Treatments can affect:

• how you feel about yourself sexually
• your ability to get an erection (erectile function)
• your desire to have sex (libido)
• your ability to ejaculate and have an orgasm
• your fertility
• the appearance of your body
• your relationships.

But there are treatments and support that can provide some answers and ways for you to work through any problems.

For more detailed information on the risks of sexual problems for each different prostate cancer treatment, read our treatment pages.

Speak to your GP or doctor or nurse at the hospital to find out more about treatments for sexual problems. Some men will be referred to a specialist service such as an erectile dysfunction (ED) clinic.

Men with prostate cancer can get free medical treatment for problems with erections or other sexual problems on the NHS. Your GP or doctor or nurse at the hospital can prescribe treatment if you want help getting erections for masturbation or sex. There is no age limit for receiving treatment but there may be a limit on how much your GP can prescribe¹.

After treatment for prostate cancer you may have difficulty getting or keeping an erection. This is also known as erectile dysfunction (ED) or impotence. Many men get problems with their erections and this is more likely to happen as men get older³.

Causes of erection problems

When you are sexually aroused your brain sends signals to the nerves in your penis. The nerves increase the blood flow to your penis, and fills the spongy tissues, making it stiff and giving you an erection. Anything that interferes with your nerves, blood supply or your sexual desire (libido) can make it difficult to get or keep an erection.

Causes of erection problems include one or a combination of the following: treatment for prostate cancer, other health problems, certain medicines and depression or anxiety.

Many of the treatments for ED work by improving the flow of blood to the penis. The treatments are:

• tablets
• injections
• pellets
• vacuum pump
• surgical implant
• sex therapy.

Because getting an erection also relies on your thoughts and feelings, tackling any worries or relationship issues as well as having medical treatment for erection problems, often works well^4,5,6.

There is not enough evidence to say whether one treatment for erection problems is better than another in men who have had treatment for prostate cancer⁷. The effectiveness of each treatment varies. You can try one treatment, stick with it for a while but if you find this doesn't work for you remember that there are other options⁸.

Some treatments for erection problems can make men feel like they lose the moment when they are aroused⁹, but people do gradually get used to them. Some couples even use preparation for treatment, such as vacuum pumps or pellets as part of their foreplay. Read more about sex and relationships below.

Will the treatments work if I am on hormone therapy?

All types of hormone therapy may reduce or cause you to lose your desire for sex, so treatments that only work when you have desire, such as PDE5 inhibitor tablets like sildenafil (Viagra^®), are unlikely to work. However injections, pellets, vacuum pumps and surgical implants should be able to give you an erection as you don't need to have sexual desire for them to work.

Side effects

Read the information leaflet that comes with your treatment for details of how to use the treatment and possible side effects. Your doctor or nurse will discuss these with you before you start a treatment. You should also let them know about any other health problems you have or medicines you are taking.

Tablets
A group of medicines called phosphodiesterase type 5 (PDE5) inhibitors can help men get erections. These are called:

• sildenafil (Viagra^®)
• tadalafil (Cialis^®)
• vardenafil (Levitra^®).

These tablets don't cause spontaneous erections, they only work if you are sexually stimulated. They normally take 30 minutes to an hour before they start to work. If you take Viagra^® and Levitra^® it will be active in the body for around four hours and you will be able to get an erection with sexual stimulation within that time. Cialis^® will be active for about 36 hours, so you will have a longer window of time to have sex¹⁰.

Cialis^® (tadalafil) also comes in a one-a-day version¹¹. You might prefer to take a tablet once a day if you want to have sex often or if you and your partner prefer spontaneous rather than pre-planned sex.

You should not take PDE5 tablets if you are taking a group of heart drugs called nitrates¹². Nitrates are usually used to treat heart problems. If you have a heart problem or are using nitrates you should get your medication reviewed and discuss ways to treat erection problems with your GP or specialist. There are other drugs that you should not take PDE5 tablets with, check the patient information leaflet that you get with the drugs or ask your doctor of nurse.

Injections

Erection problems can also be treated with a drug called alprostadil (Caverject^®, Caverject Dual Chamber^® or Viridal Duo^®) injected into your penis.

