How cancer treatment affects sexual desire and response

Lack of desire

Both men and women often lose interest in sex during cancer treatment, at least for a time. At first, concern for survival is so great that sex is far down on the list of needs. This is normal. Few people are interested in sex when they feel their lives are in danger.

When people are being treated for cancer, worry, depression, nausea, pain, or fatigue may cause loss of desire. Cancer treatments that disturb the normal hormone balance can also lessen sexual desire.

If there is a conflict in the relationship, one partner or both might lose interest in sex. Many people who have cancer worry that a partner will be turned off by changes in their bodies or by the very word cancer.

Keep in mind that each part of a man's sexual cycle is somewhat independent from other parts of the cycle. That is why, after some types of cancer treatment, a man may still desire sex and be able to ejaculate but not have an erection. Other men may have the feeling of orgasm along with the muscles contracting in rhythm, even though semen is no longer ejaculated.

Erection

Cancer treatments can interfere with erection by damaging a man's pelvic nerves, pelvic blood vessels, or hormone balance. Sometimes these side effects cannot be avoided if the cancer is to be controlled. After cancer treatment, medical or surgical treatments can often restore erections. If a man has a problem getting or keeping an erection, the condition is called impotence or erectile dysfunction (ED).

Any emotion or thought that keeps a man from feeling excited can also get in the way of getting or keeping an erection. A common anxiety is the nagging fear of not being able to get an erection or satisfy a partner. (See "When is sexual counseling helpful?" in the section "Ways to Cope with Sexual Problems").

Premature ejaculation

Premature ejaculation means reaching a climax too quickly. Men who are having erection problems often lose the ability to delay orgasm, so they ejaculate quickly.

Premature ejaculation is a very common problem, even for healthy men. It can be overcome with some practice in slowing down excitement. A few of the newer anti-depressant drugs have the side effect of delaying orgasm. This side effect can be used to help men with premature ejaculation. Some men can also use creams that decrease the sensation in the penis. Talk to your doctor about what kind of help might be right for you.

Pain

Men sometimes feel pain in the genitals during sex. If the prostate gland or urethra is irritated from cancer treatment, ejaculation may be painful. Pain in the penis as it becomes erect is less common, but in some men, the penis can develop a painful curve or "knot" with erection. This condition, called Peyronie's disease, does not seem to be any more common in men with cancer. Peyronie's disease is most often due to a scar inside the penis, and may be treated with injections of certain drugs or with surgery. Tell your doctor right away about any pain in the genital area.

Pelvic surgery to treat cancer can affect erections

Surgery types

Some types of cancer surgery can interfere with erections. These include:

• radical prostatectomy -- the removal of the prostate and seminal vesicles for prostate cancer

• radical cystectomy -- the removal of the bladder, prostate, upper urethra, and seminal vesicles for bladder cancer. Removal of the bladder requires a new way of collecting urine, either through an opening into a pouch on the belly (abdomen) or by building a new "bladder" inside the body. (See "Urostomy, colostomy, or ileostomy" in the section, "Special Aspects of Some Cancer Treatments" to learn more about the opening and the pouch.)

• abdominoperineal (AP) resection -- the removal of the lower colon and rectum for colon cancer. This surgery may require an opening in the belly (abdomen) for removal of solid waste. (See "Urostomy, colostomy, or ileostomy" in the section, "Special Aspects of Some Cancer Treatments.")

• total pelvic exenteration -- the removal of the bladder, prostate, seminal vesicles, and rectum, usually for a large tumor of the colon, requiring openings for both urine and solid waste to leave the body. (See "Urostomy, colostomy, or ileostomy" in the section, "Special Aspects of Some Cancer Treatments" for more about this.)

These operations can interfere with erections in different ways, mainly by damaging nerves or blood vessels. We will go into more detail about this below, and also talk about other factors that can affect erections after surgery.

