Redefining Intimacy: Sex After Prostate Cancer

Life does not stop after prostate cancer, and neither should your sex life. While treating the disease may be an arduous process, you can rest assured that numerous treatments exist for erectile dysfunction, including support after prostate or testicle removal. Although you may still experience some noticeable differences in your sex life as compared to before, there are still ways to help mitigate the impact of these changes on your life. When it comes to improving the quality of your sex life, the three main considerations your recovery may focus on include: erectile dysfunction, ejaculation and orgasm.

The prostate and the surrounding seminal vesicles are key to producing most of the liquid needed for ejaculation. However, for sex after prostatectomy, you will no longer be able to ejaculate. While there may be a chance of painful or altered sensations, the possibility of enjoying the pleasure of orgasm remains, simply dry instead.

Conversely, if both your testicles have to be removed as part of surgical androgen deprivation therapy (ADT), you will likely still be able to ejaculate. Unfortunately, the procedure would cause infertility, as the testicles remain the only source of sperm production. Another thing to note about ADT, whether surgery or drug-based, is that it forces your testosterone levels down to an all-time low, likely leading to difficulties with your libido and maintaining erections.

Currently, there are a few ways available to deal with erectile dysfunction after prostate cancer. Oral medications are the first recommended and easiest solution, followed by self-delivered injections to the penis and finally, surgical implants as a last resort.

The first line of treatment for erectile dysfunction are the phosphodiesterase type-5 (PDE-5) inhibitors, a type of oral medication taken as needed to induce erections. They block the release of blood from your penis, thereby keeping it erect for longer.

Currently, there are four options available that have been approved by the US Food and Drug Administration (FDA). However, none are more clearly superior than the other, and your decision will lie in your personal preferences or insurance coverage. The various options are compared here:

Overall, while these medications have been found to be quite safe, common side effects still exist, including headaches, flushing, indigestion and stuffy nose or congestion.

The next recommended alternative are injections self-delivered directly to the penis. Currently, only alprostadil has been approved by the US FDA. While the idea may be off-putting, if oral medications are not working for you, this would be your next best option.

Back in 1983, one of the pioneers of this treatment infamously took to a major conference, using himself to demonstrate its efficacy in real-time, hoping to overcome the hesitation surrounding this option.

The most common side effect is penile pain, occurring for 1 in 10 patients. Notably, this method may be inconvenient to some, due to the need for careful administration and safe storage.

Another way to manage the side effects of prostate cancer treatment would be testosterone replacement therapy (TRT). Many forms exist currently, including gels, patches, pills or injections. The treatment was found to improve quality of life and erectile function greatly, helping even those who did not initially respond to PDE-5 inhibitors.

One concern may be that testosterone therapy could trigger the return of prostate cancer. However, according to the American Urological Association, there still remains a lack of evidence for this worry. For example, in 2018, a study of 147,593 male US Veterans, it was found that in men with normal PSA and low testosterone levels, testosterone replacement therapy was not associated with a higher risk of prostate cancer.

A 2021 review by researchers from the University of Utah and Baylor College of Medicine also reiterates that significant evidence now suggests that testosterone replacement therapy does not increase the risk of prostate cancer. In any case, to minimize any risk, experts recommend that only the lowest dose necessary to achieve improvement should be used, together with regular screening.

If the previous methods prove to be ineffective, a final option still remains: a surgical penis implant to improve erectile function.

Used since the 1970s, an inflatable implant for the penis has been considered a safe and highly effective treatment for erectile dysfunction. There are a few types, which can be customized to fit your body’s measurements:

• Two-piece inflatable implant
• Three-piece inflatable implant
• Hybrid implants
• Semi-rigid rod

In the inflatable implants, a small reservoir of salt water is used to fill and drain from the penis implant, allowing erections to rise as needed, with a simple press of a pump. Afterwards, the water can be drained back to the reservoir with the use of a valve switch. The reservoir can be placed in the pelvic region, slightly above the penis, or in the scrotum.

Out of all the options, a three-piece implant reports the highest satisfaction levels. However, it takes up more space and may be more prone to breakdown compared to the two-piece version. Alternatively, a hybrid implant would not require a reservoir, and will instead rely on two pre-filled cylinders and a pump in the scrotum. This eliminates the additional risk of implanting a reservoir as well during the surgery, minimizing the risk you face.

However, a much simpler alternative would be the semi-rigid rod, which is easily adjusted to create an erection, carries no risk of breakdown, but may cause discomfort. An example of the semi-rigid rod is the Genesis® Malleable Penile Prosthesis, a flexible silicone device which would be implanted into the penis. Its advantage is that it can be easily adjusted for those with finger or hand dexterity issues, or a limited range of mobility.

While many medical interventions exist to improve erectile function after prostate cancer treatment, whether you choose to pursue this route depends on you and your partner’s preferences. When making your decision, it is good to remember that there are other solutions available to meet your needs. Even if you have difficulties with erections, enjoying the pleasure of orgasm is still possible beyond penetrative sex through alternatives such as oral sex or sex toys.