Cancer — not a sexy topic, and not what you’d expect me to write about on Christmas Eve. But cancer knows no seasons and respects no holidays. Maggie, age 62, wrote to me:
Recently, I met a nice guy who after dating for a while, told me that he had surgery for prostate cancer 7 months ago. He went on to tell me all the bad news that the Dr. had told him about side effects. My question is, do you know any where that I can get some straight answers on what we are looking at, possibility wise? The information I have found online so far has been very negative, almost always putting the pressure on the woman if things were going to work or not. He advised me that he would never be able to have an ejaculation & that sex for him would never be the same. I got the idea that he would never feel the pleasure of having a climax again. My fear is that if this is true, what would be the point of him having sex? I am a very sexual woman & would just like to know if there is any chance that there can be a sexual relationship? Any guidance that you could offer would be greatly appreciated.
I sent Maggie’s question to cancer and sexuality specialist, Anne Katz, RN, PhD. Here is her response:
There are a number of possibilities in this situation, some of them good and some of them not so good. Here are the facts:
1. Having surgery for prostate cancer (a radical prostatectomy or complete removal of the prostate gland) will result in significant changes in a man’s ability to have an erection. Depending on what his erections were like before the surgery and the amount of damage done to the nerves responsible for erections during the surgery, the man may be able to have erections after the surgery but he is most likely always going to need some help (from medication like Viagra, Cialis or Levitra). These medications only help about 50% of the time but there are other erectile aids (the vacuum pump or penile injections) that can help too. Some men are able to have an erection but it may not last very long. Some men can only achieve a thickening of the penis and this may not be sufficient for penetration. Progress in regaining erections may continue for up to two years after surgery but what he has at that point is usually as good as it is going to get.
2. Orgasms are still possible, even with a flaccid penis. The orgasm will not be accompanied by ejaculation however (the prostate gland makes the fluid portion of the ejaculate and so when it is gone, so is the emission). Some men report more intense orgasms after this surgery; some say they are much less intense.
3. Libido (or sexual desire) is not affected by removal of the prostate but the mind is a very important part of a man’s sexuality. Repeated failure to have an erection sufficient for penetration may cause him to lose some interest. Although some men just keep on trying and trying and trying – the human spirit is a powerful force and many men retain hope for many years despite little success.
4. Many couples find a way around these difficulties. There are more ways than just penetration for both the man and the woman to achieve orgasm and satisfaction and some creativity goes a long way. This may be challenging for a new relationship. But the lust and attraction in a new relationship may also provide more impetus than a 30 year relationship! There is no right way or wrong way in this; a lot depends on how you want to look at the situation.
5. If you read anything that you feel puts the onus on the woman (or male partner) to fix things, then stop reading! This is a couple’s issue and both partners have to work on finding a solution. Communication is a very important part of sexuality. You should be able to talk openly about what works for him and what doesn’t. You should be able to talk about what you want and what creativity you can both bring to sexual activity. In your letter you state that you “got the idea” – you will have to ask questions and not rely on innuendo to help you understand what is possible and what is not.
New relationships are challenging and exciting and inspiring and joyful. When illness or injury have occurred it puts a lot of pressure on this new partnership. Good luck!
Anne Katz, RN, PhD, is the author of the award-winning text book Breaking the Silence on Cancer and Sexuality: A Handbook for Health Care Providers . Dr Katz has also written three books for consumers: Sex When You’re Sick: Reclaiming Sexual Health after Illness or Injury; Woman Cancer Sex, and Man Cancer Sex. She is the sexuality counselor at CancerCare Manitoba in Winnipeg, Manitoba, where she provides counseling to men and women experiencing sexual difficulties as a consequence of cancer and its treatments. Visit her website at http://www.drannekatz.com/.
Neil, age 74, who wrote his Personal View of Prostate Surgery and Sex here, wants to add this:
I hope I did not leave the impression that I am anti-physician. I do not want to imply that my caregivers were incompetent or uncaring. I certainly don’t think anyone lied to me. I am blessed with a caring and extremely competent urologist who has given me nine years free of prostate cancer.