How surgery can affect erections

Damage to nerve bundles that allow blood flow to the penis: All of the operations listed above can damage the nerves that control blood flow to the penis. Damaging the nerves is like fraying a telephone wire -- the message to start an erection is either weakened or completely lost. The nerves surround the back and sides of the prostate gland between the prostate and the rectum, and fan out like a cobweb around the prostate. During surgery the doctor may not be able to see the nerves, which makes it easy to damage them.

There are different ways to do all of these surgeries. For example, some doctors use surgical methods that try to remove the prostate while sparing the nerves around it. Some surgeons have even tried to locate the nerves more quickly by using a mild electric current to find the spot where stimulating a nerve will cause an erection. This method has also been used to test the nerve bundles to be sure that they still worked after removal of the prostate. But continued study suggests that this method is not a reliable measure of potency after surgery.

When the size and location of a tumor are right for nerve-sparing surgery, more men recover erections than with other techniques. Nerve-sparing methods are sometimes used in radical prostatectomy, radical cystectomy, or AP resection. Doctors are now also trying to repair or graft nerves when they cannot avoid cutting them during surgery. This practice is being studied to find out whether it helps preserve erections.

Reduced blood flow to the penis: Some of the problems with erections after these operations may be caused by a loss of blood flow to the penis. The surgeon must seal off some of the small arteries that feed into the 2 main blood vessels involved in erection. Blood flow is then slowed, like a river after the streams that run into it have been dammed. Usually a man has partial erections after such surgery. His penis swells when he feels excited, but the penis may not become firm enough for penetration. Skin sensation and the ability to feel an orgasm should remain normal.

Some men do regain full erections after surgery, but it can sometimes take up to 2 years. We do not know all the reasons that some men regain full erections and others do not. Men are more likely to recover erections when nerves on both the left and right sides of the prostate are spared. The healing and growth of new blood vessels may also help restore blood flow to the penis. This healing takes time, which could explain part of the delay in the return of erections.

The type of surgery affects the outcome: Some operations cause more problems with sexual function than others. We do not know of any man who has regained full erections after having total pelvic exenteration (the total removal of all organs in the pelvis). But this surgery is so rare that statistics are not available.

At least 15% of men who have standard surgery to remove the bladder or the prostate have full erections again. But surgeons report better erection recovery rates if they are able to spare the nerve bundles during these surgeries. After AP resection (removal of the lower colon and rectum), the ability to have erections returns more often than it does after surgeries that also remove the prostate.

Age: For the most part, the younger a man is, the more likely he is to regain full erections after surgery. Men under 60, and especially those under 50, have much higher erection recovery rates than older men. For instance, some cancer centers that perform many radical nerve-sparing prostatectomies report impotence rates as low as 25% to 30% for men under 60, and as low as 10% for men under 50. But other doctors have reported higher rates of impotence in similar patients. Impotence happens in about 70% to 80% of men over 70, even if nerves on both sides are not removed or cut.

Erections before surgery: Men who had good erections before cancer surgery are far more likely to have a full sexual recovery than are men who had erection problems.

Early sexual rehabilitation after surgery: Studies have been done in which doctors tested different methods to promote erections starting just weeks after surgery. The idea was that this would help with recovering sexual function after surgery. The results of these studies suggest that these methods can help. Everything from pellets in the urethra to penile injections to vacuum devices seemed to make a difference for the overall groups who used them, but these methods did not help all of the men. Many of the men who had at least one intact nerve bundle were also helped by phosphodiesterase inhibitors (also called PDE-5 inhibitors) such as sildenafil (Viagra®). (For more about these medicines, see "Is there a pill that will cure sexual problems?" in the section "Ways to Cope with Sexual Problems.")

Pelvic radiation therapy and erection

Prostate, bladder, and colon cancer are often treated with radiation to the pelvis. This can also cause problems with erections. The higher the total dose of radiation and the wider the section of the pelvis irradiated, the greater the chance of an erection problem later.

One way that radiation affects erection is by damaging the arteries that carry blood to the penis. As the irradiated area heals, internal tissues become scarred. The walls of the blood vessels lose their ability to stretch. They can no longer expand enough to let blood speed in and create a firm erection. Radiation can also speed up hardening (arteriosclerosis), narrowing, or even blockage of the pelvic arteries. Radiation may also affect the nerves that control a man's ability to have an erection.

