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.

Watch our video on how to use tablets to get an erection.

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.

Watch our video on how to safely use a vacuum pump to get an erection.

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.

Watch our video on how to use injections to get an erection.

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. Watch our video on how to use the pellet to get an erection.

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. Watch our video on how to use the cream to get an erection.

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.

Watch our video on how to use an implant to get an erection.

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.

• Ervik B, Asplund K. Dealing with a troublesome body: a qualitative interview study of men’s experiences living with prostate cancer treated with endocrine therapy. Eur J Oncol Nurs Off J Eur Oncol Nurs Soc. 2012 Apr;16(2):103–8.
• Elliott S, Latini DM, Walker LM, Wassersug R, Robinson JW. Androgen Deprivation Therapy for Prostate Cancer: Recommendations to Improve Patient and Partner Quality of Life: Improving Life on ADT. J Sex Med. 2010 Sep;7(9):2996–3010.
• O’Shaughnessy PK, Laws TA, Esterman AJ. The prostate cancer journey: results of an online survey of men and their partners. Cancer Nurs. 2015 Feb;38(1):E1–12.
• Shivananda MJ, Rao TSS. Sexual dysfunction in medical practice: Curr Opin Psychiatry. 2016 Nov;29(6):331–5.
• McCabe M, Althof SE, Assalian P, Chevret-Measson M, Leiblum SR, Simonelli C, et al. Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction. J Sex Med. 2010 Jan;7(1):327–36.
• Emanu JC, Avildsen IK, Nelson CJ. Erectile dysfunction after radical prostatectomy: prevalence, medical treatments, and psychosocial interventions. Curr Opin Support Palliat Care. 2016 Mar;10(1):102–7.
• Steentjes L, Siesling S, Drummond FJ, van Manen JG, Sharp L, Gavin A. Factors associated with current and severe physical side-effects after prostate cancer treatment: What men report. Eur J Cancer Care (Engl). 2018 Jan;27(1):e12589.
• Clavell-Hernandez J, Wang R. Penile rehabilitation following prostate cancer treatment: review of current literature. Asian J Androl. 2015;17(6):916.
• Levinson AW, Lavery HJ, Ward NT, Su L-M, Pavlovich CP. Is a return to baseline sexual function possible? An analysis of sexual function outcomes following laparoscopic radical prostatectomy. World J Urol. 2010 Nov 24;29(1):29–34.
• Agochukwu NQ, Wittmann D, Boileau NR, Dunn RL, Montie JE, Kim T, et al. Validity of the Patient-Reported Outcome Measurement Information System (PROMIS) Sexual Interest and Satisfaction Measures in Men Following Radical Prostatectomy. J Clin Oncol Off J Am Soc Clin Oncol. 2019 Aug 10;37(23):2017–27.
• Ralph S, Richardson C. Developing UK guidance on how long men should abstain from receiving anal sex before, during, and after investigations and treatments for prostate cancer [MClin Res dissertation]. University of Manchester; 2018.
• Kilminster S, Müller S, Menon M, Joseph JV, Ralph DJ, Patel HRH. Predicting erectile function outcome in men after radical prostatectomy for prostate cancer. BJU Int. 2011;110(3):422–6.
• Abdollah F, Sun M, Suardi N, Gallina A, Bianchi M, Tutolo M, et al. Prediction of Functional Outcomes After Nerve-Sparing Radical Prostatectomy: Results of Conditional Survival Analyses. Eur Urol. 2012 Jul;62(1):42–52.
• Kirby MG, White ID, Butcher J, Challacombe B, Coe J, Grover L, et al. Development of UK recommendations on treatment for post-surgical erectile dysfunction. Int J Clin Pract. 2014 May;68(5):590–608.
• Donovan JL, Hamdy FC, Lane JA, Mason M, Metcalfe C, Walsh E, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2016 Oct 13;375(15):1425–37.
• Frey AU, Sønksen J, Fode M. Neglected Side Effects After Radical Prostatectomy: A Systematic Review. J Sex Med. 2014 Feb;11(2):374–85.
