What happens to your sex life after prostate cancer treatment
Being on the receiving end of a prostate cancer diagnosis is tough for any man to face, with one of the biggest challenges being life post-treatment. The impact that cancer treatment can have on a man’s sex life includes everything from erectile dysfunction, low libido and difficulty achieving orgasm to low sperm count.
Prostate cancer is the most common male cancer in the UK, with more than 52,000 new cases diagnosed in the UK every year, usually affecting men aged 50 and above, with the risk increasing as men get older. The prostate gland is a small organ that’s part of a man’s reproductive anatomy and about the size of a walnut. It’s found deep in the pelvis, between the penis and the bladder. Its most important job is producing seminal fluid. It also plays a part in hormone production and helps regulate urine flow.
The most common surgery for prostate cancer removes the entire prostate gland using a procedure called radical prostatectomy, and you may also have radiotherapy and hormone therapy. Advances in screening and nerve-sparing robotic (minimally invasive) surgery and other techniques can help minimise life-changing side effects.
“The development of MRI scanning and robotic surgery has meant outcomes are much better than they were 15 years ago,” says Giles Hellawell, consultant urological surgeon at London’s Charing Cross Hospital.
However, Prostate Cancer UK has revealed that in a survey of men who had received treatment for prostate cancer, 81 per cent reported erectile dysfunction. In fact, many experts agree that most men will experience some side effects either temporarily or permanently. Although, as Hellawell says: “The sexual dysfunction impact is also dependent on many factors such as the patient’s general health, any other medical problems and their level of sexual function and ability before treatment.”
How prostate cancer treatment affects your sex life
Kelly Kusinski, a urology advanced nurse practitioner at The Royal Wolverhampton NHS Trust, says: “While changes may be temporary and some men will recover over time, some will experience lifelong changes that require medical intervention and help in maintaining sexual intimacy.”
It is not only physical challenges that cause problems. Mentally, it is incredibly hard to deal with any changes to sexual function, leaving many men with feelings of anger, anxiety, frustration and embarrassment. “There’s a shame attached to this issue and we need to get rid of it, as well as the taboo around asking for help,” says Lorraine Grover, of The Prostate Centre, London, and one of the UK’s leading psychosexual nurses.
“There are things people can do to help with the recovery of a sex life,” she adds. “There is hope for all, no matter what kind of treatment they’ve had. For some, their sex life can be improved as there may have been issues before diagnosis, but no one to turn to for help and advice.”
Living with sexual dysfunction
“After my prostatectomy it took me 15 months to achieve any sort of useful erection,” says Andrew Taylor*, 68, who had his prostate removed eight years ago and has been married for 44 years. “I take a small daily dose of Cialis and I’m able to get an erection but not one suitable for penetrative sex. That doesn’t necessarily mean I don’t have a close and intimate relationship with my wife. There are other ways of giving your partner an orgasm.”
Unfortunately, Taylor, a retired bank manager from Surrey, suffered two priapism episodes [a long-lasting and painful erection] on the occasions he tried injections. He adds: “I’ve spoken to many men and injections are superb for them, but none of my experiences have been good. I’m not risking another medical emergency.”
His marriage remains strong, but many relationships can become strained. It is important to talk to your partner about how you are feeling and keep an open dialogue. There are many ways to be intimate that do not involve full penetration, such as massage, sex toys and rediscovering each other’s bodies in a playful and non-pressured way.
“This is an opportunity for men and their partners to reflect and talk about intimacy and their sex lives,” says Grover. “Some couples may never have done this before. It’s about staying positive and not spiralling into negative thoughts.” Psychosexual counselling or couples therapy can help people to discuss their feelings, support each other and find new ways to remain intimate.
Sex after prostate cancer treatment: what to expect
Sex can feel psychologically and physically different after treatment. Nerves and blood vessels that control erectile function run along the sides of the prostate gland, and during treatment these can be damaged or removed.
“Many treatments can affect a man’s ability to gain and maintain an erection,” says Kusinski. “When a man becomes aroused, the brain sends signals to the nerves in the penis, which then cause blood to flow into it and make it erect. Any treatments that interfere with or cause changes to these nerves and the blood supply can make it difficult to get and sustain an erection, as well as reducing the desire for sexual intimacy.”
Along with a reduced libido, there is a connection between hormone therapy, which may be administered as part of the treatment, and genital size.
Hormone therapy works by either stopping your body from making testosterone, or by stopping testosterone from reaching the prostate cancer cells, which usually need testosterone to grow. A loss of testosterone can mean the penis and testicles may become smaller, and achieving an orgasm may be challenging because low testosterone levels generally reduce libido.
What are the treatment options?
“What’s important is that the man has a plan of action,” says Grover. “Some call it penile rehabilitation, but I call it ‘recovery and discovery’, as it’s far more than just the penis – it’s a holistic programme looking at the whole patient. If one treatment doesn’t work, we move on to another and look at what impact that may be having on their psychological self.”
