Prostate Cancer, treatment and its effect on sexuality

Cancer treatment can interfere with ejaculation by damaging the nerves that control the prostate, seminal vesicles, and the opening to the bladder. It can also stop semen from being made in the prostate and seminal vesicles.

Despite this damage, a man can still feel the sensation of pleasure that makes an orgasm. The difference is that, at the moment of orgasm, little or no semen comes out. Some men say an orgasm without semen feels totally normal. Many others say the orgasm does not feel as strong, long-lasting, or pleasurable.

Men often worry that their partners will miss the semen. Most of the time, their partners cannot feel the actual fluid release, so this is generally not true. Some men’s chief concern is that orgasm is less satisfying than before. Others are upset by “dry” orgasms because they want to father a child. If a man knows before treatment that he may want to have a child after treatment, he may be able to bank (save and preserve) sperm for future use.

Some men also feel that their orgasm is weaker than before. A mild decrease in the intensity of orgasm is normal with aging, but it can be more severe in men whose cancer treatments interfere with ejaculation of semen

Surgery and ejaculation

Surgery can affect ejaculation in 2 different ways. The first is when surgery removes the prostate and seminal vesicles, so that a man can no longer make semen. The other is surgery that damages the nerves that come from the spine and control emission (when sperm and fluid mix to make semen). Note that these are not the same nerve bundles that pass next to the prostate and control erections.

The surgeries that cause ejaculation problems are discussed below

Removal of the prostate gland and seminal vesicles can cause dry orgasm

The types of cancer surgery that remove the prostate gland and the seminal vesicles are called:

  • Radical prostatectomy (removal of the prostate)
  • Cystectomy (removal of the bladder)

A man will no longer produce any semen after these surgeries. The sperm cells made in his testicles ripen, but then the body simply reabsorbs them. This is not harmful. After these cancer surgeries, a man will have a “dry” orgasm or an orgasm without semen.

Sometimes the semen is there, but doesn’t come out

There are other operations that cause ejaculation to go back inside the body rather than come out (this is called retrograde ejaculation). At the moment of orgasm, the semen shoots backward into the bladder rather than out through the penis. This is because the valve between the bladder and urethra stays open after some surgical procedures. This valve normally shuts tightly during emission. When it’s open, the path of least resistance for the semen then becomes the backward path into the bladder. This does not cause pain or harm to the man. When a man urinates after this type of dry orgasm, his urine looks cloudy because the semen mixes in with it during the orgasm.

A transurethral resection is an example of an operation that usually causes retrograde ejaculation. This surgery cores out the prostate by passing a special scope into it through the urethra; this often damages the bladder valve.

Nerve damage

We have already discussed the nerve bundles that sit on both sides of the prostate and control blood flow to cause erections. Now, we are talking about the nerves that come from the spine and control emission. The cancer operations that can cause “dry” orgasm by damaging the nerves that control emission (the mixing of the sperm and fluid to make semen) are:

  • Abdominoperineal (AP) resection, which removes the rectum and lower colon
  • Retroperitoneal lymph node dissection, which removes lymph nodes in the belly (abdomen) Some of the nerves that control emission run close to the lower colon and are damaged by AP resection.
  • Lymph node removal (dissection) damages the nerves higher up, where they surround the aorta (the large main arteryin the abdomen).

The effects of the 2 operations are probably very much alike, but more is known about sexual function after lymph node surgery. Sometimes the node dissection only causes retrograde ejaculation. But it usually paralyzes emission. When this happens, the prostate and seminal vesicles cannot contract to mix the semen with the sperm cells. In either case the result is a “dry” orgasm. The difference between no emission at all and retrograde ejaculation is important if a man wants to father a child.

Retroperitoneal node dissection does not stop a man’s erections or ability to reach orgasm. But it may mean that his pleasure at orgasm will be less intense.

Urine leakage during ejaculation

Climacturia is the term used to describe the leakage of urine during orgasm. This is fairly common after prostate surgery, but may not even be noticed. The amount of urine varies widely — anywhere from a few drops to over an ounce. It is more common in men who also have stress incontinence. (Men with stress incontinence leak urine when they cough, laugh, sneeze, or exercise. It is caused by weakness in the muscles that control urine flow.) Urine is not dangerous to the sexual partner, though it may be a bother during sex. The leakage tends to get better over time, and condoms and constriction bands can help. (Constriction bands are tightened at the base of the erect penis and squeeze the urethra to keep urine from leaking out.) If you or your partner is bothered by climacturia, talk to your doctor to learn what you can do about it.

