Cancer, Sex, and Sexuality

Source: American Cancer Society

 

When you first learned you had cancer, you probably thought mostly about survival. But after awhile, other questions may have started coming up. You may be wondering “How ‘normal’ can my life be, even if my cancer is under control?” Or even “How will cancer affect my sex life?”

Sex and sexuality are important parts of everyday life. The difference between sex and sexuality is that sex is thought of as an activity – something you do with a partner. Sexuality is more about the way you feel and is linked to your need for caring, closeness, and touch.

Feelings about sexuality affect our zest for living, our self-image, and our relationships with others. Yet patients and doctors often do not talk about the effects of cancer treatment on their sex lives or how a person may feel as a sexual being. Why? A person may feel uneasy talking about sex with a professional like a doctor or even with a close sex partner. Many people feel awkward and exposed when talking about sex.

Here, we offer you and your partner some information about cancer, sex, and sexuality. This information applies to all men with cancer – regardless of sexual orientation. We cannot answer every question, but we will try to give you enough information to help you and your partner have open, honest talks about your sex life. We will also share some ideas about talking with your doctor and your cancer care team.

Keep in mind that sexual touching between you and your partner is always possible, no matter what kinds of cancer treatment you have had. This may surprise you, especially if you are feeling down or have not had sex for a while. But it is true. The ability to feel pleasure from touching almost always remains.

The first step is to bring up the topic of your sex life with your doctor or another member of your health care team. You have a right to know how your treatment will affect nutrition, pain, and your ability to return to work. You also have the right to know the facts about your sex life.

What is a normal sex life?

People vary a great deal in their sexual attitudes and practices. This makes it hard to define “normal.” Some couples like to have sex every day. For others, once a month is enough. Many people see oral sex (using the mouth or tongue) as a normal part of sex, but some believe it is not OK. “Normal” for you and your partner is whatever gives you pleasure together. Both partners should agree on what makes their sex life good.

It is normal for some people with cancer to lose interest in sex at times. Doubts and fears, along with cancer and cancer treatment, can make you feel less than your best. At times, concern about your health may be much greater than your interest in sex. But once you get back to your normal routines, your interest in sex may begin to return.

It is also normal to be interested in sex all of your life. There are some who think sex is only for the young, and that older people lose both their desire for sex and their ability to “perform.” These beliefs are largely myths. Many men and women can and do stay sexually active until the end of life. No one should ever have to apologize for still having an interest in sex at any age.

Still, it is true that sexual response and function may change with aging. For example, women may notice changes as they get older, sometimes even before menopause begins. A decrease in sexual desire and problems with vaginal dryness may increase during and after menopause. Men also have changes that come with age. More than half of men over age 40 have at least a little trouble with erections. The problem often worsens as men get older. For instance, among men who are 40 to 49, about 3 in 10 have some problem with erections (erectile dysfunction or ED). In groups of men aged 70 and older, nearly 9 in 10 are having some problem with erections.

Sometimes, sexual problems center around anxiety, tension, or other problems in a relationship. Other times, they may be the result of a physical condition, a medical condition, or medicines that cause or worsen sexual problems.

Besides age, there are some other risk factors for erectile dysfunction, including:

  • Smoking
  • Diabetes
  • Heart and blood vessel disease
  • Certain blood pressure medicines and anti-depressant medicines

But most symptoms can be treated. There are medicines, therapy, surgery, and other treatments to help people deal with most kinds problems they may have. If you want to keep your sex life active, you can very likely do so. Still, sex may not be quite the same for older men as it was when they were younger. But keep in mind that the best measure of your worth as a sexual partner is the pleasure you and your partner find together.

If you are in a relationship and one of you has a sexual problem, it affects both of you. If you are dealing with sexual problems, it works best when your partner can be part of the solution.

What is a healthy sexual response?

The sexual response of men and women has 4 phases:

  • Desire
  • Excitement
  • Orgasm
  • Resolution

A person goes through the phases usually in the same order. But the sexual response can be stopped at any phase. For instance, you don’t have to reach orgasm each time you feel a desire for sex.

Desire is an interest in sex. You may just think about sex, feel attracted to someone, or be frustrated because of a lack of sex. Sexual desire is a normal part of life from the teenage years on.

