Sex after Prostate Cancer Treatment : What You Need to Know

• Active Surveillance and Focal Therapy preserve male sexual function
• Radical prostate cancer treatments damage male sexual function
• 76% of men rate their sexual function as poor 5 years after radical treatment
• Significant penile rehabilitation is needed after radical treatment
• Intimate communication with wives or partners can help to preserve relationships

Prostate cancer is the most common form of cancer found in men in the UK, with over 47,500 men diagnosed each year. 

55% of these men will be diagnosed with organ-confined, localised prostate cancer. These men have fully curable prostate cancer with a variety of treatment options available to them.  The first question many of them ask after understanding that their prostate cancer can be cured is

“How will prostate cancer treatment affect my sex life ?”

In this article, we will explore the link between prostate cancer, decisions about treatment options and a man’s sex life, his level of sexual desire and the impact on intimacy and relationships with partners.

The Europe Uoma Survey 2022 showed that the loss of Sexual Function is important to men.

This report was the result of a detailed survey of 2,900 men with an average age of 71 who had been first diagnosed with prostate cancer at an average age of 66, 5 years earlier. The survey asked about the impact that their prostate cancer had on their quality of life. It was reported anonymously and is regarded as the most reliable report on this subject at this time. 

Prostate cancer treatment damaged the sex life of 73% of men  

Prostate cancer and sexual health can be difficult and sensitive topics to discuss.

So, whether you or someone you know has been affected by prostate cancer, we hope that this article will provide the information and support you need.

2. The Link Between Prostate Cancer and Sexual Function

The male reproductive system is a complex network of organs and tissues that work together to produce and transport sperm, as well as facilitate sexual function. The primary organs of the male reproductive system are the testes, which produce and store sperm, and the penis, which is responsible for sexual arousal, and ejaculation.

Established whole-gland, Radical Prostate Cancer treatments offered to men in the UK cause:

• Erectile dysfunction: the inability to achieve or maintain an erection sufficient for sexual intercourse.
• Reduced libido, or a decreased interest in sexual activity, is a side effect of combination hormone and radiotherapy treatment.
• Dry orgasm: a decreased intensity of orgasm as men lose the ability to ejaculate.
• Loss of fertility: fertility is lost due to the loss of the ability to produce semen or to ejaculate.
• Shorter penis length after surgery.
• Relationship damage. Men experience feelings of anxiety and shame related to their sexual function which can impact their relationships with their partners.

Clinicians often over-emphasise cancer control and underestimate the psychological and emotional importance of a healthy sex life to men and their wives or partners.

Many prostate cancer patients who have localised prostate cancer would choose to trade off a small increase in cancer risk in return for the ability to maintain an active sex life with their wives or partner.

“A lot of men have said to me over the years that they would rather be sexually potent… sexually active, than not being sexually active and having their cancer cured.”

– Lorraine Grover, Psychosexual Nurse Specialist

Treatment options for prostate cancer vary depending on the stage and type of the disease, as well as the overall health of the patient.

3. Prostate Cancer Treatment and reduced Sexual Function

Prostate Cancer is a disease of older men and it is important to be aware that about 40% of older men have impaired sexual function by the age of 71. This can be attributed to factors such as diabetes, heart disease, stress and anxiety and general ageing.

Results of the Europa survey of 2,940 men with an average age of 71, 5 years after treatment for prostate cancer are shown below. The men were asked about their sexual function and quality of life after prostate cancer in a series of questionnaires.

5 years after radical prostate cancer treatment 76% of men rated their sexual function as poor and only 10% of men felt that their ability to function sexually was good or very good.

Over  75% of men report that their decline of sexual function is a problem in their lives.

The extent of this impact is rarely fully explained to men before they decide to proceed with radical prostate cancer treatment and has been shown to lead to significant levels of post-treatment regret.

Given the significant impact on sexual function and quality of life from radical prostate cancer treatment, the question is how to advise men before their treatment decision and how to help men after treatment to accept penile rehabilitation to minimise their loss of sexual function and to engage in intimate communication with their wives or partners to minimise relationship damage.

4. Sexual Impact of the Prostate Cancer treatments options

Based upon the Europa Uoma study we have unbiased survey information on the sexual impact of prostate cancer treatments 5 years after treatment.

A. Active Surveillance

The Active Surveillance cohort did not have any treatment and therefore their level of sexual function can be considered normal for their age group. ie at age 71, 57% of men retain adequate sexual function.

For men with early-stage prostate cancer which is unlikely to become clinically significant Active Surveillance is preferable to radical treatment. (Gleason score 3+3=6 or small volume 3+4=7) This is especially true for men who are older and where the likelihood of their prostate cancer developing to become clinically significant and having any impact on their quality of life or mortality is low.

