Managing side effects

You may have trouble getting or keeping an erection firm enough for intercourse or other sexual activity after any treatment for prostate cancer. This is called erectile dysfunction or impotence. While erection problems become more common with age, they can also be affected by health conditions such as diabetes and heart disease; certain medicines for blood pressure or depression; previous surgery to the bowel or abdomen; smoking or heavy drinking; or emotional concerns.

The prostate lies close to nerves and blood vessels that help control erections. These can be damaged during treatment. If the nerves are removed during surgery, erection problems occur immediately. After radiation therapy and ADT, problems may develop more slowly.

The quality of your erections usually improves over time and can continue to improve for up to three years after treatment has finished. Sometimes, erection problems may be permanent.

Before and after treatment, you can help keep your penis healthy (penile rehabilitation) in various ways. These may include:

• engaging in foreplay and other sexual intimacy with a partner or masturbating
• trying to get erections, starting a month after surgery
• taking prescribed medicines to maintain blood flow in the penis
• stopping smoking and limiting the amount of alcohol you drink
• doing pelvic floor exercises
• injecting prescribed medicine into the penis.

Even without a full erection, you can still reach orgasm by stimulating the penis.

Ways to improve erections

There are several medical options for trying to improve the quality of your erections, regardless of the type of prostate cancer treatment you have had. Ask your treatment team for more details about these methods and other things you can do to improve erections.

Tablets 

Your doctor can prescribe tablets to increase blood flow to the penis. These only help if the nerves controlling erections are working. These tablets should not be taken with some blood pressure medicines. Check with your doctor.

Your doctor may recommend using the tablets before and soon after surgery, as the increased blood flow can help preserve penis health until the nerves recover. Tablets are also an option after radiation therapy and ADT.

Vacuum erection device

A vacuum erection device (VED) or “penis pump” uses suction to make blood flow into the penis. This device can also help to strengthen or maintain a natural erection. Talk to your doctor about suitable devices for you and where to buy them.

You place a clear, rigid tube over the penis. A manual or battery-operated pump then creates a vacuum that causes blood to flow into the penis so it gets hard. You place a rubber ring at the base of the penis to keep the erection firm for intercourse after the pump is removed. The ring can be worn comfortably for 30 minutes.

Penile injection therapy (PIT)

PIT involves injecting the penis with medicine that makes blood vessels in the penis expand and fill with blood, creating an erection. This usually occurs within 15 minutes and lasts for 30–60 minutes.

The medicine has to be prescribed by a doctor. It often comes in pre-loaded syringes, which are single use. You can also buy it in vials from a compounding pharmacy and measure it out into a syringe yourself.

You will be taught how to inject the penis. Injecting your penis may sound unpleasant, but many people say it causes only a moment of discomfort.

PIT works well for many people, but a few may have pain and scarring. A rare side effect is a prolonged and painful erection (known as priapism). This needs emergency medical attention.

Implants

A penile prosthesis is a permanent implant that allows you to create an erection. Flexible rods or thin, inflatable cylinders are placed in the penis during surgery and connected to a pump in the scrotum. You turn on or squeeze the pump when you want an erection.

An implant is not usually recommended for at least a year after prostate cancer treatment, and non-surgical options such as oral medicines or injections will usually be tried first.

Occasionally, penile implants need to be removed. If this happens, you will no longer be able to  have an erection.

You may see or hear ads for ways to treat erection problems. These ads may be for herbal  preparations, natural therapies, nasal sprays and lozenges. If you are thinking about using these products, talk to your doctor first, as there could be risks without any benefits. Products that contain testosterone or act like testosterone in the body may encourage the prostate cancer to grow.

Trouble controlling the flow of urine (urinary incontinence) is a common side effect of some treatments for prostate cancer.

After prostate surgery, issues with urinary incontinence are common for several weeks or months and usually improve slowly over time. Most people will need to use incontinence pads in the first few weeks after surgery. Only a small number will need to use incontinence pads long term. You may find that you:

• lose a few drops of urine when you cough, sneeze, strain or lift something heavy
• leak some urine during sex
• have blood in your urine that may last a few weeks.