Excitement is the phase when you feel aroused or “turned on.” Touching and stroking feel much more intense when a person is excited. Excitement also results from sexual fantasies and sensual sights, sounds, scents, and tastes. Physically, excitement means that:

  • The heart beats faster.
  • Blood pressure goes up.
  • Breathing gets heavy.
  • Blood is sent to the genital (or “private”) area. The surge of blood creates an erection, or a stiff penis. (In a woman, the surge of blood makes the genital area and the clitoris swell. The vagina becomes moist and gets longer and wider, opening up like a balloon.)
  • The skin of the genitals (“private parts”) turns a deeper color of red or purple.
  • The body may sweat or get warmer.

Orgasm is the sexual climax. In both men and women, the nervous system creates intense pleasure in the genitals. The muscles around the genitals contract in rhythm, sending waves of feeling through the body. In men, these muscle contractions cause ejaculation (or release) of semen.

Resolution occurs within a few minutes after an orgasm. The body returns to its unexcited state. Heartbeat and breathing slow down. The extra blood drains out of the genital area. Mental excitement subsides.

If a person becomes excited but does not reach orgasm, resolution still takes place, but more slowly. It is not harmful to become excited without reaching orgasm, though it may feel frustrating. Some men and women may feel a mild ache until the extra blood leaves the genital area.

Refractory period: Men have a certain amount of time after orgasm in which they are physically unable to have another orgasm. This time, called the refractory period, tends to get longer as a man ages. A man in his 70s may need to wait several days between orgasms. Women do not have a refractory period. Many can have multiple orgasms, one after another, with little time in between.

The normal cycles of the mature male body

During the teenage years and afterward, the testes (testicles) produce a steady supply of hormones – mostly testosterone. The testes also make millions of sperm each day. It takes about 74 days for the sperm to grow and mature. As part of this process, the newly made sperm must travel through a 20-foot-long tube called the epididymus to ripen. This tube forms a coiled structure that sits on top of and behind each testicle.

After the sperm mature, another tube called the vas deferens takes them from the epididymus into the body toward the prostate gland. There the sperm is mixed with special fluids from the prostate and the seminal vesicles, which sit on either side of the prostate. These whitish, protein-rich fluids help to support and nourish the sperm so that they can live for some time after ejaculation. During orgasm this mixture of fluid and sperm, called semen, is moved through the urethra and out of the tip of the penis. The drawing below shows the male sex organs.

The role of testosterone

Testosterone is the main male hormone. It causes the reproductive organs to develop, and promotes erections and sexual behavior. Testosterone also causes secondary sexual characteristics at puberty, such as a deeper voice and hair growth on the body and face. The testes make most of this hormone. The adrenal glands, which sit on top of the kidneys, also make small amounts of the hormone in both men and women.

The hypothalamus region of the brain controls the amount of hormone the body makes. When the testosterone level gets low, the hypothalamus signals the pituitary gland at the base of the brain. The pituitary sends a hormone messenger through the bloodstream to tell the testicles to speed up production.

Men’s hormone levels vary widely, but most men have more testosterone in the bloodstream than they need. A man with a low level of testosterone may have trouble getting or keeping erections and may lose his desire for sex. In the healthy younger man, hormone problems are rare and anxiety is the main cause of erection problems. (Common medical causes for erection problems include medicines and problems with the blood vessels or nerves in the pelvic area.)

The normal pattern of arousal and erection

An erection begins when the brain sends a signal down the spinal cord and through the nerves that sweep down into the pelvis. Some of these important nerves run along both sides of the prostate gland.

When this signal is received, the spongy tissue inside the shaft of the penis relaxes and the arteries (blood vessels) that carry blood into the penis expand. As the walls of these blood vessels stretch, blood races into the penis at up to 50 times its usual speed. The blood fills 2 spongy tubes of tissue inside the shaft of the penis. The veins in the penis, which normally drain blood out of the penis, squeeze shut so that more blood stays inside. This causes a great increase in blood pressure inside the penis, which produces a firm erection.

The nerves that allow a man to feel pleasure when the penis is touched run in a different path from the nerves that control blood flow. Even if nerve damage or blocked blood vessels keep a man from getting erections, he can almost always feel pleasure from being touched. He can also still reach orgasm.

A third set of nerves, which run higher up in a man’s body, controls ejaculation of semen.

