Cancer and sex: overcoming men’s sexual health after cancer treatment and surgery

Key takeaways

• Most sexual difficulties experienced by men living with cancer or living beyond cancer present as a loss or reduction in sexual desire, erectile difficulties (ED) and ejaculatory and orgasmic changes.
• It’s important to remember that there are many options which can reduce or alleviate your symptoms. These include the supplementation of testosterone, oral medicines and psychosexual therapy.
• Sexual difficulties should not be taboo, getting help when it’s required is as important to your recovery as any other aspect of care you receive.

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Sexual dysfunction is common among men (and women) living with cancer and living beyond cancer. It’s important to acknowledge this in order to get the care and support you need to move forward.

Here, Perci’s psychosexual therapist Dr. Isabel White and our cancer specialist nurse Johanna Bowie outline the sexual difficulties that can occur, plus ways to reduce or alleviate the symptoms post cancer treatment or surgery.

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The most common cancer treatment-induced sexual difficulties experienced by men are:

• Loss of or reduced sexual interest or desire
• Erection difficulties (ED)
• Ejaculatory and orgasmic changes

Loss of or reduced sexual desire or interest

People going through or having completed cancer treatment can experience a low or loss of sex drive for several psychological, relationship or physical reasons and sometimes it is a combination of factors that cause and maintain this reduction in sexual wellbeing.

Up to 88% of men with colorectal cancer experience sexual difficulties after treatment.

MJ Traa et al, 2012.

If you are experiencing a reduction in or loss of sexual desire, but you and your partner(s) are not distressed by this, then you may not consider it a problem and it may not be necessary for you to seek help about this matter. However, if you / and or any partner are distressed by this change in your sexual wellbeing then you may decide to seek professional advice or support.

Testosterone

If loss of sexual desire is caused by a physical impact of your cancer treatment, such as a reduction in testosterone, it may be appropriate for you to discuss this with your treatment team or GP so that they can consider whether you would benefit from testosterone replacement or supplementation. You may be referred to a urology or andrology service to further investigate the most appropriate medical management for your low testosterone level.

Low testosterone levels are more commonly seen after intensive systemic cancer treatments such as after high dose chemotherapy or stem cell transplantation but may also occur after testicular surgery (if the remaining testis is not working optimally or must be removed) or a prostatectomy.

Loss of desire is also a common side effect of androgen deprivation therapy (ADT) given in the short-term or longer-term management of prostate cancer. In this clinical situation it is usually contraindicated to offer testosterone treatment. Where the man is on long-term ADT, some consultants will consider a “hormone holiday” for a few months where ADT is temporarily stopped. If that is something the man and his partner wish to explore, it allows some time to see if testosterone level recovery will lead to improvements in sexual desire and arousal (erectile function).

However, if you are someone who has been previously treated for prostate cancer and have now completed all treatment, but your desire has still not recovered, it can be worthwhile speaking to your GP or your treatment team to ask them if they would check your testosterone level in case this is contributing to your persistent lack of sexual interest or erection difficulties.

Talking therapy

Loss of desire can also commonly occur for emotional or psychological reasons associated with your cancer experience or other things happening in your life such as work-related stress, low mood or depression, high anxiety or where there are challenging relationship dynamics.

Whether the cause of loss of desire is physical, emotional, or related to relationship challenges, psychosexual counselling or therapy can be useful in helping you and your partner to explore ways of becoming sexually intimate again in ways that are ‘low demand’ and encourage gradual sensual and sexual feelings to return.

Erection difficulties (erectile dysfunction / ED)

Erection difficulties may be caused by nerve damage after pelvic surgery such as radical prostatectomy for prostate cancer or following surgery for rectal or other pelvic malignancies.

Erection difficulties are typically more severe when it has not been possible to spare the nerves that control erectile function due to the extent of surgery necessary to remove the cancer successfully. After surgery erection difficulties are present immediately and nerve recovery, where it can occur, can take up to two years.

Erection difficulties are also caused by pelvic radiotherapy, particularly where the treatment involves external beam treatment to the pelvis, whereas sexual function tends to be less significantly affected when brachytherapy is given, for example as a more closely targeted treatment for prostate cancer. After pelvic radiotherapy erection difficulties may not be immediately evident but changes in the blood vessels (fibrosis that leads to narrowing of the vessels) may develop over up two years after radiotherapy has been completed.

Less commonly, erection difficulties can also occur because of peripheral neuropathy caused by certain chemotherapy agents.

Erection difficulties are also a common side effect of androgen deprivation therapy (ADT) where the action of testosterone on the body is blocked by endocrine treatments to reduce the influence of testosterone on cell growth.

Effective treatments for erection difficulties

Whether your changes in erection function are temporary, intermittent, or persistent and whether it is still possible for you to get a partial erection or there is no non-assisted erectile function at all, there are a number of effective treatments available through your treatment team or GP that can help.

Most men explore a range of medical treatments for erectile difficulties (ED) which range from oral tablets to more intensive treatments such as injection therapy or surgical implant surgery.

