Americans are having less sex than ever before. Should we be worried? Ask your prostate.

A 2022 study from the National Survey of Sexual Health and Behavior found that the rate of all types of sexual intercourse have declined from 2009 to 2018. While the authors speculate as to why this may be the case – it is unlikely they examined the role of prostate cancer.

In 2021, there were an estimated 248,530 new prostate cancer diagnoses made in the United States alone – with a 97.5% 5-year survival rate. Most men will develop prostate cancer by the age of 65 and are more likely to die with prostate cancer, not from prostate cancer.

While the treatments for prostate cancer improve, men often experience significant side effects from the treatments.

One of the biggest issues I hear as a radiation oncologist who treats prostate cancer is that most men were surprised about the sexual side effects that they experience from the treatments. I’m here to save you that trip to the doctor and provide you with the answer to the questions you might be too afraid to ask.

First, sexual dysfunction is a common side effect of prostate cancer itself even before treatment may begin. About ⅓-½ of men already experience some sort of sexual dysfunction by the time they are diagnosed with prostate cancer. Additionally, the anxiety of a cancer diagnosis alone can reduce sexual drive, and the cancer may affect parts of the prostate that would make it difficult to have an erection.

But the real problems start when we talk about the treatments. Treatment options include surgery, radiation and hormone therapy. Patients often have to have a combination of these treatments as well.

A study from the New England Journal of Medicine found that surgical removal of the prostate had the worst effect on sexual function. At baseline, 67% of men were able to have an erection, but this was reduced to just 12% amongst the men who underwent surgery. This number increased to 17% 6 years later. Likewise, after undergoing radiation treatments, 22% of men were able to maintain an erection at 6 months and this increased to 27% at six years. Comparatively, for men who underwent active surveillance for their cancer (i.e. no treatment, but just monitored with blood tests), 30% were able to achieve an erection 6 years out.

An updated study from JAMA in 2020, confirmed these results and even found that radiation was not clinically different from the men who underwent active surveillance.

To be sure, surgery does have its benefits and was found to have better relief of urinary obstructive symptoms and bowel toxicities, but radiation was found to have better sexual function and fewer incontinence issues. Most of the side effects from radiation will resolve about 6 months after treatment, but some side effects can be permanent.

Unfortunately, one of the medications given for prostate cancer can cause a significant amount of to sexual dysfunction as well.

Hormonal therapy is given to reduce testosterone that can feed the cancer cells. Blocking testosterone essentially will put men into “male menopause” causing weight gain, fatigue and decrease sexual function. Even after just 3-4 months of hormonal therapy, there may be permanent erectile dysfunction.

When patients get a cancer diagnosis, the only thought that goes through their head is about the treatment, but these side effects are often overlooked. More than 70% of men who started hormonal therapy to treat their cancer were unaware of the side effects that can be caused by the medication.

While erectile dysfunction is the most common sexual side effect men experience after their cancer treatments, many men have also reported reduced penis size after treatment. Men who underwent surgery or hormonal therapy experienced the largest reduction in size. Luckily, only about 3% of men in the study reported a reduction in size, and it was usually about a half-inch or less.

Likewise, treatment can affect orgasms and fertility. Surgery and radiation can reduce the ability to make semen which will ultimately give men “dry organisms.” Radiation can also cause sharp pain when they ejaculate when approaching the end of treatment. If fertility is a concern, men can bank their sperm prior to initiating treatment.

The good news is that there are treatment options for a lot of these issues. Men who had good erectile function prior to treatment may benefit from oral medications, vacuum erection devices, penile injections or penile implants.

Ultimately, it’s hard to avoid some of the side effects of treatment, but more men need to have frank – and oftentimes uncomfortable – discussions with their providers about what quality of life factors matter to them.

If sexual function matters to you, then it will matter to your provider as well.

Kevin Charles King is a radiation oncology resident.

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