What to expect

Many sexual problems that men have after cancer treatment will not last long. For instance, pain with erection or ejaculation soon after pelvic surgery or radiation is likely to go away. The stress of treatment can also reduce hormone levels for a few weeks. This may cause decreased desire or erection problems until hormone levels go back to normal.

As you feel more in control of your body and your life, you will find that your self-confidence returns and your sex life often gets better.

But some cancer treatments can cause a lifelong change in a man's sexual function. It's hard to know what will happen to any one person. For example, one man's erections may come back after radical prostatectomy while another man's may not. But if you do have a sexual problem, your health care team can often find the cause and give you an idea of your chance for recovery.

One clue that a problem is a medical one and permanent is if it happens in all situations. Otherwise, it may be psychological and short term. For example, if you have trouble getting or keeping an erection, does it happen every time you have sex? Are your erections better when you relax, when you stimulate your own penis, or when you unexpectedly see someone attractive? If you have a few partners, are your erections better with one of them than with the others?

Dealing with short-term problems

As men age or go through health problems, feelings of sexual excitement no longer lead to an instant erection. You may just need more time and stroking to get aroused.

If you have trouble reaching orgasm during sex, perhaps you have not found the right kind of caressing. You might even think about buying a hand-held electric vibrator. A vibrator can provide very intense stimulation. Try having a sexual fantasy or looking at erotic stories or pictures. The more excited you are, the easier it is to reach orgasm.

A number of men have their first orgasm after cancer treatment while asleep, during a sexual dream. If this happens to you, it is proof that you are physically able to have an orgasm. Because sleep erections aren't affected by mood or state of mind, they give you an idea of the best erection your body can produce. Now it is up to you to set things in motion when you are awake.

Finding the cause of problems that appear to be permanent

The best time to talk with your doctor or cancer team about side effects or long-term changes in your sex life is before treatment, so that you can learn about the usual recovery and how long it takes. But you can bring up the subject any time during and after treatment too. Unless you have had surgery and are trying the "early rehabilitation" approach, don't be surprised if you need several months to recover from treatment. If erection problems last longer, talk with your doctor and try different ways to overcome them. If your problem doesn't get better, your doctor may ask you some questions about your sex life, and then use special medical tests to help find the cause. You may need to see more than one doctor to help you find out exactly what the problem is and get the treatment you need.

Tests to measure nighttime erections

One of the tests used most often is done while you sleep. Your doctor may send you for 2 or 3 nights to a sleep lab to check your sleep erections. A technician watches your brain waves and breathing during the night to make sure that your sleep patterns are normal. At the same time, elastic loops placed around the base and tip of your penis are connected to a recorder. The recorder measures changes in the size of your penis during the night. If your sleep erections are firm and long-lasting, your problem may respond well to some sexual counseling. If your sleep erections are poor or you don't have an erection, you may need surgery or medical treatment to correct the problem.

Since sleep lab testing costs a lot, most doctors use other ways to check sleep erections. Many send a man home with an electronic monitor to wear on the penis at night. This can be a very good test. A less accurate test is to use a plastic strip (or snap gauge). The patient wears it around the shaft of the penis during sleep. An erection breaks 1 to 3 bands of plastic film on the gauge, depending on the firmness of the erection. Another option is a strain gauge, a circular device placed at the base and tip of the penis that stretches during erection. It also measures the change that happens with erection.

Other medical tests

Other tests, done in a doctor's office, can measure blood flow in the penis. One such test uses a doppler ultrasound. The doctor passes a hand held device over the penis, and reflected sound waves show the speed and direction of blood flow. This type of test looks for a block in circulation that could be causing the erection problem. Sometimes the test includes injecting medicine into the shaft of the penis to produce an erection. In that case, the ultrasound imaging test is done on the erect penis. Tests of nerve sensitivity and reflexes in the genital area are sometimes done, too. Blood tests are also commonly done to check the levels of the 2 hormones most closely linked to men's sexual function, testosterone and prolactin.

When is sexual counseling helpful?

Any sexual problem caused or worsened by anxiety can respond to counseling with a sex therapist. For men, problems caused by anxiety can include:

• loss of sexual desire
• erection problems without a medical cause
• trouble reaching orgasm
• premature (early) ejaculation

When a medical problem limits a man's sexual function, sex therapy can still be helpful. But the goals may change. For example, instead of expecting a man to regain full erections, the therapist may help him and his partner learn to enjoy sexual caressing without erections. Sex therapists may also be able to help you and your partner decide whether to have medical or surgical treatments for erection problems. (See the section, "Professional help.")