How male orgasm happens

A man’s orgasm has 2 stages. The first stage is called emission. This is when the prostate, seminal vesicles, and vas deferens (the tubes joining the testicles with the seminal vesicles) contract. During emission, the semen is deposited near the top of the urethra (the tube running through the penis), so that it is ready to be pushed out (ejaculated). At this time, a small valve at the top of the tube shuts to keep the semen from going upward and into the bladder. A man feels emission as “the point of no return,” when he knows he is about to have an orgasm. Emission is controlled by the sympathetic or involuntary nervous system.

Ejaculation is the second stage of orgasm. It is controlled by the same nerves that carry pleasure signals when the genital area is caressed. Those nerves cause the muscles around the base of the penis to squeeze in rhythm, pushing the semen through the urethra and out of the penis. At the same time, messages of pleasure are sent to the man’s brain. This sensation is known as orgasm or climax.

Here are some points to help your sex life during or after cancer treatment.

Learn as much as you can about the effects your cancer treatment may have on sexuality. Talk with your doctor, nurse, or any other member of your health care team. When you know what to expect, you can plan how you might handle those issues.

Keep in mind that, no matter what kind of cancer treatment you have, you will still be able to feel pleasure from touching. Few cancer treatments (other than those affecting some areas of the brain or spinal cord) damage the nerves and muscles involved in feeling pleasure from touch and reaching orgasm. For example, some types of treatment can damage a man’s ability to have erections. But most men who cannot have erections or produce semen can still have the feeling of orgasm with the right kind of touching. This makes it worthwhile for people with cancer to try sexual touching. Pleasure and satisfaction are possible, even if some aspects of sexuality have changed.

Try to keep an open mind about ways to feel sexual pleasure. Some couples have a narrow view of what is normal sex. If both partners cannot reach orgasm through or during penetration, they feel cheated. But for people treated for cancer, there may be times when intercourse is not possible. Those times can be a chance to learn new ways to give and receive sexual pleasure. You and your partner can help each other reach orgasm through touching and stroking. At times, just cuddling can be pleasure enough. You can also continue to enjoy touching yourself. Do not deny yourself and your partner other ways of showing you care just because your usual routine has been changed.

Try to have clear, 2-way talks about sex with your partner and with your doctor, too. The worst enemy of sexual health is silence. If you are too embarrassed to ask your doctor whether you can have sex, you may never find out. Talk to your doctor about sex and tell your partner what you learn. Otherwise, your partner may be afraid that sex might hurt you. Good communication is the key to adjusting your sexual routine when cancer changes your body. If you feel weak or tired and want your partner to take a more active role in touching you, say so. If some part of your body is tender or sore, you can guide your partner’s touches to create the most pleasure and avoid pain.

Boost your confidence. Remind yourself about your good qualities. If you lose your hair, help yourself to look and feel better by shaving your head with an electric razor. Or try out different kinds of hats to find one you feel comfortable wearing. Eating right and exercising can help keep your body strong and your spirits up. Talk to your doctor or cancer care team about the type of exercise you are planning before you start, or ask to be referred to a physical therapist. Find something that helps you relax – movies, hobbies, getting outdoors. Get professional help if you think you are depressed, or if anxiety is causing problems.

How cancer treatment affects sexual desire and response

These are some general changes in sexual desire and response that may be linked to cancer and cancer treatment. Specific changes linked to certain types of treatment are covered in more detail in the next sections.

Lack of desire

Both men and women often lose interest in sex during cancer treatment, at least for a time. At first, concern for survival is so great that sex is far down on the list of needs. This is normal. Few people are interested in sex when they feel their lives are in danger. When people are in treatment, worry, depression, nausea, pain, or fatigue may cause loss of desire. Cancer treatments that disturb the normal hormone balance can also lessen sexual desire.

If there is a conflict in the relationship, one partner or both might lose interest in sex. Many people who have cancer worry that a partner will be turned off by changes in their bodies or by the very word cancer.

Keep in mind that each part of a man’s sexual cycle is somewhat independent from other parts of the cycle. That is why, after some types of cancer treatment, a man may still desire sex and be able to ejaculate but not have an erection. Other men may have the feeling of orgasm along with the muscles contracting in rhythm, even though semen no longer comes out.

