Getting support for sexual problems

The National Institute for Health and Care Excellence (NICE) 

• NICE provides guidance on:

  • How different conditions should be treated.
  • What treatments should be made available.

  Learn more about NICE and what they do by visiting their website (this link will open in a new tab).

  NICE has put together guidelines for the diagnosis and management of prostate cancer. 

  Please note that these are just guidelines and are not a legal requirement. 

  You can use this information to help you to ask questions of your healthcare team. 

   

Before deciding on a treatment,  your healthcare team should:

Tell you about the risk of dry orgasms and fertility issues after some treatments for prostate cancer. This should happen before you make your treatment decision.

Offer you the chance to freeze your sperm.

You can learn more about sperm banking from the Human Fertilisation and Embryology Authority (HFEA). You can visit HFEA’s website here (this will open an external tab).

Cancer Research UK (CRUK) also have information about sperm collection and storage on their website. You can visit CRUK’s website here (this will open an external tab).

If you are having problems getting an erection, you should be offered:

Access to specialist services that can help you.

Medication called PDE5 inhibitors (for example, Viagra or Cialis).

If tablets don't work you should be offered the chance to try:

• A vacuum erection device (penis pump)
• Alprostadil - this improves blood flow to the penis. It comes as cream, pellets or an injection.

You should also be offered the chance to talk to a psychosexual therapist.

• A dry ejaculation happens when you orgasm during sex or masturbation but do not ejaculate.
• Sperm is produced in your testes. 
• The fluid that surrounds and nourishes the sperm (seminal fluid or semen) is mostly produced in your prostate and seminal vesicles. 

Dry ejaculations after radical prostatectomy

• When you have a prostatectomy, your seminal vesicles and prostate are removed.
• You will still be able to have an orgasm, but you will not ejaculate. This is called a dry ejaculation. 
• Your testicles still produce sperm cells, but they are reabsorbed by the body.  

Dry ejaculations after external beam radiotherapy

• If you have had radiotherapy on your prostate, you may produce less semen. Some men may produce no semen.
• You may experience a sharp pain when you ejaculate. This is because the radiation can irritate the tube that carries pee from your bladder to the outside (urethra). 
• This can start while you are still having radiotherapy. The pain may start to ease a few weeks after your treatment has ended.  

Dry ejaculations after brachytherapy

• You may see a reduction in the amount and consistency of your ejaculate after brachytherapy. 
• At first it may be dark and bloodstained. 
• After a while it will clear. It can be clearer than normal and have a more liquid texture. Eventually, you may find that you stop ejaculating any semen at all.

Dry ejaculations whilst on hormone therapy

• You will produce little or no semen if you have had previous treatments such as:
  • Radiotherapy
  • Radical prostatectomy
  • Brachytherapy 
• It is likely that you will still produce little or no semen when you orgasm even If you have had no previous treatment. 
• This is because hormone therapy lowers or blocks the amount of testosterone in your body. 

The significance of ejaculation

• For some men, the lack of ejaculation may lead to a great feeling of loss or emptiness.
• This may cause problems particularly for those who are looking for new partners and contacts. 

• It can be helpful to speak to others who understand what you are experiencing. 
• You could go along to a support group. 
• See our living with side effects page for more information. 
• As well as general support groups there are support groups specifically for those from the LGBTQ and Black communities. 

• Sexual and relationship therapy may help you to adapt to your new circumstances. Ask your healthcare team if you can be referred. 

• You will still be able to orgasm after radical treatment for prostate cancer.
• However, it may feel different.

Some Facts about orgasms after or during treatment for prostate cancer.

• When a man has an orgasm, there is usually a build up of semen in the urethra.
• This can create a feeling of fullness and inevitability for men.
• In a radical prostatectomy, the seminal vesicles and the prostate are removed. Therefore, there is no longer a build up of fluid. If this was an important part of your orgasm, your 'new' orgasm will feel different.
• You can have a dry orgasm without an erection.

• Some people may feel that their orgasm is better than before and more of a 'whole body experience'.
• It may take you longer to orgasm.
• The sensation that you get may be less intense than it was before.
• You may find it more difficult to reach orgasm.
• Your penis may feel less sensitive in some areas.
• You may experience some pain when you orgasm. This can improve with time and with sexual stimulation.
• If you are on hormone therapy, you may find it more difficult to reach orgasm. This is because your levels of testosterone are low. You may also have less semen.

What about orgasms and anal sex?

