The truth is more complicated: A man facing treatment should prepare himself for the probability of ED. But while typical, ED is not inevitable. And any man who develops it can still enjoy great sex — including deeply satisfying orgasms — as long as he is willing to stop viewing an erection as a prerequisite.
Most treatments are equally effective
Assuming annual checkups, prostate cancer is likely to be diagnosed early, before it has spread outside the gland. Early detection means a good prognosis: The American Cancer Society estimates there were 239,000 new diagnoses of prostate cancer in 2013, but only 30,000 deaths — a death rate of 13 percent. (By comparison, there were 232,000 new diagnoses of breast cancer the same year, with 40,000 deaths — 17 percent.)
Doctors treat most early prostate cancers in one of three ways: surgical removal of the gland (radical prostatectomy), radiation from an external source (external beam) or insertion of a radioactive pellet (seed implantation). All three methods are about equally effective. When researchers at M.D. Anderson Cancer Center reviewed outcomes for 2,991 consecutive men, they found that 1,034 had radical prostatectomy, 785 had external beam radiation and 950 had seed implantation (222 had a combination of external beam and seed). Five-year survival rates were 81 percent for radical prostatectomy, 81 percent for external beam, 83 percent for seeds and 77 percent for combined therapy.
Risk factors for ED after treatment
Who develops ED after treatment? It depends on luck, the tumor's location in the prostate, the aggressiveness of its cells and two main risk factors:
Age. Whether you have prostate cancer or not, ED risk increases with age. The same goes for men with the cancer — that is, as your age at treatment increases, so does your risk of ED.
Treatment type. Surgery causes somewhat more ED than radiation. National Cancer Institute researchers followed 1,187 men for five years — 901 had surgery, 286 radiation. Sexual function declined in both groups, but was more pronounced after surgery. Twenty-one percent were potent after surgery, 36 percent after radiation. Other studies generally agree that prostatectomy causes somewhat more erection impairment than radiation.
Prostatectomy-related ED develops immediately, but some men recover some function over time. After radiation, fewer men report sudden ED; over time, however, it becomes more common.
Prostate-cancer treatment causes ED because the nerves involved in erection border the gland. Surgery often cuts these; radiation frequently damages them.
A special surgical approach called nerve-sparing prostatectomy can push your ED risk below that of radiation. Studies report "functional" erections in 60 to 80 percent of men who have nerve-sparing surgery. Just don't expect miracles: At best, nerve-sparing surgery leaves men with erections not quite as firm as they were before surgery. In addition, nerve-sparing surgery may not be possible if the tumor is located near a nerve line.
Surgery plus erection drugs
Several studies show that erection drugs help restore erectile function, but usually only after nerve-sparing prostatectomy. Here's why:
Erection medications work by coaxing more blood into the penis. If a man doesn't have enough nerve function to enable erection, the amount of blood in the penis won't matter; no nerve function means no erection. Nerve-sparing surgery, by contrast, allows a man to retain nerve function, so erection drugs can help.
Italian researchers analyzed 11 studies of men who took erection drugs after prostatectomy. After conventional surgery, erection medication helped 15 percent of them. (That's because conventional surgery sometimes preserves the nerves.) After nerve-sparing surgery, however, the drugs helped about 50 percent of the men.
Bottom line: For the best chance of preserving sexual function, opt for nerve-sparing surgery, then use erection medication.
Men don't need erections to enjoy pleasurable orgasms
Different nerves control erection and orgasm. So even when prostate-cancer treatment damages or destroys the erection nerves, those that govern orgasm usually remain intact. Yes, it's an adjustment to have a flaccid penis stimulated to orgasm. But in an erotic context with sufficient stimulation by hand, mouth or vibrator, it's entirely possible.
A recent Canadian study shows that sex therapy helps couples resume sex after prostate-cancer treatment. The 77 couples who participated in the study enjoyed "significant gains in sexual function." To find a sex therapist near you, visit the American Association of Sexuality Educators, Counselors and Therapists; the Society for Sex Therapy and Research; or the American Board of Sexology.
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