• Capogrosso P, Ventimiglia E, Cazzaniga W, Stabile A, Pederzoli F, Boeri L, et al. Long-term penile morphometric alterations in patients treated with robot-assisted versus open radical prostatectomy. Andrology. 2018 Jan;6(1):136–41.
• Capogrosso P, Ventimiglia E, Cazzaniga W, Montorsi F, Salonia A. Orgasmic Dysfunction after Radical Prostatectomy. World J Mens Health. 2017;35(1):1.
• Clavell-Hernández J, Martin C, Wang R. Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature. Sex Med Rev. 2018 Jan 1;6(1):124–34.
• Green TP, Saavedra-Belaunde J, Wang R. Ejaculatory and Orgasmic Dysfunction Following Prostate Cancer Therapy: Clinical Management. Med Sci. 2019 Dec 10;7(12):109.
• Tran S, Boissier R, Perrin J, Karsenty G, Lechevallier E. Review of the Different Treatments and Management for Prostate Cancer and Fertility. Urology. 2015 Nov;86(5):936–41.
• Boeri L, Capogrosso P, Ventimiglia E, Cazzaniga W, Pederzoli F, Gandaglia G, et al. Depressive Symptoms and Low Sexual Desire after Radical Prostatectomy: Early and Long-Term Outcomes in a Real-Life Setting. J Urol. 2018 Feb;199(2):474–80.
• Avellino G, Theva D, Oates RD. Common urologic diseases in older men and their treatment: how they impact fertility. Fertil Steril. 2017 Feb;107(2):305–11.
• Ralph, Sean, Richardson, Clifford. How Long Should Men Abstain from Receiving Anal Sex Following Treatments for Prostate Cancer? In 2019. p. 1.
• Mohan R, Schellhammer PF. Treatment options for localized prostate cancer. Am Fam Physician. 2011;84(4):413–20.
• Siglin J, Kubicek GJ, Leiby B, Valicenti RK. Time of Decline in Sexual Function After External Beam Radiotherapy for Prostate Cancer. Int J Radiat Oncol Biol Phys. 2010 Jan;76(1):31–5.
• Ridout A, Emberton M, Moore C. Sexual dysfunction and prostate cancer therapy. In: Minhas S, Mulhall J, editors. Male Sexual Dysfunction [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2016 [cited 2020 Jan 23]. p. 302–13. Available from: http://doi.wiley.com/10.1002/9781118746509.ch32
• Olsson CE, Alsadius D, Pettersson N, Tucker SL, Wilderäng U, Johansson K-A, et al. Patient-reported sexual toxicity after radiation therapy in long-term prostate cancer survivors. Br J Cancer. 2015 Sep 1;113(5):802–8.
• White ID, Wilson J, Aslet P, Baxter AB, Birtle A, Challacombe B, et al. Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer. Int J Clin Pract. 2015 Jan;69(1):106–23.
• Farhood B, Mortezaee K, Haghi‐Aminjan H, Khanlarkhani N, Salehi E, Nashtaei MS, et al. A systematic review of radiation‐induced testicular toxicities following radiotherapy for prostate cancer. J Cell Physiol. 2019 Sep;234(9):14828–37.
• Gaither TW, Awad MA, Osterberg EC, Murphy GP, Allen IE, Chang A, et al. The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis. J Sex Med. 2017 Sep;14(9):1071–8.
• Bownes P, Coles I, Doggart A, Kehoe T. UK Guidance on Radiation Protection Issues following Permanent Iodine- 125 Seed Prostate Brachytherapy [Internet]. 2012. Available from: https://www.ipem.ac.uk/ScientificJournalsPublications/UKGuidanceonRadiationProtectionIssuesfollowi.aspx
• International Commission on Radiological Protection. Radiation safety aspects of brachytherapy for prostate cancer using permanently implanted sources. A report of ICRP Publication 98. Ann ICRP. 2005;35(3):iii–vi, 3–50.
• Royal College of Radiologists. Quality assurance practice guidelines for transperineal LDR permanent seed brachytherapy of prostate cancer. 2012.
