Sex and relationships

This is an operation to remove the prostate and seminal vesicles.

When can I have sex or masturbate?

• It’s safe to have erections, and masturbate when you feel like it – but if you have a catheter, having an erection or masturbating could feel uncomfortable, so you may want to wait until it is removed.
• After keyhole surgery, you can have sex or be sexually active once your catheter is removed.
• After open surgery, wait until the wound has healed and it feels comfortable before you try having sex.
• If you have anal sex, wait about six weeks before having anal sex.

What problems might I have?

• Surgery often causes problems getting an erection. Many men find these problems improve with time, but not all men get their erections back.
• Your penis may become a little shorter and change shape slightly.
• You won’t ejaculate any semen but can still orgasm, although it’s likely to feel different – some men find that the feeling is better than before, whilst others may find that the feeling isn’t as good.
• You won’t be able to have a child naturally (infertility).
• You may leak urine during sex.
• You may feel some pain when you orgasm.
• You may lose your desire for sex (libido).

This is where radiation is directed at the prostate from outside the body.

When can I have sex or masturbate?

• You can have sex or masturbate as soon as you feel like it.
• You may wish to use contraception during treatment and for at least one year afterwards if there is a chance of your partner becoming pregnant.
• If you receive anal sex, wait until any bowel problems or sensitivity in this area have passed.

What problems might I have?

• Erection problems can develop slowly after treatment.
• You may find ejaculation uncomfortable.
• You may produce less or no semen.
• You can still orgasm but it may feel different.
• You may not be able to have a child naturally (infertility)

This is a type of radiotherapy where tiny radioactive seeds are put inside the prostate and left there permanently.

When can I have sex or masturbate?

• After treatment, wait a few days before you try having sex or masturbating.
• It’s rare for seeds to come out in your semen, so use a condom the first five times you ejaculate.
• Use contraception during treatment if there is a chance of your partner becoming pregnant. You may have to use contraception for up to a year after having treatment but ask your doctor about this.
• If you receive anal sex, wait until any bowel problems or sensitivity in this area have passed. It’s possible that your partner might be exposed to some radiation during sex for the first few months after treatment. So for the first six months, it’s sensible to keep the length of time you have sex for as short as possible.

What problems might I have?

• Erection problems can develop slowly over time.
• You may produce less semen but can still orgasm.
• Ejaculation may feel different and sometimes be painful, especially soon after seeds have been inserted.
• You might not be able to have a child naturally (infertility)

This is a type of radiotherapy where thin tubes are put into your prostate. A source of radiation is passed down the tubes for a few minutes to destroy the cancer cells, then the tubes are removed.

When can I have sex or masturbate?

• After treatment, wait at least one week before you try having sex or masturbating.
• Use contraception for a while after treatment if there is a chance of your partner becoming pregnant. Speak to your doctor about how long you need to do this for.
• If you receive anal sex, wait two months before having sex.

What problems might I have?

• You may have erection problems that can slowly get worse over several years.
• You may produce less semen but can still orgasm.
• You may not be able to have a child naturally (infertility)

This uses high-frequency ultrasound energy to heat and destroy cancer cells.

 When can I have sex or masturbate?

• After HIFU, wait at least one to two weeks before you try having sex or masturbating.

  What problems might I have?        

• You may have erection problems.
• You may produce less or no semen but can still orgasm.
• You may not be able to have a child naturally (infertility)

This uses extreme cold to freeze and destroy cancer cells.

When can I have sex or masturbate?

• After cryotherapy, wait at least one week before you try having sex or masturbating.

What problems might I have?

• You may have erection problems.
• You may not be able to have a child naturally (infertility)

Hormone therapy stops the hormone testosterone from reaching cancer cells. This  stops the cancer cells from growing. It can be given by injection, implants, tablets or surgery.

When can I have sex or masturbate?

• It’s safe to have sex or masturbate if you’re having injections, implants or tablets.
• If you’ve had surgery (orchidectomy), wait until the wound has healed and it feels comfortable before you try having sex.

What problems might I have?