Erection

If a man has a problem getting or keeping an erection, the condition is called impotence or erectile dysfunction (ED). ED becomes more common as men get older, and if they have certain medical problems, such as diabetes, vascular (blood vessel) problems, or stroke.

Cancer treatments can interfere with erection by damaging a man’s pelvic nerves, pelvic blood vessels, or hormone balance. Sometimes these side effects cannot be avoided if the cancer is to be controlled. After cancer treatment, medical or surgical treatments can often restore erections.

Any emotion or thought that keeps a man from feeling excited can also get in the way of getting or keeping an erection. A common anxiety is the nagging fear of not being able to get an erection or satisfy a partner.

Premature ejaculation

Premature ejaculation means reaching a climax too quickly. Men who are having erection problems often lose the ability to delay orgasm, so they ejaculate quickly.

Premature ejaculation is a very common problem, even for healthy men. It can be overcome with some practice in slowing down excitement. A few of the newer anti-depressant drugs have the side effect of delaying orgasm. This side effect can be used to help men with premature ejaculation. Some men can also use creams that decrease the sensation in the penis. Talk to your doctor about what kind of help might be right for you.

Pain

Men sometimes feel pain in the genitals during sex. If the prostate gland or urethra is irritated from cancer treatment, ejaculation may be painful. Scar tissue that forms in the abdomen and pelvis after surgery (such as for colon cancer) can cause pain during orgasm, too. Pain in the penis as it becomes erect is less common, but in some men, the penis can develop a painful curve or “knot” with erection. This condition, called Peyronie’s disease, does not seem to be any more common in men with cancer. (Peyronie’s disease is most often due to a scar inside the penis, and may be treated with injections of certain drugs or with surgery.) Tell your doctor right away if you have any pain in your genital area.

Surgery types

Some types of cancer surgery can interfere with erections. These include:

  • Radical prostatectomy – the removal of the prostate and seminal vesicles for prostate cancer
  • Radical cystectomy – the removal of the bladder, prostate, upper urethra, and seminal vesicles for bladder cancer. Removal of the bladder requires a new way of collecting urine, either through an opening into a pouch on the belly (abdomen) or by building a new “bladder” inside the body. (See the “Urostomy, colostomy, and ileostomy” section to learn more about the opening and the pouch.)
  • Abdominoperineal (AP) resection – the removal of the lower colon and rectum for colon cancer. This surgery may require an opening in the belly (abdomen) where solid waste can leave the body.
  • Total pelvic exenteration – the removal of the bladder, prostate, seminal vesicles, and rectum, usually for a large tumor of the colon, requiring openings for both urine and solid waste to leave the body.

These operations can interfere with erections in different ways, mainly by damaging nerves or blood vessels. We will go into more detail about this below, and also talk about other factors that can affect erections after surgery.

How surgery can affect erections

Damage to nerve bundles that allow blood flow to the penis

All of the operations listed above can damage the nerves that control blood flow to the penis. Damaging the nerves is like fraying a telephone wire – the message to start an erection is either weakened or completely lost. The nerves surround the back and sides of the prostate gland between the prostate and the rectum, and fan out like a cobweb around the prostate. During surgery the doctor may not be able to see the nerves, which makes it easy to damage them.

There are different ways to do all of these surgeries. For example, some doctors use surgical methods that try to remove the prostate while sparing the nerves around it. Some surgeons have even tried to locate the nerves more quickly by using a mild electric current to find the spot where stimulating a nerve will cause an erection. This method has also been used to test the nerve bundles to be sure that they still worked after removal of the prostate. But ongoing study suggests that this method is not a reliable measure of potency after surgery.

When the size and location of a tumor are right for nerve-sparing surgery, more men recover erections than with other techniques. When possible, nerve-sparing methods are used in radical prostatectomy, radical cystectomy, or AP resection. Doctors are now also trying to repair or graft nerves when they cannot avoid cutting them during surgery. This is being studied to find out whether it helps preserve erections.

Reduced blood flow to the penis

Some of the problems with erections after these operations may be caused by a loss of blood flow to the penis. The surgeon must seal off some of the small arteries that feed into the 2 main blood vessels involved in erection. Blood flow is then slowed, like a river after the streams that run into it have been dammed. Usually a man has partial erections after such surgery. His penis swells when he feels excited, but the penis may not become firm enough for penetration. Skin sensation and the ability to feel an orgasm should be normal.