• Nasser NJ, Cohen GN, Dauer LT, Zelefsky MJ. Radiation safety of receptive anal intercourse with prostate cancer patients treated with low-dose-rate brachytherapy. Brachytherapy. 2016 Aug;15(4):420–5.
• Mottet N, Bellmunt J, Briers E, Bolla M, Cornford P, De Santis M, et al. Guidelines on prostate cancer. European Association of Urology; 2016.
• Peters M, van Son M, Moerland M, Kerkmeijer L, Eppinga W, Meijer R, et al. MRI-Guided Ultrafocal HDR Brachytherapy.pdf. Int J Radiat Oncol Biol Phys. 2019;104(5):1045–53.
• Strouthos I, Tselis N, Chatzikonstantinou G, Butt S, Baltas D, Bon D, et al. High dose rate brachytherapy as monotherapy for localised prostate cancer. Radiother Oncol. 2018 Feb 1;126(2):270–7.
• Ramsay CR, Adewuyi TE, Gray J, Hislop J, Shirley MD, Jayakody S, et al. Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation. Health Technol Assess. 2015 Jul;19(49):1–490.
• Faure Walker NA, Norris JM, Shah TT, Yap T, Cathcart P, Moore CM, et al. A comparison of time taken to return to baseline erectile function following focal and whole gland ablative therapies for localized prostate cancer: A systematic review. Urol Oncol Semin Orig Investig. 2018 Feb;36(2):67–76.
• Valerio M, Cerantola Y, Eggener SE, Lepor H, Polascik TJ, Villers A, et al. New and Established Technology in Focal Ablation of the Prostate: A Systematic Review. Eur Urol. 2017 Jan;71(1):17–34.
• Wassersug RJ. Maintaining intimacy for prostate cancer patients on androgen deprivation therapy: Curr Opin Support Palliat Care. 2016 Mar;10(1):55–65.
• Haliloglu A, Baltaci S, Yaman O. Penile length changes in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer. J Urol. 2007 Jan;177(1):128–30.
• Nguyen PL, Alibhai SMH, Basaria S, D’Amico AV, Kantoff PW, Keating NL, et al. Adverse Effects of Androgen Deprivation Therapy and Strategies to Mitigate Them. Eur Urol. 2015 May;67(5):825–36.
• Donovan KA, Walker LM, Wassersug RJ, Thompson LMA, Robinson JW. Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners: Psychological Effects of ADT. Cancer. 2015 Dec 15;121(24):4286–99.
• Docetaxel 20 mg/ml concentrate for solution for infusion - Summary of Product Characteristics (SmPC) - (emc) [Internet]. [cited 2020 Feb 5]. Available from: https://www.medicines.org.uk/emc/product/7206/smpc#PREGNANCY
• Jevtana - Summary of Product Characteristics (SmPC) - (emc) [Internet]. [cited 2020 Feb 5]. Available from: https://www.medicines.org.uk/emc/product/4541#PREGNANCY
• Voznesensky M, Annam K, Kreder KJ. Understanding and Managing Erectile Dysfunction in Patients Treated for Cancer. J Oncol Pract. 2016 Apr;12(4):297–304.
• Letts C, Tamlyn K, Byers ES. Exploring the Impact of Prostate Cancer on Men’s Sexual Well-Being. J Psychosoc Oncol. 2010 Aug 24;28(5):490–510.
• National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management. NICE guideline 131. 2019.
• Saitz TR, Serefoglu EC, Trost LW, Thomas R, Hellstrom WJG. The pre-treatment prevalence and types of sexual dysfunction among patients diagnosed with prostate cancer. Andrology. 2013 Nov;1(6):859–63.
• DeLamater J, Karraker A. Sexual functioning in older adults. Curr Psychiatry Rep. 2009 Feb;11(1):6–11.
• Hatzimouratidis K, Giuliano F, Moncada I, Muneer A, Salonia A, Verze P. EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism. European Association of Urology; 2019.