• You may have erection problems and you may lose your desire for sex (libido).
• Your penis may become shorter and your testicles smaller due to lower testosterone levels in your body.

• You may not be able to orgasm or you may have less intense orgasms. And you may produce less semen.
• You may have changes to your body which can affect how you feel about sex, such as weight gain or hot flushes.

Chemotherapy uses anti-cancer drugs to kill cancer cells, wherever they are in the body.

When can I have sex or masturbate?

• Unless your doctor tells you otherwise, it’s safe to have sex or masturbate as soon as you feel like it.
• Use contraception during treatment if there is a chance of your partner becoming pregnant. You may have to use contraception for up to six months after having treatment but ask your doctor about this.

What problems might I have?

• You may not be able to have a child naturally (infertility).
• You can still orgasm but it may feel different.
• You may have changes to your body that can affect how you feel about sex, such as hair loss, feeling tired or feeling unwell.

• You can’t pass on cancer through sex.
• Having sex won’t affect how well your treatment works.
• Having sex has no effect on your cancer or the chance of it coming back after treatment.
• It’s safe to have an erection if you have a catheter in.

A group of drugs called PDE5 inhibitors (phosphodiesterase type 5 inhibitors) could help you get an erection.

These include:

• sildenafil (generic sildenafil or Viagra^®)
• tadalafil (generic tadalafil or Cialis®)
• vardenafil (Levitra^®)
• avanafil (Spedra^®).
  
  

How well do they work?

How well these drugs work varies from man to man. The tablets are quick and easy to take and they don’t interfere with foreplay. It’s good to start taking them soon after prostate cancer treatment as you may get your erections back sooner. They could also help your recovery so that in the future, you can get erections without medical help.

There hasn’t been any research comparing how well the different types of PDE5 inhibitor tablets work in men who have prostate cancer treatment, so we can’t say if one drug is better than another.

How do they work?

You need to be sexually aroused for the tablets to work. If you have a low sex drive or low testosterone level, for example if you’re on hormone therapy, they might not work so well for you.

The tablets normally start to work about 30 minutes to an hour after taking them. Make sure you allow enough time for them to work, otherwise it might seem like they’re not working when they are.

You can take sildenafil, avanafil and vardenafil when you need to. They will keep working for four to six hours, or up to eight hours for vardenafil. So if they work you should be able to get an erection if you’re sexually aroused during that time.  

You can take tadalafil when you need to. It can work for up to 36 hours, so it lets you be more spontaneous.  Or your doctor may suggest you take a low-dose (5mg) tadalafil tablet every day.

If you have a choice of drug, think about which one fits in best with your sex life.

The dose you have will vary. Some men start with a low dose but you can go up to a higher dose if the drug isn’t working. If the maximum dose of one drug doesn’t work, another drug may work better for you.

Tablets might not work well for everyone, including some people who take certain medications. For example, you may be offered a smaller dose if you’re already taking medication for HIV (antiretroviral drugs). This is because HIV drugs can react with some other medicines. This can cause side effects that may be serious. Always check with your doctor or nurse if you’re not sure whether tablets are right for you.

Don’t give up

The tablets may not work the first few times. It can take a while to get the timing right. Try each tablet at least eight times before changing to a different one. You may need to take your tablet on an empty stomach as some tablets don’t work as well after a big or fatty meal, or with alcohol or grapefruit juice. Read the leaflet that comes with your tablets for more information or ask your doctor, nurse or a pharmacist if you’re not sure.

If you had surgery and your surgeon was able to save the nerves that help you get erections (nerve-sparing surgery), you’ll be offered PDE5 inhibitors. It can take months or even years for the nerves to fully recover. This means it can feel like a long time before the tablets start working. It’s important to keep your penis active with other treatments, such as injections or a vacuum pump.

If your surgeon wasn’t able to save the nerves, your doctor might still suggest you try PDE5 inhibitors, as they can still sometimes have an effect.

Side effects

PDE5 inhibitor tablets are generally safe to use, but they can cause side effects. They are usually mild and don’t last long. They include:

• headaches
• indigestion
• a flushed face
• itchiness or swelling in your nose (rhinitis)
• muscle pain
• back pain
• leg pain.

