Prostate Cancer Can Change Your Sex Life. What Men Should Know Before and After Treatment

When a man is diagnosed with prostate cancer, the first questions are usually about survival, treatment and whether the cancer has spread.

Sexual health may be much farther down the list.

But prostate cancer and its treatment can affect erections, sexual desire, orgasm, ejaculation, fertility and intimacy. The changes can happen before treatment begins, immediately afterward or months and years later, depending on the cancer and the treatment used.

That makes sexual health something worth discussing before treatment starts, not something to wait to address afterward.

The cancer diagnosis itself can affect intimacy

Sexual problems do not always begin with surgery or radiation.

A cancer diagnosis can bring fear, anxiety, sadness and concerns about changes to the body. Those emotions can reduce sexual interest and make intimacy more difficult for both a man and his partner. Existing erectile dysfunction and other health conditions can also affect sexual function before treatment begins.

If sexual function changes after treatment, it may not be possible to attribute every change to the treatment itself. Age, overall health, medications, relationship stress and sexual function before treatment can all play a role.

Surgery can affect erections, ejaculation and fertility

A radical prostatectomy removes the prostate and seminal vesicles, along with some surrounding tissue.

Because nerves and blood vessels involved in erections run near the prostate, surgery can affect the ability to get or maintain an erection. The American Cancer Society says most men have erection problems immediately after prostatectomy, although some recovery can occur during the first two years.

Surgery can also change what happens during orgasm.

A man may still be able to experience an orgasm, but without semen coming out of the penis. This is sometimes called a dry orgasm. The absence of semen does not necessarily mean the loss of sexual pleasure, although some men notice changes in orgasm intensity.

Fertility is a separate issue.

Because prostatectomy removes the prostate and seminal vesicles and changes the reproductive pathway, men who may want biological children should discuss fertility before treatment. Sperm banking may be an option in appropriate circumstances.

Radiation can affect sexual function too

Radiation treatment can also affect the nerves and blood vessels involved in erections.

One difference is timing. Erectile problems after radiation may develop gradually, sometimes over several years, rather than appearing immediately after treatment. The American Cancer Society notes that long-term rates of erectile dysfunction can become similar after surgery or radiation, although the pattern of recovery can differ.

Radiation can also affect ejaculation. It may reduce the amount of semen produced and, in some men, cause pain with ejaculation that generally improves after treatment ends.

Hormone therapy can change sexual desire

Hormone therapy, also called androgen-deprivation therapy or ADT, works by lowering or blocking hormones such as testosterone that can help prostate cancer grow.

One of its most common sexual effects is a major reduction in sexual desire. It can also cause erectile dysfunction and problems with orgasm. Some men experience physical changes, including shrinkage of the testicles and penis.

This is important because low libido and erectile dysfunction are not the same problem.

A medication designed to help produce an erection may not restore sexual desire when hormone therapy has substantially lowered testosterone.

And testosterone replacement should not be viewed as a routine solution for men with prostate cancer. The American Cancer Society notes that testosterone is generally not given to men with prostate cancer because testosterone can stimulate prostate-cancer growth. Anyone concerned about low testosterone should discuss testing and treatment with their cancer-care team.

Sex is more than erections

A common mistake is to treat sexual health after prostate cancer as if the only question is whether a man can get an erection.

It isn’t.

Treatment can affect:

• Erections — difficulty getting or maintaining an erection.
• Desire — reduced interest in sexual activity, particularly with hormone therapy.
• Orgasm — orgasms may feel different, become weaker or sometimes become painful.
• Ejaculation — some men have little or no semen after treatment.
• Fertility — the ability to father a child can be affected even when sexual pleasure remains possible.
• Intimacy — fear, embarrassment, body-image changes and anxiety can affect physical and emotional closeness.

The Prostate Cancer Foundation specifically identifies erectile dysfunction, orgasm difficulties, changes in libido and urinary leakage during sex among sexual-health issues that can occur following prostate-cancer treatment.

There are treatments and ways to adapt

Sexual problems after prostate cancer do not necessarily mean that a man’s sex life is over.

Depending on the problem and a person’s medical situation, doctors may recommend medications for erectile dysfunction, vacuum erection devices, penile injections or, in some cases, penile implants. A cancer-care team or urologist can help determine which options are appropriate.

Sexual health can also involve counseling.

The Prostate Cancer Foundation recommends considering sex therapy and emphasizes that intimacy does not have to depend entirely on erections or intercourse. Couples may need to explore different forms of physical intimacy while sexual function changes or recovers.

That can be particularly important for men receiving hormone therapy, when sexual desire itself may be reduced.

The conversation should start before treatment

Before choosing or beginning treatment, men can ask their doctors:

• How could this treatment affect my erections?
• Could it affect my ability to have an orgasm?
• Will I still produce semen?
• Could treatment affect my fertility?
• What should I expect in the first weeks and months afterward?
• When should sexual rehabilitation begin?
• What treatments are available if I develop erectile dysfunction?
• If I receive hormone therapy, how might it affect my libido?
• Who can I talk to if sexual changes are affecting my relationship or emotional well-being?

These are legitimate medical questions, not secondary concerns.

The American Cancer Society advises people with cancer to talk with their health care team about sexual problems and to ask about potential effects before treatment begins.

What the evidence can tell us

Prostate cancer and its treatments can affect several dimensions of sexual health. The specific effects depend on the treatment, the person’s health and sexual function before treatment, and other individual factors.

Some men recover erectile function over time. Others continue to need treatment or assistance. Some experience changes in orgasm or ejaculation even when they retain sexual pleasure. Hormone therapy can have particularly strong effects on sexual desire.

What the evidence cannot tell us

Statistics cannot predict exactly what will happen to one individual man.

They cannot tell a patient whether he will regain erections, how his orgasms will feel after treatment, or how a relationship will respond to changes in sexual function.

Those outcomes depend on the individual and the treatment.

That is why sexual health belongs in the treatment conversation before a decision is made.

The bottom line

Prostate cancer treatment is fundamentally about controlling the cancer and protecting a man’s health.

But quality of life matters too.

For men facing prostate cancer, understanding the possible effects on sex, intimacy, fertility and sexual function can help them enter treatment with a more complete picture of what to expect — and a plan for addressing problems if they occur.