Thank you to Dr. Jeffrey Albaugh and Dr. Anne Katz for their expertise, content and guidance in putting this page together.
If you are one of the three million men diagnosed with prostate cancer in the United States, you have undoubtedly seen how the disease touches other aspects of your personal life. Prostate cancer is an overwhelming and trying diagnosis that often leaves men and their loved ones emotionally and physically exhausted – and it can easily creep into work and personal life. According to a study that looked at the personal impact a prostate cancer diagnosis could have, a quarter of all participants stated that they experienced significant negative impacts to their personal activities. The same study saw 42% of participants report that the cancer had a negative effect on their sexual relationship.1
Clearly, men who experience this phenomenon are not alone, in spite of how isolating it may feel. You may have found your own sexual relationship has become strained, or increasingly stressful, after undergoing treatment for your cancer. Many couples are unprepared to face sexual issues, like erectile dysfunction (ED) and urinary incontinence, that can occur in the wake of the prostate cancer treatment. This can put an added burden on top of the already exhaustive task of tackling your cancer, and possibly lead to anxiety and depression for both you and your partner.
A prostate cancer diagnosis can be overwhelming and devastating for men and their partners. Since the prostate is part of the sexual system, treatment of prostate cancer may result in sexual dysfunction. Sexual dysfunction is often identified as the most common long term side effect after prostate cancer treatment (with both surgery and radiation therapy). Sexual issues after prostate cancer treatment can negatively impact quality of life. The road towards healing can be a challenging journey, but it is possible to have fulfilling sex and intimacy after prostate cancer treatment. In terms of sex, for the purpose of this website, it refers to any genital stimulation or activities that lead to arousal, orgasm and sexual satisfaction Genital stimulation can be manual (using the hands to stimulate genitals), oral (using the mouth to stimulate genitals), rubbing (rubbing parts of the body or genitals against a partner’s genitals), vibratory (using vibratory stimulation to stimulate genitals), or penetrative (penetrating the vagina or rectum for sexual pleasure). Intimacy involves communication on all levels and connectedness on a deep level to another person. Human beings are hardwired for connectedness to other human beings. That connectedness to a significant other can especially be important after a cancer diagnosis.
The prostate and seminal vesicles produce the majority of the fluid released during ejaculation, so when the prostate is removed or radiated, orgasm will be absent of ejaculation fluid. The feeling of climax/orgasm typically still occurs and is enjoyable (although it may feel different, diminished or more intense). Most men after prostate cancer surgery will have a dry orgasm experience, but about a third of men may have urine leakage during climax or sexual stimulation.
It may be helpful for you and your partner to assess and discuss your goals regarding both sex and intimacy. In terms of intimacy, you and your partner might find that after prostate cancer treatment you need deeper communication and understanding. Intimacy means closeness to your partner. Connectedness/closeness is important because one of the challenges of dealing with a cancer diagnosis and treatment is the potential for isolation between a man and his partner. Affection and physical touch may also be reassuring and may play an important role in a deeper connection with a partner. Your thoughts and goals in terms of sex may vary greatly as you navigate through prostate cancer diagnosis, treatment, and recovery, so it is important to discuss them. Even though sex may not be one of the most important things on a man’s mind when first diagnosed with prostate cancer, it is likely to become a weighty concern after treatment. Organ contained prostate cancer is often successfully treated, but the post treatment sexual dysfunction can be the ongoing issue that is problematic for some men. After treatment, some men/couples feel unprepared to deal with the physical and emotional impact on their intimate relationship.
Men get erections every day of their lives. The penis is usually erect multiple times during any 24 hour period, primarily during deep rapid eye movement (REM) sleep at night. A man experiences approximately four to six erections every night. When a man thinks sexual thoughts or his penis is stimulated or both, that information is synthesized in the frontal lobe of the brain. The message travels down the spine to the peripheral nerves. The peripheral nerves wrap around the prostate and go to the penis. In the penis, the nerve impulse activates chemicals in the penis which tell the blood vessels to dilate. The penis becomes engorged with blood, making it erect.
Every night a man’s penis gets a workout with the smooth muscles around the blood vessels expanding and contracting to let more blood in the penis when it is erect and allowing less blood in the penis when it is flaccid. This is like pushups for the penis! The muscles around the penis literally get a workout from relaxation and contraction around the blood vessels. The increased blood flow associated with nighttime erections helps to keep the tissue of the penis healthy and normal.
