This article is based on a session held at the AUA 2025 Annual Meeting.

Prostate cancer (PC) is the second most common cancer among men in high Human Development Index countries (37.5 per 100,000) and the most common in low and middle Human Development Index countries (11.3 per 100,000).¹ Sexual dysfunction is the most commonly reported health-related quality of life outcome following therapies for PC, affecting men, partners, and their relationships.² However, sexual health is currently not routinely addressed as part of survivorship care after a PC diagnosis. Recent international consensus guidelines for addressing sexual health care after PC were developed to address this significant gap in care.

As clarified in Statement 1 of “Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel,” proactive clinician-initiated conversations, pretreatment counseling, and inclusive care strategies³ should be fundamental aspects of PC care. Clinicians must initiate open discussions about the sexual side effects of PC treatments with patients and, when appropriate, their partners. These guidelines also recognize that differences in national origin, ethnicity, and race influence perspectives on gender roles, sexual orientation, relationships, and culture-driven health beliefs, in addition to disparities in access to health care and the uptake of available services. Further, it is recommended that counseling should also be inclusive, addressing the needs of gay, bisexual, transgender, and nonbinary individuals, and be culturally contextualized. At AUA2025, in a collaborative session led by the International Society for Sexual Medicine and Movember, Dr Akanksha Mehta, Dr Sharon Bober, Dr Daniela Wittmann, and Dr Tet Yap spoke in detail about Statement 1 and shared valuable insights on optimizing recovery outcomes and addressing the often-overlooked sexual health needs of diverse PC patient populations.

Why Does Pretreatment Counseling Matter? (Dr Sharon Bober’s Report)

Pretreatment counseling plays a key role in shaping the sexual health outcomes and overall well-being of PC survivors. Many patients have unrealistic expectations about posttreatment sexual function, which often lead to decisional regret, distress, and a diminished quality of life.

Kinsella et al⁴ reported that only 1 out of 41 men who received a single preoperative educational session reported decisional regret, compared with 20% in the standard care group. Research showed that structured counseling interventions, even when brief, can significantly reduce rates of decisional regret.

A study involving couples undergoing intracavernosal injection therapy found that those who received additional couples-based sexual counseling reported better International Index of Erectile Function (IIEF) scores, higher completion rates, and improved emotional outcomes.⁵ Dr Bober also presented the Acceptance and Commitment Therapy for Erectile Dysfunction model for pretreatment counseling. It is a coaching-based approach that helps patients with cognitive defusion, defusing shame and anxiety, and committing to realistic recovery goals—resulting in significantly higher adherence to treatment.⁶

Dr Bober suggested that counseling sessions do not need to be lengthy or ongoing to be effective. A short and focused conversation that sets realistic expectations and outlines a recovery roadmap can profoundly impact patient satisfaction and adherence to sexual rehabilitation strategies. It is a low-resource, high-impact intervention that every urologist can integrate into clinical practice.

Creating a Postsurgical Care Pathway: “Convince the Patients, Convince your Colleagues, and Convince the Institution” (Dr Akanksha Mehta’s Report)

PC treatments have become increasingly effective, but postsurgical sexual rehabilitation remains inconsistent and underresourced in many institutions. Therefore, it is important to develop structured, institution-supported care pathways that are feasible, scalable, and patient centered.

A prior study evaluating the Brandon Prostate Cancer Survivorship Program⁷ showed that participation ranged from 67% to 97% for patients and 61% to 81% for partners, with 86% to 97% of patients and 90% to 100% of partners reporting high satisfaction. Over 80% in both groups supported survivorship care and would recommend the program to others considering PC surgery.⁷

Moreover, Dr Mehta stated that partners play an essential role during recovery. The partner is not only a caregiver and cheerleader, but sometimes also a decision-maker; therefore, it is essential to educate and support partners to enhance recovery and help manage couples’ recovery of sexual intimacy.

Currently, urologists, advanced practice providers, sexual therapists, and nurse navigators manage all aspects of sexual dysfunction and andrology, including outpatient and surgical procedures. Dr Mehta advocated for the inclusion of physical therapists, radiation oncologists, medical oncologists, and gynecologists in posttreatment care to customize pathways and improve treatment outcomes. The postsurgical care pathway should prioritize accessibility, include both pre- and postsurgical visits, be tailored to individual patient needs, and normalize emotional responses to sexual changes. The treatment pathway focuses on sexual dysfunction treatments and sexual aids during the first 0 to 6 months and shifts to sexual recovery after 6 months.

Overall, there is a critical need to establish structured, institution-supported care pathways that are feasible, scalable, and patient centered. Convincing institutions to invest in sexual rehabilitation services requires not only clinical justification but also patient demand and professional advocacy.

Inclusion of Sexual and Gender Minorities (Dr Tet Yap’s Report)

PC treatments have traditionally focused on heterosexual intercourse, but this framework excluded the sexual and gender minority (SGM) patients such as gay, bisexual, transgender, and nonbinary individuals. Current sexual function scales often fail to capture issues such as receptive anal intercourse pain (ano-dyspareunia), altered sexual roles, and orgasmic changes in nonheterosexual sexual contexts. A study showed that only 14% of National Cancer Institute–affiliated cancer centers routinely collect sexual orientation data, and only 19% distinguish gender identity from sex assigned at birth.⁸

SGM patients often report discrimination, stigma, and unsafe health care experiences, which can deter them from seeking help for sexual side effects. Also, transgender and gender nonconforming patients face additional clinical challenges; for example, those with neovaginal anatomy may require specific biopsy techniques, and radiation or surgery may compromise neovaginal integrity. This is due to inadequate understanding of needs among health care providers.

To bridge the gap, Dr Yap presented the use of the Sexual Minorities and Prostate Cancer Scale (SMACS), a validated tool by the Restore Group⁹ to assess domains previously overlooked in mainstream tools like the IIEF. SMACS includes subscales addressing problems with receptive anal intercourse and role-in-sex adjustment, enabling clinicians to better understand and manage sexual dysfunction in SGM patients.

To move forward, Dr Yap has successfully validated (vs IIEF and International Consultation on Incontinence Questionnaire–Lower Urinary Tract Symptoms) SMACS in an unselected general population of PC patients. The results showed that the SMACS was rated highly acceptable, easy to understand, simple to complete, relevant to sexual issues, and appropriately phrased.¹⁰ He is planning to validate and measure acceptability of the SMACS in geographically diverse patients and develop educational resources tailored to both patients and health professionals.