Sexual problems – male sex organs

Cancer and its treatments can affect your sexual health. You may have difficulty having an orgasm, ejaculation problems, trouble getting or keeping an erection (called erectile dysfunction, or ED) or a low sex drive.

Many sexual problems related to cancer can be treated or managed. But first, you need to be able to talk about them. You're not alone if you find it very hard to talk about sex. Don't let feeling awkward or embarrassed get in the way of getting the help you need. Sexual health is just as important as other areas of health. Doctors and nurses are there to help, not to judge. And everything you tell them is confidential. It's worth trying to find someone on your healthcare team you can talk to about sex, or ask to see a new healthcare professional. Try to think of a sexual problem as being like any other side effect – you need to be open and honest with your healthcare team in order to get the best treatment for you.

Find out about the male sex organs and reproductive system.

Before explaining the types of sexual problems that can develop after cancer treatment, it's important to understand that an orgasm is different from ejaculation. An orgasm is a feeling of intense pleasure during sexual activity. Ejaculation is when an orgasm causes fluid to come out of the penis. You can have an orgasm without ejaculating. You can also have an orgasm without an erection. The nerves that help you feel pleasure are different than the nerves that cause an erection.  

These are some of the sexual problems that can develop after cancer treatment:

Cancer or its treatments can lead to ejaculation problems including:

• painful ejaculation
• retrograde ejaculation, when semen flows backward into the bladder instead of going out through the penis
• dry orgasm (also called dry ejaculation), when you have an orgasm but don't ejaculate semen
• climacturia, when a small amount of urine (pee) leaks out during an orgasm

For the penis to penetrate a vagina or an anus, it needs to be erect, or stiff. Erectile dysfunction (ED) is the inability to get and keep an erection firm enough for sexual penetration. Cancer or treatments that damage nerves or blood vessels in the pelvis can cause ED. It can also develop if cancer or cancer treatments change hormone levels in your body. ED can be temporary or permanent. Often the younger you are, the more likely you are to regain erectile function. People under 60, and especially those under 50, have much higher recovery rates than older people. You can still have an orgasm and be fertile with ED.

Side effects of treatment can change how you feel and affect your sexual desire. Emotional factors and changes to how you feel about your body (body image) can lower your sex drive. Some treatments and medicines can lead to your body producing less testosterone, which can lower your sex drive.

Treatments for cancers of the sex organs or nearby organs, such as penile, testicular, prostate, bladder, colon or rectal cancer, can cause sexual problems.

The following surgeries can cause sexual problems:

A radical prostatectomy is surgery for prostate cancer. It removes the prostate and some tissues around it, including the seminal vesicles. It can damage the nerves needed for an erection and cause ED. If the cancer is found early, the surgeon may be able to do nerve-sparing surgery. Removing the prostate also causes dry orgasm as the prostate makes the liquid portion of the semen. It can also cause the penis to be shorter (called penile shrinkage).

A radical prostatectomy can change how you experience sex and lower your sex drive. The surgery can make the prostate no longer sensitive to touch and pressure.

A radical prostatectomy can cause incontinence. Not being able to control when you urinate (pee) or have a bowel movement (poop) can affect body image and lower your sex drive.

A radical cystectomy is surgery for bladder cancer. It removes the bladder along with the prostate, upper urethra and seminal vesicles. You will have a urostomy so that urine can pass out of the body. A radical cystectomy causes ED and dry orgasm.

An abdominoperineal resection is surgery used to treat colon cancer. It can damage nerves in the pelvis and cause ED and dry orgasm.

A pelvic exenteration is surgery done for advanced cancer in the pelvis. It removes the bladder, prostate, seminal vesicles and rectum. A pelvic exenteration damages nerves in the pelvis and causes ED and dry orgasm. Recovery from a pelvic exenteration takes a long time.

Orchiectomy is surgery to remove a testicle. Feeling embarrassed by a missing testicle may affect how you feel about sex or change your sexual experiences. A testicular prosthesis can be placed in the scrotum.

