How cancer treatment can affect erections
Surgery
Some types of cancer surgery can effect 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 Treating Sexual Problems for Men With Cancer 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) where solid waste can leave the body. (See Treating Sexual Problems for Men With Cancer to learn more.)
- Total mesorectal excision (TME) – the removal of the rectum as well as the tissues that support it (called the mesorectum) for treating rectal cancer
- Total pelvic exenteration – the removal of the bladder, prostate, seminal vesicles, and rectum, usually for a large tumor of the colon, requiring new openings for both urine and solid waste to leave the body. (See Treating Sexual Problems for Men With Cancer for more on this.)
These operations can effect erections in different ways. We will go into more detail about this below, along with other factors that can affect erections after surgery.
Most men who have these types of surgeries will have some difficulty with erections (called erectile dysfunction or ED). Some men will be able to have erections firm enough for penetration, but probably not as firm as they were before. Others may not be able to get erections. The good news is that today there are many different treatments for ED that can help most men get their erections back. It might take some time, but if you are willing to try the different options, you’ll most likely find one that will work.
Damage to the nerve bundles that cause erections
The most common way surgery affects erections is by removing or injuring the nerves that help cause an erection. All of the operations listed above can damage these nerves. 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.
When possible, “nerve-sparing” methods are used in radical prostatectomy, radical cystectomy, AP resection, or TME. In nerve-sparing surgery, doctors carefully try to avoid these nerves. When the size and location of a tumor allow for nerve-sparing surgery, more men recover erections than with other techniques. But even if the surgeon is able to spare these nerves, they might still be injured during the operation and need time to heal.
Even when the nerves are spared, research has shown that the healing process takes up to 2 years for most men. We don’t know all the reasons some men regain full erections and others do not. We do know that men are more likely to recover erections when nerves on both the left and right sides of the prostate are spared.
Other things that affect erections after surgery
Age: A wide range of ED rates have been reported, even in men who haven’t had surgery. But 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, are more likely to recover their erections than older men.
Strength of erections before surgery: Men who had good erections before cancer surgery are far more likely to recover their erections than are men who had erection problems.
Other conditions, such as Peyronie’s disease: In some men, the penis can develop a painful curve or “knot” when they have an erection. This condition is called Peyronie’s disease. It’s most often due to scar tissue forming inside the penis, and has been linked to some cancer surgeries, such as surgery to remove the prostate (prostatectomy). Still, Peyronie’s disease is rarely linked to cancer treatment, and it can be treated with injections of certain drugs or with surgery. If you have painful erections, ask your doctor for help finding a urologist with experience treating this disease.
Early penile rehabilitation after surgery
Studies suggest that different methods to promote erections starting within weeks or months after surgery can help some men recover sexual function. You may hear this called penile rehabilitation, or erectile rehabilitation.
Any kind of erection is thought to be helpful. An erection pulls oxygen-rich blood into the tissues of the penis, helping keep this tissue healthy. As mentioned before, the recovery time for erections after surgery can be up to 2 years. If a man does not have an erection during this time period, the tissues in his penis may weaken. Once this happens, he will not be able to get an erection naturally.
The idea of penile rehabilitation is to use some type of medicine to be sure that a man is getting regular erections while his nerves are healing. This helps keep the tissue in the penis healthy. Most studies have suggested using medicine to get an erection hard enough for penetration about 2 to 3 times a week. The erections do not need to be used for sexual activity; the goal is to keep the tissue in the penis healthy.
In penile rehabilitation, medicines to help produce erections – pills such as sildenafil (Viagra
®), tadalafil (Cialis
®), or vardenafil (Levitra
®) − are typically tried first. But these drugs may not produce an erection because they need the nerves responsible for erections to be healthy. In fact, the pills only work in a small portion of men in the first few months after surgery. If the pills don’t work, penile injections or vacuum devices are often tried. Most sexual medicine specialists suggest using penile injections before the vacuum devices. (You can read more about these treatments in
Treating Sexual Problems for Men With Cancer.)
The other part of penile rehabilitation is taking a pill (again, usually sildenafil, tadalafil, or vardenafil) at a low dose on the days you are not trying to get an erection. This low-dose pill will not be strong enough to help you get an erection, but it will help increase the blood flow around the nerves that help produce erections. This increased blood flow can help the nerves heal.
