Prostate cancer treatment frequently leads to sexual side effects. While a cancer diagnosis is overwhelming, the physical and emotional changes to a man’s sexual health can create substantial distress. The primary treatments for prostate cancer impact the nerves, blood vessels, and hormones necessary for a healthy sex life.
Sexual Changes Following Radical Prostatectomy
The surgical removal of the prostate gland, known as radical prostatectomy, immediately and profoundly affects a man’s sexual function by impacting both erectile ability and ejaculation. The nerves responsible for achieving an erection run in delicate bundles along either side of the prostate. Even with the most careful surgical technique, these nerves can sustain damage from stretching, thermal energy, or inflammation during the procedure, leading to immediate erectile dysfunction (ED).
Surgeons may attempt a “nerve-sparing” approach to preserve these bundles, which significantly increases the likelihood of recovering natural erectile function over time. However, the extent of nerve sparing often depends on how close the cancer is to the nerve bundles; if cancer cells are present, the nerves must be removed to ensure the best oncological outcome. Recovery is slow even when nerves are spared.
The physical act of ejaculation is also permanently altered following radical prostatectomy. Consequently, a man will experience a “dry orgasm” after the operation, where the sensation of climax occurs without the release of fluid. While the ability to feel an orgasm is typically preserved, some men report that the sensation is less intense or different, and a small number may also experience the distressing side effect of involuntary urine leakage during orgasm.
Impact of Hormone Therapy and Radiation on Sexual Health
Androgen Deprivation Therapy (ADT), or hormone therapy, is designed to reduce the body’s level of androgens, such as testosterone, because these hormones can fuel prostate cancer growth. Since testosterone is the primary driver of male sexual desire, suppressing it causes a dramatic and often immediate decrease in libido.
The reduction in testosterone also directly contributes to erectile dysfunction and can lessen the intensity of orgasms. For men receiving ADT, the rate of ED can be as high as 80% to 91% within a year of starting therapy.
Radiation therapy, whether delivered externally (External Beam Radiation Therapy) or internally (Brachytherapy), causes erectile dysfunction through a different mechanism than surgery. The high-energy rays gradually damage the delicate blood vessels and nerves within the pelvic region over time. This process can lead to tissue fibrosis and a progressive decrease in the penis’s ability to trap blood for a rigid erection. Unlike the immediate onset of ED following surgery, the decline in function after radiation is often more gradual, developing over many months or even years post-treatment.
Medical Approaches to Restoring Erectile Function
The inability to achieve or maintain an erection is one of the most common physical sequelae, but a comprehensive set of medical interventions is available. Penile rehabilitation protocols are often initiated shortly after surgery to encourage blood flow and oxygenation to the penile tissue, which helps prevent atrophy and the formation of scar tissue. This restorative process typically involves the regular use of devices or medication to induce an erection several times per week.
Oral medications, known as phosphodiesterase type 5 (PDE5) inhibitors, are a first-line treatment for ED and include drugs like sildenafil (Viagra) and tadalafil (Cialis). These medications work by inhibiting the PDE5 enzyme, which increases the availability of nitric oxide, a signaling molecule that relaxes the smooth muscle of the penis and allows for increased blood flow. While highly effective in the general population, they may be less effective immediately after nerve-sparing surgery until some nerve function returns.
If oral medications are ineffective, men can utilize a Vacuum Erection Device (VED). The VED is a cylinder placed over the penis that uses negative pressure to draw blood into the shaft, creating a rigid erection that is maintained by a tension ring placed at the base.
Another highly reliable option involves Intracavernosal Injections (ICI), where a small amount of vasoactive medication, such as alprostadil or a multi-drug mixture, is injected directly into the side of the penis to pharmacologically induce an erection. For men with end-stage ED who have not responded to less invasive methods, a penile implant, or prosthesis, can be surgically placed to provide a reliable, user-controlled erection.
Maintaining Emotional and Relational Intimacy
The physical changes following prostate cancer treatment can introduce significant psychological stress, often leading to performance anxiety and body image issues. This anxiety can become a self-fulfilling prophecy, making physical intimacy more difficult and compounding the existing ED. Open and honest communication with a partner is therefore paramount to navigating these challenges.
Emotional intimacy can be maintained and even strengthened when couples address the changes as a shared experience. Shifting the focus from intercourse to a broader definition of sexual expression allows couples to explore alternative ways of giving and receiving pleasure. Counseling or sex therapy can provide a neutral space to discuss fears, manage expectations, and develop new strategies for physical closeness that are satisfying for both individuals.