Male Sexual Functioning After Cancer

Survivors sometimes experience sexual dysfunction after cancer treatment. Knowing what some of the causes are and being able to describe your symptoms to your health care team can help you manage sexual dysfunction.

Male Sexual Functioning After Cancer: Detailed Information

This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Additional Resources sections for questions to ask and for more resources.

Cancer and treatment can affect survivors in different ways. One area of life that might change is the ability to have or enjoy sex. Such changes in men following cancer or treatment are sometimes referred to as male sexual dysfunction. Whether the cause is physical or emotional, there are often ways to treat and manage concerns about sexual functioning after cancer.

If you have sexual functioning concerns, discuss treatment options with your health care team.

Some men feel uncomfortable discussing sexual concerns with a doctor or other members of the health care team. However, your health care team can answer questions, refer you to a specialist if needed, and help you find solutions.

What are some indicators that may cause concern?

The following may be indicators or signs that it is time to talk with your health care provider about concerns related to sex after cancer treatment:

• Inability to get or keep a firm erection (erectile dysfunction or ED)
• Loss of desire for sex
• Difficulty reaching climax
• Having a dry orgasm or a climax without any semen
• Having urine leak out at climax instead of semen
• Orgasms (climaxes) that don't feel as good as they did before cancer
• Pain in the penis or testicles during sex

These types of symptoms are not generally considered to be medical emergencies. For this reason, you may wonder if you should bring them up to a member of your health care team. Keep in mind that all of your physical and emotional concerns are important. This is especially true if you are experiencing pain during sex or feeling that your intimate relationship has become less enjoyable.

Prepare in advance to talk with your health care provider. Write down any questions and concerns about your sexual health before your medical appointments. There may be a need to request extra time for your appointment to allow enough time for a discussion. Share this information with your health care provider and ask for answers to your questions. If he or she cannot help you, ask for a referral to another health care professional who specializes in this area.

When are problems with sexual functioning likely to appear?

Not all survivors will experience sexual problems. If a problem is going to happen, it is likely to start during or after cancer treatment. Problems caused by radiation to the pelvis may develop months or even years after cancer treatment is done. Be certain to discuss any concerns with your health care provider if you begin to notice any changes in your ability to have or enjoy sex. Because all men are more likely to have sexual dysfunction as they age, you may notice a new problem years after cancer treatment. Your cancer treatment may or may not be a cause of such sexual dysfunction.

In some cases, a survivor may decide to wait for a while after treatment before having sex. Another man may be ready to begin having sex again right away. There is growing evidence that staying sexually active, especially having erections regularly after cancer treatment, may help men avoid worse problems as time passes. In any case, there may ways to prepare emotionally for trying sex again as well as options to make the sexual experience more comfortable.

What causes sexual functioning concerns after cancer?

There are many different causes for sexual functioning concerns in male cancer survivors. Some are physical causes. Others may be due to changes in how you feel about yourself, your body, or other aspects of your life.

Certain types of cancer, such as those that affect organs in the pelvis, may put survivors at risk for problems. These include prostate cancer and cancers of the bladder, colon, or rectum. Men treated for prostate cancer have higher rates of dysfunction--up to 75 to 85 percent.

Different types of sexual functioning concerns in male survivors can result from:

• A drop in testosterone levels (the hormone made in the testicles) during hormone therapy for prostate cancer, or after pelvic radiation or high-dose chemotherapy
• Damage to areas of the brain by cancer or treatment
• Radiation to the pelvic area affecting the prostate, bladder, rectum, testicles, or penis
• Surgery removing pelvic organs such as the prostate, seminal vesicles, areas of the colon or the penis
• High doses of chemotherapy may damage sexual desire or the ability to have erections
• Side effects of medicines to treat pain, nausea, depression or anxiety

Sexual functioning challenges can become more common in men as they get older. For example, about half of men without a cancer history will experience erection problems by age 70. This means that older male survivors may experience sexual functioning problems later in life that are not related to cancer or the treatment they received.

Other factors can also affect sexual functioning. For example, men are more likely to develop erectile dysfunction if they are overweight, smoke, or drink heavily. In addition, other health problems like heart disease, high blood pressure, kidney disease, or diabetes may also affect a man's erections.

The emotional effects of cancer may contribute to survivors feeling anxious, depressed, or self-conscious. This can also create stress for a partner. In some cases, the result may be challenges with sexual functioning. Working with a licensed mental health professional to deal with these types of emotions is often very helpful.

