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Erectile Dysfunction After Prostate Cancer Treatment
Erectile dysfunction means trouble getting or keeping an erection. After prostate cancer treatment it is common, expected, and treatable. Raising it in clinic is a standard part of prostate cancer follow-up — your urologist has this conversation constantly.
Why Each Treatment Causes It
Surgery. The nerves that control erections sit right next to the rectum and wrap around the back and sides of the prostate gland. The American Cancer Society states that "most men who have these types of surgeries might have some trouble with erections." Where the surgeon is able to spare those nerves, outcomes are better: "more men recover erections after nerve-sparing surgery than men who have surgery in which nerve sparing isn't possible." Nerve healing is slow. ACS says "this healing can take up to 2 years." If you are three months out and nothing is working yet, that is within the expected range.
Radiation. Trouble with erections comes on more slowly with radiation than with surgery. ACS reports problems typically appearing between 6 months and 2 years after radiation ends. It also notes the problems "are not always permanent. They might get better after 2-3 years." NCI adds that pelvic radiation — both external-beam and brachytherapy — can damage blood vessels or nerves, making it difficult to get or keep an erection.
Hormone therapy (ADT). NCI lists both "loss of interest in sex (lowered libido)" and "erectile dysfunction" as side effects of androgen deprivation therapy. One point from NCI's hormone therapy fact sheet is worth knowing before you spend money on pills: "Erectile dysfunction drugs such as sildenafil (Viagra) do not usually work for men undergoing hormone therapy because these drugs do not address the loss of libido (sexual desire) that is associated with a lack of androgens." On recovery, NCI says most sexual and emotional side effects "will eventually go away if a man stops taking hormone therapy," but for older men and those on ADT a long time, "testosterone levels may not fully recover and these side effects may not disappear completely."
Other factors. ACS notes that men under 60 tend to recover better, and that erection quality before treatment matters, as do diabetes, high blood pressure, heart disease, obesity, and smoking.
What Can Be Done
The NIH's National Institute of Diabetes and Digestive and Kidney Diseases lists the standard options, generally tried in this order:
Oral medicines. PDE5 inhibitors "improve blood flow to the penis" and "may help you get and keep an erection." Note the caveat above about hormone therapy.
Injections and urethral suppositories. These produce "a quick, automatic erection by increasing blood flow to the penis." The injection goes into the penis; the suppository is inserted into the urethra. Your health care professional "will teach you how to give yourself an injection or insert a suppository" — you learn this in clinic.
Vacuum erection devices. Three parts: a plastic tube around the penis, a pump that creates a vacuum, and an elastic ring to hold the erection. Side effects can include coldness, numbness, purple discoloration, or bruising — usually painless, and they disappear in a few days.
Testosterone therapy. NIDDK describes this for men who have ED plus low testosterone, given as an oral medicine, patch, or gel, usually with a PDE5 inhibitor. That page addresses ED generally, not men treated for prostate cancer — and hormone therapy for prostate cancer deliberately lowers testosterone. Ask your oncologist before assuming it applies to you.
Surgery. NIDDK covers implanting a prosthesis and repairing arteries, noting artery repair works best in younger men. NCI describes the implant as "a firm rod or inflatable device (penile implant)" that allows a man to have and keep an erection.
Counseling. NIDDK recommends counseling where mental health or emotional issues are involved, to lower anxiety and stress about sex.
Lifestyle. Quitting smoking, limiting alcohol, more physical activity, reaching a healthy weight, and stopping illicit drug use.
Where the Evidence Here Is Thin
These federal and cancer-organization pages do not give success rates for each option after prostate surgery or radiation, do not name individual drugs with doses or timing, and do not set out a "penile rehabilitation" protocol. Anyone quoting a precise percentage should be able to show you the study. Ask your urologist what the numbers look like for your case.
Other Changes You Might Notice
NCI notes that damage to the prostate from radiation can cause dry orgasm — orgasm without semen. Chemotherapy, hormone therapy, and some other medications may lower testosterone and sexual desire. Pain, fatigue, hair loss, depression, and sleep problems reduce interest in sex too, and treating those can matter as much as treating the erection.
Questions Worth Asking
NCI suggests: What sexual problems are common among men receiving this treatment? When might these changes occur, how long might they last, and will any be permanent? How can they be prevented, treated, or managed? What specialists would you suggest I talk with?
Sources
- National Cancer Institute: Sexual Health Issues in Men and Cancer Treatment. https://www.cancer.gov/about-cancer/treatment/side-effects/sexuality-men
- National Cancer Institute: Hormone Therapy for Prostate Cancer Fact Sheet. https://www.cancer.gov/types/prostate/prostate-hormone-therapy-fact-sheet
- National Institute of Diabetes and Digestive and Kidney Diseases (NIH): Treatment of Erectile Dysfunction. https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment
- American Cancer Society: How Cancer Can Affect Erections. https://www.cancer.org/cancer/managing-cancer/side-effects/sexual-side-effects/erections-and-treatment.html
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