These men do need to continue to monitor their prostate cancer to ensure that it does not progress through PSA tests, occasional MRI tests and a biopsy if there is evidence of significant progression then they will proceed to the definitive treatment.

Active Surveillance should be considered as the first treatment in order to ensure the best quality of life.

B. Focal Therapy

Modern Focal Therapy treatments for prostate cancer were not reviewed in the Europa Uoma study.

Focal therapies which rely upon precision imaging and diagnostics are easily tolerated day-case procedures with minimal impact upon sexual function.

In clinical trials conducted in the UK more than 95% of men with adequate function before Focal Therpay treatment had no sexual problems 6 weeks after treatment.

Men can have sex or masturbate once the catheter is removed but will notice that they produce less semen than before and may experience infertility.

Focal Therapy treatment for men with localised prostate cancer has equivalent success in controlling prostate cancer to surgery or combination hormone and radiotherapy treatment.

This emphasises the value of early detection of prostate cancer. Potentially up to 55% of men who are diagnosed with prostate cancer in the UK are eligible for Focal Therapy options. These treatment options include HIFU, NanoKnife and Cryotherapy treatments.

Focal Therapy offers a middle way between Active Surveillance and Radical Prostate Cancer treatments

Focal Therapy provides excellent cancer control at 8 years with minimal impact upon sexual function or urinary continence.

C. Surgery and Robotic Prostatectomy

In the NHS the established standard of care for younger men with localised prostate cancer is Robotic Prostatectomy using the high-precision De Vinci Robot system.

Prostate surgery is a significant invasive operation which takes between 6 and 10 weeks to recover from. Incontinence and sexual function side effects are significant.

In the first months, incontinence is acute but this eases for most men. In the Europa Uoma survey, after 5 years, 38% of men were still using 1 pad a day and 20% of men felt that dripping or leakage is a moderate or big problem for them.

Sexual impairment is substantial. The Europa Uoma study has shown that 62% of men with good function before treatment will lose it permanently and that less than 10% of men will have a quality of erection as good as before treatment even with the use of Viagra/Cialis tablets.

After surgery, men have no erectile function however 50% of men who had a nerve-sparing procedure can hope to recover erectile function sufficient for intercourse within 6 months of treatment. Penile Rehabilitation is essential to enable and accelerate this recovery process.

Men will notice some shortening of their penis and will no longer ejaculate semen but can have a Dry Orgasm. Men will no longer be able to have a child naturally and there is a risk of some urine leakage during orgasm.

Radical prostatectomy an effective in terms of cancer control however it is invasive and has a major  impact on urinary incontinence and sexual function.

The Europe Uomo study shows that at 5 years after Robotic Prostatectomy 55% of men report that the loss of sexual function is a major or moderate problem in their lives.

D. Hormone Therapy and External Beam Radiotherapy Treatment

A combination of Hormone therapy and External Beam Radiotherapy treatment is the standard of care for men whose prostate cancer has progressed beyond the prostate gland or who are not robust enough to withstand surgery.

The combination of Hormone Therapy (Androgen deprivation therapy) with Radiotherapy  has been clinically proven to improve survival rates.

Hormone Therapy lowers the expression of testosterone dramatically leading to a reduction in the size of the prostate before radiotherapy. It is normally given for 3 to 6 months before radiotherapy treatment and may be continued for some years afterwards in cases where there is a concern about a risk of extracapsular extension.

This therapy promptly leads to a loss of libido and can cause muscle wastage, reduction in vitality and energy and mental alertness. After the hormone therapy is stopped men can expect to recover within a few months. Men need a rehabilitation exercise programme afterwards if they wish to recover their muscle strength and vitality.

External Beam Radiotherapy is typically given over 30 days or so with more modern SBRT protocols providing higher doses over a shorter time frame.

After the treatment men will suffer fatigue but will typically recover within 3 to 6 months. Men will normally recover some erectile function at this stage. Urinary problems are rare and bowel irritation and continence issues have been greatly reduced in recent years.

Men can have sex or masturbate after their treatment but most will need some time to recover their libido. Men may recover erectile function within a few months however many will see a gradual decline in function during the first 15 months after treatment due to radiation-induced damage to the nerves which control erectile function.

The Europe Uomo study shows that at 5 years sexual problems after Hormone and Radiotherapy treatment are a major or moderate problem for 45% of men.

5. Penile Rehabilitation after prostate cancer treatment

After radical prostate cancer treatment, all men will experience some degree of erectile dysfunction due to nerve damage or other factors related to the surgery or their combination of hormone and radiotherapy treatment.

Penile rehabilitation is a form of sex therapy that aims to minimise damage to penile tissue and penile size following prostate cancer treatment to help men to recover some of their erectile function.

