All prostate cancer treatments, including ‘surgery’, ‘radiation therapy’ and ‘hormone therapy’ can affect your sexual function in a variety of ways. The following section will discuss the commonly used treatments for prostate cancer and the side effects that can occur.
‘Prostate Cancer Surgery’ – ‘Radical Prostatectomy Surgery’:
The side effects relate to physical changes to that area of your body after the prostate gland has been removed and learning about the possible side effects from surgery is particularly important because some side effects can be permanent. When your prostate gland is removed with a ‘radical prostatectomy’ (open, laparoscopic or robotic), a number of things occur during the surgical procedure that can impact on your sexual function. These include:
Changes during orgasm:
The removal of the prostate can cause changes during orgasm. Your entire prostate gland is removed along with the seminal vesicles. It is important to understand that after surgery you will have a ‘dry’ orgasm because semen is no longer produced. There is no ejaculate during orgasm but you will still feel the muscular spasms and pleasure that produce the orgasm. The lack of semen and sperm means that you will not be able to conceive children naturally in the future (see below). Other changes could include the following:
- Painful orgasm: Pain is felt during orgasm but little is known about its cause. This usually settles after a few orgasms.
- Leaking urine on orgasm: There may be some involuntary release of urine during orgasm.
- Men report different experiences with dry orgasm; some describe a more intense orgasm while others feel orgasm is not as pleasurable. Pain may be experienced in the short term but this generally improves as healing to the area occurs.
NOTE: Infertility occurs in all men after radical prostatectomy. If you plan to have children following treatment, discuss this with your healthcare team. If fertility is important to you, you could ask to be referred to a service that provides fertility- preserving options such as sperm banking (having some of your sperm stored) before you start treatment. That way, fathering a child using your stored sperm may be possible in the future.
- Speak with a continence nurse or physiotherapist as they can offer you techniques to improve any problems you may have.
- Empty your bladder before intercourse or use condoms if you leak urine during orgasm.
- Talk with a health professional, such as a sex therapist/counsellor who can give you strategies to help you manage your feelings about, and reduce the impact of, any changes during orgasm.
It is likely you will have some difficulties getting and maintaining an erection after the surgery. How long this will last depends on a number of factors such as whether the erectile nerves were preserved at the time of surgery. The nerves that enable you to have an erection are on either side of the prostate. If cancer has not grown near the nerves, a nerve-sparing operation may be able to be performed when removing the prostate. This means the chance of you regaining the ability to have an erection naturally is increased. If these nerves are permanently damaged or removed, erectile difficulties may be ongoing. It is important that you know what treatments are available that can help. Members of your healthcare team can provide you with information appropriate to your needs.
In advanced prostate cancer, the cancer itself can also cause erectile dysfunction by invading the bundles of nerves that lie close to the prostate.
- Think about other ways that you could enjoy sex without penetration (e.g. oral sex, kissing, masturbation or mutual masturbation). Many men can still achieve orgasm without a full erection.
- Talk with your sexual partner(s) about what feels good for you and ask what feels good for them.
- Talk to your treating healthcare team about being referred to a professional (e.g. Sex Therapist) or service that specialises in sexuality matters.
Change in penis size:
A possible side effect of a radical prostatectomy surgery is a reduced length and width of the penis, while erect and/or flaccid/soft. Many men report penile shortening and shrinkage following surgery. It is thought there are a number of factors that may contribute to this, including scar tissue formation, reconnecting of the urethra to the bladder, and damage or interruption to the blood supply of the nerves. The reasons for penile shortening and shrinkage are not yet fully understood.
- Talk with a health professional such as a sex therapist who can give you strategies to help you manage your feelings about changes to the appearance of your penis, if this does occur.
The removal of the prostate gland may affect your ability to control the flow of urine from the bladder. This is because the urethra (the tube that urine passes through as it leaves the bladder) runs through the prostate gland. The mechanisms for urinary control (the bladder neck and the urinary sphincter) are located very close to the prostate and can be affected during the surgery.
- Many men experience some degree of urinary incontinence in the short term following surgery. This usually resolves over time.
- When the urinary sphincter is affected, people can experience stress urinary incontinence – losing control of the bladder during physical activities (e.g. exercising) or strain (e.g. coughing, sneezing).
- All men will have a temporary urinary catheter for a short period after surgery. This is a thin, soft plastic tube that runs from inside the bladder to a bag outside of your body to collect the urine.
- Men normally need a catheter for a week after surgery, but sometimes up to three weeks. After the catheter is removed, it is not unusual to have some mild urinary incontinence.
- Improvement can occur quickly, but if you are still troubled after 6 months, then further treatments can help. Talk to members of your healthcare team who are supporting you if you are concerned.
- Many men experience some degree of urinary incontinence in the short term following surgery.
- Talk to a continence nurse who can offer suggestions about the best continence products for your needs. The Continence Aids Payment Scheme (CAPS) may provide financial assistance for continence products (see www.bladderbowel.gov.au/caps/capsfaq.htm).
- Talk with a continence nurse or physiotherapist for information on pelvic floor muscles training. Pelvic floor muscles are important for continence control (see www.bladderbowel.gov.au/adults/pelvicmen.htm), and are best learned and started before surgery, and continued afterwards.
- You can obtain more information about surgery from the Understanding surgery for prostate cancer resource available from PCFA (www.pcfa.org.au).
