How can prostate cancer affect sexual function?

What are the basis of erections?

The critical components to getting an erection are;

1) intact nerves,

2) good blood flow to the penis,

3) sexual desire,

4) sexual stimulation,

If any of the above is affected, erectile dysfunction will result.

The negative effect on sex life is not limited to the physical aspect—loss of erections, inability to father children, dry orgasm, or change in orgasm—but extends to the psychological and social domains. How you feel about yourself and your relationship impacts your overall health.

I am going to describe the effects your sexual life may experience. If you are a single man or in a relationship, I hope this article will encourage you to explore treatment options for erectile dysfunction.

How does prostate cancer affect your sexual life?

Sex is a vital part of life for most of us. Being diagnosed with prostate cancer and experiencing the side effects of prostate cancer treatments will undoubtedly affect your sexual life. Most men state that this is one of the most significant burdens they experience.

Often, the sex life impact, even though mentioned in the pre-treatment phase, is placed on the back burner when one is diagnosed with prostate cancer. The focus is on the treatment, which aims to kill cancer cells. Erectile function depends on intact blood vessels, nerve tissue, hormones, and psychology (thoughts and feelings). Prostate cancer treatments affect one or more of these, leading to erectile dysfunction.

However, prostate cancer treatments have advanced, and patients are living longer.  Treating erection problems is a must to address an unmet need that men surviving prostate cancer experience.

Men deal with changes in their sexual lives in different ways. Some are not interested in pursuing their sexual lives. Others will want to address the erection problems. Some explore alternative intimate ways to rekindle the connection with their partner. What a satisfying sexual life means is based on the individual. There is no shame in coming forward.

Regaining erectile function through penile rehabilitation, sex therapy, medications, and other treatments is possible in most men. Speak to your specialist nurse, NHS consultant, or private urologist to access the available help.

Emotional well-being impacts

When you feel down, depressed, or anxious, your sex life starts to feel different, and your sex drive dwindles. All these lead to a vicious whirlpool. If not broken, this negative cycle can lead to a deterioration of your overall health.

You are not alone. There are many treatment options for penile rehabilitation and sex therapy sessions, all aimed at helping men gain a satisfying sex life.

Erectile issues: Can I speak about it?

Erectile dysfunction is often unspoken as cancer treatment and overall health is given precedence. It is pretty challenging to talk about one's sex life, sexual desire, and erectile function. Many men feel ashamed. A healthy sexual life is more than an erection.

Trained doctors and cancer nurse specialists are there to help you regain sexual function and address any sexual problems you are experiencing.

What physically happens

As discussed, prostate treatment can damage the nerve tissue and blood vessels (blood supply), which are crucial for erectile function. Erections may not happen; if they do, they may not be as strong or last as long.

Hormone therapy lowers testosterone, and the sex drive, called libido, goes down.

Studies have shown that sex drive can decrease even without prostate cancer treatment. Around 25% of men start to suffer from erectile dysfunction side effects after being told that they have prostate cancer.

Relationship challenges

Erectile dysfunction affects not only the physical sex life but can lead to emotional and closeness issues with your partner. Sex therapy, survivorship program, and other treatments for erectile dysfunction help men and their partners build a satisfying sex life.

Can I pass on the prostate cancer to my partner?

No.  

Will I be able to gain back an erection?

After prostate cancer treatment, many men wonder if they can get an erection and have sex like before. Many factors play a role in gaining back your sexual life, including:

• cancer treatments you've had
• how sexually active were you?
• sexual problems you experienced (pre-treatment function)
• mental state
  

Men respond to cancer treatment differently. Some men achieve their natural erectile function shortly after. Others will overcome their erectile dysfunction with therapy. There are prostate cancer patients who, despite exploring all the treatment options for erectile dysfunction, are not able to overcome their erectile dysfunction.

What are the effects different prostate cancer treatments have on sexual life?

There are different treatment options for prostate cancer. These include;

1) Radical prostatectomy (nerve-sparing surgery or non-nerve-sparing surgery)

2) Radiation therapy

3) Focal therapy (High-intensity focused ultrasound or NanoKnife)

4) Hormone therapy

5) Chemotherapy

There are other treatments but the above are the standard cancer treatments most men take and will be discussed in detail.

I had a radical prostatectomy. When can I have sex? Can I have sex with a catheter?

This is the removal of the prostate gland and seminal vesicles. These organs form part of the male reproductive system. The side effects of your sexual life depend on your erectile function before prostate cancer treatment and whether nerve-sparing surgery was performed.

Nerve-sparing prostatectomy (one or both sides of nerve-sparing surgery) preserves the nerves responsible for erection. If a nerve-sparing technique is done, this carries a 50% chance of regaining erectile function. A nerve-sparing prostatectomy cannot be offered to all men undergoing surgery. This depends on the prostate cancer stage and pre-treatment function. Men younger than 64 tend to get erectile function compared to older men.