A transurethral resection of the prostate (TURP) removes part of the prostate through the urethra. A TURP can cause retrograde ejaculation because the bladder sphincter is widened during this surgery.

A retroperitoneal lymph node dissection (RPLND) removes lymph nodes in the pelvis. It is used to treat testicular cancer and often causes dry orgasms.

A penectomy is surgery to remove part or all of the penis. It can be used to treat penile cancer. You can still have an erection if only part of the penis is removed. If all of the penis is removed, you won't be able to have an erection but you may still be able to have an orgasm. Everyone experiences pleasure in different ways, and it can be pleasurable to touch sensitive areas, such as the scrotum. It's sometimes possible to reconstruct the penis after a total penectomy using skin grafts and skin flaps, but this surgery is very rare.

Radiation therapy to the lower pelvis can lead to pain during ejaculation. Radiation to the pelvis can damage the arteries that carry blood to the penis or can affect the nerves needed for an erection.

Radiation therapy for prostate cancer can also cause incontinence, which can affect sex and your sex drive. Feeling embarrassed by incontinence may affect how you feel about sex or change your sexual experiences.

Radiation therapy to the lower pelvis that involves the rectum (such as for prostate cancer or bladder cancer) can cause bowel problems. Feeling embarrassed by bowel problems may affect how you feel about sex or change your sexual experiences.

Chemotherapy, hormone therapy (androgen deprivation therapy) and medicines, such as pain medicines, antidepressants or blood pressure medicines, can lower testosterone levels. This can lower sexual desire and lessen the ability to have an erection. Hormone therapy can also cause depression, which may affect your sex drive. Side effects of cancer treatments such as fatigue and pain can also affect your sex drive.

Emotional factors, such as the following, can also affect sexual function and lower your sex drive:

• anxiety, depression and stress
• changes in body image, confidence or self-esteem
• fear of pain
• worrying about sexual performance
• unhappiness and embarrassment because of physical changes

Whether it is safe to have sex during treatment depends on your treatment plan. Ask your doctor if there are times when you should avoid having sex and what you should do to protect yourself and your partner when you do have sex. For example, if you had surgery to the pelvic area, you may have to wait for your body to completely heal before you try having sex.

Your healthcare team may recommend using condoms for a few days after chemotherapy to prevent exposing your partner to chemotherapy drugs that can get into semen.

During some types of low dose brachytherapy for prostate cancer, your healthcare team may recommend using condoms to prevent exposing your partner to remaining radiation.

Some cancer treatments may cause birth defects to a developing fetus so you should use birth control to avoid pregnancy during treatment. Talk to your healthcare team about which birth control method is best for you and how long you should use it for.

Your doctor may do a physical exam to help find the cause of your sexual problems. Your doctor will also ask you questions about your sexual history, the type of sex you have and how it fits into your life, whether or not you have a partner and personal questions about your daily life and feelings.

Once the type and cause of the sexual problem is known, your healthcare team can suggest ways to manage it. Talking openly and honestly with your sexual partner will be important, both as a first step and as you continue to find ways to feel sexual pleasure together. Information and counselling can help. Some psychologists or social workers specialize in sex therapy. Your healthcare team can also suggest relaxation exercises and techniques to reduce anxiety.

The following may help you manage sexual problems.

A physiotherapist or other healthcare professional may be able to help with painful orgasms. They can teach you pelvic floor exercises that stretch the pelvic floor muscles and return their tone to normal. A physiotherapist may also suggest internal massage of scar tissue and pelvic floor muscles to relieve pain.

Dry orgasm and retrograde orgasm are different, but they both cause an orgasm without semen. Some say that a dry orgasm feels different, but many say it's just as enjoyable as a normal orgasm. You may worry that your partner will notice the difference in their sexual experience. But most of the time, partners cannot feel the release of fluid during sex. Dry orgasm or retrograde orgasm can also cause fertility problems.

Climacturia is common after prostate surgery, but you or your partner might not even notice it, and it can get better with time. If it concerns you, you could try having sex in the shower or using a condom or a constriction band. A constriction band is tightened at the base of an erect penis to put pressure on the urethra to keep urine from leaking out.