Things to be aware of

PDE5 inhibitor tablets can cause a drop in your blood pressure, but this doesn’t cause problems for most men. Tell your doctor or nurse if you’re taking medicines to control your blood pressure. If you take alpha blockers they may suggest taking the drugs at least four hours apart.

You shouldn’t take PDE5 inhibitor tablets if you’re taking drugs called nitrates. Taking these treatments at the same time can cause your blood pressure to drop dangerously low, which can be fatal. Nitrates are usually used to treat heart problems. They are also used in recreational drugs known as poppers. If you have a heart problem or take nitrates, ask your doctor or specialist about other ways to treat erection problems.

Buying tablets on the internet

Only use medicines that have been prescribed to you by a health professional or that you have purchased from a pharmacy. Sildenafil is available free on the NHS so you shouldn’t have to buy your treatment. Buying tablets on the internet can be dangerous as they may be fake, it’s impossible to know the dose, and they could contain ingredients that are harmful or react with other drugs. If you do order medicine online, make sure it’s from a well known pharmacy that you trust. If your GP doesn’t want to prescribe tablets then ask to be referred to an ED clinic.

Herbal medicine

Herbal medicines for erection problems, like ‘herbal Viagra’ which is sold in Chinese herbal medicine stores, can also be unsafe. Speak to your doctor before taking any herbal remedies.

Vacuum pumps can be used to give you an erection. There are two reasons men use a vacuum pump. One is to get an erection for sex or masturbation and the other is to keep the penis healthy in the long term. It could also help to maintain its size.

How well does it work?

The vacuum pump can be an effective way to get an erection hard enough for penetration. Satisfaction with the pump varies, but men who have good results will often keep using it. A lot of men use the pump in combination with other treatments such as tablets.

The vacuum pump may also help maintain the length and thickness of the penis if used regularly and soon after surgery.

How does it work?

You put your penis into the cylinder and use the pump to draw air out of the cylinder, creating a vacuum inside it. This makes blood flow into your penis to make it hard. Your nurse or doctor will show you how it works.

If you are using the pump for sex or masturbation

After using the pump to get an erection, you slip a constriction ring from the end of the cylinder around the base of your penis. This stops most of the blood escaping when you remove the pump. You shouldn’t wear the ring for longer than 30 minutes at a time.

Some men find that because the base of their penis is still soft it moves around, so it can be difficult to have sex at first. You or your partner may need to guide the penis in.

Shaving the hairs around the base of your penis can make it easier to use the pump.

Some men prefer the vacuum pump because you don’t need to use tablets or injections and you can use it as often as you like. With a little practice, the pump can help you get an erection in two to three minutes.

The way the vacuum pump works doesn’t involve the nerves that are usually needed for erections. So if your nerves were removed or affected during your prostate cancer treatment, the vacuum pump could be a good option for you.

If you are using the pump to keep your penis healthy

To keep your penis healthy, you could use the pump every day. Use the pump to get an erection and hold the erection in the cylinder for 20 seconds. Then release the pressure and pump again to get another erection. Keep repeating this for no more than 10 minutes, as more than that could become uncomfortable. Check the instructions or speak to your doctor or nurse.

Don’t use a constriction ring – only use a ring when you want an erection for sex or masturbation. This is because the ring stops blood and oxygen from flowing into your penis, and your penis needs oxygen to stay healthy.

Side effects

Vacuum pumps are very safe to use and you can use them along with other treatments. You may notice your penis feels slightly cooler than usual and you might not be able to ejaculate if you’re using a constriction ring. Some men also find it painful or uncomfortable or experience some bruising or numbness. 

Things to be aware of

The vacuum pump might not be suitable if you have a bleeding disorder, if you take drugs to thin your blood, or you have Peyronie's disease (where the penis is curved). Speak to your doctor or nurse about whether it’s suitable for you.

Buying vacuum pumps

Vacuum pumps are usually available on the NHS. If you choose to buy one, ask your doctor, nurse or specialist for advice on choosing one that’s suitable. The Sexual Advice Association also has information on buying a vacuum pump.

