Between the Sheets - July 2022

QUESTION FROM PROSTATE CANCER SURVIVOR:

I am a 52-year old gay man whose 10-year relationship just ended. That was a long time coming, but of more concern to me right now is that I have been diagnosed with prostate cancer and I don’t know what to do about choosing a treatment. I have been offered surgery (radical prostatectomy using a robot) but I am not sure I want to go that route because of the potential for loss of erections. The surgeon I saw looked really embarrassed when I asked him about anal sex and left the exam room in a big hurry. I need to know what I am looking at if I do go with the surgery. I am not interested in a new relationship right now… But I also don’t want to be alone forever.

RESPONSE FROM DR. ANNE KATZ:

You are asking all the right questions and, of course, it’s always better to get the information you need BEFORE you have a treatment that can affect all aspects of quality of life. Decisional regret is more common than you might think! So… let me get to the nitty gritty of the sexual side effects of surgery for prostate cancer.

Surgery to remove the prostate (radical prostatectomy – robotic, open, or laparoscopic), has the potential to significantly alter your ability to have or maintain an erection. There is a high probability (95% risk) of loss of erections six months after surgery (Neal, et al., 2020), and less than half of men see a return to the same level of functioning they had before the surgery (Barocas, et al., 2017). But that’s not the whole story. Men also experience loss of penile length as well as dry orgasms, and some men experience pain with orgasm or loss of orgasm intensity.

In terms of anal sex, it depends on whether you are the insertive or receptive partner. You need very rigid erections if you are the insertive partner, so that might pose a problem if you have softer erections or if you have problems maintaining rigidity. Less rigid erections make using a condom a challenge too. If you are the receptive partner during anal sex, lack of erections may not be a functional problem, but the loss of ejaculate (dry orgasms) may be, and the loss of sensation due to the absence of the prostate itself may also be concerning. But… it is still possible to have orgasms without erections (you have to try it) and orgasms may even be more intense than before. However, it is also important to mourn what has been lost – spontaneity, confidence, perception of attractiveness – in order to move on to a new way of being sexual, with or without a partner.

Loss of sexual function can be a barrier to establishing a new relationship – and that is very sad. As we grow older, there is a natural and entirely normal decline in arousal. You may find that men your age or older have also experienced sexual changes and may be interested in a relationship with you, in spite of (or perhaps even because of) your challenges and experience with cancer treatment that might match their own.

Do you have a question about sexual health or intimacy? If so, we invite you to send it to ZERO. We’ll select questions to feature in future Between the Sheets columns. Please email your question to: bts@zerocancer.org.