Grover warns that the availability of treatments on NHS prescription can be a postcode lottery. However, Kusinski explains that having knowledge of what is available will allow men to try different treatments and discuss outcomes with healthcare practitioners until they find the one that works best.
Here, she sets out the options of dealing with erectile dysfunction:
Oral medication
These drugs are called phosphodiesterase type 5 inhibitors (PDE5 inhibitors) and they temporarily increase blood flow to the penis. There are several types, including sildenafil (sold under the brand name Viagra), vardenafil (Levitra), tadalafil (Cialis) and avanafil (Spedra). These are not aphrodisiacs and basically enhance the body’s own mechanism to produce an erection. They will not work if sexual desire is absent and they need to be taken prior to sex. Your healthcare practitioner should review what other medication you take to ensure there are no complications from combining them.
Vacuum therapy
An erection is produced by creating a vacuum around the penis using a pump device. This results in blood being drawn into the penis, and the erection is maintained using a constriction band worn at the base. Most men can achieve an erection well enough for sexual intercourse within a few minutes, but the band shouldn’t be worn for longer than 30 minutes. Some practitioners recommend the use of a vacuum device as daily exercise. This can improve blood flow to the penis and help to keep it healthy. If a pump is being used for this purpose, the constriction band should not be used. Proper initial instruction is strongly advised.
Pellets and topical treatments
Medicated Urethral System for Erection (Muse) is a form of the drug alprostadil that’s made into a pellet approximately the size of a grain of rice. This needs to be inserted into the urethra with a small plastic applicator. With massage and foreplay, the pellet dissolves and is absorbed into the penile tissues and an erection can be achieved in around 10 minutes. Topical creams and gels such as Vitaros may also stimulate the nerves in the head of the penis, helping to make the penis erect.
Penile injections
These are artificial hormones that stimulate blood flow to the penis and are a very effective method of achieving an erection. Prior to using the injections yourself, a nurse or doctor will show you how to mix the medication and self-inject into the side of the penis using a very thin needle. The penis can become rigid within five to 15 minutes and the erection can last up to an hour. However, on rare occasions these injections can cause priapism. This happens when the penis does not become soft again because the blood is unable to flow back out of the penis. If an erection lasts beyond two hours, it is important you inform your GP or go to an A&E department for treatment.
Penile implants
One kind of implant involves semi-rigid rods that are placed in the penis under general anaesthetic and can be bent upwards when an erection is required and back down afterwards. Because the implants are malleable, they can be set in various positions, as needed.
The other type of penile implant is inflatable. It remains in the penis and a pump is inserted in the scrotum. When an erection is required, the pump is activated. Insertion of any penile prosthesis results in the destruction of internal erectile tissue and should only be considered when all other treatment options have been tried.
There is a risk of infection, or that the body may reject the implants, which would then require them to be removed. The other treatment options mentioned above cannot be tried afterwards. Not every hospital provides this surgery, so referrals are made to a specialist centre.
Which health professionals can help?
Initial discussions can start with either your GP, consultant urologist or urology specialist nurse. If you are suitable for tablet treatment, a GP can prescribe it. Other treatment options may be recommended and commenced by your urology team. “Your GP will be informed of your treatment option,” says Kusinski, “and can continue with the prescriptions subsequently.”
There are other ways to seek help, such as the UK’s prostate cancer charities and nationwide support groups. In 2023, Prostate Cancer Research launched The Infopool, a comprehensive website that includes stories and videos of men and their partners talking about their experiences with prostate cancer, including living with sexual dysfunction.
“People want to find experiences they can relate to,” says David James, director of patient projects at Prostate Cancer Research. “People can search for stories by age, ethnicity, sexual orientation, and so on.”
Former patient Andrew Taylor regularly attends a support group organised by Tackle, a patient-led, UK-wide prostate cancer charity. “I go every month and it’s immensely useful. It’s given me a safe space to have the courage to say things that only other people there can understand. There’s even an online group and a group set up by Tackle just for wives and partners.”
Will there be infertility issues?
Depending on what treatment you have for your cancer, your fertility may be affected and you may not be able to father children naturally. Of course, this may not be an issue for you, but if it is, sperm banking is the best chance for having children after cancer treatment, and sperm can usually be stored for up to 10 years.
“Men don’t become infertile after treatment, they are just not able to naturally conceive,” says Prof Hashim Ahmed, chairman of urology and head of speciality surgery at Imperial College London. “If men haven’t saved sperm and later on they’re thinking about having children, we can still retrieve it directly from the testicles.”
Boosting a low libido
“Touching, caressing each other and thinking about sexual fantasies are some things that may help,” suggests Kusinski. “Using sex toys and having physical contact can slowly lead to being aroused and improving the libido.”
It is also reassuring for men and their partners to realise that sex doesn’t have to be about penetration, she explains. Spending quality time together can help couples become more comfortable. She advises setting time aside to enjoy each other’s bodies without the pressure of thinking about having sex.
Grover agrees: “It is possible to have a healthy sex life after prostate cancer treatment. It just might take a bit of time.”
*Name has been changed
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