Is there a pill that will cure sexual problems?

In 1998 the Food and Drug Administration (FDA) approved a drug called sildenafil citrate (Viagra®) to treat impotence. Since then, 2 similar drugs have been approved, vardenafil (Levitra®) and tadalafil (Cialis®). All of these drugs help a man get and keep an erection by causing more blood to flow to the penis. About half of men with impotence due to medical (rather than psychological) problems are helped to some extent by these drugs.

Studies suggest that problems due to nerve damage from prostate cancer treatment may not respond as well to these drugs as some other physical causes of impotence. But recent research suggests that using one of these drugs within 6 months of surgery, on a regular basis, does improve the rate of spontaneous erections after nerve-sparing radical prostatectomy. (See "Early sexual rehabilitation after surgery" under "Effects of Cancer Treatment on Male Sexuality.") Some men who don't get a good enough result with one of these drugs may do better when they use it along with the penile injection. (See "Penile injections" below.)

Many drugs are known to interact with this group of drugs. For example, nitrates (like nitroglycerin and other drugs used to treat heart disease) may interact to cause very low blood pressure, a complication that can be fatal. Be sure your doctor knows about all medicines you take, even those you take rarely.

The most common side effects of these impotence drugs are headache, flushing (skin becomes red and feels warm), upset stomach, sensitivity to light, and runny or stuffy nose. In rare cases, these drugs may block blood flow to the optic nerve in the back of the eye. This could lead to blindness. Men who have had this problem were more likely to have been smokers or had problems with high blood pressure, diabetes, or high levels of cholesterol or fat in their blood.

Other medicines to treat impotence are being studied. You might want to ask your doctor about any new medicines or treatments for erection problems. We will describe some other methods next.

Is there a way to restore erections if the nerves or blood supply of the penis has been damaged?

Blood supply: If a blockage in the main artery that brings blood to the penis is causing an erection problem, surgery may help. The surgeon can take an artery that usually supplies blood to the abdominal wall and re-route it by connecting it to the tiny blood vessels inside the penis. But results have been disappointing in men who have poor circulation, diabetes, or other diseases of the arteries. Still, some men may be helped if they have an injury that blocked the artery to the penis, and are otherwise healthy.

Nerve supply: During the first 3 to 12 months after radical prostatectomy, most men will not be able to get an erection without using medicines or other treatments. The effect of this operation on a man's ability to get an erection is related to his age and whether nerve-sparing surgery was done. Nearly all men who have a radical prostatectomy should expect some decrease in their ability for a few months after surgery. After a year or 2, most men have some return in their ability to have an erection, but younger men may expect to retain more of their ability. Some experts use treatments to improve erections soon after surgery to find out if it speeds recovery and helps heal minor short term damage to the nerves and blood supply. (See "Early sexual rehabilitation after surgery" in the section, "Effects of Cancer Treatment on Male Sexuality.")

After standard radical prostatectomy, between 65% and 90% of men will become impotent, depending on their age. But if the surgeon does not remove or damage the nerves on either side of the prostate, the impotence rate drops to between 25% and 30% for men under 60. The impotence rate is higher for men over 70, even if nerves on both sides are not damaged or removed. After surgery, there is no ejaculation of semen. (See "Removal of prostate gland and seminal vesicles can cause dry orgasm" in the section "Effects of Cancer Treatment on Male Sexuality."). Even with a dry orgasm, the sensation should still be pleasurable.

New research is looking at transplanting nerves to restore erections, but further research is needed to find out how well it will work. (See "Damage to nerve bundles that allow blood flow to the penis" in the section, "Effects of Cancer Treatment on Male Sexuality.")

Though surgery to correct blood flow problems has been disappointing so far, 3 non-surgical treatments have become widely used: penile injection therapy, urethral pellets, and vacuum devices. We will also discuss surgical options, called implants.

Penile injections

Many urologists (doctors who specialize in conditions and diseases of the genitals and urinary tract) teach men to inject their penises with medicines that cause erections. The drug is injected into the side of the shaft of the penis through a very small needle a few minutes before starting sex. The combination of sexual excitement and medicine helps to produce a firmer and longer-lasting erection.