• Schartau P, Nazareth I, Muneer A, Kirby M. Erectile dysfunction. InnovAiT Educ Inspir Gen Pract. 2018 May;11(5):269–76.
• Yafi FA, Jenkins L, Albersen M, Corona G, Isidori AM, Goldfarb S, et al. Erectile dysfunction. Nat Rev Dis Primer. 2016 Dec;2(1):16003.
• Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, et al. Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med. 2017 Mar;14(3):285–96.
• Schover LR, Canada AL, Yuan Y, Sui D, Neese L, Jenkins R, et al. A randomized trial of internet-based versus traditional sexual counseling for couples after localized prostate cancer treatment. Cancer. 2012 Jan 15;118(2):500–9.
• Latini DM, Hart SL, Coon DW, Knight SJ. Sexual rehabilitation after localized prostate cancer: current interventions and future directions. Cancer J Sudbury Mass. 2009 Feb;15(1):34–40.
• Kimura M, Caso JR, Bañez LL, Koontz BF, Gerber L, Senocak C, et al. Predicting participation in and successful outcome of a penile rehabilitation programme using a phosphodiesterase type 5 inhibitor with a vacuum erection device after radical prostatectomy. BJU Int. 2012 Dec;110(11 Pt C):E931-938.
• Basal S, Wambi C, Acikel C, Gupta M, Badani K. Optimal strategy for penile rehabilitation after robot-assisted radical prostatectomy based on preoperative erectile function. BJU Int. 2013 Apr;111(4):658–65.
• Beck AM, Robinson JW, Carlson LE. Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. Urol Oncol Semin Orig Investig. 2009 Mar;27(2):137–43.
• Doherty W, Bridge P. A Systematic Review of the Role of Penile Rehabilitation in Prostate Cancer Patients Receiving Radiotherapy and Androgen Deprivation Therapy. J Med Imaging Radiat Sci. 2019 Mar;50(1):171–8.
• Garcia FJ, Chung E, Brock G. Drug therapy for erectile dysfunction. In: Minhas S, Mulhall J, editors. Male Sexual Dysfunction [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2016 [cited 2020 Jan 23]. p. 172–93. Available from: http://doi.wiley.com/10.1002/9781118746509.ch19
• National Institute for Health and Care Excellence. Erectile dysfunction: avanafil. 2014.
• Hatzimouratidis K, Giuliano F, Moncada I, Muneer A, Salonia A, Verze P. EAU guidelines on erectile dysfunction, premature ejaculation, penile curvature and priapism. European Association of Urology; 2016.
• National Institute for Health and Care Excellence. Prostate Cancer: diagnosis and treatment. Full guideline 175. 2014.
• Electronic Medicines Compendium. Sildenafil Accord 100 mg Film-coated Tablets - Summary of Product Characteristics [Internet]. 2016 [cited 2017 Jan 16]. Available from: http://www.medicines.org.uk/emc/medicine/28203
• Electronic Medicines Compendium. Cialis 2.5mg, 5mg, 10mg & 20mg film-coated tablets: Summary of Product Characteristics [Internet]. 2016. Available from: https://www.medicines.org.uk/emc/medicine/11363
• Ahmed N, Bestall JE, Ahmedzai SH, Payne SA, Clark D, Noble B. Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals. Palliat Med. 2004;18(6):525–542.
• Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, et al. Sexual Rehabilitation After Treatment For Prostate Cancer—Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med. 2017 Mar;14(3):297–315.
• Medicines and Healthcare products Regulatory Agency (MHRA). Herbal products: safety update [Internet]. 2009 [cited 2017 Jan 16]. Available from: https://www.gov.uk/drug-safety-update/herbal-products-safety-update
• Raina R, Pahlajani G, Agarwal A, Zippe CD. Early penile rehabilitation following radical prostatectomy: Cleveland clinic experience. Int J Impot Res. 2007;20(2):121–126.
• Dougherty P. Erectile Dysfunction. Physician Assist Clin. 2018 Jan;3(1):113–27.
