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Ways of Dealing With Sexual Problems
Will a Sexual Problem After Cancer Treatment Be Permanent?
Many sexual problems that men have after cancer treatment will not last long. For instance, pain with erection or ejaculation soon after pelvic surgery or radiation will probably disappear. The stress of treatment can also reduce hormone levels for a few weeks. This may cause decreased desire or problems with erection.
As you feel more in control of your body and your life, you will find that your self-confidence returns and your sex life gets better.
Unfortunately, some cancer treatments can permanently change a man’s sexual function. It’s hard to know what will happen to any one person. For example, one man may regain erections after radical prostatectomy while another man may not. If you do develop a sexual problem, your health care team can often find the cause and give you an idea of your chance for recovery.
One clue that a problem is a medical one and permanent is if it occurs in all situations. Otherwise, it may be psychological and temporary. For example, if you have trouble getting or keeping an erection, does it happen every time you have sex? Can you get better erections when you relax, when you stimulate your own penis, or when you unexpectedly see someone attractive? If you have a few partners, are your erections better with one of them than with the others?
Overcoming Temporary Problems
As men age or go through health problems, feelings of excitement no longer lead to an instant erection. Perhaps you just need more time and stroking to get aroused.
If you have trouble reaching orgasm during sex, perhaps you have not found the right kind of caressing to use. You might even consider buying a hand-held electric vibrator. A vibrator can provide very intense stimulation. Try having a sexual fantasy or looking at erotic stories or pictures. The more excited you are, the easier it is to reach orgasm.
A number of men have their first orgasm after cancer treatment while asleep, during a sexual dream. If this happens to you, it is proof that your equipment is in working order. Because sleep erections aren’t affected by mood or state of mind, they provide a measure of the best erection a man’s body can produce. Now it is up to you to set things in motion during your waking sex life.
Finding the Cause of Problems That Appear to Be Permanent
Give yourself several months to recover from treatment and try several ways to overcome your problem. If the problem doesn’t go away, special medical tests can be used to find the cause. You may need to see more than one doctor to help you find out exactly what the problem is and get the treatment you need.
One of the exams used most often takes place while you sleep. Your doctor may send you for 2 or 3 nights to a sleep laboratory to check your sleep erections. A technician watches your brain waves and breathing during the night to make sure that your sleep patterns are normal. At the same time, elastic loops placed around the base and tip of your penis are connected to a recorder. The recorder measures changes in the size of your penis during the night. If your sleep erections are firm and long-lasting, your problem should respond well to some sexual counseling. If your sleep erections are poor or you don’t have an erection, you may need surgery or medical treatment to correct the problem.
Since sleep laboratory evaluations are expensive, most doctors use other ways to screen sleep erections. Many send a man home with an electronic monitor to wear on the penis at night. This can be a very good test. A less accurate test is to use a plastic strip (or snap gauge). The patient wears it around the shaft of the penis during sleep. An erection breaks 1 to 3 bands of plastic film on the gauge, depending on the firmness of the erection.
A strain gauge is a circular device placed at the base and tip of the penis that stretches during erection. This provides measurement in the changes with erection.
Other tests, done in a doctor’s office, can measure blood pressure and pulse in your penis. These tests look for a block in circulation that could be causing the erection problem. Many of these tests include injecting medication into the shaft of the penis. This can produce an erection. Then special ultrasound tests or x-rays can be done. Tests of the reflexes in the genital area are sometimes done. Also common are blood tests to check the levels of the 2 hormones most closely linked to men’s sexual function, testosterone and prolactin.
When Is Sexual Counseling Helpful?
Any sexual problem caused by anxiety can respond to the counseling that a sex therapist provides. For men, problems caused by anxiety can include:
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loss of sexual desire
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erection problems without a medical basis
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trouble reaching orgasm
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premature ejaculation
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When a medical condition limits a man’s sexual function, sex therapy can still be helpful. However, the goals may change. For example, instead of expecting a man to regain full erections, the therapist may help him and his partner learn to enjoy sexual caressing without erections. Sex therapists are also becoming involved in helping men and their partners decide whether to have medical or surgical treatments for erection problems.
Is There a Pill That Will Cure Sexual Problems?
In March of 1998, the Food and Drug Administration (FDA) approved a medication called sildenafil citrate (Viagra) to treat impotence. Since then, 2 similar drugs have been approved, vardenafil (Levitra) and tadalafil (Cialis). All of these drugs help the body’s ability to achieve and maintain an erection during sexual stimulation by increasing blood flow to the penis. About half of men with impotence due to medical (rather than psychological) problems are helped to some extent by these medicines. Initial studies suggest that nerve damage due to prostate cancer treatment may not respond quite as well as some other physical causes of impotence, but more research in this area is needed. There are several drugs known to interact with this group of drugs. For example, nitrates (drugs often used as treatment for heart disease, such as nitroglycerin) may interact to cause very low blood pressure, a complication that can be fatal. Be sure to inform your doctor about all medicines you take, even those you take rarely.