• If you have anal sex, this may feel different too.
• For some men, the prostate is a point of pleasure during sex. Therefore, if you have your prostate removed, your orgasm will feel different.
• If you have had radiotherapy, the sensitivity of your prostate gland may decrease.
• However, some men feel that pleasure comes from the feeling along the whole anal canal or the outer edge of the anus. If this is the case, the pleasure from the orgasm may be the same. 

What can I do to help me get an orgasm?

• Choose a time when you feel relaxed, and you have plenty of time to explore.
• This can be on your own or with a partner. Have no expectations – just try to enjoy the process.

• You can experiment with sex toys such as:
  • Vibrators - these can stimulate the nerves in the penis and the signals that go to your brain.
  • Pulsing toys
  • Male masturbators
  • Anal sex toys.
• Explore sensations in other parts of the body. The body has many erogenous zones (sensitive spots) that can lead to arousal.

• After treatment for prostate cancer, you may get some changes to the size and shape of your penis.
• After prostatectomy, you may lose some length. This can be anything up to 2cm. 
• Some men may also see some slight curving of the penis. This is called Peyronie's disease.
• Some men may regain their original length over time. 
• If you are on hormone therapy, you may get some shrinkage of your testicles. 

What can I do to help manage these changes?

• You may be prescribed PDE5 inhibitors. This has been found to help the return of penile length in some people.

• The use of a vacuum erection device may also help to increase blood flow. 

  

• Ask for a referral to a psychosexual counsellor. You may be able to access this service via the NHS. You can also look for a private counsellor. See the resources section for more information. 

• Peeing when you are aroused or when you orgasm is called climacturia.
• Climacturia can happen after a radical prostatectomy.
• Some men may leak during physical or psychological arousal. This is called arousal incontinence (AI). It is sometimes called foreplay incontinence.
• The amount of pee leaked is usually small. Up to one teaspoon.
• Climacturia and AI may get worse when you are tired. For example, at the end of the day. This may be related to a relaxation of your pelvic floor.
• Alcohol may also worsen these conditions.
• These problems can improve or stop altogether over time.

What can I do to help ease these problems?

• Pelvic floor exercises may help.
• In men, the pelvic floor goes from the tailbone (coccyx) to the pubic bone. It supports the bladder and bowel.
• The tube that brings pee from your bladder to the outside is called the urethra. The urethra and the rectum pass through the pelvic floor muscles.

Why is the pelvic floor important?

• The pelvic floor is important in:
  • Bladder and bowel control
  • Helping to keep an erection.
• Pelvic floor exercises can help to strengthen your pelvic floor muscles. See the resources section for more support and information. 

Other things you can do include:

• Emptying your bladder before sex or masturbation
• Using a condom
• Cutting down on fluids before sex
• Avoiding food and drinks that may irritate your bladder for example:
  • Tea
  • Coffee
  • Alcohol
  • Fizzy drinks.
• Using a constriction device at the base of your penis. The band puts pressure on the urethra. This helps to stop pee leaking out. Please note, this can only be left in place for 30 minutes. Leaving it on for longer may cause damage to the penis. Always talk to your healthcare team before using this type of device.
• Having sex in the shower.
• Making sure you have towels or absorbent pads nearby. 

• Pain that is experienced either during or after receptive anal sex is called anodyspareunia.
• This can sometimes happen after radical treatment for prostate cancer for example, prostatectomy or radiotherapy.
• Talk to your healthcare team about when it is safe to return to start receiving anal sex or using anal toys following treatment. If you return too soon you may be more likely to experience long-term problems like rectal bleeding.
• Do not be afraid to speak to your healthcare team about any anal pain that you are experiencing. 

Guidance on how long men should abstain from receiving anal sex before, during and after treatments and tests for prostate cancer. 

• This guidance was put together by a group of clinical oncologists and urological surgeons across the UK.  You can find the original scientific journal article on ‘Clinical Oncology online’. This link will open in a new tab.
• This is just guidance. Always talk to your own healthcare team for advice that best suits your own situation. 

PSA test

If you still have a prostate, avoid anal sex for one week before a PSA test. Prostate massage can increase PSA levels. 

Prostate biopsy

Avoid anal sex for two weeks following a transrectal prostate biopsy. This allows the skin in your rectum to heal properly. This will decrease the chance of infection. 

Avoid anal sex for one week after a transperineal prostate biopsy. This allows the skin to heal and any bruising to calm down. Allowing time to heal will reduce the chance of painful sex. 