Some men do regain full erections after surgery, but it can sometimes take up to 2 years. We do not know all the reasons why some men regain full erections and others do not. We do know that men are more likely to recover erections when nerves on both the left and right sides of the prostate are spared. The healing and growth of new blood vessels may also help restore blood flow to the penis. This healing takes time, which could help explain the delay in the return of erections.

The type of surgery affects the outcome

Some operations cause more sexual problems than others. For instance, it is not known that any man has regained full erections after having total pelvic exenteration (the total removal of all organs in the pelvis). But this surgery is so rare that statistics are not available.

At least 15% of men who have standard surgery to remove the bladder or the prostate have full erections again. But surgeons report better erection recovery rates if they are able to spare the nerve bundles during these surgeries. After AP resection (removal of the lower colon and rectum), the ability to have erections returns more often than it does after surgeries that also remove the prostate.

Other things that affect erections after surgery

Age: For the most part, the younger a man is, the more likely he is to regain full erections after surgery. Men under 60, and especially those under 50, have much higher erection recovery rates than older men. For instance, some cancer centers that do many radical nerve-sparing prostatectomies (taking out only the prostate and trying not to injure the nearby nerves) report impotence rates as low as 25% to 30% for men under 60, and as low as 10% for men under 50. But other doctors have reported higher rates of impotence in similar patients. Impotence happens in about 70% to 80% of men over 70, even if nerves on both sides are not removed or cut.

Erections before surgery: Men who had good erections before cancer surgery are far more likely to have a full sexual recovery than are men who had erection problems.

Early sexual rehabilitation after surgery

Studies have been done in which doctors tested different methods to promote erections starting just weeks after surgery. The results of these studies suggest that these methods can help some men. You may hear this called “penile rehabilitation.” The idea is that ensuring erections within weeks of surgery can help men recover sexual function. Any kind of erection is thought to be helpful, including sleep erections. The thought is that they keep the tissues of the penis healthy and help prevent tissue changes that can make erections almost impossible.

Men who have at least one intact nerve bundle may be helped by phosphodiesterase inhibitors (also called PDE-5 inhibitors) like sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®). Other treatments, such as pellets in the urethra, penile injections, and vacuum devices have been used, too. No single method has been shown to help all men. Talk to your doctor about how your nerves were affected by surgery and whether penile rehabilitation is right for you.

Some cancer treatments can cause men to become infertile (unable to father a child). Total body irradiation (as used in stem cell or bone marrow transplant) and radiation treatment to an area that includes the testes can reduce both the number of sperm and their ability to function. This does not mean that pregnancy can’t happen, but it becomes far less likely.

Some types of chemo can damage the sperm over the short term, while others can cause life-long infertility. It depends on the types and doses of the drugs used. The short-term changes have been shown to last about 3 months after the last treatment. Because the risk of birth defects due to sperm damage is hard to study, there is not much information about this link. To reduce this possible risk, doctors often recommend that a man use careful birth control during chemo and for some months after treatment is complete. So far, no studies have reported increased birth defects or cancers in children naturally conceived from fathers who had cancer treatment in the past.

Several types of surgery to the pelvic and genital area can cause infertility. If both testicles are removed, for example, sperm cells are no longer made and a man becomes infertile (or sterile).

If you want to father a child and are concerned about fertility, talk to your doctor before starting treatment. One option may be to bank (save and preserve) your sperm. If you are not sure about your wishes to be a father in the future, you may want to work with a sperm bank to learn more about the procedure and its costs.