‘TURP’ (Transurethral Resection 0f the Prostate):
A side effect is ‘retrograde ejaculation’, when semen is forced back into the bladder during ejaculation due to damage to the internal sphincter muscle (valve) located near the prostate. The valve cannot close shut, so semen flows back into the bladder. It is then passed out with urine the next time you go to the toilet; potentially giving your urine a cloudy appearance. This is a harmless effect which occurs in most men having this type of surgery.
Radiation Therapy (External Beam Radiation Treatment or EBRT):
Generally people are having this treatment in a hospital setting daily, Monday to Friday, for 7-8 weeks. During your EBRT treatment, you can continue to do what you would normally if you’re able; however, the multiple hospital visits and side effects associated with treatment may interfere with some day-to-day activities.
- Inflammation to the surrounding areas can cause pain. A small leakage of urine on ejaculation can occur. This is generally a short term side effect and improves as inflammation settles.
- Due to damage to the prostate cells that produce ejaculation fluid, you can notice a decreased amount of fluid or dry ejaculation.
- Unlike surgery, radiation therapy doesn’t usually have immediate effects on erectile function. Erectile problems typically occur in the longer term, commencing six months after treatment and progressing over the following years. Ageing and progressive damage to the blood vessels and nerves to the penis contribute to this.
- Radiotherapy will not affect your libido directly but the whole process may mean that you do not feel like having sex during the weeks of, or after, the treatment. There is no reason to avoid sex if you feel ready.
- If you wish to have children in the future, you will need to discuss alternatives such as having some of your sperm stored before treatment starts (this is called sperm banking). You can ask to speak with a fertility counsellor or be referred to a service that specialises in fertility issues.
- Hormone therapy is often used in conjunction with radiation therapy treatment, which can increase the impact on erectile function as well as libido.
‘Brachytherapy’ (Low dose rate: LDR):
Note: There is a very small chance of passing a radioactive seed during sexual activity. A condom is recommended for use for the first two months after implantation. If your partner is pregnant, use condoms for the whole pregnancy as a precaution.
- Placement requires surgery that may take a few hours. You may have the treatment as a ‘day-only patient’ or have an overnight stay.
- Your semen may be discoloured or blood-stained for the first few weeks after placement, due to the bruising or bleeding from the prostate caused by treatment. This usually resolves with time.
- You may have pain on ejaculation as the prostate contracts with orgasm. This is a short term side effect.
High dose rate (HDR):
The procedure takes place at a hospital but may require a longer stay than LDR brachytherapy. HDR brachytherapy is generally a treatment option for men with intermediate risk or locally advanced prostate cancer, and is often given in conjunction with EBRT.
- The side effects of high dose rate brachytherapy are similar to those of low dose rate brachytherapy.
- Often men have hormone (androgen deprivation) therapy or external beam radiation therapy in conjunction with high dose rate brachytherapy. Side effects from these treatments on sexual function may also be experienced.
You can obtain more information about brachytherapy from the Understanding brachytherapy for prostate cancer resource available from PCFA (www.pcfa.org.au).
Prostate cancer is driven by hormones. By reducing these hormones, it is possible to slow the growth of the cancer. This is known as hormone therapy, also known as androgen deprivation therapy (ADT), and is the standard first treatment when prostate cancer has spread (metastatic prostate cancer).
There is also a surgical hormone treatment called ”orchiectomy’, ‘, in which the testicles are surgically removed. The testicles are responsible for a high percentage of testosterone production, so removing them starves the prostate cancer cells of testosterone.
Testosterone is a male sex hormone (or androgen), which is produced by the testicles. It is vital in reproductive and sexual function. Hormone therapy reduces testosterone levels, and can often keep the cancer under control for several years by shrinking it, delaying its growth and reducing symptoms. How well hormone therapy controls the cancer is different from one man to another. It depends on how aggressive the cancer is, and how far the cancer has spread when you start hormone therapy.
What to expect: Hormone therapy side effects can be difficult to predict. It is important that you tell your healthcare team about the side effects you’re having as they may be able to offer you ways to manage them (e.g. medications, techniques).
- Lowering testosterone levels may cause a reduction in sex drive and erectile difficulties.
- Work with a health professional (e.g. Sex Therapist) who specialises in sexuality matters.
- Explore ways of being intimate with your partner that are not related to sex.
- Erectile dysfunction (ED) is the inability to achieve or maintain an erection firm enough for penetration. ED can be variable, with some men still able to achieve erections but not for long periods or with the ability to reach orgasm.
- Medications: Some medications in tablet and injectable forms can be prescribed to manage erectile difficulties. Because these medications can have side effects, discuss with your healthcare team if they are suitable for you.
- Implants/devices: If you don’t want to use medications, devices that draw blood into the penis (e.g. vacuum erection device) or the use of penile implants (e.g. flexible rods or inflatable tubes) could be ways of getting an erection. Members of your healthcare team (e.g. urologist, nurse, sex therapist) can provide you with information about these.
- Other physical side effects of hormone therapy, such as loss of muscle, weight gain, hot flushes and growth in breast tissue can impact how you feel about yourself sexually. You can obtain more information about hormone treatment from the Understanding hormone therapy for prostate cancer resource available from PCFA.
- Prostate cancer is driven by hormones. By reducing these hormones, it is possible to slow the growth of the cancer.
The information above has been adapted from: the PCFA Prostate Cancer Resources, & www.prostate.org.au