The following table lists some of the possible causes of sexual dysfunction and issues that can be discussed with your health care team:

Possible Physical Problems	Type of Cancer Treatment That May Affect Sexual Functioning	Possible Symptoms
Low testosterone levels	Removal of testicles Hormone therapy for prostate cancer Intensive chemotherapy Radiation near testicles	Loss of desire for sex Trouble feeling excited during sex Erectile dysfunction Trouble reaching an orgasm
Damage to nerves near prostate	Radical prostatectomy Radical cystectomy Abdomino-perineal resection Damage to blood supply of nerves after pelvic radiotherapy Toxic side effect of chemotherapy	Trouble getting and keeping erections
Damage to blood flow to the penis	Damage to blood vessels during pelvic surgery Scarring of blood vessels from pelvic radiation therapy	Trouble getting and keeping erections
Damage to nerves controlling outflow of semen during orgasm	Removal of lymph nodes in men with testicular cancer Surgery on some parts of the colon	Having a "dry orgasm" with a feeling of pleasure but no semen coming out of the penis Orgasms may not feel the same as they did before cancer
Removal of prostate and seminal vesicles	Radical prostatectomy Radical cystectomy	Having a "dry orgasm" with a feeling of pleasure but no semen coming out of the penis Some men leak urine at the moment of orgasm Orgasms may not feel the same as they did before cancer
Radiation near the prostate and seminal vesicles	Radiation therapy for prostate, bladder, or rectal cancer	Having an almost "dry orgasm" with a feeling of pleasure but little or no semen coming out of the penis Orgasms may not feel the same as they did before cancer
Removal of part or all of the penis	Partial or total penectomy to treat cancer of the penis	Erection possible after partial penectomy Orgasms and ejaculation continue to be possible, but after total penectomy, semen comes out of new opening on the area behind the testicles

Are there successful treatments for men with sexual concerns?

There are a number of treatment options that can help men with sexual problems. It is important to discuss problems and concerns with your doctorhealth care provider as early as possible. There is growing evidence that if a man goes for more than a few weeks without being able to get erections, the tissue in the penis may be damaged. Men can work with their health care provider after pelvic surgery or radiation therapy to try medical treatments that promote erections in order to optimize the chance of maintaining or recovering good sexual function. However, counseling, medical treatments, and surgery are all options to treat cancer-related sexual problems in men.

Your health care team can help you learn more about how to treat concerns and improve your ability to enjoy sex again. There are many ways to enhance and share pleasure and closeness with your partner. Even survivors who no longer have sex are able to find ways to continue to enjoy affection and closeness with their partners.

Sometimes you have a choice of some options to treat your cancer that have lower rates of sexual side effects. Of course, the most important factor in choosing a cancer treatment is its ability to control cancer. However, your sexual health is also important. If you are worried about sexual dysfunction after cancer treatment, talk with your health care team soon as you can about the different therapies that may be available to help you.

The following is a list of sexual functioning concerns and how to find help:

Sexual Functioning Concerns	How to Find Help
Loss of desire for sex after cancer	Have a member of your health care team check your medications for possible side effects. See a urologist or an endocrinologist to find out if your testosterone may be low. However, if you had prostate cancer, taking testosterone is controversial. Some oncologists worry that it may cause a recurrence but recent studies find that some prostate cancer survivors may be able to use it safely. Discuss your options with your health care team. If there are no physical causes, see a licensed counselor to find out if problems could be related to feelings of depression, anxiety, a change in self-esteem, or tension with your partner.
Erection problems (erectile dysfunction or ED)	See a urologist or other provider who has had special training in treating men’s sexual problems. Ask your healthcare provider for a referral to an expert in your community. If you think your problem is caused by anxiety or stress and not physical damage from cancer treatment, you may want to talk with a licensed counselor. In addition, sexual counseling can help a man or couple adjust to a medical treatment for erections and improve sexual communication. A combination of medical treatment and counseling often gets the best results.
Concerns about orgasm	Ask your health care team if this might be a side effect of one of your medicines. Discuss fertility concerns and treatment options with your healthcare provider. Try not to put pressure on yourself to have an orgasm. This may make it hard for you to relax. Give yourself time and focus on having fun with touch. After pelvic cancer surgery or radiation, men may leak urine at orgasm. A urologist can often prescribe medications or suggest options to avoid this problem.
Pain in the penis or testicles during sex	Consult a urologist if experiencing pain in the penis during erection. This may be a sign of inflammation or scarring, especially if the penis curves when it is erect. A sharp pain in the penis or testicles during climax can result from scar tissue after surgery or radiation therapy, chronic tension in muscles on the floor of the pelvis, or occasionally, an infection in the prostate. Consult a urologist.

The following is a list of treatment options that may be available for erectile dysfunction along with some of the pros and cons for using them. Talk with your health care team about the best options for you.