How common cancer treatments can affect sexuality and fertility

  • Treatment
  • Low sexual desire
  • Erection problems
  • No orgasm
  • Dry orgasm
  • Weaker orgasm
  • Infertility
  • Chemotherapy
  • Sometimes
  • Rarely
  • Rarely
  • Rarely
  • Rarely
  • Often
  • Pelvic radiation therapy
  • Rarely
  • Sometimes
  • Rarely
  • Rarely
  • Sometimes
  • Often
  • Retroperitoneal lymph node dissection
  • Rarely
  • Rarely
  • Rarely
  • Often
  • Sometimes
  • Often
  • Abdominoperineal (A-P) resection
  • Rarely
  • Often
  • Rarely
  • Often
  • Sometimes
  • Sometimes*
  • Radical prostatectomy
  • Rarely
  • Often
  • Rarely
  • Always
  • Sometimes
  • Always
  • Radical cystectomy
  • Rarely
  • Often
  • Rarely
  • Always
  • Sometimes
  • Always
  • Total pelvic exenteration
  • Never
  • Often
  • Rarely
  • Always
  • Sometimes
  • Always
  • Partial penectomy
  • Rarely
  • Rarely
  • Rarely
  • Never
  • Rarely
  • Never
  • Total penectomy
  • Rarely
  • Always
  • Sometimes
  • Never
  • Sometimes
  • Usually*
  • Orchiectomy (removal of one testicle)
  • Rarely
  • Rarely
  • Never
  • Never
  • Never
  • Rarely**
  • Orchiectomy (removal of both testicles)
  • Often
  • Often
  • Sometimes
  • Sometimes
  • Sometimes
  • Always
  • Hormone therapy for prostate cancer
  • Often
  • Often
  • Sometimes
  • Sometimes
  • Sometimes
  • Always

*Artificial insemination of a woman with the man’s semen may be possible.

**Infertile only if remaining testicle is not normal

 

What to expect

Many sexual problems that men have after cancer treatment will not last long. For instance, pain with erection or ejaculation soon after pelvic surgery or radiation is likely to go away. The stress of treatment can also reduce hormone levels for a few weeks. This may cause decreased desire or erection problems until hormone levels go back to normal.

As you feel more in control of your body and your life, you will find that your self-confidence returns and your sex life often gets better.

But some cancer treatments can cause a lifelong change in a man’s sexual function. It’s hard to know what will happen to any one person. For example, one man’s erections may come back after radical prostatectomy while another man’s may not. But if you do have a sexual problem, your health care team can often find the cause and give you an idea of your chance for recovery.

One clue that a problem is a medical one and one that may not go away is if it happens in all situations. Otherwise, it may be psychological and short term. For example, if you have trouble getting or keeping an erection, does it happen every time you have sex? Are your erections better when you relax, when you stimulate your own penis, or when you unexpectedly see someone attractive? If you have a few partners, are your erections better with one of them than with the others?

As men age or go through health changes, it is common that feelings of sexual excitement no longer lead to an instant erection. You may just need more time and stroking to get aroused.

If you have trouble reaching orgasm during sex, you may not have found the right kind of touching. You might even think about buying a hand-held electric vibrator. A vibrator can give very intense stimulation. Try having a sexual fantasy or looking at erotic stories or pictures. The more excited you are, the easier it is to reach orgasm.

A number of men have their first orgasm after cancer treatment while asleep, during a sexual dream. If this happens to you, it is proof that you are physically able to have an orgasm. Because sleep erections aren’t affected by mood or state of mind, they give you an idea of the best erection your body can produce. Now it is up to you to set things in motion when you are awake.

The best time to talk with your doctor or cancer team about side effects or long-term changes in your sex life is before treatment, so that you can learn about the usual recovery and how long it takes. But you can bring up the subject any time during and after treatment too. Unless you are trying early penile rehabilitation, don’t be surprised if you need several months to recover from treatment. If erection problems last longer, talk with your doctor and try different ways to overcome them. If your problem doesn’t get better, your doctor may ask you some questions about your sex life, and then use special medical tests to help find the cause. You may need to see more than one doctor to find out exactly what the problem is and get the treatment you need.

Tests to measure nighttime erections

One of the tests used most often is done while you sleep. Your doctor may have you spend 2 or 3 nights in a sleep lab to check your sleep erections. A technician watches your brain waves and breathing during the night to make sure that your sleep patterns are normal. At the same time, elastic loops placed around the base and tip of your penis are connected to a recorder. The recorder measures changes in the size of your penis during the night. If your sleep erections are firm and long-lasting, your problem may respond well to some sexual counseling. If your sleep erections are poor or you don’t have an erection, you may need surgery or medical treatment to correct the problem.

Since sleep lab testing costs a lot, most doctors use other ways to check sleep erections. Many send a man home with an electronic monitor to wear on the penis at night. This can be a very good test. A less accurate test is to use a plastic strip (or snap gauge). The patient wears it around the shaft of the penis during sleep. An erection breaks 1 to 3 bands of plastic film on the gauge, depending on the firmness of the erection. Another option is a strain gauge, a circular device placed at the base and tip of the penis that stretches during erection. It also measures the change that happens with erection during sleep.