The urologist was aggressive in treatment. Tests were conducted well before my PSA even reached critical numbers. Normal range is 1 to 4 — mine was a little over 2. The disease was caught early because of a very dedicated doctor.
My urologist routinely spends 12 to 14 hour days in the battle against cancer and has very little personal time. I am grateful for what was done for me. My physician, by the way, was not the person who gave the word that sex didn’t matter after 55. That was a second opinion guy at another medical center.
I suppose the myths and lack of information come from two areas:
(1) The work load of dedicated health care professionals is unbelievable. When faced with a choice of saving life or providing sexuality education, I would want my doctor to first go after the cancer. I was very grateful my urologist did just that. I am here today because of this priority.
(2) While some counseling was given, my physician candidly stated that not much training was given in matters of sexuality. There simply was not enough time for everything. I believe that. As I have talked to other urologists, the story is the same. There is just not enough time to get everything into the program of study.
I am sure that we, as sex educators, have some responsibility to assist in making things better. Perhaps more of us will somehow find our way into relationships with medical school faculties. Hopefully, we can also raise awareness that would provide support to local medical groups as well. I would hope that we could be of assistance to the medical profession without getting in the way of their very important clinical work. I am sure that your book will also provide more information that can be placed in the hands of the health care community.
Above all, I want to leave the message for men to find a competent urologist and stay with their professional judgment. This stuff is nothing to mess with or take lightly. I prefer that we work hand in hand with health care professionals in the battle against cancer as well as the enhancement of sexuality.
Neil, age 74, offers this startling information about sex after prostate cancer surgery. I’m grateful to Neil for his willingness to share his personal story:
A diagnosis of cancer is very frightening. For me the journey was scary enough without the myths and misinformation I was told about cancer of the prostate. I share my experience in the hope that this information will be of help to others.
Myth # 1: “After Age 55, Sex Doesn’t Matter That Much Anyway.”
I heard these words from a physician who specializes in the treatment of prostate cancer. A very nice person, considered extremely competent, he believed his words would be comforting. They weren’t!
Sex does matter after 55. I promised the doctor that I would look him up on his 55th birthday and tell him to “cut that out.” He sheepishly smiled and said, “Oh my. I think I said something wrong.”
Myth # 2: “What You Have At The End Of A Year Is What You Get.”
Although many men are told that any rehab after prostate cancer treatment will peak in twelve months, every case is different. Some methods of prostate cancer treatment can result in serious damage to sexual performance. On the other hand, robotic surgery and nerve sparing have greatly improved sexual potential. Whatever the case, don’t give up! There are options for almost every case of sexual impairment.
But I must warn about some of the product advertisements that flood the market about penile enhancement, instant erections, and so on. Some of these products can be harmful to a cancer survivor. Some are loaded with testosterone which can cause further growth of prostate cancer. Check with your physician before trying any of these medications.
At all times, keep your partner involved in the options you’re considering. They can be our most precious friends and supporters. They deserve to be part of the solution to our new life experiences.
What We Are Often Not Told:
The penis will be about an inch shorter after surgery. Because the urethra passes through the prostate, when the prostate is removed, that portion of the urethra is removed as well. Then, when the urethra is resectioned, the penis is drawn in towards the abdomen. Secure circumcised males seem able weather this storm but uncircumcised males have an additional problem. The surgery leaves more foreskin than before. This additional tissue traps urine and produces odor. Baby Wipes do a very fine job of solving this problem. They are easy to carry and save a lot of embarrassment.
The “Missionary” position usually is no longer successful after prostate surgery. Because the prostate stabilizes the penis and prevents it from receding into the abdominal cavity, removal of the prostate decreases penile stability. The angle of the vagina, coupled with a shortened penis with no internal stability means vaginal intercourse may not work. However, “Doggie Style” and “Woman on Top” work just fine.
I welcome feedback about the experience of others regarding sex and prostate surgery!
9/22/2009: Neil added these comments about how his urologist saved his life.