During a nerve-sparing prostatectomy, the surgeon will aim to keep intact nerves and preserve the blood vessels of the penis to keep the blood flow to the penis healthy. This is another crucial element for erectile function. The nerve-sparing technique is also beneficial for gaining urinary continence.

The catheter can pose a challenge. Men typically have a urinary catheter for the first 7 to 14 days. One can have erections, masturbate, or have sexual intercourse with a catheter in place, but it can be uncomfortable. Most men attempt masturbation or sexual intercourse after it is removed.

Most prostate cancer surgery is done robotically and less often laparoscopically in the UK. Keyhole surgery is associated with a faster recovery. If you underwent open surgery, it could take a bit longer to return to your sexual life.

Anal sex. A 6-week recovery period is recommended after prostate cancer surgery before one can attempt anal sex. When men have radiotherapy as their cancer treatment, they are suggested a more extended recovery period, around 8 weeks.

Radical prostatectomy impacts sexual function.

• Erectile dysfunction.
• Erections are not strong.
• Erections do not last as long as before.
• Libido goes down.
• Penis size: on the 10th day after prostate cancer surgery, men notice that their penis has shortened. The absolute majority will regain this lost length within 6 months.
• Dry orgasms. The orgasm may feel different. You may experience some pain when you orgasm. You will not be able to conceive naturally.
• You may leak urine during sex or when you orgasm (climacturia). This can be annoying and take a toll on your sexual desire. Pelvic floor muscle exercises help, but one needs to be patient until the pelvic floor muscles recover. Healing from the radical prostatectomy does take time.
  

Radiation therapy for prostate cancer treatment

The types of radiation that can be offered are:

1) External radiotherapy

2) Brachytherapy

3) High-dose brachytherapy boost (HDR therapy)

These prostate cancer treatments aim to kill cancer cells. Prostate cancer patients receiving radiation therapy must know that there could be a tangible effect on their sexual function.

External radiotherapy and brachytherapy may lead to fewer ejaculation volumes, but you may still be fertile. Even though fathering children naturally is possible, it can be challenging.

I had external radiotherapy as my prostate cancer treatment. When can I return to my sex life?

External radiotherapy means radiation is generated from a machine outside your body, and the rays are directed at the prostate gland.

• When you feel comfortable, you can get back to your sex life.
• Men in a relationship with partners who can potentially become pregnant should use contraception during cancer treatment and for at least one year after completion of therapy.
• Anal sex. 8 weeks of recovery is recommended before attempting anal sex. If radiotherapy leads to bowel problems, one must wait until this settles.

What sexual side effects might I experience after external radiotherapy?

• Change in orgasm sensation
• Ejaculation may be uncomfortable, and volumes of ejaculation may vary.
• Erectile function may be challenged. It may not be as hard, or it becomes more difficult to achieve an erection. You may experience difficulty in maintaining an erection.
  

I had brachytherapy as my prostate cancer treatment. When can I return to my sex life?

Brachytherapy cancer radiation therapy is when radioactive seeds are implanted in the prostate gland.

• Leave a few days before attempting to masturbate or have sex.
• Do use a condom for the first five to ten times you ejaculate. Do not get alarmed if you find the brachytherapy seeds in the condom.
• Men in a relationship with partners who can become pregnant should use contraception for at least one year. Inform your oncologist regarding guidance in timing the pregnancy.
• Brachytherapy can lead to bowel problems; one must wait until this settles. Men need to be aware that during anal sex, their partner may be exposed to radiation, primarily in the first 6 months. It is recommended to keep anal intercourse as short as possible. Seek advice from your oncologist and cancer nurse specialist.

What sexual problems might I experience after brachytherapy?

• Change in orgasm sensation
• Ejaculation may be uncomfortable, and volumes of ejaculation may vary.
• Erectile function may be challenged. It may not be as hard, or it gets more difficult to achieve an erection. It may not last as long.
  

I had a high dose of brachytherapy (HDR) boost. When can I return to my sex life?

A high-dose brachytherapy (HDR) boost is when fine tubes are introduced into the prostate gland. A high radiation dose is released through these tubes for a few minutes to kill cancer cells. Once completed, these tubes are removed.

• Leave at least 7 days before attempting to masturbate or have sex.
• Men in a relationship with partners who can become pregnant should use contraception for a few months. Discuss with your oncologist regarding guidance.
• If you wish to engage in anal sex, wait two months. Have a conversation with your oncology specialist, nurse, or oncologist. If you suffer from bowel problems, wait until they settle down.
  

What sexual problems might I experience after high-dose brachytherapy radiation therapy?

• Change in orgasm sensation
• Ejaculation may be uncomfortable, and volumes of ejaculation may vary.
• Erectile function may be challenged, especially as time goes by. It may not be as hard, or it gets more challenging to achieve an erection. It may not last as long.

