TO ANY PHYSICIANS TREATING YOU FOR RECTAL BLEEDING.
- There are new laser therapies, which are very superficial
and are more likely to be safe, but this should only be used
in cases of severe rectal bleeding that cannot be controlled
by more conservative means.
- Rectal
ulcers are very uncommon. The first sign of an ulcer may
be moderate to severe rectal pain, which is usually associated
with bleeding. However, these symptoms can also occur with
hemorrhoids. RECTAL ULCERS MUST NOT BE CAUTERIZED, LASERED
OR OPERATED ON.
- THE
MOST SEVERE RECTAL INJURY IS A FISTULA. Fortunately, fistula
are very uncommon. A rectal fistula is a hole that develops
between the rectum, and the bladder or urethra. The first
signs are pain associated with the leakage of urine through
the rectum. Usually a colostomy must be done. FOLLOWING SEED
IMPLANTS, RECTAL FISTULAS CAN BE CAUSED BY CAUTERY FOR RECTAL
BLEEDING, OR HEMORRHOID SURGERY. THESE MUST BE AVOIDED.
- Erectile
Dysfunction
Erectile dysfunction (ED) is the most common
complication following all treatments of prostate cancer.
The good news is that most cases of ED following seed implant
therapy can be successfully treated with medication (Viagra,
Levitra or Cialis). If a patient has good erections prior
to treatment, the probability that he will maintain an erection
satisfactory for sexual intercourse after treatment is about
80 percent; however, the majority of patients will use one
of these medications at least some of the time. If the erection
is already impaired prior to the seed implant, these drugs
are less likely to work. If they are unsuccessful, other
treatments such as penile injections may prove effective.
For several months following the implant, the ejaculate may
be discolored. Usually the color is very dark as the result
of old blood. Eventually, most patients report that the ejaculate
dries out, and that very little semen is ejaculated. Fortunately,
the quality of the orgasm is usually not affected.
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