Putting this all together, penile rehabilitation has 2 parts:
- Making sure you are getting regular erections that are hard enough for penetration. It’s best if you can have an erection 2 to 3 times a week. This will help keep the tissue in your penis healthy.
- Using a low-dose pill to help the blood flow around the nerves and help the nerves heal.
Talk to your doctor about how your nerves might have been affected by surgery and whether penile rehabilitation is right for you. You might need to see a doctor who specializes in sexual medicine, as these types of doctors are more likely to know about penile rehabilitation.
Pelvic radiation therapy
Prostate, bladder, colon, and rectal cancer are sometimes treated with radiation to the pelvis. This can cause problems with erections. The higher the total dose of radiation and the wider the section of the pelvis treated, the greater the chance of erection problems later.
One way that radiation affects erections is by damaging the arteries that carry blood to the penis. As the treated area heals, the blood vessels lose their ability to stretch due to scar tissue in and around the vessels. They can no longer expand enough to let blood speed in and create a firm erection. Radiation can also lead to hardening (arteriosclerosis), narrowing, or even blockage of the pelvic arteries. Radiation may affect the nerves that control a man’s ability to have an erection, too.
Some men who get radiation will notice that their erections change for the worse over the first year or so after 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.
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 radiation treatment. Doctors are looking at whether early penile rehabilitation could help after radiation therapy, too. (Penile rehabilitation is discussed above, in the surgery section.)
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 to check for low testosterone. But this is not a common problem after radiation therapy, so extra hormones may not be needed. And many doctors feel that men with prostate cancer should not take testosterone, since it can speed up the growth of prostate cancer cells.
For men with prostate cancer treated with radiation
Some men will have issues with erections (erectile dysfunction or ED) within a few years of external beam radiation for prostate cancer. Some of these men may have erections that allow penetration, but only a small portion report their erections are as good as they were before treatment.
Many men with early stage prostate cancer have a choice between radiation and surgery to treat their cancer. When looking at how men’s erections are affected by these treatments, there does not seem to be much long-term difference between the two. Men who have had radiation may see a general decrease in the firmness of their erections over time (up to several years after radiation). In contrast, after surgery most men have erection problems right away and then have a chance to recover erections in the first 2 years following the surgery. About 4 years after either treatment, the percentage of men reporting ED is about the same. Treatments can often help these men get their erections back whether they’ve had surgery or radiation.
Chemotherapy
Most men getting chemotherapy (often called chemo) will still have normal erections.But a few do develop problems. Erections and sexual desire often decrease right after getting chemo but return soon after treatment.
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 treatment ends.
Some chemo drugs like cisplatin, vincristine, paclitaxel, bortezomib, and thalidomide can damage parts of the nervous system, usually the small nerves of the hands and feet. (This is called peripheral neuropathy.) These drugs have not been found to directly injure the nerve bundles that allow erection. But some people have concerns because the drugs are known to affect nerve tissue, and there are many nerves involved in sexual function.
Chemo can also cause a flare-up of genital herpes or genital wart infections if a man has had them in the past.
Stem cell transplant
Men who have had graft-versus-host disease after a stem cell transplant are more likely to have a long-lasting loss of testosterone. In some cases, these men may need testosterone replacement therapy to regain sexual desire and erections.
The psychological effects of cancer treatment on erections
Many men report disappointment, fear, and distress when they have trouble with erections. They report that they don’t feel “like a man” and that something important is missing. Men may report a general unhappiness with life and depression when they have problems with erections. These feelings are a natural part of coping with erection problems. And most men, if they are able find effective treatments to help with their erections, will start to feel better. If these feelings are severe or persist, most men find it very helpful to see a mental health professional who specializes in sexual issues or a psychiatrist who can help address these feelings.
Worries about self-image and performance can sometimes lead to erection problems, too. Instead of letting go and feeling excited, a man may focus on whether he will be able to function, and fear of failure might 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.
A therapist who specializes in helping patients with sexual issues can often assist in the treatment of erection problems caused by anxiety and stress. Any treatment for an erection problem should be based on the results of a thorough exam, which should include both medical questions (history) and certain medical tests. (See Questions Men Have About Cancer, Sex, and Getting Professional Help for more information.)