The treatments available are summarised below and should be discussed with your treatment team or GP regarding which is more appropriate for your needs:

• Oral medication e.g. Sildenafil (Viagra), Tadalafil, Avanafil for use on demand immediately prior to sexual activity (NB. this does not work as effectively for men after non-nerve sparing surgery or men on androgen deprivation therapy- ADT).
• Oral medication used at a low dose daily (usually Tadalafil 5mgs) to promote improved blood vessel function after surgery or pelvic radiotherapy may be given in addition to on-demand medication by some specialists.
• Intracavernosal injection (ICI) of Alprostadil or Invicorp where a small amount of the active drug is injected (self-administered) at the side of the base of the penis to create an erection
• Surgical implantation of a semi-rigid or inflatable penile implant (NB. this treatment option is usually reserved for men who have tried all other treatments without success as it is necessary to remove the erectile tissue in the penis to insert the implant and is thus an irreversible procedure).
• Psychosexual therapy or counselling is often used alongside biomedical treatments for erection difficulties, especially where there may be challenges in accommodating medical treatments within the person’s sexual lifestyle or relationship or where it would be helpful to combine medical treatments with counselling to support sexual adjustment more broadly. This can also be helpful where biomedical treatments have not been able to completely resolve erection difficulties. 

Ejaculatory and orgasmic changes including dry ejaculation

Reaching climax or orgasm through sexual stimulation by ourselves or with a partner is seen by many as one of the satisfying aspects of being sexual / expressing ourselves sexually. The majority of men consider orgasm and ejaculation an important element of sexual satisfaction but may vary in the type and intensity of stimulation necessary to achieve orgasm.

Understanding what is normal or usual for each one of us is helpful before we consider how the experience of cancer and its treatment may affect our experience of orgasm. 

Orgasmic changes may be experienced after pelvic surgery or radiotherapy for a rectal or urological cancer, they can also occur following treatments that affect our level of male hormones, such as ADT for prostate cancer or after the testicles have been removed or irradiated, especially if we are not able to have testosterone replacement therapy.

There are several treatment-related ejaculatory and orgasmic changes that can affect men after cancer. These include:

• Anorgasmia: inability to reach orgasm. Can occur after some types of radical pelvic surgery or after prostatectomy where pelvic nerve damage has occurred.
• Delayed orgasm / ejaculation: difficulty in reaching orgasm / taking a much longer time to reach orgasm than usual. Can occur after pelvic surgery, as a side-effect of some antidepressant medications (SSRI’s) and in association with high anxiety or low mood.
• Retrograde ejaculation: when the bladder neck muscle doesn’t tighten properly and as a result, ejaculate (semen) enters the bladder instead of being ejected out of your body through the penis. This can be caused by bladder neck surgery, retroperitoneal lymph node dissection surgery for testicular cancer or prostate surgery. Men still experience the sensation of orgasm, but it is what some men call a “dry orgasm”. Retrograde ejaculation can be treated by a urologist or andrologist and treatments can include the use of medication called alpha agonists (such as Ephedrine).
• Dry Ejaculation / orgasm: the ejaculation of little or no semen. Usually happens after removal of the prostate (prostatectomy), removal of the bladder (cystectomy) or after radiotherapy to treat cancer in the pelvis. A dry orgasm may feel different in intensity or sensation.
• Climacturia: the involuntary loss of urine at the point of climax. This can occur in approximately 25 – 30% of men after a radical prostatectomy and occurs because of the removal of the internal urethral sphincter with relaxation of the external sphincter. Management includes pre-sexual urination to empty the bladder and urethra, condoms, penile constriction loops or rings to compress the urethra and prevent urination, the use of medications called alpha blockers or alpha agonists (see your GP or urologist / andrologist to discuss), pelvic floor muscle rehabilitation, and/or the surgical insertion of sphincters or slings if other measures do not resolve the problem. In many men climacturia improves as urinary control and improved pelvic floor muscle function after surgery is restored.
• Painful orgasm: a small number of men experience painful orgasm (associated with sparing of part of seminal vesicles). Treatment for painful orgasm can include regular sexual activity; non-steroidal medication; psychosexual therapy; pelvic floor physiotherapy to help manage increased pelvic floor tension reduction and the use of medication such as alpha blocker drugs.
• Orgasm with a non-erect penis: after surgery or radiotherapy the nerves that control erections may not recover fully. However, it is still possible to achieve an orgasm through stimulation of a soft or semi-erect penis. Orgasm changes or difficulties can also occur because of emotional difficulties such as high anxiety or depression, as a side-effect of anti-depressant medication (SSRIs), drugs used to reduce anxiety, as a side-effect of some strong pain control medication (strong opioid drugs such as morphine or diamorphine), cannabis or increased alcohol intake.

Find out more about Dr. Isabel White and her availability for psychosexual therapy. Or read Johanna Bowie’s Perci profile and book an appointment.

While we have ensured that every article is medically reviewed and approved, information presented here is not intended to be a substitute for professional medical advice, diagnosis, or treatment. If you have any questions or concerns, please talk to one of our healthcare professionals or your primary healthcare team.