• Wassersug R, Wibowo E. Non-pharmacological and non-surgical strategies to promote sexual recovery for men with erectile dysfunction. Transl Androl Urol. 2017 Nov;6(S5):S776–94.
• Zippe CD, Pahlajani G. Vacuum erection devices to treat erectile dysfunction and early penile rehabilitation following radical prostatectomy. Curr Urol Rep. 2008 Nov;9(6):506–13.
• Caverject 5 micrograms powder for solution for injection: Summary of Product Characteristics [Internet]. 2013. Available from: https://www.medicines.org.uk/emc/medicine/1480
• National Institute for Health and Care Excellence. Aviptadil with phentolamine mesilate - British National Formulary [Internet]. NICE; [cited 2020 Apr 1]. Available from: https://bnf.nice.org.uk/drug/aviptadil-with-phentolamine-mesilate.html
• Electronic Medicines Compendium. Vitaros 3 mg/g cream - Summary of Product Characteristics [Internet]. 2016 [cited 2017 Jan 16]. Available from: https://www.medicines.org.uk/emc/medicine/28866
• Electronic Medicines Compendium. MUSE 1000 microgram urethral stick. [Internet]. 2014. Available from: http://www.medicines.org.uk/emc/medicine/22218
• NHS Choices. What should I do if my erection won’t go down? [Internet]. 2016 [cited 2017 Jan 16]. Available from: http://www.nhs.uk/chq/Pages/883.aspx?CategoryID=61&SubCategoryID=612
• Sherer BA, Levine LA. Current management of erectile dysfunction in prostate cancer survivors: Curr Opin Urol. 2014 Jul;24(4):401–6.
• Reinstatler L, Shee K, Gross MS. Pain Management in Penile Prosthetic Surgery: A Review of the Literature. Sex Med Rev. 2018 Jan;6(1):162–9.
• O’Connor DB, Lee DM, Corona G, Forti G, Tajar A, O’Neill TW, et al. The Relationships between Sex Hormones and Sexual Function in Middle-Aged and Older European Men. J Clin Endocrinol Metab. 2011 Oct;96(10):E1577–87.
• Bassil N, Alkaade S, Morley JE. The benefits and risks of testosterone replacement therapy: a review. Ther Clin Risk Manag. 2009 Jun;5(3):427–48.
• Morgentaler A. Testosterone therapy in men with prostate cancer: scientific and ethical considerations. J Urol. 2013 Jan;189(1 Suppl):S26-33.
• Kaplan AL, Hu JC, Morgentaler A, Mulhall JP, Schulman CC, Montorsi F. Testosterone Therapy in Men With Prostate Cancer. Eur Urol. 2016 May;69(5):894–903.
• Hannan JL, Maio MT, Komolova M, Adams MA. Beneficial Impact of Exercise and Obesity Interventions on Erectile Function and Its Risk Factors. J Sex Med. 2009 Mar;6(S3):254–61.
• Meldrum DR, Gambone JC, Morris MA, Esposito K, Giugliano D, Ignarro LJ. Lifestyle and metabolic approaches to maximizing erectile and vascular health. Int J Impot Res. 2012 Apr;24(2):61–8.
• Ying M, Zhao R, Jiang D, Gu S, Li M. Lifestyle interventions to alleviate side effects on prostate cancer patients receiving androgen deprivation therapy: a meta-analysis. Jpn J Clin Oncol. 2018 Sep 1;48(9):827–34.
• Kessels E, Husson O, van der Feltz-Cornelis CM. The effect of exercise on cancer-related fatigue in cancer survivors: a systematic review and meta-analysis. Neuropsychiatr Dis Treat. 2018 Feb 9;14:479–94.
• Keilani M, Hasenoehrl T, Baumann L, Ristl R, Schwarz M, Marhold M, et al. Effects of resistance exercise in prostate cancer patients: a meta-analysis. Support Care Cancer. 2017 Sep 1;25(9):2953–68.
• Geraerts I, Van Poppel H, Devoogdt N, De Groef A, Fieuws S, Van Kampen M. Pelvic floor muscle training for erectile dysfunction and climacturia 1 year after nerve sparing radical prostatectomy: a randomized controlled trial. Int J Impot Res. 2015;28:9–13.
