What Can You Do for a Healthy Sex Life After Prostate Cancer?

Most men after prostate cancer treatment will experience some problems in the bedroom, but these problems are usually temporary or treatable.

At first, you may feel angry, sad or inadequate, but be patient. With time and the right treatments, you will probably be able to have a satisfying sex life after prostate cancer.

Whether you are single or in a relationship, and whatever your sexuality, we hope you will find this article useful. You may also find it helpful if you are the partner of a man with prostate cancer.

Your prostate lies beside important nerves, blood vessels and muscles that help you get an erection. Surgery and external and internal radiotherapy used to treat your cancer can damage these areas, making it difficult to get an erection or have an orgasm. However, if you had erection problems before treatment, you will probably continue to have them.

The most common complaint after prostate cancer treatments — for about 8 out of 10 men — is difficulty getting an erection, which we call erectile dysfunction. This means you cannot get or maintain an erection firm enough for penetration. But even if you have erectile dysfunction after treatment, you can still have an orgasm. In fact, most men can have an orgasm without an erection.

In addition to erectile dysfunction, a man with prostate cancer may have the following symptoms or complaints:

• Dry orgasm without semen
• A reduction in penis length
• Reduced libido (less interest in sex)

These problems can last a few weeks or longer. This depends on the type of treatment you have and how you feel. Half of men who undergo nerve-sparing prostate surgery or radiation therapy experience an improvement in sexual intercourse within a year after treatment.

How Does Prostate Cancer Affect My Sex Life?

Prostate cancer can affect your sex life in three overlapping ways — your psychology, your body and your relationships.

Psychology

Learning that you have cancer can change how you feel about sex by making you feel low or anxious.

Body

Treatment can damage the nerves and blood supply needed for an erection. Hormone suppression therapy can affect your desire for sex.

Relationships

Coping with cancer can change your close relationships or your thoughts about starting a new relationship.

What Causes Erection Problems?

When you are sexually aroused, your brain sends signals to the nerves in your penis. The nerves then increase blood flow to your penis, producing an erection. Anything that interferes with your nerves, blood flow or desire for sex (libido) can make it difficult to get or maintain an erection. You may hear this called erectile dysfunction or impotence.

Many men have problems with erections, and this becomes more likely as men get older.

Both prostate cancer treatments and other health problems can cause erectile dysfunction.

Treatments for prostate cancer

Some treatments for prostate cancer, such as surgery, radiotherapy, HIFU (high-intensity focused ultrasound) and cryotherapy (freezing), can damage the nerves and blood vessels needed for an erection.

Hormone suppression therapy can also reduce your desire for sex by lowering testosterone levels, and being sexually inactive can negatively affect sexual performance.

Other health problems

• Other health problems can cause erection problems, including:
• Hypertension (high blood pressure)
• Diabetes (sugar disease)
• Heart disease
• High cholesterol
• Neurological conditions such as epilepsy, stroke, multiple sclerosis or Parkinson's disease
• Other prostate problems, such as an enlarged prostate or prostatitis, and their treatments
• Hormone problems such as low testosterone
• Some drugs that lower your mood, or feeling anxious, and lifestyle factors such as smoking, drinking too much alcohol or being overweight can also cause erection problems.

Treatments for Erection Problems

A range of treatments that work in different ways is available for erection problems. Treatments include:

• Tablets
• Vacuum pump
• Injections
• Pellet or cream
• Implant
• Testosterone therapy

Tablets

A group of drugs called PDE5 inhibitors (phosphodiesterase type 5 inhibitors) can help you get an erection. These include:

• sildenafil (equivalents containing sildenafil or Viagra®)
• tadalafil (generic tadalafil or Cialis®)
• vardenafil (Levitra®)
• avanafil (Spedra®)

You need to be sexually aroused for these drugs to work. The tablets usually start working about 30 minutes to an hour after you take them.

