Prostate cancer is one of the most common cancers diagnosed in men, and while the disease itself does not typically cause immediate sexual dysfunction, the treatments used to cure or manage it frequently impact a man’s sexual health. The prostate gland is located in a complex pelvic area surrounded by nerves and blood vessels necessary for sexual function. Consequently, the most common and significant changes to a man’s sex life are direct results of interventions like surgery, radiation, and hormone therapy. Addressing potential sexual side effects is a fundamental part of the recovery process and survivorship.
Impact of Primary Treatments on Erectile Function
Erectile function often changes following primary curative treatments for localized prostate cancer, such as radical prostatectomy (surgery) and radiation therapy. Radical prostatectomy involves removing the entire prostate gland, carrying an immediate risk of damaging the delicate cavernous nerves responsible for erections. These nerves run in bundles close to the prostate, and even with a modern “nerve-sparing” technique, temporary injury from stretching or inflammation is common, resulting in immediate post-operative erectile dysfunction.
The decision to spare the nerves depends on the location and aggressiveness of the cancer, as preserving the nerves is secondary to removing all cancerous tissue. Even when both nerve bundles are successfully spared, recovery is gradual, often taking up to two years, though many men see substantial improvement within the first 12 months. Studies show that between 40% and 60% of men who undergo bilateral nerve-sparing surgery may regain the ability to have intercourse with or without the aid of medication by the two-year mark.
In contrast, radiation therapy (external beam or brachytherapy) affects erectile function more slowly and progressively. Radiation damages the small blood vessels and tissues in the penis and surrounding area, leading to a gradual thickening and scarring process known as fibrosis. This vascular and tissue damage restricts blood flow over time, meaning that while erections may be preserved initially, dysfunction often develops months or years after treatment. The risk of developing erectile dysfunction after radiation can range widely, with rates often reported between 30% and 70% within two years of treatment.
Changes to Ejaculation and Orgasm
While the ability to achieve an erection is a primary concern, prostate cancer treatments also fundamentally change the mechanics of climax. The most consistent change following a radical prostatectomy is the occurrence of a “dry orgasm,” or anejaculation. Since the prostate gland and seminal vesicles (which produce the fluid components of semen) are removed during surgery, there is no fluid emission upon climax.
Despite the absence of fluid, the sensation of orgasm is often preserved, though many men report a diminished intensity or a different feeling compared to before the surgery. Another complication is climacturia, the involuntary leakage of urine during orgasm or sexual excitement. While distressing, this is a common side effect that can often be temporary or managed with various techniques.
Sexual Effects of Hormone Therapy
For advanced or recurrent prostate cancer, treatment often involves Androgen Deprivation Therapy (ADT), which lowers the body’s levels of androgens, such as testosterone. Since testosterone fuels the growth of prostate cancer cells, reducing its presence slows the disease’s progression. However, testosterone is also a major driver of sexual desire, meaning ADT profoundly affects a man’s libido.
The reduction in sexual desire is the most common and pervasive sexual side effect of hormone therapy, which can occur even if physical erectile function was previously intact. The suppression of testosterone can also lead to or worsen existing erectile dysfunction, making it more difficult to achieve and maintain an erection. ADT can also cause systemic effects like fatigue, hot flashes, and changes in body composition, which indirectly contribute to reduced interest in sex and negative sexual self-perception.
Strategies for Sexual Rehabilitation and Intimacy
A proactive approach to sexual rehabilitation is important for maximizing the chance of recovering physical function and adapting to changes. Penile rehabilitation is often recommended to preserve penile tissue health by encouraging regular blood flow and oxygenation, preventing scar tissue and atrophy. This process typically begins within a few weeks after surgery and may involve the use of low-dose, daily phosphodiesterase type 5 (PDE5) inhibitors, such as tadalafil or sildenafil, to promote blood vessel health.
If oral medications are not sufficient, other treatments offer reliable alternatives for achieving a functional erection. These include a vacuum erection device (VED), which draws blood into the penis, or intracavernosal injections, where a medication like alprostadil is injected directly to induce an erection. For men who do not respond to other therapies or who seek a permanent solution, a penile implant is a highly effective, surgically placed device that allows for on-demand rigidity.
Beyond physical recovery, maintaining emotional and sexual intimacy requires open communication with a partner. Psychosocial support and counseling can help men and their partners navigate performance anxiety, body image concerns, and changes in sexual routine. Intimacy does not solely rely on penetrative intercourse, and adapting to new ways of expressing closeness, affection, and sexual pleasure is a significant component of sexual survivorship following treatment.