Penile injections can have side effects. Because of this, the first injection is usually done in the doctor's office. A few men may get an erection that will not go down. If this happens, the man needs to go to an emergency room right away for treatment. Some men develop scarring in the spongy tissue of the penis after repeated injections. Scarring is often not noticed by the man, but in severe cases can make erections permanently curved. The only way to treat severe scarring is by surgery on the penis.

Urethral pellets

A way of delivering the same drug used for penile injections is to have a man use an applicator to insert a tiny pellet or suppository into his urethra (urinary tube opening at the tip of the penis). As the pellet melts, the drug is absorbed through the lining of the urethra and enters the spongy tissue of the penis. The man must urinate before putting in the pellet so that the urethral lining is moist. After the pellet is put in, the penis must be massaged to help the pellet absorb. Although this system may be more convenient than injections, it does not always work as well and can lead to much the same kind of side effects. Because the pellet may cause dizziness in some men, a test dose in the doctor's office may be needed. It can also cause some burning in the urethra. Bits of the pellet may also enter the partner during sex and cause burning, itching, or other discomfort.

Vacuum constriction devices

Another treatment, the vacuum constriction device (VCD), is less risky but may interrupt lovemaking more than an injection does. A man places a plastic cylinder over his penis and pumps out air to produce a vacuum around the outside of the penis. The suction draws blood into the inside of the penis, filling up the spongy tissue. When the penis is firm, the man takes the pump off and slips a stretchy band onto the base of his penis to help it stay erect. The band can be left on the penis for up to half an hour. Some men use the pump before starting sexual touching, but others find it works better after some foreplay has produced a partial erection. The erection from a vacuum device is usually firm, but may swivel at the base of the penis, which can limit comfortable positions for intercourse. It may take some practice to learn how to use a vacuum device properly. Although most vacuum devices are prescribed by physicians, the FDA has approved some that are available over the counter.

Vacuum devices, penile injection, and the urethral pellets have a success rate between 50% and 70%. When injections or a vacuum device is suggested, some sexual counseling can help a couple discuss their options and plan how to make the new treatment a comfortable part of their sex life.

Penile prostheses or implants

Surgery to implant a prosthesis in the penis was the first really successful treatment for medical erection problems. Over the past 20 years, many of these operations have been done, and they still work quite well to treat permanent erection problems. Several types of prostheses are now in use.

Semi-rigid rods: For the simplest type, 2 silicone rods are placed into the spongy tissue of the penis. The result is a penis that hangs about 45 degrees from the body and always stays about 80% erect. Since it is above the urethra, the prosthesis does not affect urination. Most semi-rigid prostheses now are easily shaped. A thin metal core runs through each rod. When you bend the penis up or down to conceal it during non-sexual activities, it stays bent. With any of the semi-rigid prostheses, a man can avoid an obvious bulge at his crotch by wearing briefs made for athletics, with heavier than normal elastic in front.

Inflatable 3-part pump (multi-part pump): The inflatable penile prosthesis has 3 main parts, and it offers the choice of a soft or hard penis. It is a pump system placed entirely inside a man's body. Two tough inflatable silicone cylinders are placed inside the penis just as the rods are in the semi-rigid implant. A balloon-shaped reservoir (storage tank) that contains a mixture of salt water and x-ray dye is tucked behind the groin muscles. A pump is placed inside the loose skin of the scrotal sac. All the parts are connected with tubing.

Usually, the salt water stays in the reservoir, leaving the cylinders in the penis empty. From the outside, the penis looks the same as it normally does when not erect, except that it is always a little fuller. When you are ready for sex, you stiffen the penis by squeezing the pump under the skin of the scrotum several times. This pumps the salt water into the cylinders and inflates the penis as blood does in a natural erection. When you have finished sexual activity and no longer want an erection, you press a release valve on the bottom of the pump. The cylinders will deflate. The salt water then returns to its reservoir and your penis becomes soft.

Inflatable 2-part pump: A simpler 2-piece inflatable prosthesis is a cross between the semi-rigid and multiple part types. It has 2 cylinders that connect to a combined pump-and-reservoir unit that is placed in the scrotal sac. The 2-piece inflatable prosthesis cannot produce as long or thick an erection as the newest multi-part inflatable. When the penis is not inflated, it will be softer than with a semi-rigid prosthesis, but not as soft or small as with a multi-part inflatable.