The National Institutes of Health Health (NIH) defines erectile dysfunction as the “inability to attain and/or maintain a penile erection sufficient for satisfactory sexual performance” (NIH Consensus Development Panel on Impotence, 1993) and this definition is still used today. Men experiencing erectile dysfunction (ED) after prostate treatment have trouble getting and/or keeping erections hard enough for penetrative types of sexual activity.
ED can be caused by any disease process that impacts nervous conduction and/or blood flow such as diabetes, high blood pressure, heart disease, high cholesterol, obesity, head/neck/back disorders, or stroke (to name a few). ED can also be caused by surgery or radiation that impacts nervous conduction or blood flow necessary for erections. After prostate removal or radiation of the prostate, the nerves for erections are traumatized and do not function properly. Sometimes it is necessary to destroy these nerves during surgery. This happens when the cancer has grown close to where the nerves lie on the back of the prostate. If the nerves are damaged or destroyed, they cannot conduct impulses. Not only can conduction be compromised from the dissection of these nerves away from the prostate or radiation of the nerves, but the chemicals in the penis that tell the muscles to dilate may also be diminished. The cavernosal nerve is a source of synthesis for nitric oxide, which is one of the most important chemicals in the penis that helps blood vessels dilate. This lack of nerve conduction can lead to less blood flow to the penis and can change the structure of the penis and lead to diminished function. Hormone deprivation therapy can also cause a reduction in libido (desire) and possible difficulties with erections. This may be reversible when the therapy is discontinued.
Studies on the prevalence of ED in men after prostatectomy have reported the condition to be as high as 78%-87% two to 15 years after treatment (Resnick, et al., 2013;. In the same multicenter study, erectile dysfunction in men who undergo radiation therapy post treatment is also prevalent ranging from 61-94% at two to 15 years after treatment (Resnick, et al., 2013). Erectile dysfunction may have a negative impact on quality of life or life satisfaction. Sexual function remains important to many men with continued interest in sex into the later decades of life. In light of the high survival rates associated with prostate cancer, issues impacting quality of life, such as ED, need to be addressed and treated in those men who are upset by their inability to get and keep erections.
Some men have described shrinkage of their penis after radical prostatectomy. You may or may not have noticed shrinkage of the flaccid penis after prostate removal. Penile shrinkage may be related to several factors. Unchallenged muscle tone within the penis after removal of the prostate may cause some shrinkage. When your penis is full of blood, the smooth muscles around the penis are relaxed; when your penis goes back to the soft/flaccid state, the muscles are contracted around the blood vessels. So if the muscles that surround the blood vessels are no longer contracting and relaxing with nighttime erections, the muscles of the penis are no longer getting a workout, muscle mass can diminish, and the penis can shrink. The flaccid penis seems to disappear up into the body. This diminished flaccid penis size can be upsetting for some men. The shrinkage can be transient and may resolve over time however many men report loss of length and girth that persists.
Getting regular erections may help diminish penile shrinkage, but getting erections can be challenging after prostate cancer treatment. If pills or injections help with getting erections, they may also help with penile shrinkage when taken regularly. A vacuum device may also be of benefit for stretching the tissue of the penis and filling the penis with blood.
Many couples who have successfully faced ED and prostate cancer stress the many facets of their journey:
Most couples do not realize is that there may be possible solutions to restoring sexual function, even after prostate cancer treatment. From pills, to external devises, injections and surgical procedures, there are solutions for nearly everyone. With persistence, a little humor, open discussion, and medical support, couples may reclaim sexual function once again.
If reproduction is not the reason for sex, the goals of sex for most people become about connectedness to a partner, pleasure and/or orgasm/climax. The goals of sex and connectedness, pleasure and orgasms can be accomplished with or without a hard penis. Neither men nor women need a hard penis to climax. Oral stimulation, manual stimulation (using hands to stroke the genitalia), rubbing genitals together and vibratory stimulation can all lead to orgasm/climax. The penis and clitoris are primary areas for stimulation and sexual arousal, but other parts of the body may also be sensitive to stimulation. The willingness to explore other forms of non-penetrative sex opens many possibilities for connectedness, pleasure and orgasm/climax. Intercourse or penetrative sex is simply one way to reach climax, but it is not the only way. As men and women get older, many of the various medical conditions that negatively impact penetrative sex occur for either partner. The most common problem impacting penetrative sex in men is erectile dysfunction and the most common problem in women is vaginal dryness and atrophy (shrinkage and changes in the tissue leading to pain). Some partners choose to be sexual without penetration. This is an option that doesn’t require erections, eliminating the need for erectile dysfunction treatment.
