Sex after Prostate Cancer

I am a prostate cancer survivor.

My story is unusual. After my diagnosis, I underwent radiation treatment, which failed to eliminate the cancer. Few surgeons will attempt to remove the prostate after radiation, because the treatment creates scar tissue that makes the surgery very difficult.

Fortunately, I found an excellent surgeon, Dr. Jonathan Eandi, who has performed several “salvage” prostatectomies, and was willing to undertake the procedure. The surgery went very well. Now, with the help of my partner, I am recovering and dealing with the side effects.

Before my surgery, Dr. Eandi spent a lot of time discussing the side effects (and they are so severe that I seriously considered not having the surgery). A diagnosis of cancer is very scary, and it’s hard to digest all the information and make good decisions.

I was very fortunate that my partner was with me throughout the process. Because I was so stressed, I often didn’t hear or forgot what my doctor said. By coming to the appointments, she was able to able to understand all our options, and remind me of things the doctor said.

Unfortunately, based on my reading, most doctors do not adequately prepare their patients and their partners for the full impact of the surgery, making the effects all the more difficult to deal with.

The Impact of Prostate Cancer Treatment on Your Sex Life

The effects of a prostatectomy are apparent immediately after surgery, while the effects of radiation treatment may occur months or years later, as cells continue to die from the radiation exposure. In either case, the effects can be severe, and may include:

  • Incontinence (uncontrolled leaking of urine)
  • Erectile Dysfunction (the complete inability to get an erection, even with oral medication)
  • Shrinking of the penis (in both flaccid and erect states)
  • Inability to have orgasms

Without proper care and treatment these conditions can become permanent, and even in the best case, recovery can take 6-24 months.

In my own case, I’ve experienced incontinence and ED. It’s important to realize that these conditions are not permanent, and there are treatment options. It’s also important to discuss these issues with your partner, and have his or her support.

Sadly, very few doctors are trained in “sexual rehabilitation” – once the cancer is treated, they consider their job done. Even when sexual rehabilitation treatment is available, there is usually no psychological support, and patients often suffer from anxiety and depression.

If you are facing or have recently undergone prostate cancer treatment, I strongly recommend that you find a urologist who specializes in sexual health and rehabilitation, and a coach or counselor to provide support to you (and your partner).

In the following sections, I’m going to tell you a little bit about the side effects, and treatment options. You’re going to want to know a lot more, so Jennifer has provide some resources for further reading.

Incontinence after Prostate Cancer

Following prostate cancer treatment, you will probably experience urinary leaking. Right after surgery, this may be a pretty constant flow. After time, it will decrease, and will probably only happen when there is physical pressure, which could include standing up / sitting down, coughing, lifting things, etc.

Urinary leaking can also happen during sex, which can have a big psychological impact on you and your partner.
For most men, incontinence lasts 6-12 months.

Practical Advice

  • To recovery as quickly as possible, practice Kegel exercises several times each day. Some doctors recommend starting two weeks before your surgery.
  • To deal with leakage, I recommend Depends Real Fit incontinence briefs for men. These briefs look and feel much like regular underwear. The built-in absorbent pads will wick away urine without feeling wet.
  • Remember that urine does not contain bacteria and isn’t a health problem.

Erectile Dysfunction after Prostate Cancer

After prostate cancer treatment, most men (like me) will experience the complete inability to get an erection, even with oral medications like Viagra or Cialis.

Initially this is due to damage to the nerves that trigger erections. Even with “nerve sparing” surgery, the nerves will be bruised and damaged, and recovery will take six to twenty-four months.

But this isn’t the only problem. The erectile tissues in the penis – the tissues that become engorged with blood – actually require blood flow to stay healthy. This blood flow comes from regular erections (most men have 2 or 3 erections while sleeping each night). Without this regular blood flow, the erectile tissues will be permanently damaged. In other words, if you can’t have an erection, you may permanently lose the ability to have a normal erection.

Finally, there is a psychological “catch 22.” Men who have problems achieving erections experience stress, which releases adrenaline… and adrenaline relaxes the erectile tissues, making it impossible to achieve or maintain an erection.

For most of us, the ability to get an erection is central to our sense of masculinity. Although there are treatment options for ED, it’s very hard to avoid feelings of inadequacy and depression. I am fortunate to have a very understanding partner to talk to, and we are working together to find ways to maintain our sex life. If you’re not comfortable talking with your partner about these issues, it’s important to get help from an intimacy coach or counselor.

