One of the most significant impacts of prostate cancer treatment is on sexual health. All forms of treatment for prostate cancer – including surgery (prostatectomy), external beam radiation therapy, and brachytherapy can have an impact on erectile dysfunction and sexual health more broadly. In particular, treatments for prostate cancer can affect interest in sex (libido), the mechanical ability to have an erection, the ability to orgasm, and the ability to ejaculate. Understanding the impact of prostate cancer treatment on your sex life is an important piece in evaluating prostate cancer treatment options. For those patients who do suffer from sexual side effects, understanding treatment options to improve sexual health is equally important.

Sexual Health at Baseline

A tool that many prostate cancer experts use is the Sexual Health Inventory for Men (SHIM) Questionnaire to evaluate sexual health. Questions on this questionnaire include the following:

  1. How do you rate your confidence that you could get and keep an erection? 
  2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
  3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? 
  4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 
  5. When you attempted sexual intercourse, how often was it satisfactory for you? 

Each question is rated with a 0-5 score. Patients with lower scores (0-7) have severe erectile dysfunction while patients with higher scores (22-25) have little to no signs of erectile dysfunction. As men age, most men develop some degree of erectile dysfunction.  Approximately 5-10% of men under the age of 40 do have some amount of erectile dysfunction.  At age 40, approximately 22% of men have moderate to complete erectile dysfunction.  By age 70, almost 50% of patients have moderate to complete erectile dysfunction.

Differentiating worsening erectile dysfunction due to prostate cancer treatment from natural processes can help men evaluate the potential impact of different treatment options on their sexual health. 

How does surgery or radiation therapy affect erectile dysfunction? 

The mechanism of erectile dysfunction between radiation and surgery are quite different. Prior to the advent of nerve-sparing techniques, virtually all men developed erectile dysfunction after surgery for prostate cancer.  In 1982, Dr. Patrick Walsh developed the nerve-sparing prostatectomy surgery.  This surgery spares the neurovascular bundle which, thus improving erectile function. However, for many men with more advanced prostate cancers, sparing the neurovascular bundle or can increase the chance of positive margins (leaving prostate cancer behind at the time of surgery), and thus appropriate patient selection very important.  Patients should ask the surgeons whether they believe they are appropriate candidates for nerve-sparing surgery.  However even with nerve-sparing surgery, many men still do develop erectile dysfunction.  In a study published in the Journal of the American Medical Association in the year 2000 of approximately 1300 men, among patients who were potent before surgery, 65.6% developed erectile dysfunction after non-nerve sparing surgery and 56.0% developed erectile dysfunction after bilateral nerve sparing surgery.  The nerves that control erectile function are especially sensitive and even minor damage to these nerves in a nerve-sparing surgery can significantly affect erectile function.

The etiology of erectile dysfunction related to radiation therapy is quite different than surgery.  Although radiation can have some damage on the nerves, which may contribute to erectile dysfunction, nerves in general are generally quite resistant to radiation therapy.  In particular, the nerves related to erectile dysfunction are quite resistant to the effects of radiation therapy when done with low-dose rate radiation therapy approach using brachytherapy seeds. The impact of radiation induced erectile dysfunction is more commonly thought to be related to fibrosis and vascular damage which leads to less blood supply to penile tissue. Thus, radiation induced erectile dysfunction is often quite responsive to medications such as Viagra and Cialis.

Comparing the impact of Surgery, External Beam Radiation, and Brachytherapy on Erectile Dysfunction

There are several studies which evaluate the impact of radiation therapy versus surgery on sexual health.  The largest and most well-known study, which compares surgery to radiation therapy, is the PROTECT trial, which was a study of 1643 men in the United Kingdom.  In this study, patients with mostly low risk prostate cancer were randomized to radiation therapy, surgery, or active surveillance.  In that study, patients who received brachytherapy or received active surveillance had the best sexual health outcomes. Patients who received surgery tended to have the worst overall sexual health outcomes. Table S3 shows the results of this study in more detail: Link to Study

Other more recent studies, including a study published of 835 men treated for prostate cancer in North Carolina between June 2011 to 2013, showed that patient has received external beam radiation therapy or brachytherapy alone had better sexual health outcomes at 12 and 24 months after treatment for prostate cancer compared to patients who received external beam radiation therapy with androgen deprivation therapy or radical prostatectomy. The full results of this study can be found here: Link to Study

The skill of the treating physician including the surgeon, radiation oncology, or brachytherapist can significantly impact the sexual health outcomes of prostate cancer treatment.  Choosing a physician who primarily specializes in prostate cancer and treats a high number of patients is important in order to achieve the best sexual health outcomes.  The physicians at Western Radiation Oncology have a thorough discussion with each patient on the impact of prostate cancer treatment on their sexual quality of life.

Treatment of Erectile Dysfunction after Prostate Cancer Treatment

For men seeking to preserve their sexual health after prostate cancer treatment, early intervention is key.  Certain exercise interventions have been found to improve sexual dysfunction in patients treated for prostate cancer.  Physicians often prescribed oral medications (such as Cialis or Viagra), injectable medications (such as TriMix), and penile pumps or implants to improve erectile function. 

We encourage our patients to contact their urologist if they have questions about interventions to improve their sexual wellbeing. One of our urology partners in the San Francisco Bay Area, Dr. Chris Threatt, a urologist practicing in Atherton and Redwood City, focuses on sexual function recovery after the treatment of prostate cancer. After treating men with prostate cancer for 20 years, Dr. Threatt recently founded co-founded Kane Health, a men’s health clinic that utilizes advances in medicine and technology to provide men with a safe, whole-body approach for male health and sexual wellness. 

Kane Health’s innovative program is multi-focal and comprehensive. It involves proprietary medications, micro-dosed to your body’s personal chemistry, paired with acoustic wave therapy administered at critical intervals to stimulate angiogenesis, or the growth of new blood vessels. This, along with other regenerative therapies, are used to regenerate cells and accelerate healing. Their comprehensive program is designed to address the factors that contribute to the loss of sexual function during treatment and help patients maintain or regain meaningful, lasting sexual function.

Details about this program can be found here: 

At Western Radiation Oncology, Dr. Ankit Agarwal and Dr. Steve Kurtzman take pride in offering the very best options for the treatment for prostate cancer, with a focus on preserving sexual health. If you are in California and would like to consult with one of Western Radiation Oncology’s physicians, please contact us here.