Other medicines are still being studied. You may also want to ask your doctor about any new medications or treatments for erection problems.
Can Testosterone Restore Sexual Functioning?
In the rare case that a man has a hormone imbalance, testosterone may restore his desire and erections. However, hormones are too often used without careful thought. Most men, even after age 50 or 60, have enough testosterone. Taking extra hormones will not cure a sexual problem. In fact, it can have serious side effects.
In addition, extra testosterone could cause undetected prostate cancer to grow and spread. Men with a history of prostate cancer are never advised to take testosterone pills or shots, even if their own hormone levels are low. Testosterone is most helpful as a temporary way to restore sexual desire and erections in men who have damaged testicles from large doses of radiation or chemotherapy. Only a few men, however, really need extra hormones.
Is There a Way to Restore Erections If the Nerves or Blood Supply of the Penis Has Been Damaged?
If the cause of an erection problem is simply a blockage of the arteries that bring blood to the penis, some newer operations are available. The surgeon can take an artery that usually supplies blood to the abdominal wall and re-route it by connecting it to the tiny blood vessels inside the penis. Follow-up results have been disappointing so far; only about a quarter of the men have had long-term improvement in their erections.
During the first 3 to 12 months after radical prostatectomy, most men will not be able to get a spontaneous erection and will need to use medications or other treatments if they wish to have an erection. The effect of this operation on a man’s ability to achieve an erection is related to his age and whether nerve-sparing surgery was done. Nearly all men who have a radical prostatectomy should expect some decrease in their ability to have an erection, but younger men may expect to retain more of their ability. Some experts recommend trying one of the impotence-treating drugs, such as Viagra, soon after surgery to find out if it is helpful. After standard radical prostatectomy, between 65% and 90% of men will become impotent, depending on their age.
If surgery does not remove the nerves on either side of the prostate, the impotence rate drops to between 25 and 30% for men under 60. But impotence is higher for men over 70, even if nerves on both sides are not removed. After surgery, the sensation of orgasm should continue to be pleasurable, even though there is no ejaculation of semen. In other words, the orgasm is dry.
New research explores transplanting nerves to restore erections, but further research is needed to determine its success. Surgical techniques are also being improved through the use of nerve stimulation so that surgeons can avoid cutting nerves needed for erections. Surgery to remove veins that allow too much blood to drain out of the erect penis has had very limited success.
Though surgery to correct blood flow problems has been disappointing, 3 non-surgical treatments have become widely used: penile injection therapy, urethral pellets, and vacuum devices.
Penile injections: Many urologists teach men to inject their own penis with medications that produce erection. Medicine is injected into the side of the shaft of the penis through a very small needle a few minutes before starting sexual activity. The combination of sexual excitement and medication helps to produce a firmer and longer lasting erection than was occurring before. Penile injections can have side effects. A few men may get an erection that will not go down. If this happens, the man needs to go to an emergency room right away for treatment. Some men develop scarring in the spongy tissue of the penis after repeated injections. Scarring is often not noticed by the man, but in severe cases can make erections permanently curved. The only way to treat severe scarring is by reconstructive surgery on the penis.
Urethral pellets: A new way of delivering the same medication used for penile injections is to have a man use an applicator to insert a tiny pellet into his urethra (urinary tube opening at the tip of the penis). As the pellet melts, the medication is absorbed through the lining of the urethra and enters the spongy tissue of the penis. Although this system may be more convenient than injections, it is not always as effective and can produce similar side effects.
Vacuum constriction devices: Another treatment, the vacuum constriction device (VCD), is less risky but also may interrupt lovemaking more than an injection does. A man places a plastic cylinder over his penis and pumps out air to produce a vacuum around the outside of the penis. The suction draws blood into the inside of the penis, filling up the spongy tissue. When the penis is firm, the man takes the pump off, slipping a stretchy band onto the base of his penis to help it stay erect. The band can be left on the penis for up to half an hour. Some men use the pump before starting sexual touching, but others find it works better after some foreplay has produced a partial erection. The erection from a vacuum device is usually firm, but may swivel at the base of the penis, limiting comfortable positions for intercourse. It may take some practice to learn how to use a vacuum device properly. Although most vacuum devices are prescribed by physicians, the FDA has approved some that areavailable over-the-counter.
Vacuum devices, penile injection, and the urethral pellets have a success rate between 60% and 70%. When injections or a vacuum device is suggested, some sexual counseling can help a couple discuss their options and plan how to make the new treatment a comfortable part of their sex life.