ED can be treated with medicines, devices and prosthetics. Even if you can't get a full erection, you can still reach orgasm and have a sex life. Restoring the ability to get an erection often means trying different methods. Some studies say it's important to start trying to have an erection as soon as a few weeks or months after surgery. This lets you know how your erections are improving. It also helps keep the tissues in the penis healthy and gets the blood flowing around the nerves to help them heal. While erections are recovering, many healthcare professionals recommend masturbating, or self-stimulating, 2 to 3 times a week. This does not mean you have to have sex each time. The purpose is to keep the tissue healthy.

The following methods may be used to help with having an erection:

Medicines or creams are available to help get and keep an erection. Medicines or creams usually only work in a small number of people. They work best once you are able to have a partial erection on your own. The erection won't happen just by using the medicine. Your penis will need to be physically stimulated. These types of medicines have no effect on sexual desire or interest.

You will need a prescription from your doctor for most of the medicines available for ED. Each medicine has side effects and should be used as directed. Some medicines treat ED by improving the flow of blood to the penis. Oral drugs include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). Alprostadil is a cream that is applied to the tip of the penis.

Injections or pellets may be used to help get and keep an erection if medicines or creams don't work. Injections of alprostadil (Caverject) may be given into the shaft of the penis. Alprostadil is also available in pellets that are put into the urethra with a special device. This is called medicated urethral system for erection (MUSE).

Vacuum pumps are another option. Vacuum pumps are also called vacuum constriction devices (VCDs). These devices can increase blood flow by drawing blood into the penis. A hollow tube is placed around the penis and the vacuum is applied. Once you get an erection, you put an elastic band or ring around the base of the penis to keep the blood in the penis and maintain the erection.

Implants may work if other treatment options don't. A penile implant is a device that is surgically placed in the penis to help it become erect. The most commonly used type is an inflatable implant. It is made up of 2 hollow cylinders, a pump and a small bag of saline. The surgeon places the hollow cylinders in the shaft of the penis. The pump is placed in the scrotum and the small bag of saline is put in the lower abdomen. Squeezing the pump moves the saline from the bag to the cylinders in the penis and makes the penis hard. You can release the fluid from the cylinders after sex and the penis will become soft again. Another type of implant is a semi-rigid implant. The surgeon places 2 flexible rods into the shaft of the penis. The penis is erect all the time but the implant has joints that allow you to position the penis. You can move it up for sexual intercourse and down to pee.

Dildos or vibrators may also be used. A strap-on dildo can be attached to the body with a strap around the waist. It allows you to go through the hip movements of having sex.

Sex may not have been a priority for you or your partner during treatment. When you feel you are ready to start to try having sex, think about what sparked romance for you before treatment and try the same thing. Try music, a romantic meal or a night out. Relax and take your time. Talk about how you feel and simply enjoy being together.

Other effects of cancer such as body changes, pain, fatigue, depression or trouble sleeping can lower your sex drive. Some people worry that they are no longer attractive to others. Try to focus on things that you think are most attractive about yourself. Have sex partially clothed instead of naked if it makes you feel more comfortable. Being physically active, maintaining a healthy weight and eating well can help you feel better about yourself and it can also help with fatigue and other side effects.

Talk to your partner about how you feel, what feels good and what doesn't, and if you are tired or uncomfortable. Even if you can't have sex you can still enjoy holding hands, kissing, cuddling and other ways of being close with your partner.

Surgery for cancer may make a certain position painful. Try different positions to find out what works for you and your partner.

Talk to your healthcare team about coping with changes in your body image and sexual health. They may be able to suggest ways to help you manage side effects that also affect your sex drive such as fatigue, hair loss, pain, difficulty sleeping or depression. You may find it helpful to talk to others in a support group or online discussion board.

Our booklet Sex, Intimacy and Cancer has more information to help you and sexual partners understand and cope with the ways that cancer and its treatments can affect sex and sexuality.