A reasonable estimate is that one quarter to one third of the men who get radiation will notice that their erections change for the worse over the first year or so after radiation treatment. This change most often develops slowly. Some men will still have full erections but lose them before reaching climax. Others no longer get firm erections at all.

In older studies, about 3 out of 4 men were impotent within 5 years of having external beam radiation therapy (though some of these men had erection problems before treatment). In men who had normal erections before treatment, about half had become impotent at 5 years. It's not clear if these numbers will apply to newer methods that better limit radiation exposure to normal tissue.

As with surgery, the older you are, the more likely it is you will have problems with erections. And men with heart or blood vessel disease, diabetes, or who have been heavy smokers seem to be at greater risk for erection problems. This is because their arteries may already be damaged before treatment.

In a few men, testosterone production will slow after pelvic radiation. The testicles may be affected either by a mild dose of scattered radiation or by the general stress of cancer treatment. If a man notices erection problems or a loss of desire after cancer treatment, his first thought may be that he needs to have a blood test for testosterone. But testosterone levels usually come back within 6 months after radiation therapy, so extra hormones may not be needed. And men with prostate cancer should not take testosterone, since it can speed up the growth of prostate cancer cells.

Chemotherapy and erection

Most men getting chemotherapy (often called chemo) still have normal erections. But a few develop problems. Erections and sexual desire often decrease right after getting chemo but return in a week or so.

Chemo can sometimes affect sexual desire and erections by slowing testosterone output. Some of the medicines used to prevent nausea during chemo can also upset a man's hormone balance. But hormone levels should return to normal after treatments end.

Men who have had graft-versus-host disease after a bone marrow transplant are more likely to have a long-lasting loss of testosterone. In some cases, these men may need to have testosterone replacement therapy to regain sexual desire and erections.

A few cancer treatment drugs like cisplatinum, vincristine, bortezomib, and thalidomide can cause lifelong damage to parts of the nervous system, usually the small nerves of the hands and feet. There are no studies in the available medical research to show that these drugs directly injure the large nerve bundles that allow erection. But some people have concerns because the drugs are known to affect nerve tissue, and there are many other nerves involved in sexual function.

Chemotherapy can also cause a flare up of genital herpes or genital wart infections if a man has had them in the past. It can also cause short-term and life-long infertility. (See the section "Fertility and cancer treatment.")

Hormone therapy, desire, and erection

Treatment for prostate cancer that has spread beyond the gland often includes changing a man's hormone balance. This can be done in one or more of the following ways:

• removing a man's testicles (called orchiectomy)
• using drugs to keep testosterone from being made
• using drugs that block cells from using testosterone

The choice to use drug treatment to block testosterone is a kind of hormone therapy that allows the testicles to stay in place. A simpler form of hormone treatment is to remove the testicles. If you and your doctor choose this method, you may want to see the information under "Loss of one or both testicles" in the section, "Special aspects of some cancer treatments."

The goal of hormone therapy is to starve the cancer cells of testosterone. This slows the growth of the prostate cancer. All of these treatments have many of the same kinds of sexual side effects, because they all block testosterone.

The most common problem with hormone treatment is a decrease in desire for sex (libido). This may be one reason men often have trouble getting or keeping erections or reaching orgasm.

Some men on hormone therapy say that their sexual desire is still strong, but they have problems getting an erection. Or they may have problems reaching orgasm. The effects of hormones on the erection response are not well understood, and the side effects of hormone treatment are hard to predict. Some men are able to feel desire and have erections and orgasms, even with their testosterone blocked. Other men function well for a few years, then slowly lose interest in sex. The strong desire to stay sexually active may be the key.