How other cancer treatments affect ejaculation

Some cancer treatments reduce the amount of semen that is produced. After radiation to the prostate, some men men ejaculate only a few drops of semen. Toward the end of radiation treatments, men often feel a sharp pain as they ejaculate. The pain is caused by irritation in the urethra (the tube that carries urine and semen through the penis). It should go away over time after treatment ends. In most cases, men who have hormone therapy for prostate cancer also produce less semen than before. Chemotherapy very rarely affects ejaculation. But there are some drugs that may cause retrograde ejaculation by damaging the nerves that control emission.

Second Cancers Caused by Cancer Treatment

Men whose prostates have been removed or destroyed with radiation can no longer get a new case of prostate cancer, but they can get recurrence of the original prostate cancer (the cancer can come back after treatment). Men who are treated with radiation therapy have a higher risk of bladder cancer later on than men who had surgery to remove their prostates. They may also have a higher risk for colon and rectal cancer. This increased risk is mainly seen in men who were treated with external beam radiation therapy (EBRT). Men who had seed implants (brachytherapy) without EBRT may have a slightly increased risk of these cancers, but it is lower than what is seen with EBRT. Overall, the risk seen with radiation therapy is not high, but it can continue for more than 10 years after treatment. The risk is likely related to the dose of radiation, as it is with other cancers. Men who get seed implants typically get less radiation to nearby organs than those who get EBRT, either by itself or along with seeds.

Newer methods of giving EBRT, such as intensity modulated and conformal beam radiation therapy, may have different effects on the risks of a second cancer. Because these methods are newer, the long-term effects have not been studied as well. Some studies looking at the long term effects of prostate cancer treatment have found an increased risk of melanoma (a type of skin cancer) after radiation therapy, but this higher risk was seen after prostatectomy (surgery to remove the prostate) as well.

At one point, high doses of the female hormone estrogen were used to treat advanced prostate cancer. This was linked to breast cancer in some men. Estrogen is no longer a standard treatment for prostate cancer.

Follow-up care

Survivors who are treated with radiation have an increased risk of certain second cancers, so they should get careful follow-up. There are no special recommendations for watching for second cancers after prostate treatment at this time, although men who have had radiation to treat prostate cancer should be careful to follow screening recommendations for colorectal cancer to improve the chance of early detection. Your doctor will also be watching closely for recurrence of the prostate cancer. You should also report problems passing urine, blood in your urine, rectal pain, or rectal bleeding to your doctor right away.

All patients should be encouraged to avoid tobacco smoke. Men who smoke may further increase their risk of bladder cancer after prostate radiation, since smoking is a known risk factor for bladder cancer.

What Happens After Treatment for Prostate Cancer?

Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer coming back. (When cancer comes back after treatment, it is called recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are living full lives.

Follow-up care

When treatment ends, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or x-rays and scans to look for signs of cancer or treatment side effects. Your doctor should give you a follow-up plan. This plan usually includes regular doctor visits, PSA blood tests, and digital rectal exams, which will likely begin within a few months of finishing treatment. Most doctors recommend PSA tests about every 3-6 months for the first 5 years after treatment, and at least yearly after that. Bone scans or other imaging tests may also be done, depending on your medical situation.

Almost any cancer treatment can have side effects. Some may last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have. See our section on late effects

Prostate cancer can recur many years after initial treatment, which is why it is important to keep regular doctor visits and report any new symptoms (such as bone pain or problems with urination). Should your prostate cancer come back, your treatment options will depend on where it is thought to be located and what types of treatment you’ve already had.

Dealing with sexual problems

What to expect

It’s hard to know what will happen to any one person. For example, one man’s erections may come back after radical prostatectomy while another man’s may not. But if you do have a sexual problem, your health care team can often find the cause and give you an idea of your chance for recovery.

One clue that a problem is a medical one and one that may not go away is if it happens in all situations. Otherwise, it may be psychological and short-term. For example, if you have trouble getting or keeping an erection, does it happen every time you have sex? Are your erections better when you relax, when you stimulate your own penis, or when you unexpectedly see someone attractive? If you have a few partners, are your erections better with one of them than with the others?