• Siegel AL. Pelvic floor muscle training in males: practical applications. Urology. 2014 Jul;84(1):1–7.
• Verze P, Margreiter M, Esposito K, Montorsi P, Mulhall J. The Link Between Cigarette Smoking and Erectile Dysfunction: A Systematic Review. Eur Urol Focus. 2015 Aug;1(1):39–46.
• Nguyen C, Lairson DR, Swartz MD, Du XL. Risks of Major Long-Term Side Effects Associated with Androgen-Deprivation Therapy in Men with Prostate Cancer. Pharmacother J Hum Pharmacol Drug Ther. 2018 Oct;38(10):999–1009.
• Botrel TEA, Clark O, dos Reis RB, Pompeo ACL, Ferreira U, Sadi MV, et al. Intermittent versus continuous androgen deprivation for locally advanced, recurrent or metastatic prostate cancer: a systematic review and meta-analysis. BMC Urol. 2014;14:9.
• Magnan S, Zarychanski R, Pilote L, Bernier L, Shemilt M, Vigneault E, et al. Intermittent vs Continuous Androgen Deprivation Therapy for Prostate Cancer: A Systematic Review and Meta-analysis. JAMA Oncol. 2015 Sep 17;1–10.
• O’Shaughnessy P “Kevin, Laws TA, Esterman AJ. The Prostate Cancer Journey: Results of an Online Survey of Men and Their Partners. Cancer Nurs. 2015;38(1):E1–12.
• McKee AL, Schover LR. Sexuality rehabilitation. Cancer. 2001;92((Suppl 4)):1008–12.
• Walker LM, Robinson JW. The Unique Needs of Couples Experiencing Androgen Deprivation Therapy for Prostate Cancer. J Sex Marital Ther. 2010 Feb 23;36(2):154–65.
• Choices NHS. Loss of libido (reduced sex drive) - NHS Choices [Internet]. 2017 [cited 2017 Jul 18]. Available from: http://www.nhs.uk/conditions/loss-of-libido/Pages/Introduction.aspx
• Langston B, Armes J, Levy A, Tidey E, Ream E. The prevalence and severity of fatigue in men with prostate cancer: a systematic review of the literature. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2013 Jun;21(6):1761–71.
• Holloway V, Wylie K. Sex drive and sexual desire. Curr Opin Psychiatry. 2015 Nov;28(6):424–9.
• Berookhim BM, Nelson CJ, Kunzel B, Mulhall JP, Narus JB. Prospective analysis of penile length changes after radical prostatectomy. BJU Int. 2014 May;113(5b):E131-136.
• Ilie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Int. 2007 Jun;99(6):1335–9.
• Barnas JL, Pierpaoli S, Ladd P, Valenzuela R, Aviv N, Parker M, et al. The prevalence and nature of orgasmic dysfunction after radical prostatectomy. BJU Int. 2004 Sep;94(4):603–5.
• Royal College of Physicians of London, Royal College of Radiologists (Great Britain), Royal College of Obstetricians and Gynaecologists (Great Britain). The effects of cancer treatment on reproductive functions: guidance on management : report of a working party. Royal College of Physicians; 2007.
• Human Fertilisation and Embryology Authority S and ID. Freezing and storing sperm [Internet]. [cited 2015 Feb 26]. Available from: http://www.hfea.gov.uk/74.html
• Wittmann D, Northouse L, Foley S, Gilbert S, Wood DP, Balon R, et al. The psychosocial aspects of sexual recovery after prostate cancer treatment. Int J Impot Res. 2009 Apr;21(2):99–106.
• Rivers BM, August EM, Gwede CK, Hart A, Donovan KA, Pow-Sang JM, et al. Psychosocial issues related to sexual functioning among African-American prostate cancer survivors and their spouses. Psychooncology. 2011 Jan;20(1):106–10.