How will high-intensity-focused ultrasound (HIFU) prostate cancer treatment affect your sexual life?

HIFU is an experimental focal treatment. High-frequency sound waves are generated in targeted areas of the prostate or for the whole prostate gland. These waves create heat, which kills cancer cells.

After high-intensity focused ultrasound prostate cancer treatment, one must wait at least two weeks before attempting to get an erection or have sex. You may experience the following:

• Ejaculation volumes may vary.
• Difficulty in maintaining an erection. It may not be as hard, or it gets more challenging to achieve an erection.
  

Hormone prostate cancer treatment sexual issues

Hormone therapy aims to lower testosterone. Prostate cancer cells need testosterone to thrive. This will weaken the prostate cancer cells, making them vulnerable to additional treatment combined with hormonal therapy.

When testosterone levels go below a certain level, men may experience the following:

• Difficulty in getting an erection.  
• Difficulty in keeping an erection
• Loss of orgasm or change in your orgasm
• The sex drive calms down.
• Change in  penile length (may become shorter)
• Change in testicular size (may become smaller)
• Change in your body, weight gain, and breast enlargement affect your sex life as you will experience a different body image.
• Hormone use is linked with difficulty in controlling your sugar (diabetes) and cholesterol levels, which lead to heart problems. This will affect the blood flow to the penis leading to erectile dysfunction.
• Fatigue and tiredness associated with hormonal therapy can tank your sex drive.
  

Chemotherapy cancer treatment affects sex life.

Chemotherapy's aim is to kill cancer cells. There is no restriction to continue with your sex life. If your partner is of childbearing age, the use of protection during and for 6 months after treatment is recommended.

Chemotherapy may alter your body image perception and impact your sex drive. Men may notice that the orgasm does not feel the same. If your experience any of these side effects, do raise your concern; there is help.

I am suffering from erectile dysfunction from prostate cancer treatment. What help can I seek?

A urologist, specialist nurse, andrologist, or sex therapist may be involved in your care.

A detailed history, physical examination and investigations are ordered.

• List medical conditions or medications that may contribute to your impotence
• assess your pre-treatment function,
• determine your physical activity
• to establish a baseline of your post-treatment erectile function,
• and organize a blood panel check which includes a full blood count, kidney and liver function, hormonal profile (testosterone, prolactin, thyroid, luteinizing hormone, and follicle-stimulating hormone), PSA, lipid profile and sugar levels.

Lifestyle changes are fundamental: aim for a healthy weight, exercise, eat healthily, stop smoking, and decrease alcohol intake. These all impact the blood flow to the penile tissue and are the essential building blocks for penile rehabilitation.

What medical treatment and non-medical options are there to get hard again?

• There are four main oral medications: vardenafil (Levitra), sildenafil (Viagra), tadalafil (Cialis), and avanafil (Spedra). Increasing blood flow to the penis is their primary mode of action.
• Topical medication (penile injections, MUSE urethral pellets, and Vitaros cream)
• Vacuum pump
• Rejuvenation therapy (Shockwave therapy and Pelvic floor exercises)
• Testosterone replacement therapy
• Penile prosthesis surgery

Erectile dysfunction is not responding to treatment. Is that normal?

Getting an erection (naturally) may take time. Some studies quote 3 to 4 years.  

Do not compare yourself to others. Each man has to find what works for him.   The treatments received, like radical prostatectomy, hormone therapy, radiation therapy, and other treatments, contribute to erectile dysfunction differently. We are all different and will experience different side effects.

Erectile dysfunction may not respond to one treatment. Be prepared that various approaches, including combinations (for example, oral medications with vacuum pumps and others), need to be explored.

Each treatment option to address erectile dysfunction carries its own implications. Have an honest conversation with your caring team. Voice your concerns. If you are in a relationship, think of your partner.

Men who involve their partners achieve a more satisfying sexual life. Set realistic expectations. Do not expect a substantial improvement or a sudden boost in your sexual drive. Be prepared for the little bumps. Penile rehabilitation can be challenging, but there are options.  

Will my penis remain shorter with treatment?

After radical prostatectomy, hormone therapy, or radiation therapy, some men notice that their penis is shorted or its shape has changed.

To keep the penis healthy to be able to get an erection, a vacuum pump, with or without certain medications, could help to regain the lost length.

Can you produce sperm after prostate cancer treatment?

Sperm banking before treatment for prostate cancer is recommended. Sperm can usually be stored for up to 10 years in most countries.

After radical prostatectomy, men experience a dry orgasm, but they still have sperm production in the testicles.

After radiation therapy, you can ejaculate; even though men complain of low volumes, you may still be fertile.

Care must be taken when receiving radiation therapy and chemotherapy, as they affect sperm quality. Using contraception is recommended.