Practical Advice

  • There isn’t much that can be done to hasten nerve healing, but it’s very important to prevent long-term damage to erectile tissues. Studies have shown that taking a small daily dose of erection-enhancing medications (Viagra, Cialis, Levitra) will produce enough blood flow to preserve healthy tissue. Another option is to use a penile injection of a drug like alprostadil to produce an erection at least three times per week.
  • It’s important to understand that complete erectile function may never return, but most men will eventually be able to produce an erection with a full dose of Viagra or similar drugs. In the event that this can’t be achieved, you may need to consider options such as regular penile injections, a vacuum pump, or a penile implant.
  • Whether used short-term or long-term, many men find that they are able to achieve a serviceable erection using a vacuum pump device. This certainly takes the spontaneity away from sex, and I can state from personal experience that the use of a pump can be uncomfortable or even painful – though not all men experience problems. I recommend the Pos-T-Vac manual vacuum pump. It’s inexpensive, and the manual pump gives you more control than electric pump models.
  • Sexual rehabilitation coaching or counseling may be needed, for you and your partner, to reduce stress and feelings of depression, and to encourage intimacy during your recovery process.

Shrinking of the Penis after Prostate Cancer

Several studies have shown that following treatment for prostate cancer, even after recovery, the size of a man’s erection may be smaller. Surgery does not directly cause this, so doctors believe that it’s due to damage to the erectile tissue.

Practical Advice

  • Maintaining blood flow in the penis preserves healthy erectile tissue, and is believed to prevent shrinking of the penis.
  • Regular use of a penile extender traction device (several hours per day over a period of months) has been shown to maintain or even increase both the flaccid and erect length of the penis.

Lack of Ejaculation (“dry” orgasms)

Two organs – the prostate and the surrounding seminal vesicles – produce the semen that is ejaculated during the male orgasm. When these organs are surgically removed, or damaged by radiation, no semen is produced. Men can still experience an orgasm, but no “ejaculate” will be produced.

For some men a so-called dry orgasm does not feel as satisfying (though a small number of men say that orgasms are more intense after treatment for prostate cancer).

In other cases the lack of ejaculate can be psychologically damaging.

The lack of semen production is permanent; there is no treatment for this condition.

Inability to Have Orgasms

Many men are surprised to find that they are able to stimulate the penis and achieve an orgasm even without an erection. This can be a good way to preserve a sexual connection with a partner.

However, some men find that they are unable to have an orgasm, even if they achieve an erection using oral medicine, injections, or vacuum pumps.

There is no physical reason that prostate cancer treatment should prevent orgasms, but there is a great deal of psychological stress for most men. Overcoming a lack of orgasms will therefore require counseling or coaching.

Treatment Options

As described above, restoring the ability to have an erection depends on maintaining blood flow through the use of low-dose oral medications or injections. It’s important to start this soon after your cancer treatment, and continue with daily doses.

In the interim – and possibly permanently – options for achieving erections include penile injections and vacuum pumps. I personally found the vacuum pump to be uncomfortable, and it did not give me a satisfactory erection.  I have started using an injection of “bi-mix,” prescribed by my doctor, and I’m pleased with the results.

If erectile function cannot be restored, it is possible to surgically implant a device that can be inflated (using a small pump in the scrotum) to achieve an erection.

The important thing to remember is that there are options to restore your erectile functions, although it may take some time. You should also explore ways to achieve sexual intimacy with your partner without having an erection. This is another area where sex therapy or coaching can help.

Conclusions

The side effects of prostate cancer treatments – both physical and psychological – can have a severe impact on your sex life and intimate relationships. There are treatments and techniques that can greatly improve your recovery process, but it’s important to understand that it will take time and effort.

Studies have shown significant benefit from early steps, such as the use of low-dose oral medications, penile injections, or vacuum pump therapy.

Most men (and their partners) will need advice, support, and counseling that are not usually available from urologists or other medical practitioners.

Coaching or counseling will help you to:

  • Understand options and find resources to help
  • Keep a positive outlook and avoid depression.
  • Stick with your recovery program and exercises.
  • Communicate with your partner and have an active and intimate sex life during your recovery and after.

If you’d like to explore how coaching can help you and your partner, please contact Jennifer.

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