Special things to think about before choosing an implant: Men in poor health are advised to try the semi-rigid or 2-piece inflatable types, since the surgery is minor and the risk of future problems is so low. A man who has superficial bladder tumors that keep coming back may need an inflatable prosthesis because the semi-rigid rods interfere with cystoscopy (a test that looks inside the bladder.) A man who is physically active, either on the job or in his leisure time (jogging, playing tennis, riding), may be more pleased with an inflatable type, since it does not get in the way as much.

If you are seriously thinking about prosthesis surgery, you might read the chapters on medical and surgical treatments in the books listed in the "Additional resources" section. Implants carry some risk of complications, such as infection. Also, the devices with more parts are more prone to failure, which then requires a second surgery.

Learn as much as you can and ask your urologist questions about possible complications before making your decision. A man who is married or in a committed relationship should include his partner in any decision about implants. Your partner needs to understand the procedure and to have a chance to discuss any fears or questions with your surgeon. You must be realistic about what a prosthesis can and cannot do for you. Any penile prosthesis is just a mechanical stiffener for the penis. Having a penile implant cannot solve any other problems, such as low sexual desire, lack of sensation on the skin of the penis, or trouble reaching orgasm. It cannot transform a poor sexual relationship into a great one.

A couple needs to talk openly before they have sex after implant surgery. You may need to experiment with different kinds of touching or with different positions. Make sure you are truly excited before trying to have intercourse, rather than starting sex just because your penis is erect. Couples who have maintained mutual touching, even if an erection problem prevented penetration, tend to adjust more easily to the prosthesis.

Can testosterone restore sexual functioning?

In the rare case that a man has a hormone imbalance, testosterone may restore his desire and erections. But hormones are too often used without careful thought. Most men have enough testosterone, even after age 50 or 60. Taking extra hormones will not cure a sexual problem. In fact, it can have serious side effects.

One big problem is that extra testosterone could cause undetected prostate cancer to grow and spread. Men who have had prostate cancer should never take testosterone pills or shots, even if their own hormone levels are low. Testosterone is most helpful as a short-term way to restore sexual desire and erections in men who have damaged testicles from large doses of radiation or chemo. But very few men really need extra hormones.

What about herbs or natural cures for erection problems?

Many supplements are sold over the counter as "natural" cures for erection problems. These herbs and supplements have not been proven to help men regain erections. And in the past, many supplements have been found to not contain the ingredients listed on their labels.

Another problem is that some of the supplements contain extra ingredients that are not listed on their labels. Even though they are sold as "natural supplements" to help erections, some have been found to contain sildenafil (Viagra®) or a substance much like it in the same family of prescription drugs. As these are discovered by the FDA, the pills are recalled, but usually not until after many men have taken them. These supplements can be very risky because the contents are not labeled correctly and the man doesn't know what he is getting. One danger is that he may take other medicines that interact with the drug in a harmful or even fatal way. Or he may take too much of a substance that is said to be harmless and without side effects, not knowing what to expect.

Is there a way to make orgasm as intense as it used to be?

Some men treated for cancer notice that their orgasms become weaker or last a shorter time than before. Sometimes, a mildly weaker orgasm is just part of normal aging. As men age, the muscle contractions at climax are no longer as strong. More severe weakening of orgasm often goes along with erection problems. In those cases, treating the erection problem may not improve a man's orgasms. Men who have dry orgasms after cancer treatment also say they sometimes have reduced sensation.

Few medicines can make a man's climax stronger. Most of these medicines have dangerous side effects or may stop working after a few doses. Some common-sense advice is to make sure you are as excited as possible during sex. Focus on your sensations of pleasure or on an arousing fantasy and take a long time for foreplay. If you find yourself getting close to orgasm, ask your partner to tease you a little by slowing down the caresses. Let your excitement die down and rebuild several times before you actually climax.

You can practice this teasing technique during your own self-stimulation, too. When you feel your excitement is high, stop touching your penis, even if you lose part of your erection. Then caress yourself again, stopping and starting several times before you ejaculate. Whether by yourself or with a partner, make sure your erection is as full as can be before you use the strong, rhythmic caresses that bring on your orgasm. Some men learn to ejaculate with a soft penis. But many find they have stronger orgasms if they can delay orgasm until their erection is as firm as possible.

Last Medical Review: 02/02/2009
Last Revised: 02/02/2009