You can take sildenafil, avanafil and vardenafil when needed. They will continue working for four to six hours, or up to eight hours for vardenafil. So, if they work, you should get an erection if you are sexually aroused during that time.

You can take tadalafil when needed. This drug can work for up to 36 hours, allowing you to be more relaxed about timing. Or your doctor may recommend taking a low-dose (5 mg) tadalafil tablet every day.

Do not take PDE5 tablets with nitrates in the following situations: Nitrates are usually used to treat heart problems and are used in some recreational drugs (called poppers). If you have heart problems or take nitrates, ask your doctor or specialist about other ways to treat erection problems. 

Injections

Erection problems can also be treated with drugs using an injection you give yourself. These include:

• alprostadil (Caverject®, Caverject® Dual Chamber, Viridal Duo®) 
• aviptadil with phentolamine mesylate (Invicorp®)

An injection may sound off-putting, but many men who have tried it find that it is not so bad and does not hurt. Your nurse or doctor will show you how to inject into the side of your penis with a very fine needle.

The drug causes the penis to fill with blood, and you get an erection within 5 to 10 minutes. The erection lasts about an hour.

Pellets or cream

The active ingredient alprostadil is also available as a small pellet called MUSE® and a cream called Vitaros®.

These do not work as well as injections, but they are a good alternative if you do not like the idea of injections.

You use an applicator to apply the pellet or cream to the tip/opening of the penis. Urinate before applying the pellet. You can massage your penis to help the cream absorb.

If the pellet works, you should get an erection within 5-10 minutes that lasts up to an hour. The cream may take a little longer to work. 

Vacuum pump

You use a pump and a plastic cylinder to create a vacuum that draws blood into your penis. This can give you an erection. After using the pump to produce an erection, you slide a constriction ring from the end of the cylinder onto the base of your penis. This stops most of the blood when you remove the pump. You should not wear the ring for more than 30 minutes at a time.

A vacuum pump can be an effective way to get an erection firm enough for penetration. It may also help preserve penis length and girth if used regularly and early after surgery.

Implant

This involves having an operation to place an implant inside your penis. Although it may sound off-putting, it can be a good option if other treatments have not worked. There are two main types:

• Semi-rigid rods that keep your penis fairly firm all the time but allow it to bend when you do not want an erection.
• An inflatable implant in the penis and a pump in your scrotum (the skin around the testicles). When you squeeze the pump, the implant fills with fluid (salt water) to make the penis firm. Your erection lasts as long as the implant is inflated, and you can deflate it whenever you want.

Testosterone replacement therapy

If you have been treated for prostate cancer contained within the prostate and have erection problems caused by low testosterone levels, you may be able to have testosterone replacement therapy. However, there are concerns about testosterone replacement therapy because its mechanism of action is opposite to that of prostate cancer drugs.

Sex therapy

Because getting an erection also depends on your thoughts and feelings, addressing any worries or relationship problems as well as receiving medical treatment for erection problems often works well.

Self-help

Maintaining a healthy weight, stopping smoking and doing pelvic floor exercises may help improve your erections.

Talking About Sex

Talking about sex can be difficult, but speaking with your doctor, nurse or another health professional means you can get treatment and support. It may also help you feel more positive and more in control.

You can ask about sexual problems at any stage before, during or after your prostate cancer treatment. Talking about it before treatment means you know what to expect and may help you start treatments for sexual problems soon afterward.

During your prostate cancer treatment, your team should ask about your erections and sex life. But if they do not, you may need to bring it up yourself.

Your Desire for Sex (Libido)

Prostate cancer and its treatment can affect your desire for sex.

Hormone suppression therapy for prostate cancer is likely to lower your sex drive. This is because some types of hormone therapy lower your testosterone level, which gives you your sex drive.

If you are having long-term hormone therapy, ask your doctor or nurse about intermittent hormone therapy. Your desire for sex may increase after hormone therapy is stopped, but this may take several months.

Even if your sex drive is low, you may want to try treatments for erection problems. Some treatments for erection problems may still work for you.