If you or your partner has been diagnosed with cancer, what part does sexuality play in your quality of life? How will cancer treatment impact your sexuality — physically and emotionally? How do you cope with changes in function, libido, body image, and pain? How can you maintain intimacy in the face of these challenges?
“Sexuality is all about who you are as a man or a woman,” says Sage Bolte, MSW, LCSW, OSW-C, a renowned authority on sex and intimacy after cancer and an oncology counselor at Life with Cancer®, an Inova Health System service in northern Virginia. “It’s a critical part of your quality of life.” Sex and intimacy are key ways to affirm, “I’m alive, I’m human,” and of getting back what was important to you before cancer.
On March 11, 2008, the Leukemia and Lymphoma Society presented a teleconference with Bolte for 1,400 listeners. It was superb. Fortunately, the teleconference will be available as a transcript and MP3 recording sometime in April 2008 at www.lls.org/survivorship.
Forty to 100 percent of people with cancer will experience some form of change in sexual function, says Bolte, which can impact willingness to engage in sexual activity. However, she assures us, “Patience and techniques can help you regain a sense of sexual self and confidence.”
Although Bolte’s message was targeted at the special challenges of cancer, all of her suggestions also apply to living with any chronic or life-threatening illness, as well as the sexual challenges of aging itself. Here are some of her techniques for coping with specific problems:
Vaginal dryness and discomfort: Apply 100% vitamin E oil to the vaginal tissues and clitoris on a regular basis after showering, and use a water-based lubricant as needed during sex. Talk to your doctor about whether an estrogen ring or testosterone patch would be appropriate to regain moisture and restore elasticity of the vagina.
Erectile dysfunction: Tell your physician about this problem and have him/her look at all your medications. Have your testosterone levels checked. If you’re having a harder time maintaining an erection, try finding the positions that is most stimulating for you. Help your partner reach orgasm before intercourse. Devices for men that may help include penile pump; penile injections, suppositories, penile implant, penile rings. But if you’re on blood thinner or have low platelets, you need to consult with your physician before using any of these devices, because they might put you at risk. Viagra and similar medications are not recommended for men who have heart concerns or are taking blood pressure medications.
Pain and fatigue: After cancer treatment, the time of day that’s right for sex might change. If you’re too exhausted in evening, switch to morning or have a special lunch break. Take pain medication 30 to 60 minutes before activity. Get exercise, which can minimize fatigue and assist in decreasing some joint pain. “Remember that we can rest during sex,” says Bolte. “It’s not a marathon.”
Fear of rejection: Consider seeing a couples counselor or sex therapist. Often the problems of miscommunication, misinterpretation, and anxiety get in the way of your sexuality and intimacy. Work on your communication skills. (Note: I’ll be writing more on this topic in another post.)
Difficulties reconnecting with your partner: Communicate your own desires, ask for what you need, and ask your partner to communicate honestly, too. Be affectionate. Take it “slow and easy.” Take time to be together and to connect. Find other ways for both of you to have pleasure.
Redefine your expectations,” suggests Bolte. “Sometimes you can’t get back to the function you had prior to cancer, but that doesn’t mean it can’t be good or pleasurable.” Focus on touch, sensation, pleasurable feelings. Use sex toys. Engage in mutual masturbation. Read fantasy to each other. Touch yourself. Massage each other and cuddle.
“Take more time to get stimulated, talk yourself into sex,” Bolte recommends. Realize that instead of the physiological response coming first and driving the emotional response, it may need to be the other way around, a “mind thing first.” Schedule your sex time – plan it, think about it, fantasize, and work yourself up to the mental excitement that will stimulate the physical excitement.
Don’t let sex feel like pressure to perform. Sometimes practice just touching without the expectation of intercourse. Re-explore alone what feels good to your body now. “Start with self-pleasuring experiences,” says Bolte. “Your body has changed since treatment. You need to be comfortable touching yourself and knowing what feels good now.”
I applaud the Leukemia and Lymphoma Society for recognizing the importance of sexuality to people diagnosed with cancer and Sage Bolte for generously providing her expertise.