Penile “Prostheses” or Implants
Surgery to implant a “prosthesis” in the penis was the first really successful treatment for medical erection problems. Over the past 20 years, many of these operations have been done, and they are still one of the most effective ways to treat a permanent erection problem. Several types of prostheses are now in use. For one type, 2 silicone rods are placed into the spongy tissue of the penis.
The result is a penis that hangs about 45 degrees from the body and always stays about 80% erect. Since it is above the urethra, the prosthesis does not affect urination. Most semi-rigid prostheses now are easily shaped. A metal core runs through each rod. When you bend the penis up or down to conceal it during nonsexual activities, it stays bent. With any of the semi-rigid prostheses, a man can avoid an embarrassing bulge at his crotch by wearing briefs made for athletics, with heavier than normal elastic in front.
The inflatable penile prosthesis offers the choice of a soft or hard penis. It is a pump system placed entirely inside a man’s body. Two tough inflatable silicone cylinders are placed inside the penis just as the rods are in the semi-rigid implant. A balloon-shaped reservoir that contains a mixture of salt water and x-ray dye is tucked behind the groin muscles. A pump is placed inside the loose skin of the scrotal sac. All the parts are connected with tubing.
Usually, the salt water fills the reservoir, leaving the cylinders in the penis empty. From the outside, the penis looks the same as it normally does when not erect, except that it is always a little fuller. When you are ready for sex, you stiffen the penis by squeezing the pump under the skin of the scrotum several times. The salt water flows into the cylinders. This inflates the penis as blood does in a natural erection. When you have finished sexual activity and no longer want an erection, you press a release valve on the bottom of the pump. The cylinders will deflate. The salt water then returns to its reservoir and your penis becomes soft.
A simpler 2-piece inflatable prosthesis is a compromise between the semi-rigid and multiple component inflatable types. It simply has 2 cylinders that connect to a unified pump and reservoir placed in the scrotal sac. The 2-piece inflatable cannot produce as long or thick an erection as the newest multipart inflatable. When the penis is not inflated, it will be softer than with a semi-rigid prosthesis but not as soft or small as with a multipart inflatable.
Men in poor health are advised to try the semi-rigid or 2-piece inflatable types, since the risk of future problems is so low and the surgery so minor. However, a man who has repeated superficial bladder tumors may need an inflatable prosthesis because the semi-rigid rods interfere with cystoscopy. A man who is physically active, either on the job or in his leisure time (jogging, playing tennis, riding), may be more pleased with an inflatable type, since it does not get in the way as much.
If you are seriously considering prosthesis surgery, you might read the chapters on medical and surgical treatments in the books listed in the “Additional Resources” section. Implants carry some risk of complications such as infection. Also, the more complicated devices are more prone to failure, which requires a second surgery. Inform yourself and ask your urologist questions about possible complications before making your decision.
Men who are married or in a committed relationship should include their partner in any decision about implants. Your partner needs to understand the procedure and to have a chance to discuss any fears or questions with your surgeon. You must be realistic about what a prosthesis can and cannot do for you. Any penile prosthesis is just a mechanical stiffener for the penis. Having a penile implant cannot solve any other problems, such as low sexual desire, lack of sensation on the skin of the penis, or trouble reaching orgasm. It cannot transform a poor sexual relationship into a great one.
A couple needs to communicate openly the first time they have sex after prosthesis surgery. You may need to experiment with different kinds of touching or with different positions for intercourse. Make sure you are truly excited before trying to have intercourse, rather than starting sex just because your penis is erect. Couples who have maintained mutual touching, even if an erection problem prevented penetration, adjust more easily to the prosthesis.
Is There a Way to Make Orgasm As Intense As It Used to Be?
Some men treated for cancer notice that their orgasms become weaker or last a shorter time than before. Sometimes, a mildly weaker orgasm is just part of normal aging. As men age, the muscle contractions at climax are no longer as strong. More severe weakening of orgasm often goes along with erection problems and may be caused either by anxiety or by damage to the nervous system. In those cases, treating the erection problem may not improve a man’s orgasms. Men who have dry orgasms after cancer treatment also say they sometimes have reduced sensation.
Few medications can increase the strength of a man’s climax. Those that do have dangerous side effects or may stop working after a few doses. Some common-sense advice is to make sure you are as excited as possible during sex. Focus on your sensations of pleasure or on an arousing fantasy and take a long time for foreplay. If you find yourself getting close to orgasm, ask your partner to “tease” you a little by slowing down the caresses. Let your excitement die down and rebuild several times before you actually climax.
You can practice this teasing technique during your own self-stimulation, too. When you feel your excitement is high, stop touching your penis, even if you lose part of your erection. Then caress yourself again, stopping and starting several times before you ejaculate. Whether by yourself or with a partner, make sure your erection is as full as can be before you use the strong, rhythmic caresses that bring on your orgasm. Some men learn to ejaculate with a soft penis. However, they find they have stronger orgasms if they can delay orgasm until their erection is as firm as possible.
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