Regardless of whether the nerves were spared during surgery or whether the most precise dose planning was used during radiation therapy, erectile dysfunction remains the most common side effect after treatment. This is because the nerves and blood vessels that control the physical aspect of an erection are incredibly delicate, and any trauma to the area can result in changes. However, even if you do experience some side effects of treatment, there is also room for optimism: many excellent options for managing erectile function exist on the market today.

However, within one year after treatment, most men with intact nerves will see a substantial improvement. The skill of your surgeon or physician can have a significant impact on this outcome, so it’s important to select your team carefully. Likewise, men with baseline erectile dysfunction and/or other diseases or disorders that impair their ability to maintain an erection, such as diabetes or vascular problems, will have a more difficult time returning to pre-treatment function. It’s important to remember that your functionality after treatment can only be as good as it was before treatment. The best predictor of how you will be after treatment is how healthy you were going into treatment.

Four main components of erectile function may be affected by prostate cancer treatment:

  1. Libido (sex drive) is most commonly affected by hormone therapy, or treatment that decreases your testosterone. You can have a low libido and still obtain an erection, but it is usually more difficult for men who have less interest in sex. This will return once your testosterone returns to normal after completing hormone therapy. Loss of libido can be a major concern for some patients and/or their partner and much less of an issue for others. Couples counseling should be considered if there is a possibility of causing stress in a relationship.
  2. Mechanical ability is the ability to achieve a firm erection. It is controlled by the nerves and vessels that are intimately associated with the prostate and structures near the penis. Mechanical ability is most affected by surgery or radiation therapy.
  3. Orgasm/climax can be more difficult after treatment, especially if libido is low or your erections are not as firm as they used to be. Also, sometimes there can be some discomfort initially after treatment when you climax. This usually is transient and will resolve. It is important to distinguish orgasm from ejaculation, as men will continue to have the pleasure sensation of orgasm without ejaculation.
  4. Ejaculate may be minimal after treatment. The prostate and seminal vesicles which function to produce ejaculate are removed and/or irradiated during treatment, so it is common to have a minimal or no ejaculate afterwards. So although you may be able to have an erection and reach an orgasm, nothing may come out.

Prostatectomy: Since the 1980s, most men are treated with what is termed a “nerve-sparing” prostatectomy. The goal of the procedure is to take the prostate and seminal vesicles out while sparing the nerves adjacent to the prostate. Studies have shown that approximately 50% of men who have the ability to have an erection before surgery will maintain this ability long-term. This number can increase or decrease based on  age, obesity, and the ability to spare the nerves. In general, men with lower-risk prostate cancer have higher rates than average of erectile function given  it is easier to spare the nerves. In contrast, in men with high-risk prostate cancer it is often more challenging to spare the nerves as the tumor may have spread past the nerves outside the prostate capsule and erectile function rates are lower than average.

Radiation therapy: Similar to surgery, damage to blood vessels and nerves after radiation therapy can result in decreased erectile function over time. In general, radiation therapy has less of an impact on erectile function in the first 5 to 10 years after treatment compared with surgery, and approximately 70% of men who have baseline erectile function before treatment will keep erectile function after treatment. However, radiation therapy has a slower delay in erectile function decline than surgery; 15 years after treatment, the rates are similar to those who underwent surgery.

These rates do not appear to be affected in the long-term by the use of short-term (4 to 6 months) hormone therapy, but will be affected by the use of long-term (18 to 36 months) hormone therapy. Newer techniques in radiation therapy, termed “vessel sparing” radiation therapy, have shown promising results for improving the preservation of erectile function, with close to 80% of men maintaining baseline function. Ask your radiation oncologist about vessel sparing radiation therapy.

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