What Else Can Affect Your Desire for Sex?

Your thoughts and feelings: If you feel stressed or low, you may be less interested in sex.

Fatigue: All treatments for prostate cancer can cause fatigue. This can occur during and after treatment. If you feel very tired, you may lose interest in sex or not have enough energy for it.

• Related topic: Weakness and Fatigue in Cancer: Why Does It Happen and How Is It Treated?

Other side effects: Other side effects of prostate cancer treatments, such as urinary and bowel problems, can affect your sex life. Physical changes caused by hormone therapy, such as weight gain or breast swelling, may make you feel embarrassed and less interested in sex.

Changes in Penis Size

Some men notice that their penis is shorter after prostate cancer surgery called radical prostatectomy. Some men notice other changes, such as a curve or a narrower area in their penis. We do not know exactly why these changes happen, but they may result from low oxygen levels in the penis caused by a lack of erections. Other treatments, such as radiotherapy and hormone therapy, may also change the size of your penis.

Encouraging blood flow to the penis after surgery may help prevent this. In particular, using a vacuum pump, alone or with PDE5 inhibitor tablets, may help preserve your penis size and improve erections.

An Active Sex Life After Surgery

You can start treatment for erection problems in the weeks immediately after surgery, even if you are not ready or recovered enough for sex. This may mean taking a low-dose PDE5 tablet once a day, using a vacuum pump, or sometimes both. Treatment combined with masturbation encourages blood flow to the penis. This may help keep your penis healthy. You may hear this called penile rehabilitation. Urologists trained in sex therapy can give you more detailed information about it.

Think of it like someone having physiotherapy after injuring an arm or a leg. Starting treatment soon after surgery may help increase your chances of getting and maintaining erections. But it may not work for every man.

Changes in Orgasm and Ejaculation

After prostate cancer treatment, you should still have sensation in your penis and be able to have an orgasm, although it may feel different from before. Some men lose the ability to have an orgasm, particularly if they are having hormone therapy.

If you have had a radical prostatectomy, you no longer ejaculate when you have an orgasm. This is because the prostate and seminal vesicles, which make some of the semen fluid, are removed during the operation. Instead, you may have a dry orgasm — feeling an orgasm without ejaculating. Sometimes a small amount of fluid from the glands lining the urethra may come out of the tip of your penis during orgasm.

If you have had radiotherapy, brachytherapy (internal radiotherapy), high-intensity focused ultrasound (HIFU) or hormone therapy, you may produce less semen during and after treatment. With radiotherapy, brachytherapy and HIFU, you may also notice a small amount of blood in your semen. This is usually not a problem, but tell your doctor or nurse if it happens. Some men having hormone therapy say their orgasms feel less intense.

If you have had surgery for an enlarged prostate called TURP (transurethral resection of the prostate) or radiotherapy, you may experience retrograde ejaculation (ejaculation into the bladder). This is when semen goes backward into the bladder rather than out of your penis when you have an orgasm. The semen leaves the body the next time you urinate. It is not harmful and should not affect your enjoyment of sex, but it may feel quite different from the orgasms you are used to.

Some men leak urine when they have an orgasm or feel pain. Others notice that sex does not last long and that they reach orgasm quite quickly.

Having Children

You may not be able to have children naturally after prostate cancer treatment. If you have a radical prostatectomy, you do not ejaculate semen. If you receive radiotherapy, radiation may affect your ability to produce sperm, although this may be temporary.

After radiotherapy, you may produce less fluid when you ejaculate, but you may still be fertile.

You may consider storing your sperm before treatment so it can be used for fertility treatment later. Ask your doctor or nurse whether a sperm bank is available locally. If medically appropriate, you can usually store your sperm for up to 10 years, and sometimes longer.

Changes to your sperm during radiotherapy and chemotherapy for prostate cancer may affect children conceived during or after treatment, but the risk of this happening is very low and unproven. You are advised to avoid having a new child during treatment and for up to two and a half years afterward.