Erection problems can also be treated with drugs using an injection that you give yourself. These include:

• alprostadil (Caverject^®, Caverject^® Dual Chamber, Viridal Duo^®)
• aviptadil with phentolamine mesilate (Invicorp^®).

An injection may sound off-putting but many men find it isn’t that bad and doesn’t hurt. Your nurse or doctor will show you how to inject the side of your penis with a very thin needle. They will make sure you’re happy giving yourself the injection before you go home.

How well does it work?

Injections often work well. They work quickly because the drug goes straight to where it’s needed, and they give a natural looking erection. It helps if you start soon after your prostate cancer treatment. Injections should work if you have little or no sexual desire (libido), but they work better when you have some sexual interest and stimulation.

How does it work?

The injection causes blood to flow into the penis, allowing it to become hard. You’ll get an erection quickly, within five to 10 minutes, and it lasts for up to an hour.

You need to be able to see your penis to use the injection – so if you have sight problems, a big belly or a hidden penis it may not be suitable for you. If you have any difficulties using your hands it may also be harder to use the injection. Your doctor or specialist could show your partner how to use the injection, or you can talk about other possible treatments.

Side effects

Some men who use alprostadil find their penis hurts or aches for a few hours afterwards. If you use aviptadil with phentolamine mesilate, you may find that your penis becomes flushed or bruised, but it shouldn’t hurt. If you have any other problems, tell your doctor or nurse.

The drug alprostadil, used in the injections described above, is also available as a small pellet called MUSE^® and as a cream called Vitaros^®.

How well do they work?

These don’t tend to work as well as the injections, but they’re a good alternative if you don’t like the idea of an injection. Pellets and creams may work if you have little or no sexual desire (libido), but they work better when you have some sexual interest and stimulation.

How do they work?

You use an applicator to insert the pellet or cream into the opening or ‘eye’ of the penis. The applicator can be difficult to use at first but it shouldn’t hurt.

With the pellet, it helps if your urethra (the tube you urinate through) is already moist, so urinate first. With the cream, you or your partner can rub in any cream that’s left on the tip and massage your penis to help it absorb the drug.

If the pellet works you should get an erection very quickly – within five to 10 minutes – which lasts for up to an hour. The cream may take a little longer to work.

Side effects

The pellets and cream can sometimes cause dizziness or a burning feeling or pain in the penis or testicles.

You should use a condom during sex as your partner could have a reaction to the drug – but this is unusual. Use a condom if your partner is pregnant.

This involves having an operation to put an implant inside your penis. Although it might sound quite off-putting, it can be a good option if other treatments haven’t worked.  

How well does it work?

Most men who have an implant are satisfied with it. It allows you to have an erection when you want one and it doesn’t affect urinating, feeling or orgasm.

How does it work?

There are two main types of implants.

• Semi-rigid rods that keep the penis fairly firm all the time but allow it to be bent down when you don’t want an erection.
• An inflatable implant in the penis and a pump in the scrotum (the skin around the testicles). When you squeeze the pump the implant fills with fluid (saline) to make the penis hard. The fluid is either contained in the pump in the scrotum, or in a separate container that sits in your lower abdomen, just above your penis. Your erection will last for as long as the implant is inflated and you can deflate it when you want to. This type of implant gives a more natural erection, although the tip of the penis may stay soft.

Side effects

These are generally safe, but about three out of 100 men (three per cent) who have an implant get an infection. This means the implant has to be taken out. You will be given antibiotics after surgery to help prevent this.

You may have some bruising and swelling around your scrotum. And you’ll feel some pain in your penis and around the cuts where your implants have been put in. You’ll be given some painkillers to help with the pain, and it should get better after a few weeks. It might help to wear supportive underwear and angle your penis upwards.

The inflatable implant usually lasts for at least 12 years. But up to about five out of 100 men (five per cent) may need to have it replaced after five years. The semi-rigid implant is less likely to need replacing.

Testosterone is a hormone that controls the growth of the male sex organs, including the prostate. It also controls other male characteristics, such as erections and muscle strength. Most of the testosterone in your body is made by the testicles.