If erections are a goal, there are many medical professionals, generally urology healthcare professionals, who specialize in treating ED. An excellent urologist/urology nurse practitioner/physician’s assistant is one who is:
A sexuality counselor or sex therapist is a valuable member of the team who may help the couple deal with changes to their previous sexual functioning and help with setting alternative goals, communication and finding other ways of being sexual.
Don’t let ED become a silent, unwelcome, over-bearing house guest. If you and your spouse are facing ED, whether is it the result of prostate cancer treatment or not, do not let fear, embarrassment, or discomfort destroy your love life. Become knowledgeable about ED. Seek help from medical professionals who specialize in sexual function and keep the lines of communication open.
There are multiple treatment options for erectile dysfunction. Each treatment option has pros and cons, so each man (and his partner- if he is partnered) needs to make his own informed decision about ED treatment.
Couples facing prostate cancer often feel the need to be more connected than ever. Instead, confusion, embarrassment and fear caused by ED can cause both parties to feel alone and disconnected.
In the midst of this difficult news, it is important to know that there is HOPE. Perhaps more importantly, there are options that make mutually satisfactory sexual relationships possible in the presence of ED and impotence. In this instance, information truly is power. Paired with open and frank discussion and a willingness to explore options, couples facing ED can find satisfying solutions.
Managing your intimacy issues requires a foundation of open and honest dialogue between you and your partner. It’s important to keep embarrassment from closing off lines of communication, and instead allow yourselves to sit together and start those often-difficult conversations.
The presence of ED and incontinence can cause both or either partner to develop depression or anxiety. Men who suffer from mild-to-severe depression or anxiety may find their quality of life effected or their immune systems compromised as a result. It’s important to recognize the causes and symptoms of depression and anxiety so they can be effectively addressed. You can learn more about how to address the psychological and emotional toll of prostate cancer as well as access numerous resources on our page, Anxiety and Depression as Related to Prostate Cancer.
Dr. Anne. Katz is a PhD-prepared nurse who has worked in the area of sexuality counseling for almost 20 years. She is also a certified sexuality counselor with extensive experience working with couples and individuals with all kinds of cancer. She has written numerous articles in the professional literature about sexuality, including sexuality after prostate and other cancers. He has given talks all over the US, Canada and beyond on the topic to both health care providers and survivors. Her book Prostate Cancer and the Man You Love: Supporting and Caring for Your Partner (Rowman & Littlefield 2012) focuses on how a man’s partner can help him negotiate the diagnosis of prostate cancer from diagnosis through advanced disease. For more information visit www.drannekatz.com.
Dr. Jeffrey Albaugh is a funded researcher and a board certified Advanced Practice Urology Clinical Nurse Specialist who is the Director of Sexual Health at NorthShore University HealthSystem and at Jesse Brown VA Medical Center in Chicago, IL. He is also a board certified Sexuality Counselor. In addition to his many publications in peer reviewed journals and chapters in books on sexual dysfunction, Dr. Albaugh published his book “Reclaiming Sex and Intimacy after Prostate Cancer Treatment.” Dr. Albaugh has been quoted in media and publications as an expert in the treatment of sexual dysfunction, including: Martha Stewart’s Whole Living, WGN News, CBS 2 News, the New York Times, The Chicago Tribune and The Red Eye. He has spoken on many topics throughout the United States and all over the world. Dr. Albaugh has been acknowledged with multiple awards including: two nursing excellence and the patient’s first award from Northwestern Memorial Hospital, multiple lectureship and literary awards and the Society of Urologic Nurses & Associates President’s Award for Contributions to Urologic Nursing. He is a member of the Us TOO Board of Directors and a former recipient of the Edward C. Kaps Hope Award from Us TOO International Prostate Cancer Education and Support Network for his volunteer work with support, education and advocacy for men with prostate cancer and their partners.
Prostate cancer survivors who attend meetings—sometimes along with spouses/partners—find invaluable information and perspective from their peers who quite often have "been there - done that" relative to their experience managing the various aspects of prostate cancer. The interactive format of a support group meeting is an educational forum that facilitates conversations to exchange information among group members assembled with the common goal of empowering each other with the knowledge that comes from experience. Find an Us TOO support group meeting near you.
This phone call support group is for the women behind the men affected by prostate cancer. Because prostate cancer is a couple's disease, the woman is often subject to her own concerns in addition to those she shares with her partner. A Forum for Her will focus on women and offer peer-to-peer support to address these concerns. Get more information or join a call by contacting Terri Likowski at 336-842-3578 or email@example.com
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