Other medical tests

Other tests, often done in a doctor’s office, can measure blood flow in the penis. One such test uses a doppler ultrasound. The doctor passes a hand-held device over the penis, and reflected sound waves show the speed and direction of blood flow. This type of test looks for a block in circulation that could be causing the erection problem. Sometimes the test includes using a needle to put medicine into the shaft of the penis to produce an erection. In that case, the ultrasound imaging test is done on the erect penis. Tests of nerve sensitivity and reflexes in the genital area are sometimes done, too. Blood tests are also commonly done to check the levels of the 2 hormones most closely linked to men’s sexual function, testosterone and prolactin.

Any sexual problem caused or worsened by anxiety can respond to counseling with a sex therapist. For men, problems caused by anxiety can include:

  • Loss of sexual desire
  • Erection problems without a medical cause
  • Trouble reaching orgasm
  • Premature (early) ejaculation

When a medical problem limits a man’s sexual function, sex therapy can still be helpful. But the goals may change. For example, instead of expecting a man to regain full erections, the therapist may help him and his partner learn to enjoy sexual caressing without erections. Sex therapists may also be able to help you and your partner decide whether to have medical or surgical treatments for erection problems.

Sildenafil citrate (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are drugs that are used to treat impotence. All of these drugs help a man get and keep an erection by causing more blood to flow to the penis. About half of men with impotence due to medical (rather than psychological) problems are helped to some extent by these drugs.

Studies suggest that problems due to nerve damage from prostate cancer treatment may not respond as well to these drugs as some other physical causes of impotence. But recent research suggests that using one of these drugs within weeks of surgery, on a regular basis, does improve the rate of spontaneous erections after nerve-sparing radical prostatectomy. Some men who don’t get a good enough result with one of these drugs may do better when they use it along with the penile injection.

Many drugs are known to interact with this group of drugs. For example, nitrates (like nitroglycerin and other drugs used to treat heart disease) may interact to cause very low blood pressure, and this can be fatal. Be sure your doctor knows about all medicines you take, even those you take rarely.

The most common side effects of these impotence drugs are headache, flushing (skin becomes red and feels warm), upset stomach, sensitivity to light, and runny or stuffy nose. In rare cases, these drugs may block blood flow to the optic nerve in the back of the eye. This could lead to blindness. Men who have had this problem were more likely to have been smokers or had problems with high blood pressure, diabetes, or high levels of cholesterol or fat in their blood.

Other medicines to treat impotence are being studied. You might want to ask your doctor about any new medicines or treatments for erection problems.

Blood supply: If a blockage in the main artery that brings blood to the penis is causing an erection problem, surgery may help. The surgeon can take an artery that usually supplies blood to the abdominal wall (inside your belly) and re-route it to the tiny blood vessels inside the penis. But results have been disappointing in men who have poor circulation, diabetes, or other artery diseases. Still, some men may be helped if they have damage that blocked the artery to the penis, and are otherwise healthy.

Nerve supply: During the first 3 to 12 months after radical prostatectomy, most men will not be able to get an erection without using medicines or other treatments. The effect of this operation on a man’s ability to get an erection is related to his age and whether nerve-sparing surgery was done. Nearly all men who have a radical prostatectomy should expect some decrease in their ability for a few months after surgery. After a year or 2, most men have some return in their ability to have an erection, but younger men may retain more of their ability. Some experts use treatments to improve erections soon after surgery to try to speed recovery and help heal minor short-term damage to the nerves and blood supply.

After standard radical prostatectomy, there are wide ranges of impotency rates in men, depending on their age. If the surgeon does not remove or damage the nerves on either side of the prostate, the impotence rate drops as low as 25% and 30% for men under 60, and as low as 10% for men under 50. The impotence rate is higher for men over 70, even if nerves on both sides are not damaged or removed. After surgery, there is no ejaculation of semen. But even with a dry orgasm, the sensation should still be pleasurable.

New research is looking at transplanting nerves to restore erections, but more research is needed to find out how well it will work.

Though surgery to correct blood-flow problems has been disappointing so far, 3 non-surgical treatments have become widely used: penile injection therapy, urethral pellets, and vacuum devices. We will also discuss surgical options, called implants.