Hormone therapy may also cause changes in how you look, such as loss of muscle mass, weight gain, or some growth in breast tissue. Doctors can pre-treat with external radiation to keep breasts from growing, and other medicines may help as well. If you are concerned about your breasts growing, let your doctor know before you start hormone therapy. A program of exercise may help you limit muscle loss, weight gain, and fatigue. Talk with your doctor about any exercise program you may have in mind, or ask to be referred to a physical therapist to help you decide where to start and how to proceed.

What are the psychological effects of hormone therapy?

Men who no longer have their testicles or who are on hormone therapy drugs often feel like "less of a man." They fear they may start to look and act like a woman. This is a myth. Manhood does not depend on hormones but on a lifetime of being male. Hormone therapy for prostate cancer may decrease a man's desire for sex, but it cannot change the target of his sexual desires. For example, a man who has always been attracted only to women will not find himself attracted to men because of this kind of hormone treatment.

Psychological effects of cancer treatment on erection

Fears about self-image and performance can sometimes lead to erection problems. Instead of letting go and feeling excited, a man may watch himself during sex to see if he will be able to function. His fear of failure can make it happen. He may blame the resulting problem on his medical condition, even though he might be able to have an erection if he were able to relax.

Sex therapy often helps treat erection problems caused by anxiety and stress, which are more common in young healthy men. Any treatment for an erection problem should be based on the results of a thorough evaluation, which should include both medical questions (history) and special medical tests.

Cancer treatment and ejaculation

Cancer treatment can interfere with ejaculation by damaging the nerves that control the prostate, seminal vesicles, and the opening to the bladder. It can also stop semen from being made in the prostate and seminal vesicles. Despite this damage, a man can still feel the sensation of pleasure that makes an orgasm. The difference is that, at the moment of orgasm, little or no semen is released.

Some men say an orgasm without semen feels totally normal. Many others say the orgasm does not feel as strong, long-lasting, or pleasurable. Men often worry that their partners will miss the semen. Most of the time, their partners cannot feel the actual fluid release, so this is generally not true.

Some men's chief concern is that orgasm is less satisfying than before. Others are upset by "dry" orgasms because they wish to father a child. If a man knows before treatment that he may want to father a child after treatment, he may be able to bank (save and preserve) sperm for future use. (See the section, "Fertility and cancer treatment.")

Some men also feel that their orgasm is weaker than before. A mild decrease in the intensity of orgasm is normal with aging, but it can be more severe in men whose cancer treatments interfere with ejaculation of semen. See the section, "Is there a way to make orgasm as intense as it used to be?"

Surgery and ejaculation

Surgery can affect ejaculation in 2 different ways. The first is when surgery removes the prostate and seminal vesicles, so that a man can no longer make semen. The other is surgery that damages the nerves that come from the spine and control emission (when sperm and fluid mix to make semen.) Note that these are not the same nerve bundles that pass next to the prostate and control erections. The surgeries that cause ejaculation problems are discussed in more detail below.

Removal of prostate gland and seminal vesicles can cause dry orgasm

The types of cancer surgery that remove the prostate gland and the seminal vesicles are called:

• radical prostatectomy (removal of the prostate)
• cystectomy (removal of the bladder)

A man will no longer produce any semen after these surgeries. The sperm cells made in his testicles ripen, but then the body simply reabsorbs them. This causes no ill effects. After these cancer surgeries, a man will have a "dry" orgasm, meaning an orgasm without semen.

Sometimes the semen is there, but doesn't come out

There are other operations that cause ejaculation to go back inside the body rather than come out (retrograde ejaculation). At the moment of orgasm, the semen shoots backward into the bladder rather than out through the penis. This is because the valve between the bladder and urethra stays open after some surgical procedures. This valve normally shuts tightly during emission. When it's open, the path of least resistance for the semen then becomes the backward path into the bladder. This does not cause pain or harm to the man. When a man urinates after this type of dry orgasm, his urine looks cloudy because the semen mixes in with it during the orgasm.

A transurethral resection is an example of an operation that usually causes retrograde ejaculation. This surgery cores out the prostate by passing a special scope into it through the urethra, which often damages the bladder valve. This procedure is not a cancer treatment but is sometimes used to diagnose cancer.