• Campbell LC, Keefe FJ, McKee DC, Waters SJ, Moul JW. Masculinity beliefs predict psychosocial functioning in African American prostate cancer survivors. Am J Mens Health. 2012 Sep;6(5):400–8.
• Canada AL, Neese LE, Sui D, Schover LR. Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Cancer. 2005 Dec 15;104(12):2689–700.
• Molton IR, Siegel SD, Penedo FJ, Dahn JR, Kinsinger D, Traeger LN, et al. Promoting recovery of sexual functioning after radical prostatectomy with group-based stress management: the role of interpersonal sensitivity. J Psychosom Res. 2008 May;64(5):527–36.
• Nilsson AE, Carlsson S, Johansson E, Jonsson MN, Adding C, Nyberg T, et al. Orgasm-Associated Urinary Incontinence and Sexual Life after Radical Prostatectomy. 2011;8:2632–2639.
• Reese JB. Coping with sexual concerns after cancer. Curr Opin Oncol. 2011 Jul;23(4):313–21.
• Ervik B, Nordøy T, Asplund K. In the middle and on the sideline: the experience of spouses of men with prostate cancer. Cancer Nurs. 2013 Jun;36(3):E7–14.
• NHS Choices. What does a sex therapist do? [Internet]. 2016 [cited 2017 Jan 16]. Available from: http://www.nhs.uk/chq/Pages/1683.aspx?CategoryID=68
• Rosser BRS, Kohli N, Polter EJ, Lesher L, Capistrant BD, Konety BR, et al. The Sexual Functioning of Gay and Bisexual Men Following Prostate Cancer Treatment: Results from the Restore Study. Arch Sex Behav. 2020 Jul;49(5):1589–600.
• Cornell D. A Gay Urologist’s Changing Views on Prostate Cancer. J Gay Lesbian Psychother. 2005 Feb 15;9(1–2):29–41.
• Goldstone SE. The Ups and Downs of Gay Sex After Prostate Cancer Treatment. J Gay Lesbian Psychother. 2005 Feb 15;9(1–2):43–55.
• Blank TO. Gay Men and Prostate Cancer: Invisible Diversity. J Clin Oncol. 2004 Sep 27;23(12):2593–6.
• Thomas C, Wootten A, Robinson P. The experiences of gay and bisexual men diagnosed with prostate cancer: results from an online focus group: Gay and bisexual men diagnosed with prostate cancer. Eur J Cancer Care (Engl). 2013 Jul;22(4):522–9.
• Hulbert-Williams NJ, Plumpton C o., Flowers P, McHugh R, Neal R d., Semlyen J, et al. The cancer care experiences of gay, lesbian and bisexual patients: A secondary analysis of data from the UK Cancer Patient Experience Survey. Eur J Cancer Care (Engl). 2017 Jul 1;26(4):n/a-n/a.
• Matheson L, Watson E k., Nayoan J, Wagland R, Glaser A, Gavin A, et al. A qualitative metasynthesis exploring the impact of prostate cancer and its management on younger, unpartnered and gay men. Eur J Cancer Care (Engl). 2017 Nov 1;26(6):n/a-n/a.
• Rose D, Ussher JM, Perz J. Let’s talk about gay sex: gay and bisexual men’s sexual communication with healthcare professionals after prostate cancer. Eur J Cancer Care (Engl). 2017 Jan;26(1):e12469.
• Kelly D, Sakellariou D, Fry S, Vougioukalou S. Heteronormativity and prostate cancer: a discursive paper. J Clin Nurs [Internet]. 2017 Apr 5 [cited 2017 May 2]; Available from: http://doi.wiley.com/10.1111/jocn.13844
• Lisy K, Peters MDJ, Schofield P, Jefford M. Experiences and unmet needs of lesbian, gay and bisexual people with cancer care: a systematic review and meta-synthesis. Psychooncology. 2018;n/a-n/a.
• Kazer MW, Harden J, Burke M, Sanda MG, Hardy J, Bailey DE. The experiences of unpartnered men with prostate cancer: a qualitative analysis. J Cancer Surviv. 2010 Nov 28;5(2):132–41.

• 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.