Testicular cancer (TC) is the most common solid tumor diagnosed in men between the ages of 15 and 35. Due to its high cure rate, focus often shifts toward long-term quality of life concerns. Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection firm enough for sexual activity. While the cancer itself rarely interferes directly with the physical mechanism of erection, many survivors report experiencing ED. The primary cause is not the tumor itself, but rather the necessary treatments used to eradicate the disease, alongside the emotional toll of a cancer diagnosis.
The Role of Hormone Disruption
The most direct physical link between testicular cancer treatment and erectile dysfunction is the disruption of hormonal balance, specifically testosterone production. Testicles are the primary site for testosterone synthesis, a hormone regulating libido and supporting the ability to achieve an erection. The surgical removal of the cancerous testicle (orchiectomy) reduces the body’s total testosterone-producing capacity.
Though the remaining testicle often compensates, some men develop hypogonadism (a testosterone deficiency). This condition results in reduced sexual desire, fatigue, and difficulty maintaining an erection. Nearly 40% of survivors treated with cisplatin-based chemotherapy experience hypogonadism. Low testosterone levels are also associated with metabolic syndrome and cardiovascular problems, further complicating erectile function.
Impact of Testicular Cancer Treatments
Beyond hormonal changes, specific cancer treatments can damage the structures required for a healthy erection. The initial treatment, radical inguinal orchiectomy, typically does not cause ED, as the essential nerves and blood vessels are not disturbed during the procedure. However, more intensive treatments can interfere with the vascular and nervous systems.
Retroperitoneal Lymph Node Dissection (RPLND)
Retroperitoneal Lymph Node Dissection (RPLND), a complex surgical procedure to remove abdominal lymph nodes, risks damaging sympathetic nerves. While the primary sexual side effect is retrograde ejaculation, nerve plexus disruption can also interfere with erection signaling. Surgeons frequently use nerve-sparing techniques, but the risk remains, especially if the procedure is performed after chemotherapy when tissue is scarred.
Chemotherapy
Chemotherapy, especially regimens containing platinum-based drugs like cisplatin, can damage blood vessels and nerves throughout the body. These agents induce vascular toxicity, resulting in endothelial dysfunction (damage to the inner lining of blood vessels). Since an erection depends on healthy blood flow, this vascular damage impairs the ability to trap blood and sustain rigidity. Chemotherapy can also cause neuropathy, a form of nerve damage affecting the peripheral nerves responsible for transmitting signals necessary for arousal and erection.
Radiation Therapy
Radiation therapy directed at the abdomen or pelvis can affect the erectile mechanism by damaging cavernous nerves and penile blood vessels. Exposure can trigger fibrosis (scarring) in the cavernous tissue of the penis, making the tissue less pliable. This impairs the tissue’s ability to expand and hold blood. This damage to both the nerves and the vascular endothelium can be progressive, meaning ED may not become noticeable until several years after treatment concludes.
Psychological and Emotional Factors
The experience of a cancer diagnosis and its demanding treatment introduces a significant psychological component that can cause or worsen erectile dysfunction. Performance anxiety is common, where the fear of failure creates psychological pressure that inhibits the physical response. Body image concerns also contribute to sexual health problems, particularly after an orchiectomy or physical changes induced by chemotherapy. Feelings of reduced masculinity or self-consciousness about the surgical site can lead to avoidance of intimacy. Furthermore, the profound fatigue, anxiety, and depression that follow cancer treatment can dramatically reduce libido.
Diagnosis and Management of Erectile Dysfunction
Diagnosis
Evaluation begins with a comprehensive assessment of both physical and psychological health factors. A physician typically orders blood tests to check for hypogonadism by measuring serum testosterone levels. These tests often include a full metabolic panel to assess for co-existing conditions like diabetes or high cholesterol, which contribute to vascular ED.
Management
Management strategies are tailored to the underlying cause, aiming to restore sexual confidence and function. For men with diagnosed hypogonadism, Testosterone Replacement Therapy (TRT) can alleviate low libido and improve erectile quality. The most common pharmacological treatment involves phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil or tadalafil), which increase blood flow to the penis. Non-pharmacological options include vacuum erection devices, which physically draw blood into the penis to create rigidity. Counseling with a sex therapist is recommended to address the psychological overlay of performance anxiety and body image issues.