How Cancer Can Affect Erections

Cancer surgery and erections

Some types of cancer surgery can change your ability to have erections.

• Radical prostatectomy: Removal of the prostate and some surrounding tissue, including the seminal vesicles. Sometimes nearby lymph nodes are also removed. (For prostate cancer.)
• Radical cystectomy: Removal of the bladder, prostate, seminal vesicles and nearby lymph nodes. Because the bladder is removed, a new way of collecting urine is needed, either into a bag through an opening on the belly (urostomy) or by building a new “bladder” inside the body. (For bladder cancer.)
• Abdominoperineal (AP) resection: Removal of the lower colon, rectum and anus. This surgery may require a colostomy, an opening in the belly (abdomen) where stool can leave the body. (For colorectal cancer.)
• Total mesorectal excision (TME): Removal of the rectum and nearby lymph nodes. The colon is then connected to the anus so stool (poop) can pass in the usual way. (For rectal cancer.)
• Total pelvic exenteration: Removal of the rectum and nearby organs that the cancer has reached. This might include the bladder, prostate, and seminal vesicles. After this surgery, new openings may be needed for both urine and solid waste to leave the body. (For a large tumor of the colon.)

Most men who have these types of surgeries might have some trouble with erections.

This is because these operations can damage the nerves needed for an erection. Some men will be able to have erections firm enough for penetration, but probably not as firm as they were before surgery. Others may not be able to get erections at all.

If any of these surgeries are part of your treatment plan, talk to your cancer care team before the procedure. Ask how surgery might affect your erections and how to manage any problems.

Nerve damage from surgery

The most common reason people have erection problems after cancer surgery is because the nerves needed for an erection were removed or damaged. These nerves are next to the rectum and surround the back and sides of the prostate gland. That makes it easy for them to get damaged during an operation.

Nerve-sparing surgery

If the size and location of a tumor allow for it, surgeons try to avoid the nerves needed for erection. When possible, surgeons use “nerve-sparing” methods in radical prostatectomy, radical cystectomy, AP resection, and TME operations.

More men recover erections after nerve-sparing surgery than men who have surgery in which nerve sparing isn’t possible.

Regaining erections after surgery

Even with nerve-sparing surgery, it can take some time to regain erections. Nerves can be injured during the operation and need time to heal before erections return. This healing can take up to 2 years.

It’s not known why some men regain full erections after surgery and others do not. But when nerves on both the left and right sides of the prostate are spared, men are more likely to regain erections.

Other things that affect erections after surgery

There are other factors that can affect whether you are able to get erections after cancer surgery, such as:

• Age: The younger you are, the more likely you are to regain full erections after surgery. Men under 60, and especially those under 50, are more likely to recover their erections than older men.
• Strength of erections before surgery: If you had strong erections before cancer surgery, you are far more likely to recover your erections than if you had erection problems.
• Other health problems: If you have other health conditions that can affect erections, you may have more trouble regaining erections after surgery. This includes diabetes, hypertension, heart disease, obesity, low testosterone levels, or depression, or if you smoke or take certain medicines.

Pelvic radiation therapy and erections

Radiation therapy to the pelvis is used to treat some kinds of prostate, bladder, colon, and rectal cancer. Because the male sex organs are in the pelvis, radiation to this area might cause problems with erections.

Radiation is done in one of two ways: external beam radiation (aimed from outside the body) or brachytherapy (placed inside the body). Either type of radiation can cause damage to the nerves and blood vessels your body needs to have erections.

As the treated area heals after radiation, scar tissue may form and keep the blood vessels from stretching like they should. This can cause trouble in having a firm erection. Radiation can also cause hardening (arteriosclerosis), narrowing, or even blockage of the pelvic arteries.

How soon after radiation do erection problems start? Are they permanent?

Trouble with erections comes on more slowly with radiation therapy than with surgery.

• If erection problems happen, they usually start between 6 months to 2 years after radiation ends.
• Some men will still have full erections but lose them before reaching orgasm.
• Other men will no longer get firm erections at all.