The idea of an injection may sound alarming but many men find it is not that bad and does not hurt. The first time you use the drug a nurse or doctor in clinic will show you how to inject it into your penis with a very fine needle. The nurse or doctor will make sure you are happy giving the injection yourself in the clinic before you go home.

The drug causes the penis to fill with blood and you will get an erection, within around 15 minutes. The erection will normally last for 30 to 40 minutes¹⁰.

Pellets

The drug alprostadil is also available as a small pellet, called MUSE^®. This is not as effective as using the injections¹³ but may be a good alternative if you do not like the idea of an injection. You use a disposable applicator to insert the pellet into the opening or 'eye' of the penis. You or your partner can then massage or stimulate your penis to melt the pellet and help the absorption of the drug. You should get an erection within five to 15 minutes, which will last between 30 and 60 minutes14.

Vacuum pump

This treatment for erections problems involves a pump and tube that creates a vacuum in order to make blood flow into your penis. The pump is made up of a plastic cylinder that you put your penis into and a pump that you operate by hand or battery. The pump creates a vacuum inside the tube, this makes blood flow into your penis and makes it erect. You then slip a rubber ring onto the base of your penis. This stops most of the blood escaping once you remove the vacuum pump.

Implants

This involves having an operation to insert an implant into your penis. There are two main types:

• Semi-rigid rods that keep the penis fairly firm all the time but allow it to be bent down when you do not need an erection.

• An inflatable implant in the penis, and a pump placed in the scrotum. When you squeeze the pump the implant fills with fluid (saline) which will make the penis become erect. Your erection will last for as long as the implant is inflated.

Testosterone replacement therapy

If you have had treatment for prostate cancer that was contained within the prostate (localised) and have erection problems caused by low testosterone levels, then you may be able to have testosterone replacement therapy^15,16,17. Find out more in our bookletProstate cancer and your sex life.

Keeping your penis active after surgery

Although you may not be ready or recovered enough to have sex, you can still start treatment for erection problems during the weeks and months immediately after surgery²¹. It could be a low daily dose of medication, or using the vacuum pump or sometimes both together. The idea is that the medication or treatment alongside masturbation, encourages blood flow to the penis and makes sure that the tissue you need for erections is kept healthy. You may hear this called penile rehabilitation.. Although some research shows that starting treatment early may be beneficial for erections, we need more research to say how effective early treatment is - it may not work for every man^21,22.

For more detailed information about treatments and support for sexual problems, read our booklet Prostate cancer and your sex life. The booklet comes with a DVD of men telling their own stories of their experiences of sex after prostate cancer treatment.

Prostate cancer and its treatment can affect your desire for sex. Hormone therapy for prostate cancer will change your sex drive and may mean you have much less interest in sex^23,24,25. This is because of the decrease in testosterone, which is the hormone responsible for giving you your sex drive. You could ask your doctor or nurse specialist team about the option of 'intermittent hormone therapy'²⁶. Desire for sex should return to normal after hormone treatment is stopped, but it can take up to a year. Read more about the side effects of hormone therapy.

You might want to try treatment for erection problems, even if your sex drive is reduced. Some of the treatments for erection problems may work for you.

Other things that effect your sex drive include: feeling depressed or anxious^27,28, feeling tired²⁹ and dealing with other physical side effects such as urinary, bowel problems and physical changes after hormone therapy, such as putting on weight, or breast swelling^9,30.

There is more information about dealing with these changes in the booklet, Prostate cancer and your sex life.

Some men find that their penis is shorter after surgery (radical prostatectomy)^31,32. Men may be less likely to experience these changes if the surgeon has been able to save the nerves that control erections during surgery (nerve sparing surgery)³³.

Other types of prostate cancer treatment such as radiotherapy and hormone therapy³⁴ may also cause changes to the size of your penis.

Encouraging blood flow to the penis after surgery may improve erections and prevent your penis becoming smaller³⁵. In particular using a vacuum pump after surgery may stretch the tissue and help maintain your penis size^36,37.