Possible treatment for erectile dysfunction	Pros	Cons
Pills (PDE-5 Inhibitors)	Easy to use Natural Only minor side-effects Safe for most men unless they have severe heart disease or use nitrates	Expensive Do not work well for men who have severe ED, which includes many men after pelvic cancer surgery or radiation
Vacuum devices	One-time purchase Covered by insurance Few side effects	Using the pump interrupts intercourse May not be comfortable Requires practice to use correctly Erection may not be firm enough or may bend at the base
Penile injections	Very effective for most men Can be used before starting sex	Expensive Must learn self-injection May cause pain for some men, especially in the first year after pelvic surgery
Penile suppositories	A small pill put inside the urinary opening that melts Same medicine as injections	Expensive Does not work for most men Can cause pain in the penis just like injection medicine
Penile prostheses	Very effective for most men Becomes part of man's body Inflatable types are not visible Erection looks and feels natural Covered by insurance	Involves surgery and pain during recovery If a part breaks, need to repair surgically Erections are slightly shorter than before Destroys natural erection reflex Not a reversible treatment
Herbs and vitamins	Inexpensive Easy to get	No herbal remedy has been shown to improve erections May interfere with other medicines May have unknown effects. Many pills advertised on the internet are not the real thing or contain harmful chemicals.

This document was produced in collaboration with:
Leslie R. Schover, Ph.D.
Professor of Behavioral Science, UT M. D. Anderson Cancer Center

Works Cited

American Cancer Society. Sexuality and Cancer: “For the Man with Cancer and His Partner.” Atlanta: American Cancer Society, 2001 (99-rev. 07/01-50M-no. 4658-HCP). Downloadable version: http://www.cancer.org/Treatment/TreatmentsandSideEffects/PhysicalSideEffects/SexualSideEffectsinMen/SexualityfortheMan/index

Mulhall, John P. “Saving Your Sex Life: A Guide for Men with Prostate Cancer.” Bethesda, MD: Ci-I-ACT Inc., 2010.

Schover, Leslie R., Rachel T. Fouladi, Carla L. Warneke, Leah Neese, Eric A. Klein, Craig Zippe, and Patrick A. Kupelian. “Defining sexual outcomes after treatment for localized prostate cancer.” Cancer 95 (1992): 1773-85.

Schover, Leslie, &. Thomas, Anthony J. Overcoming Male Infertility: A Guide for Men and Their Partners. New York: John Wiley & Sons, 2000.

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Male Sexual Functioning After Cancer: Additional Resources

The previous sections of this document provide detailed information and questions to ask related to this topic. This section offers a listing of additional resources that are known to provide support and quality services that may be helpful to survivors during the cancer journey.

LIVESTRONG Cancer Navigation Center
www.LIVESTRONG.org/GetHelp

Email:	Cancer.Navigation@LIVESTRONG.org
Phone:	1.855.220.7777 (English and Spanish)
	Navigators are available for calls Monday through Friday, 9 a.m. to 5 p.m. (Central Time). Voicemail is available after hours.

The Navigation Center provides free, confidential one-on-one support to anyone affected by cancer. This is not a medical facility, but rather a center that provides the following support services:

• Emotional Support—assistance coping with a cancer diagnosis, help accessing support groups, as well as peer-to-peer connections
• Fertility Risks and Preservation Options—information on fertility risks and help accessing discounted rates for fertility preservation options
• Insurance, Employment and Financial Concerns—information on employment rights and benefits, financial assistance and debt management, including insurance and billing issues as well as medication co-pay assistance

In addition to professional cancer navigators on staff, LIVESTRONG partners with specialty organizations such as Patient Advocate Foundation, Imerman Angels, Navigate Cancer Foundation and EmergingMed to provide support services.

American Cancer Society (ACS)
www.cancer.org

Email:	Submit questions in English or Spanish from the “Contact Us” page.
Phone:	1-800-227-2345
	TTY for deaf or hard of hearing callers: 1-866-228-4327

The American Cancer Society (ACS) offers information about many of the challenges of cancer and survivorship. You can search for information by cancer type or by topic. ACS provides a list of support groups in your area. ACS can connect you to support and services in your area. You can join online groups and message boards. Some information on the website is available in Spanish, Chinese, Korean and Vietnamese. ACS specialists can answer questions 24 hours a day by phone or email.

National Cancer Institute (NCI) — National Institutes of Health
www.cancer.gov

Online:	The LiveHelp online chat service is available Monday through Friday from 8:00 a.m. to 11:00 p.m. Eastern Time.
Email:	Send an email through the website.
Phone:	1-800-422-6237
	Information specialists answer calls Monday–Friday, 8:00 a.m. to 8:00 p.m. Eastern Time.

The National Cancer Institute's website provides accurate information about the challenges cancer can bring. You can search for information by cancer type or topic. You can find information about treatment and financial and insurance matters. You can also learn how treatments in development work and search for a clinical trial in your area. This site also has a good dictionary of cancer terms, drug information and other publications. Cancer information specialists can answer your questions about cancer and help you with quitting smoking. They can also help you with using the website and can tell you about NCI’s printed and electronic materials. The knowledgeable and caring specialists have access to comprehensive, accurate information on a range of cancer topics, including the most recent advances in cancer treatment. The service is confidential, and information specialists spend as much time as needed for thorough and personalized responses.

Web MD's Erectile Dysfunction Health Center:
www.cancer.gov

This website provides up-to-date summaries of the causes of erectile dysfunction and current treatments.

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