Is There Sex After Prostate Cancer Treatment? Good Question!

Perhaps the more apt question, given we KNOW the sex has to be different, is: What is the quality of sex after prostate cancer treatment? And to answer this question presumes not only knowing which treatment modality we are talking about, but the manner in which delivered. For example, if radical prostatectomy, then was it delivered via “robot” as in the da Vinci procedure, or via the hands of a skilled surgeon. (Typical books, and medical sites like Hopkins suggest the robotic surgeon ought to have at least 1,000 under his belt for a decent outcome).


If radiation, then what form: external beam or HDR (high dose rate) brachytherapy – where the source is directed inside the gland (such as I had done – see my blog on it “The Longest Day and Then Some”). If HDR Brachy, then where was it done, at which site?Do they specialize in it (like UCSF's Helen Diller Cancer Center) or is it one of many modalities they offer but for which prostate cancer treatment is no more focused on than say, breast cancer. All these matter. But given the lack of specifics let’s employ a more overarching addressing of the question.


Let’s understand first that testosterone presence is critical for prostate cell growth and function.Thus, these cells and their function are sensitive to the presence or absence of testosterone. Since prostate cancer cells are derived from the prostate gland it ought to come as no surprise that they’re also dependent on testosterone for survival. Cancer cells proliferate when testosterone is present and shrivel up and die in a mass cellular suicide called apoptosis when absent. Removing the whole gland can effect this, and also dosing it with high levels of radiation ….or having the cancer patient take large amounts of female hormones. (TIP treatment)


Cut the gland out and you also cut out the basis for testosterone production associated with semen production. Dose it with radiation and you ‘fry’ the prostate cells and cancer cells and reach basically the same result. Ingest enough female hormones and ditto.  The issue for most guys who choose a treatment then, is twofold: 1) get rid of the unwanted cancer cells or growth, and 2) Preserve some semblance of sexual function. Obviously if the whole gland is removed and ancillary erectile tissue – say in a radical prostatectomy, then achieving (2)  will be more difficult. It’s also one reason many guys on radical prostatectomy and de Vinci procedure net forums often complain about not having been fully informed of the loss of sexual function and the extreme lengths they must go to in order to recover it. As one guy put it on one forum after reading how another member complained about priapism after taking too large a dose of Viagra to stay hard ….”Well, there are some guys who can’t even dredge up enough desire to even want sex if we have to go to those lengths.”


The concerns are less for radiation therapy such as the HDR brachytherapy (single treatment)  I had, since the basic organs, gland and tissues remain in situ. The entire pelvic floor isn’t re-adjusted as it is for radical prostate surgery or da Vinci surgery. Still, treatment modes vary and so does the competence of those who deliver them. As my wife put it, even putting the prostate template in place – suturing it to the perineum- can vary significantly from one treatment site to the next. One small error in the template placement means the indexers will not deliver the dose to the correct locations. That can be catastrophic. The dose delivered is also critical – too much and you can't preserve function, too little and you do but the cancer comes back. You need the maximal optimal dose for the grade and stage of the cancer!


As for surgery, another risk which isn’t much mentioned (but ought to be according to the men on the surgery forums, some of whom have threatened “legal action” against their urologists for not giving them the full lowdown) is penile shrinkage. Dr. John Mulhall, in his book, Sexual Function in the Prostate Cancer Patient, notes an average of ½” shrinkage after radical prostatectomy - no matter how done. Overcoming this often demands an aggressive regimen including: Viagra, vacuum pumps and injected prostaglandins. But as Dr. Mulhall notes, to be effective the therapy needs to be started almost right after the operation. Trouble is most men are in no mood after having to have Foley catheters inserted in their urethras for days or weeks, not to mention a good deal of post-op pain and possible complications (i.e. need for a pelvic drain in case of abdominal infection after da Vinci robotic surgery)

In terms of HDR monotherapy (brachytherapy) effects, the St. Joseph Prostate Cancer Center notes (in terms of HDR brachytherapy – such as I had):

“Erectile dysfunction (ED) is often difficult to quantify; however, men who do not have ED prior to HDRB most often maintain sexual function after HDRB. Men with ED prior to HDRB will likely continue to have ED after the treatment as HDRB is not a treatment for ED”


Other than this it’s hard to gain a handle. The UCSF Patient Guide for Sexual Rehabilitation – in terms of post HDR monotherapy sexual indicators- notes that the initial ejaculations will be either bloody (laced with black blood, or old blood), “thick” and off color, or non-existent. Up to now I’ve no idea but suspect likely bloody ejaculate if there was anything. Just a guess. Obviously, from my point of view, any remote consideration of even attempting ejaculation is out of the question so long as urinating delivers a burning sensation! (So try to imagine what forcible expulsion of prostate contents would do!)