Dealing with these changes can be difficult, read about what support is available to you below.

After prostate cancer treatment you will still have feeling in your penis and you should still be able to have an orgasm but you may find that it feels different from before.

After surgery (radical prostatectomy) you will not be able to ejaculate, as the prostate gland and seminal vesicles, which store and transport semen, are removed during the operation. Instead you may have a 'dry orgasm' where you have the feeling of orgasm but semen does not come out of your penis. Occasionally, some men will find that a small amount of liquid comes out from the tip of the penis during orgasm, which may be fluid from glands lining the urethra.

If you have had radiotherapy, brachytherapy ,high intensity focused ultrasound (HIFU) or hormone therapy you may produce less semen during and after treatment.

If you have had a surgery called TURP (transurethral resection of the prostate) you may have a retrograde ejaculation. This is when you orgasm and the semen does not come out straightaway, but is passed out of the body the next time you pass urine. It is not harmful and should not affect your enjoyment of sex but it may feel quite different to the orgasms you are used to.

Prostate cancer treatment can affect your ability to produce sperm or ejaculate and can lead to infertility. This is because the prostate gland and seminal vesicles, which produce some of the fluid in semen, are removed during surgery. The cells that make semen can also be damaged during other treatments such as radiotherapy.Brachytherapy may have less of an effect on fertility than other treatments for prostate cancer⁴³ but we still need more research into this. You may notice that you produce less fluid when you ejaculate but it is possible that you are still fertile.

If you are planning to have children you may be able to store some sperm before treatment so that they can be used later in fertility treatment. There is no age limit to storing your sperm for your own use⁴⁴. Sperm banking is usually available on the NHS. But this can vary - you may need to pay for sperm storage and possibly for infertility treatment. Ask your doctor or nurse about what fertility treatment is available locally.

Changes to your sperm during radiotherapy, brachytherapy and chemotherapy could affect any children you may conceive during this time⁴⁵ but the risk of this happening is very low^46,47. You may wish to avoid fathering a child during treatment and for a while after having treatment, for example by using a condom or other form of contraception.

If you are planning to have children you should seek further information from your GP or doctor or nurse. If you have a partner, talk to them about your plans for having children and what this would involve.

Macmillan Cancer Support and Infertility Network UK produce more detailed information about other fertility treatments options that may be available.

If you have a partner, then coping with cancer and side effects may have changed your relationship and the way you have sex⁹.

Even though your sex life is unlikely to be the same as it was before cancer, you don't have to give up on having pleasure, closeness or fun together. You may not find a quick fix, but keeping some kind of physical closeness alive, in whatever ways possible, can protect or even improve your relationship⁴⁸. Some couples find it useful to see a relationship counsellor. The charity Relate provide relationship counselling and a range of other relationship support services.

Sex therapy (also sometimes called psychosexual therapy or sexual counselling) is available on the NHS or privately. You can usually refer yourself to a private counsellor, but for NHS services you will need a referral from your GP or other health professional. Check that any sex therapist you see is registered with the College of Sexual and Relationship Therapists or a general counselling organisation like British Association of Counselling and Psychotherapy.

Our booklet Prostate cancer and your sex life provides practical tips to help with your sex life, further information about sex therapy and specific information for partners.

If your ability to get erections and your experience of sex has changed then this can have a big impact on you. Dealing with sexual problems can make you feel depressed, worried, unsatisfied, angry and as if you've lost a part of yourselves ^49,50,51,52. But there are ways to tackle your issues and find solutions that work for you.

Getting support

If you are feeling very down you may need to deal with this before you can address any sexual issues⁵⁴. Counselling can help some men. Counsellors are trained to listen and work with you to understand your feelings and find your own answers. Your GP can refer you to a counsellor or you can see a private counsellor. To find out more contact the British Association for Counselling and Psychotherapy. Other organisations such as the Sexual Advice Association and the College of Sexual and Relationship Therapists can also help.

There are also other ways to face these challenges, there are suggestions below and more detailed information about what you can do to help yourself in our booklet Prostate cancer and your sex life.