Urinary problems caused by radiation therapy are usually temporary and tend to improve within a few months of finishing treatment. In some cases, radiation therapy can:

• reduce how much urine the bladder can store
• irritate the bladder
• narrow the urethra
• weaken the pelvic floor muscles.

You may also find that you need to pass urine more often or in a hurry, or that you have difficulty passing urine. Sometimes, medicines or surgery can improve urine flow – ask your doctor if this is an option for you.

Coping with urinary incontinence

• Start pelvic floor exercises before surgery to help reduce the likelihood of ongoing urinary  incontinence after surgery. The exercises are also important after surgery. Ask your doctor, urologist, continence physiotherapist or continence nurse about how to correctly do pelvic
  floor exercises.
• Drink plenty of water to dilute your urine – concentrated urine can irritate the bladder.
• Keep drinking plenty of fluids, even if you are afraid of leakage. Dehydration can cause  constipation, which can also lead to leakage and difficulty passing urine.
• Limit tea and coffee as they contain caffeine, which can irritate the bladder. Alcohol and carbonated drinks may also irritate the bladder.
• Talk to a continence nurse or continence physiotherapist about continence aids if needed. These aids can include absorbent pads to wear in your underpants, and bed and chair covers. They may also recommend medicines or special clamps for your penis.
• Ask your continence nurse or GP if you can apply for the Continence Aids Payment Scheme. This is a yearly payment to help cover the cost of continence products.
• If incontinence does not improve after 6–12 months, talk to your doctor or urologist about  whether surgery is an option. For example, a surgically inserted sling or artificial sphincter works by pulling the urethra up to help the sphincter muscle close more effectively.
• Visit the Prostate Cancer Foundation of Australia or call them on 1800 22 00 99 and the Continence Foundation of Australia or phone 1800 33 00 66 for additional resources about urinary incontinence.

For information on pelvic floor exercises:

Download our booklet ‘Exercise for People Living with Cancer’

You may notice other changes that affect your sexuality and how you express intimacy.

Loss of libido – Reduced interest in sex (low libido) is common during cancer treatment. While anxiety and fatigue can affect libido, it can also be affected by ADT, which lowers testosterone levels, and by the sexual side effects associated with radiation therapy or surgery. Sex drive usually returns when treatment ends, but sometimes changes in libido are ongoing.

Dry orgasm – After surgery, you will feel the muscular spasms and pleasure of an orgasm, but you won’t ejaculate semen when you orgasm. This is known as a dry orgasm. A dry orgasm happens because the prostate and seminal vesicles that produce semen are removed during surgery, and the tubes from the testicles (vas deferens) are sealed.

Radiation therapy may also affect how much sperm you make, but this is often temporary. While you may worry that a dry orgasm will be less pleasurable for your partner, most partners say they don’t feel the release of semen during intercourse.

Leaking urine during sex – A radical prostatectomy can weaken the sphincter muscle that  controls the flow of urine. This may cause a small amount of urine to leak during intercourse and orgasm. You may find leaking urine during sex embarrassing, but there are ways to manage this. Before sex, empty your bladder (urinate). Consider having sex in the shower, or use a condom or a constriction ring (available from sex shops) at the base of the penis to prevent leakage. Speak with your doctor if you are still concerned.

Managing changes in your sex life

• Talk about the changes and your feelings about sex. If you have a partner, these changes will probably affect you both. Reassure them that intimacy is still possible and important to you.
• Focus on giving and receiving pleasure in different ways without any expectations of sexual
  penetration. Other ways of expressing love include touching, holding, caressing and massage.
• Explore the range of adult products (e.g. sex toys like dildos and vibrators). These may help spark your interest in sex or your partner can satisfy themselves, either alone or with you present.
• Take time to get used to any changes. Look at yourself naked in the mirror and touch your genitals to feel any differences or soreness.
• Start slowly – touch each other’s skin, then include genital touching.
• When you feel ready, try intercourse even with a partial erection. This stimulation may encourage more and better erections.
• Explore your ability to enjoy sex and understand any changes by masturbating.
• Ask your partner to help you reach orgasm through gentle hand-stroking. Use silicone-based lubricants for prolonged stimulation.
• Try different positions to find out what feels comfortable. Having sex while kneeling or standing may also help with erections.
• Use mindfulness techniques to help you stay in the moment with your partner. Listen to our Finding Calm During Cancer podcast for mindfulness exercises.
• Talk to your doctor, a sexual health physician or counsellor if the changes are causing depression  or relationship problems.
• Download the Prostate Cancer Foundation of Australia’s booklet on sexual issues after prostate cancer treatment

Download our booklet ‘Sexuality, Intimacy and Cancer’

Prostate cancer can affect your sexuality in both physical and emotional ways. The impact of these changes depends on many factors, such as the cancer treatment and its side effects, your general health, whether you are single or in a relationship, how you and your partner  communicate, and your level of self-confidence.