Nerve damage

We have already discussed the nerve bundles that are routed beside the prostate and control blood flow to cause erections. Now, we are talking about the nerves that come from the spine and control emission. The cancer operations that can cause dry orgasm by damaging the nerves that control emission (the mixing of the sperm and fluid to make semen) are:

• abdominoperineal (AP) resection, which removes the rectum and lower colon

• retroperitoneal lymph node dissection, which removes lymph nodes in the belly (abdomen) (usually in men who have testicular cancer)

Some of the nerves that control emission run close to the lower colon and are damaged by AP resection. Lymph node removal (dissection) damages the nerves higher up, where they surround the aorta (the large main artery in the belly or abdomen).

The effects of the 2 operations are probably very much alike, but more is known about sexual function after lymph node surgery. Sometimes the node dissection only causes retrograde ejaculation. But it usually paralyzes emission. When this happens, the prostate and seminal vesicles cannot contract to mix the semen with the sperm cells. In either case the result is a dry orgasm. The difference between no emission at all and retrograde ejaculation is important if a man wants to father a child. Retrograde ejaculation is better for would-be fathers because sperm cells may be recovered from a man's urine and used to make a woman pregnant.

Sometimes the nerves that control emission recover from the damage caused by retroperitoneal lymph node dissection. But if ejaculation of semen does resume, it can take up to 3 years for it to happen. Because men with testicular cancer are often young and have not finished having children, surgeons have nerve-sparing methods that often allow ejaculation to remain normal after retroperitoneal node dissection. In experienced hands, these techniques have a very high rate of preserving the nerves and normal ejaculation. (See our document, Testicular Cancer for more information.) Some medicines can also restore ejaculation of semen just long enough to collect sperm for conception. If sperm cells cannot be recovered from a man's semen or urine, infertility specialists may be able to retrieve them directly from the testicle by minor surgery, then use them to fertilize a woman's egg to produce a pregnancy.

Retroperitoneal node dissection does not stop a man's erections or ability to reach orgasm. But it may mean that his pleasure at orgasm will be less intense.

How other cancer treatments affect ejaculation

Some cancer treatments reduce the amount of semen that is produced. After radiation to the prostate, some men ejaculate only a few drops of semen. Toward the end of radiation treatments, men often feel a sharp pain as they ejaculate. The pain is caused by irritation in the urethra (the tube that carries urine through the penis). It should go away over time after treatment ends.

In most cases, men who have hormone therapy for prostate cancer also produce less semen than before.

Chemotherapy very rarely affects ejaculation. But there are some drugs that may cause retrograde ejaculation by damaging the nerves that control emission.

Fertility and cancer treatment

Some cancer treatments can cause men to become infertile (unable to father a child). Radiation treatment to an area that includes the testes can reduce both the number of sperm and their ability to function. This does not mean that pregnancy can't happen, but it becomes less likely.

Some types of chemo can damage the sperm over the short term, while others can cause life-long infertility. The short-term changes have been shown to last about 3 months after the last treatment. Because the risk of birth defects due to sperm damage from the father's chemotherapy is hard to study, there is not much information about this link. To reduce this possible risk, doctors often recommend that a man use careful birth control during chemo and for some months after it is complete.

Several types of surgery to the pelvic and genital area can cause infertility. If both testicles are removed, for example, sperm cells are no longer produced and a man becomes infertile. See the section, "Surgery and ejaculation" for information on the types of surgery that can cause infertility. If you want to father a child and are concerned about reduced fertility, talk to your doctor before starting treatment. One option may be to bank (save and preserve) your sperm. (See our document, Fertility and Cancer: What Are My Options? for further information.) If you are not sure about your wishes to be a father in the future, you may want to work with a sperm bank to learn more about the procedure and its costs.

The table below shows a summary of some cancer treatments for men and their effects on sexuality and fertility.

Male sexual problems caused by cancer treatment

*Artificial insemination of a woman with the man's semen may be possible.
**Infertile only if remaining testicle is not normal.

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