Peer support services

Our peer support service offers individuals confronted with prostate cancer the opportunity to talk with a trained support volunteer. Many people find talking with someone who has been in a similar situation helpful. Our volunteers can listen to concerns and share their own personal experience to support others in a similar situation to theirs. They can talk about erection problems, the impact of prostate cancer on relationships and sex life and loss of desire. Peer support can be offered to men diagnosed with prostate cancer and their partners, friends and family. To access the peer support service please call our Specialist Nurses on our confidential helpline.

Find a support group

Get in touch with your local prostate cancer support group. Support groups can be a good way for you to meet people with similar experiences. These groups are often set up by local health professionals, or by people who have experience of prostate cancer. Meetings are usually informal and offer an opportunity to find out about other people's experiences as well as discussing your own thoughts and concerns. Many support groups also welcome partners, friends and relatives.

Join the Prostate Cancer UK online community

If you have access to the internet, sign up to the Prostate Cancer UK online community, where members share their experiences of prostate cancer. Registration is free and only takes a few minutes.

Specialist nurses

If you have questions about any of the issues described in this booklet you can speak to our specialist nurses on our confidential helpline. Some people feel embarrassed about discussing personal issues over the phone, and you can also send a query to the specialist nurses by using our email contact form.

How could my treatment for prostate cancer affect my sex life?

How soon after prostate cancer treatment can I masturbate or have sex again?

What are the treatments for erection problems and which will be best for me?

What happens if the treatment does not work? Are there other treatments I can have?

Which treatment can I get from my local NHS?

What other support is available to me?

Can my partner also get support?

British Association of Counselling and Psychotherapy (BACP)

www.itsgoodtotalk.org.uk

01455 883316
BACP will help you find qualified counselors. They are happy to discuss any queries or concerns you have about choosing a counselor or the counseling process.

College of Sexual and Relationship Therapists

www.cosrt.org.uk

020 85432707

Information on sexual and relationship therapy, including a list of therapists.

Health with Pride

www.healthwithpride.nhs.uk

An online resource for lesbian, gay and bisexual patients. This website has information on cancer issues and erection problems for gay men.

Infertility Network UK

www.infertilitynetworkuk.com

Advice line: 0800 008 7464

Support, information or advice on fertility or infertility.

LLGS

www.llgs.org.uk

Helpline: 0300 330 0630 (10am-11pm daily)

Free and confidential support and information for lesbian, gay, bisexual & transgendered communities throughout the UK

Macmillan Cancer Support

www.macmillan.org.uk

Practical, financial and emotional support for people with cancer, their family and friends. Macmillan also has further information on sex, relationships and cancer.

NHS Choices

www.nhs.uk

Provides information to support you in making decisions about your own health, including an A-Z of treatments and conditions, and information on NHS health services in your local area.

QUIT

www.quit.org.uk

UK charity that helps smokers to stop, they have a helpline and community programmes in 8 different languages.

Relate

www.relate.org.uk

Telephone: 0300 100 1234

Relate provide relationship counselling and sex therapy and a range of other relationship support services.

Samaritans

www.samaritans.org.uk

Helpline 0845 790 9090

Provides confidential non-judgmental emotional support, 24 hours a day, by telephone, email, letter, or face to face.

Sexual Advice Association

www.sda.uk.net

Helpline: 020 74867262

For detailed information on treatments for erection problems.

Reviewed by:

• Jane Booker, Macmillan Urology Clinical Nurse Specialist, The Christie NHS Foundation Trust, Manchester
  Paul Hegarty, Consultant Urologic Surgeon, Guy's & St Thomas' NHS Foundation Trust, London
• Sarah Hughes, Urology Nurse Specialist, Port Talbot Hospital, Wales
• Sue Lennon, Macmillan Urology Nurse Specialist and Psychosexual Therapist, Harrogate and. District NHS Trust
• Dr Isabel White, Psychosexual Therapist, The Royal Marsden NHS Foundation Trust, London,
• Prostate Cancer UK Specialist Nurses
• Prostate Cancer UK volunteers

Written and edited by:
Prostate Cancer UK Information Team

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