One site run by an RN who also offers massage therapy and other post-op aids, notes serious difficulties following just about any kind of prostate cancer treatment and observes even healthy males post-op will likely have much difficulty gaining and sustaining erection. She actually recommends males in this predicament just agree to use “mutual masturbation” with their wives (assuming they're willing) as a solution though she acknowledges some patients – out of religious inhibitions or proscriptions- might have problems with that.

The UCSF Guide includes a section on “solutions” to any sexual dysfunction, which range from using a “penile implant” (i.e. an inflatable device surgically implanted into the penis) to the use of a suction device or “penis pump”. Neither of these will likely be very appealing to most guys, so they also include use of Levitra or Cialis but at higher doses than what would ordinarily take - say for ordinary ED. (This may be why the guy cited earlier on the radical prostate surgery forum complained of priapism, which is a painful erection lasting 4 or more hours.)


Another aspect not much discussed is that of “dry orgasm” or retrograde ejaculation. This is normally associated with a prostatectomy but can also occur after radiation therapy. In the former case tissues associated with the muscle that normally blocks off the entrance to the bladder have been removed. In the normal case prior to the surgery, contracting muscles always force the semen unidirectionally through the penis outwards.


After the surgery, with the loss of muscle tension and control, this is no longer possible, plus the bladder neck is frequently enlarged after surgery so that it cannot close completely. Hence when the muscles associated with the urethra contract the semen is ejaculated backward through the open internal sphincter and into the bladder. This is later flushed out in the urine.


IN the case of radiation treatment, the dry orgasm is of different physiological origin since the sphincter muscles are not affected. In this case, since the whole volume of the prostate has been irradiated. My wife actually corrected me on that, as I’d earlier believed it to be a more directional treatment. Her point was that the IPSA software contour solutions provide a 3D "tunnel" around the urethra and rectum to protect them from the maximum delivered doses.  The point is that  the cells that produce prostatic fluid (the milky stuff that mixes with sperm to produce semen) are basically killed off with the affected prostate cells. Since the seminal vesicles also receive a dose of radiation (perhaps up to 10 Gray in my case or 1000 cGy) any sperm cells produced are also killed off.

In other words, after the last 'old blood' is ejaculated there’s really nothing left: all or most of the sperm cells are “cooked away” as well as the cells that generate prostatic fluid (this of course is also why one expects PSA to fall). Given there’s basically nothing left “in the tank” then there’s nothing to ejaculate. You get the sensation (at least part of it) of doing so, but nothing is being expelled.

No, I’ve not experienced any of this yet because I haven’t attempted anything! However, it falls within the bounds of what a former Nucletron Corp. radiotherapy consultant told me before I received my own treatment (he also went to UCSF for early HDR brachy), but at that time they were still delivering the dose in two treatments. Only in the last 5-6 months have they adopted the one time HDR treatment based on a study done by Dr. Alvaro Martinez at William Beaumont Hospital-Center which showed that the results for a single treatment were good, with low toxicity. (See, e.g. http://dr.beaumontphysician.com/news/pages/single-dose-brachytherapy-treatment.aspx )

So UCSF changed over to that regime.


Here’s the skinny: While many may insist that men make too big a deal out of post-treatment sex activity and add ‘You ought to be glad you’re just alive!” the truth is more complex, and the self-identity of most of us is bound up with our ability to sexually perform. Erase that, and you erase a lot of self-worth, though true …not all and not necessarily the most crucial aspects. But from reading many of the prostate cancer blogs and forums, and the degree of depression and anger in many men (especially a LOT of younger guys in mid to late 30s and early 40s, whose wives left them because of their difficulties in performing post-treatment) it is still no small deal. And little wonder 90% of these depressed guys had the radical prostatectomy and were neither informed fully of the side effects in terms of prolonged incontinence or concerning the loss of erectile ability and sexual function in 75% of cases. This may be one reason most weren’t merely depressed but bloody angry to the extent of threatening legal action against urologists.

It seems that not only do we have lots of work to do in getting information – full information – to men facing prostate cancer and treatment options – but we also need the urologists, oncologists to deliver the flat out truth instead of wishful thinking fantasies – as per their patients' expected post-op sex lives!