When a patient is diagnosed with prostate cancer, how treatment may affect their sex life may not be the first concern that comes to mind. But while treating prostate cancer can save a patient’s life, it may also change an intimate part of it. Erectile dysfunction is one of the most common sexual side effects associated with prostate cancer treatment, but it isn’t the only one.
Patients may experience a lower sex drive, changes in orgasm and ejaculation, and other changes to their sexual function. Those effects can also extend beyond the physical, affecting how patients view themselves and connect with their partners.
Yet sexual health isn’t always openly discussed as part of prostate cancer care. “Providers don’t often plainly discuss changes in sexual functioning if the conversation is not initiated by their patients,” De-Andrea Blaylock-Solar, LCSW, CST, a sexuality and relationship therapist, told BlackDoctor Pro.
For clinicians, supporting patients means making sexual health part of the conversation before treatment starts — and continuing that conversation throughout survivorship.
Nearly all prostate cancer treatments can affect a patient’s sex life, but the type and timing of those changes can vary based on the treatment they receive. With radical prostatectomy, erectile dysfunction may occur immediately following surgery and gradually improve over time, according to Parth K. Shah, M.D., a board-certified urologist at Texas Oncology. Patients can also permanently lose the ability to ejaculate semen, although they may still be able to experience an orgasm.
Nerve-sparing surgery may improve the chances of recovering erectile function for eligible patients, which is one reason early detection can be important. Radiation can affect sexual function differently. “Erection problems usually come on gradually over the first one to three years,” Dr. Shah said, adding that patients may be able to preserve ejaculation. Androgen deprivation therapy (ADT), meanwhile, can significantly decrease libido and contribute to erectile dysfunction. Patients may also experience changes to the penis and testicles, hot flashes, and fatigue.
A patient’s sexual function before treatment matters, too. Providers should discuss the patient’s baseline sexual function and use that information to help establish realistic expectations about what their sex life may look like after treatment. Those conversations shouldn’t begin once a patient experiences a problem. “The conversation should start before treatment begins — ideally at diagnosis — and continue during and after treatment,” Dr. Shah said.
Providers should explain the sexual side effects associated with each treatment option, how long those changes could last, and what resources are available to manage them. Having that information before treatment can also allow patients to weigh sexual function alongside other priorities when making decisions about their care.
The impact of sexual dysfunction doesn’t necessarily end with the physical symptoms.
“Our sexual abilities can impact our perceptions of our own masculinity or femininity,” Blaylock-Solar said. “If that is hindered or altered by prostate cancer treatment, it can impact how we perceive ourselves as whole.”
Changes in sexual function may affect sexual self-esteem, relationships, and the patient’s ability to experience intimacy in the ways they did before treatment. Blaylock-Solar says people often develop “sexual scripts,” or ideas about how sex is supposed to happen. When a person’s body can no longer follow that familiar script, adjusting can be difficult. For example, a patient who can no longer have intercourse in the same way or who needs assistance achieving an erection may have to reconsider what sex and pleasure look like for them and their partner. That makes it important for providers to avoid treating erectile dysfunction as only a physical complication.
When appropriate and with the patient’s permission, partners can be included in conversations about sexual health. Providers can also refer patients and couples to counseling or sexual health professionals who can help them navigate changes in intimacy and communication. Patients without partners shouldn’t be overlooked. Dr. Shah noted that counseling and support groups can also provide an outlet for patients navigating their sexual health individually.
Embarrassment or discomfort may keep some patients from telling their providers that they’re struggling. That’s why both Dr. Shah and Blaylock-Solar agreed that the responsibility for starting the conversation shouldn’t fall entirely on the patient. “The most important step is for the provider — not the patient — to bring up the topic first and treat it as a normal part of care,” Dr. Shah said.
That includes discussing potential sexual side effects even when a provider assumes preserving sexual function isn’t a priority for a particular patient. Providers should also avoid assumptions about a patient’s relationship status, partners, or sexual orientation. For patients who aren’t comfortable verbalizing their concerns, Dr. Shah said brief self-reported questionnaires can provide another way to communicate changes in sexual function. Providers can then use those responses to begin a conversation during the appointment.
And the subject shouldn’t disappear after one visit. Revisiting sexual health throughout treatment and follow-up care gives patients multiple opportunities to discuss concerns that may develop months or even years later.
Patients experiencing sexual side effects should know that support is available. For erectile dysfunction, medications such as sildenafil (Viagra) or tadalafil (Cialis) are often tried first. If oral medications aren’t effective, other options can include vacuum erection devices, penile injections, or urethral medications. Penile implants may be considered for patients whose erectile dysfunction doesn’t respond to other treatments.
Depending on the patient’s symptoms, pelvic floor physical therapy, counseling, and treatment for low libido or changes in orgasm may also be appropriate. Providers don’t have to address every aspect of sexual recovery themselves. Blaylock-Solar recommends having referrals readily available for sex educators, counselors, sex therapists, and pelvic floor therapists rather than waiting until a patient reports that their sex life is suffering. Patients can also be connected with urologists, sexual health specialists, and educational resources from organizations such as the American Cancer Society and National Cancer Institute.
The goal isn’t necessarily to return every patient to exactly the same sex life they had before cancer. It is to give them the information, treatment, and support needed to determine what intimacy and sexual wellness can look like after treatment. But regardless of the treatment plan, sexual health shouldn’t be an afterthought. By discussing potential changes early, routinely checking in, and connecting patients with appropriate treatment and support, providers can make sexual health part of prostate cancer care rather than leaving patients to navigate those changes on their own.
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