Erection problems are not always permanent. They might get better after 2-3 years.

Does radiation therapy always cause erection problems?

Not all men have erection problems after radiation therapy. The higher the total dose of radiation and the larger the section of the pelvis treated, the greater the chance of erection problems later.

If radiation therapy to your pelvis is part of your treatment plan, talk to your radiation therapy team before it starts. Ask how your arteries and nerves might be affected by radiation therapy, so you know what to expect.

Other things that affect erections after radiation

• Age: The older you are, the more likely you are to have problems with erections after radiation therapy. This is because as you age, your blood vessels can lose some of their ability to stretch and allow blood to flow into them.
• Damaged blood vessels: If your blood vessels have been damaged by heart or blood vessel disease, diabetes, or heavy smoking, you are also at greater risk for erection problems.

Doctors are looking at whether early penile rehabilitation could help after radiation therapy, too.

Erection problems after radiation therapy or surgery for prostate cancer

If you have early-stage prostate cancer, you may have a choice between radiation and surgery to treat your cancer. You may wonder which treatment is more likely to cause erection problems. Studies don’t show much long-term difference between surgery and radiation.

• Radiation for prostate cancer: Men who had radiation may see a general decrease in the firmness of their erections over time (up to several years after radiation).
• Surgery for prostate cancer: After surgery, most men have erection problems right away and then have a chance to recover erections in the first 2 years following surgery.

About 4 years after either treatment, the percentage of men reporting erectile dysfunction is about the same. Treatments can often help men get their erections back after prostate cancer treatment, regardless of whether they had surgery or radiation.

Hormone therapy and erections

Some prostate cancer treatments are designed to lower the amount of the male hormone testosterone that your body makes. This is called androgen deprivation therapy (ADT).

ADT can cause low sex drive, problems with erections, and problems with having an orgasm.

Your erections may or may not recover when you stop ADT. If you are younger, you are more likely to regain erections because your body already makes more of its own testosterone. But you may still need to take medicines for a full erection. Erectile dysfunction medicines may not work though, if you have lost your desire for sex.  

Chemo, targeted therapy, immunotherapy, and erections

Some chemotherapy, targeted therapy, and immunotherapy medicines can reduce the amount of testosterone your body releases. This can cause decreased sexual desire and problems with erections.

Testosterone levels usually return to normal after treatment ends. You might lose the ability to get an erection, but this usually comes back with time. Ask your cancer care team about the possible sexual side effects of any medicine that is part of your cancer treatment.

Some types of chemo can also cause short-term or long-term infertility. For more information, see How Cancer and Cancer Treatment Can Affect Fertility in Men.

Stem cell transplant and erections

Before you get a stem cell transplant (also called bone marrow transplant), you will be given high doses of chemotherapy and radiation therapy in preparation. Both treatments can lower the amount of testosterone your body makes, which can lead to problems with erections.

Graft-versus-host disease is another side effect of stem cell transplant. Men who get graft-versus-host disease are more likely to have a long-lasting loss of testosterone. If this happens, you may need testosterone replacement to regain sexual desire and erections.

How emotions can affect erections

Cancer and cancer treatment can affect your emotions, energy level, and how you feel about yourself. Your ability to have and keep erections could be affected by feelings like:

• Fatigue (low energy)
• Distress from pain
• Not feeling good about your body
• Fear that you might not be able to get and keep an erection
• Depression
• Anxiety

These symptoms can make it harder for you to relax and feel excited about intimacy.

Many men report feeling disappointed when they have trouble with erections. You may feel that something important is missing. These feelings are a natural part of coping with erection problems.

For most men, finding effective treatments for erections or figuring out other ways of being intimate with a partner can help them feel better.

If you have erection problems caused by these emotions, a therapist or other mental health professional can often help. There are mental health professionals who specialize in helping people with cancer who are having sexual issues.

Managing erection problems

You’ll have a number of options for dealing with erectile dysfunction and will likely need to use more than one. How well each works can vary greatly. You may have to try a few to find the ones that works best for you.

Many of these treatments are used during penile rehabilitation.

Learn more