It may take some time to adjust to changes in your sex drive and how this affects your self-esteem and sexual relationships.

Communicating with a new partner

Deciding when to tell a potential sexual partner about your cancer experience isn’t easy, and you may avoid dating for fear of rejection.

While the timing will be different for each person, it can be helpful to wait until you and your new partner have developed a mutual level of trust and caring. You might prefer to talk with a new partner about your concerns before becoming sexually intimate. By communicating openly, you avoid misunderstandings and may find that your partner is more accepting and supportive.

Download our booklet ‘Sexuality, Intimacy and Cancer’

Listen to our podcast ‘Sex and Cancer’

Infertility is common after surgery, radiation therapy or ADT for prostate cancer. This means you can no longer have children naturally. If you may want to have children in the future, you (and your partner if you have one) should talk to your doctor about the options before treatment starts. You may be able to store some sperm at a fertility clinic to use when you are ready to start a family.

Radiation therapy may affect sperm quality for 6–12 months after treatment and cause birth defects. You will need to use contraception or not have penetrative sex to avoid conceiving during this time.

Download our booklet ‘Fertility and Cancer’

Treatment for prostate cancer may lead to a range of other concerns, but most of these can be managed.

Fatigue – Cancer treatment often makes people very tired. After surgery, it may take some time to get back your strength. With external beam radiation therapy, you may get particularly tired near the end of treatment and for some weeks or months afterwards. Regular exercise can help reduce tiredness.

Download our fact sheet ‘Fatigue and Cancer’

Bowel problems – Although this is an uncommon side effect of radiation therapy, you may experience rectal bleeding after treatment. It is common to have a stronger sensation of needing to have a bowel movement. A gastroenterologist or colorectal surgeon may treat ongoing bowel problems with changes to your diet, steroid suppositories (a tablet that you insert into the rectum through the anus), laser therapy or other treatments applied to the bowel wall. For more  information, talk to your radiation oncologist or a continence nurse.

Hot flushes – You may experience hot flushes if you are having ADT. Things that may help include drinking less alcohol; avoiding hot drinks; wearing loose-fitting cotton clothing; getting regular exercise; learning relaxation techniques; and trying acupuncture. For more information, talk to your doctors.

Osteoporosis – Loss of bone density can be a delayed side effect of ADT, so your specialist or GP may need to monitor your bone mineral density. Regular weight-bearing exercise (e.g. brisk walking, light weights or a guided exercise program), eating calcium-rich foods (e.g. yoghurt, milk, tofu, green vegetables), getting enough vitamin D, limiting how much alcohol you drink, and not smoking will also help keep your bones strong. For more information, visit Healthy Bones Australia or call them on 1800 242 141.

Heart problems – Because ADT can increase the risk of heart problems and strokes, your GP or specialist will monitor how well your heart is working and may refer you to a dietitian or exercise physiologist.

Other ADT side effects – The risk of weight gain, mood swings, breast swelling, decreased muscle strength, changed body shape, and high cholesterol increases the longer you use ADT.

How exercise and diet can help

Studies show that regular exercise can help manage the side effects of ADT. It can help improve mood, heart health, bone and muscle strength, and energy levels.

Whatever your age or fitness level, a physiotherapist or exercise physiologist can develop an exercise program to meet your specific needs. Ask your doctor for a referral.

Our Exercise for People Living with Cancer booklet includes examples of different aerobic,  strength-training and flexibility exercises.

ADT can lead to weight gain and increase the risk of high cholesterol. Aim to eat a balanced diet with a variety of fruit, vegetables, wholegrains and protein-rich foods. It may help to see a  dietitian for advice.