Frequently men are overly optimistic that they will not experience treatment-related adverse effects or, if they do, they tend to assume that their recovery will be quick and unassisted or that erectile dysfunction treatment will be readily available and easy to use. They experience distress when they learn of the extent of physical rehabilitation required and many men abandon the use of erectile treatments even when effective in producing an erection, as treatments are often not easily integrated into couples’ sexual lives.

Penile rehabilitation involves a combination of medication, penile injections, vacuum pumps, sexual stimulation and/or penile exercises performed regularly by the man. The goal is to improve blood flow to the penis and to keep penile tissue oxygenated and stretched in order to rebuild penile tissue and minimise penile shrinkage.

Medication +

Cialis and Viagra are oral drugs that have been a major help to men with erectile dysfunction ED issues. These medications help men to have an erection when aroused and are compatible with most couples’ sex lives.

After prostate cancer treatment it may be necessary to take these medications for many months.

Vacuum Pumps +

Men can use a Vacuum Pump to achieve a functional erection. This is necessary to have sex or masturbate but also to maintain long-term penile function and health.

The Vacuum Pump is used to draw blood flow into the penis to make it hard and erect. A constricting ring can be applied around the base of the penis to allow the erection to be maintained for sex. For maintenance of penile health after surgery or when on hormone therapy men need to use the Vacuum Pump to achieve erection and deflation for 10 minutes every day.

Vacuum Pumps are very safe to use but not all men or couples are comfortable with them or find that they can be integrated into a fulfilling sex life.

Injections +

Men can be provided with access to penile injection treatments using a tiny needle to inject medication into the base of the penis. These injections are effective at generating a natural-looking erection within 5 or 10 minutes that will last for approximately 1 hour.

A sexual therapist can teach a man how to make injections into the side of the penis with a tiny needle. This can be an effective solution for many men and couples.

Similar to Vacuum Pumps, Injections can be used to help to maintain penile health during the period when inflamed nerves are recovering after radical prostate cancer treatment or when men are on hormone therapy.. This needs to be done 3/4 times a week until the nerves have recovered or the hormone therapy has worn off.

Penile Prosthesis Surgery +

Penile Prosthesis Surgery is an option for men for whom other treatments are not effective or do not fit into their sexual life. This involves implanting a penile prosthesis in a short operation. The majority of men choose an inflatable option so that they can easily control the timing of their erections.

Men and couples report a good level of satisfaction with this surgical solution.

7. Coping with diminished sexual function.

All men will experience some deterioration in sexual function after radical prostate cancer treatment. Coping with the deterioration in sexual function after radical prostate cancer treatment is a challenging and emotional experience for men but also for their wives or partners. If action is not taken it can lead to a breakdown of relationships as men react by withdrawing from intimacy and losing confidence and motivation.

The core strategy for coping and reducing harm from these changes is to maintain an open and honest dialogue with wives or partners ideally starting before the decision on treatment options is made. This helps to reduce feelings of shame or isolation and allows for the exploration of new ways to share intimacy.

Prostate Cancer Support groups and online forums are available that provide a safe space for men and their partners to share their experiences and connect with others who are going through similar challenges. These groups can offer a sense of community and support, as well as provide practical advice and strategies for coping with changes in sexual function.

By taking an active and collaborative approach to manage sexual side effects, men and their partners can significantly reduce the impact on their relationships.

8. Fertility after Prostate Cancer

For men and couples who wish to have children in the future prostate cancer treatments pose significant issues as after treatment it will be difficult to conceive naturally.

Radical Treatment of the prostate gland will make men infertile as the whole gland has been treated. Focal Therapies are likely to impact fertility and the ability to conceive naturally as the volume of semen produced will be reduced and there is a risk of damage to the seminal vesicles.

For men and couples who wish to have children after prostate cancer treatment procedures such as sperm freezing or testicular sperm extraction before treatment are recommended.

Make sure you speak to your surgeon and express your desire to explore fertility-preserving treatment options before you start prostate cancer treatment.

9. Final Thoughts

Prostate Cancer and Sexual Function are difficult topics to discuss.

Men and their wives or partners need to understand the trade-offs between minimising the risks of advanced prostate cancer and the quality of life implications of radical prostate cancer treatments for men with organ-confined prostate cancer.

Men need realistic information about the likely impact of radical prostate cancer treatment on their sexual function so that they can take action to minimise its impact upon their quality of life.

By speaking openly about these issues with a partner and healthcare professionals and by researching actively themselves, men can take an active role in

• choosing the right treatment option for them based on their clinical diagnosis
• understand the trade-offs between prostate cancer treatment and a healthy sex life,
• reduce the risk of relationship breakdowns,
• explore ways to maintain intimacy.