Prostate Cancer Treatment and Erectile Dysfunction: What to Expect

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Erectile dysfunction (ED) and incontinence (inability to hold urine) are the most common side effects of prostate cancer treatment. Although men have more questions about ED than they do about incontinence, they may be less likely to ask. Here's what you need to know.

What Is the Prostate Gland?

About the size of a walnut, your prostate gland is located just below your bladder. It wraps around the tube that carries semen and urine through your penis and out of your body. The prostate makes seminal fluid, which is part of semen. Normal functioning of the prostate gland depends on testosterone and androgen, which are hormones made by the testicles.

Libido is the desire to have sex. A low libido may be caused by low levels of testosterone. It may also be caused by:

  • Weight gain, especially around the waist
  • Sleep problems, such as sleep apnea
  • Medications, such as opioids, steroids and those prescribed for high blood pressure and depression
  • Hormone imbalances, such as a high level of cortisol (the stress hormone involved in the "fight-or-flight" response)
  • Your psychological/emotional state, such as depression, anxiety, grief, fear and insecurity. In some cases, distress is caused by the cancer diagnosis itself, or by the treatment you receive, doubts about your feelings of manliness or ability to perform sexually, or worries about your relationships or what the future holds — so your state of mind can play a big part in ED. Finding an effective ED treatment or talking with your peers or partner may help. If your negative feelings don't go away — or get worse — it may be helpful to see a counselor or psychiatrist who specializes in sexual issues.

How Erections Occur

As men become sexually aroused, the brain sends messages through the nervous system to the muscular walls of the blood vessels in the penis. The vessels enlarge, allowing more blood to flow into the penis. The incoming blood makes the penis bigger and harder, causing an erection.

Even if your libido is normal, your hormones, nervous system, muscles and blood vessels need to be working properly in order to get an erection.

Why Is Erectile Dysfunction So Common?

Prostate cancer treatments may affect your hormones, which in turn can affect your libido. Treatment may also affect the nerves, muscles or blood vessels that play important roles in causing an erection.

Surgery: The nerves responsible for an erection travel very close to the prostate gland. Nearly all men who have their prostate removed will have trouble getting an erection for a period of time, even if they have a "nerve-sparing" operation.

Radiation therapy: Radiation therapy can damage the delicate tissues involved in getting an erection, such as nerves, blood vessels or blood flow. Side effects of radiation therapy appear more slowly during the year after treatment. Men may have softer erections, lose their erection before climax (orgasm) or not be able to get an erection at all.

Chemotherapy: Chemotherapy may affect your libido and erections if it affects testosterone production, but most men still have normal erections. Chemo can also cause fatigue or distress, which can affect your sexual desire and ability to have an erection, but normal desire usually returns when treatment ends.

Hormone therapy: Androgen deprivation therapy (ADT) is hormone therapy. The prostate itself depends on androgens, such as testosterone, to do its work. Unfortunately, testosterone may help some prostate cancers to grow. By blocking androgens, ADT therapy can block or slow the growth of prostate cancer, but it can also decrease libido and sexual function. (ADT does not cure prostate cancer.)

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What Can I Expect During Recovery from Prostate Cancer Treatment?

Time is the most important factor in recovery. The healing process for men who have had nerve-sparing radical prostatectomy (removal of the prostate) is often 18 to 24 months or more, because nerve tissue requires a longer time to heal. How much erectile function returns depends on several things:

  • The type of operation you had (one, both, or no nerves spared). Most men with intact nerves will see a substantial improvement within a year of treatment.
  • Your age: Men under 50 or 60 are more likely to recover their erections than older men.
  • Your erectile function before the operation. Men who had good erections before surgery are more likely to recover their ability to get an erection than those who had previous erection problems.

It is also very common to need medications to assist with erectile function, even if you did not need them before your operation.

What Can I Do? Rehabilitation and Aids

Studies suggest that starting a program to promote erections about six weeks after surgery can help some men recover sexual function. Different methods are available, depending on your particular case, your level of motivation and the judgment of your surgeon. These penile rehabilitation programs focus on increasing blood flow to the area to encourage healing and help men have regular erections that are hard enough for penetration. Having two to three erections a week, even if there is no sexual activity, helps keep the tissues in the penis healthy.

There are different options to treat ED, and they may or may not be part of a rehabilitation program:

  • Oral medication: sildenafil/Viagara®, tadalafil/Cialis® or vardenafil/Levitra MUSE (a prostaglandin suppository that you insert into your urethra)
  • Vacuum erection devices
  • Penile self-injection with a prostaglandin: alprostadil/Caverjet/Edex

Talk to your provider in Roswell Park's Genitourinary (GU) Center about the options available to you.

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