Dealing with short-term problems

As men age or go through health changes, it’s common that feelings of sexual excitement no longer lead to an instant erection. You may just need more time and stroking to get aroused.

If you have trouble reaching orgasm during sex, you may not have found the right kind of touching. You might even think about buying a hand-held electric vibrator. A vibrator can give very intense stimulation. Try having a sexual fantasy or looking at erotic stories or pictures. The more excited you are, the easier it is to reach orgasm.

A number of men have their first orgasms after cancer treatment while asleep, during a sexual dream. If this happens to you, it’s proof that you are physically able to have an orgasm. It’s also helpful if your partner notices that you have erections during sleep. Because sleep erections aren’t affected by mood or state of mind, they give you an idea of the best erection your body can produce. Now it’s up to you to set things in motion when you are awake.

Finding the cause of problems that appear to be permanent

The best time to talk with your doctor or cancer team about side effects or long-term changes in your sex life is before treatment, so that you know what to expect and can learn about the usual recovery and how long it takes. But you can bring up the subject any time during and after treatment, too. If you did not discuss sexual side effects before treatment, it’s best to do so soon after your treatment. This way your doctor can help you find the cause of the problem and develop a plan to help you deal with it.

How cancer treatments can affect sexuality and fertility

Treatment Low sexual desire Erection problems No orgasm Dry orgasm Weaker orgasm Infertility
Chemotherapy Sometimes Rarely Rarely Rarely Rarely Often
Pelvic radiation therapy Rarely Sometimes Rarely Rarely Sometimes Often
Retroperitoneal lymph node dissection Rarely Rarely Rarely Often Sometimes Often
Abdominoperineal (AP) resection Rarely Often Rarely Often Sometimes Sometimes*
Radical prostatectomy Rarely Often Rarely Always Sometimes Always
Radical cystectomy Rarely Often Rarely Always Sometimes Always
Total pelvic exenteration(clearance) Never Often Rarely Always Sometimes Always
Partial penectomy Rarely Rarely Rarely Never Rarely Never
Total penectomy Rarely Always Sometimes Never Sometimes Usually*
Orchiectomy (removal of one testicle) Rarely Rarely Never Never Never Rarely**
Orchiectomy (removal of both testicles) Often Often Sometimes Sometimes Sometimes Always
Hormone therapy for prostate cancer Often Often Sometimes Sometimes Sometimes Always

*Artificial insemination of a woman with the man’s semen may be possible.

**Infertility happens only if the remaining testicle is not normal

Hormone therapy can affect desire

Treatment for prostate cancer that has spread beyond the gland often includes changing a man’s hormone balance. This can be done in one or more of these ways:

  • Using drugs to keep testosterone from being made
  • Using drugs that block cells from using testosterone
  • Removing a man’s testicles (called orchiectomy)

The goal of hormone therapy is to starve the prostate cancer cells of testosterone. This slows the growth of the cancer. All of these treatments have many of the same kinds of sexual side effects, because they all affect testosterone.

The most common sexual problem with hormone treatment is a decrease in desire for sex (libido). Hormone therapy may also cause changes in how you look, such as loss of muscle mass, weight gain, or some growth in breast tissue. Be sure you understand the side effects and what you can do to help manage them. For instance, a program of exercise may help you limit muscle loss, weight gain, and tiredness. Talk with your doctor about any exercise program you may have in mind, or ask to be referred to a physical therapist, who can help you decide where to start and what to do.

Psychological effects of hormone therapy

Men who are on hormone therapy drugs to lower testosterone often feel like “less of a man.” They fear they may start to look and act like a woman. This is a myth. Manhood does not just depend on hormones but on a lifetime of being male. Hormone therapy for prostate cancer may decrease a man’s desire for sex, but it cannot change the target of his sexual desires. For example, a man who has always been attracted only to women will not find himself attracted to men because of this kind of hormone treatment.

Hormone therapy in men has been linked to depression. Talk to your doctor about this because it can be treated with anti-depressant drugs and/or counseling. There’s also growing concern that hormone therapy for prostate cancer may lead to problems with thinking, concentration, and/or memory. This hasn’t been well studied, but hormone therapy does seem to lead to memory problems in some men. These problems are rarely severe, and most often affect only some types of memory. More studies are being done to look at this.