Different things can affect your testosterone levels including a number of health problems. If you have very low testosterone, you may have problems getting an erection or have a low libido. If your erection problems are caused by low testosterone, then you may be able to have testosterone replacement therapy. It works by increasing the levels of testosterone in your body to a normal level. This may improve your orgasms, ejaculation and erections. It may also make some treatments for erection problems (including PDE5 inhibitor tablets) work better.

If your doctor or nurse suggests trying testosterone replacement therapy ask them about the risks and benefits. For example, testosterone can make prostate cancer cells grow faster so isn’t usually recommended if you still have prostate cancer. And you won’t be able to have it if you’re having hormone therapy. Some research has shown that testosterone replacement therapy is safe for men who’ve been successfully treated for localised prostate cancer, where all of their cancer has been removed or destroyed. Your doctor will be able to explain more about whether this is safe for you.

If you decide to have testosterone therapy, it’s important to see the doctor or medical team who treated your prostate cancer, rather than go to a different doctor. And if you have it, you will need to have regular prostate specific antigen (PSA) blood tests and digital rectal examinations to check for any signs of your cancer returning.

Lifestyle changes such as staying a healthy weight and being physically active can help improve your sex life. Physical activity can help you stay a healthy weight and lowers the risk of some health problems that can cause erection problems, such as type-2 diabetes. It can also improve your energy levels, lift your mood and help with some of the side effects of treatment, such as fatigue.

Smoking may increase the risk of erection problems, and treatments may not work as well if you smoke. Stopping smoking isn’t easy but there is help available. The NHS website has information, advice and support for giving up smoking, including quit kits and face-to-face guidance.

With all treatments for erection problems, some men may find their erection won’t go down and can be painful. If this happens, try having sex or masturbating. Squatting, walking up and down the stairs or urinating (peeing) may also help.

Go to your nearest accident and emergency (A&E) department straightaway if your erection lasts more than four hours. This is called priapism. This is  considered a medical emergency, but it can be treated. It is very rare and less than one in 100 men who use treatments for erection problems experience this. With injections, the figure is slightly higher at about one in 100.  

Don’t use injections and PDE5 inhibitor tablets together, as this increases the risk of priapism.

Before sex, make sure your bladder and urethra are empty. After you urinate, use your fingertips to press gently upwards at the base of your scrotum. Keep pressing gently as you move your fingers forward from the base of your penis to the tip. This should squeeze out any urine that’s left in your urethra.

Sex therapy normally involves a series of counselling sessions. If you have a partner you may want them to be involved.

Sex (or psychosexual) therapists or counsellors may have a background in medicine, nursing or psychology. They’ll have had special training in the causes and treatment of sexual problems.

The first appointments will focus on the therapist getting to know you and finding out about your sex life. You and your partner may have joint and separate appointments.

You may find the conversations with the therapist uncomfortable at first, but this should improve as you get more confident. Remember, therapists talk to people about sex all the time – they are used to having these types of conversations.

At the end of these first few sessions, the therapist will give you some brief information and advice and talk to you about whether further therapy might be useful. They may refer you for couples counselling, or other psychological services or treatment.

If you have further sex therapy it will often involve more discussion of sexual problems, and specific activities and ways to work through them. You might have ‘homework’, such as a series of exercises to help you and your partner get to know each other’s bodies and how they respond sexually, find ways to communicate more effectively, or experiment with different ways of being close.

The therapist will work with you, at your own speed, to help you find solutions that work for you. There are many different options to try and only you and your partner can make those decisions. Sometimes just having someone listen to how you are feeling helps you find your own answers.

There are some myths about sex therapy – you will never be asked to undress or do anything sexual in the therapy room.

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• Vanessa Basketter, Urology Lead Nurse, University Hospital Southampton
• Lorraine Grover, Psychosexual Nurse Specialist, The London Clinic, London, and The Shelburne Hospital, Buckinghamshire
• Nicola Lancaster, Macmillan Metastatic Prostate Cancer Clinical Nurse Specialist, Darent Valley Hospital
• Our Specialist Nurses
• Our volunteers.