Radical prostatectomy

If you have had a radical prostatectomy wait for six weeks before having anal sex. You need to wait for internal healing to happen. Having anal sex before this time may make peeing problems (urinary incontinence) worse.

External beam radiotherapy

If you have had external beam radiotherapy, you should wait about two months before having anal sex. The rectal skin will be inflammed and more prone to damage. 

High-dose rate (temporary) brachytherapy 

If you have had high-dose rate (temporary) brachytherapy, you should wait two months before having anal sex. This will give time for any rectal inflammation to settle. 

Low-dose rate (permanent seed) brachytherapy

If you have had low-dose rate (permanent seed) brachytherapy, you should wait about six months. This allows for rectal inflammation to heal. This also reduces the radiation to your partner's penis during anal sex. 

• The side effects of treatment may mean that for those who take part in anal sex, a change of sexual role may be necessary.
• This can have a negative effect on some relationships.
• Sexual or relationship therapy may be helpful. This can help you work through your concerns.

• It may also be able to provide solutions or ideas that can help you.
• You can talk about your role and the possibility of switching roles to better suit your new circumstances. If you have a partner, take them with you.
• If you have a partner, talk to them! Be honest about how you feel. You can talk about:
  • Finding new ways to be intimate
  • How they feel about changing roles and
  • How you see your relationship developing.
• Most importantly, it is important to keep communication channels open.

• You can speak with a psychosexual or relationship counsellor.
• There are counsellors who specialise in working with those from the LGBTQ community.
• Psychology today have a list of accredited counsellors who specialise or have an interest in, working with LGBTQ+ individuals. This link will open in a new tab.
• Always look for a counsellor who is accredited by the British Association for Counselling and Psychotherapy. They also have a directory of therapists. You can search for therapists who have an interest in working with those from the LGBTQ community. 

lack of libido

• If you are on hormone therapy, you may:
  • Have a decreased sex drive
  • Lose interest in sex altogether.
• This is because the hormone treatment blocks or lowers the amount of testosterone in your body.

• Testosterone is a male sex hormone (an androgen). It is made mainly by your testicles.
• A small amount of testosterone is also made by your adrenal glands. These are on top of your kidneys.
• Visit our hormone therapy pages to learn more about hormone therapy:
  • Hormone therapy injections (link will open in a new tab).
  • Hormone therapy tablets (Link will open in a new tab).
• Libido can also be affected by anxiety or stress. Getting a diagnosis of cancer is stressful. There are lots of things to think about and therefore sex may not be at the top of your mind. This can put a strain on your relationship.
• Talk to your partner about how you are feeling. Being open and honest is really important.

• You can also visit a sex or relationship therapist. This service may be available on the NHS. Ask your healthcare team. You can also access a therapist privately. Look at the resources section for more information. 

What is intimacy?

• Intimacy is a feeling of:
  • Closeness
  • Togetherness and
  • Emotional connection with your partner.

How can we be intimate?

• You don't have to engage in penetrative sex to be intimate with your partner.
• Exploring non-sexual touch and taking away the expectation of penetration can help you both to relax and just focus of being close.

• Ways of expressing love and intimacy through non-sexual ways may include:
  • Mutual massage
  • Caressing
  • Cuddling
  • Sleeping together naked
  • Kissing
  • Taking a bath or shower together
  • Holding hands.
• Having an honest conversation about what you both want when you are engaging in non-sexual touch, may relieve any stress and expectation for you both. 

Date nights and having fun

• Non-physical kinds of intimacy are also important and may increase after a cancer diagnosis. Examples may include:
  • Making time to listen to each other and making the other person feel heard.
  • Giving complements.
  • Having fun together, laughing dancing and sharing experiences.
  • Giving little gifts. They don't have to be expensive.
  • Think about booking in some 'date nights'. This may be a romantic meal or some quality time together doing something you enjoy.

Can I talk to my healthcare team about fears around sexual side effects?

• Yes, it is very important to talk to your healthcare team about any concerns you have.
• Being open and honest with them will help your team to advise you about the best treatments for you.

• Have a conversation with your healthcare team about your fears around possible changes to your sex-life and relationships before you decide on a treatment. 

  

• If you are currently single, you can stress to your healthcare team that information on sex and relationships is important to you. This includes access to rehabilitation or pre-habilitation exercises or therapy.  
• If you feel comfortable to do so and you feel it is relevant, you may find it useful to disclose your sexuality. Healthcare teams may not always ask you this information. They will be able to better tailor information for your needs or signpost you to support.
• It is a good idea to involve your partner in discussions about sex and relationships with your healthcare team. Sexual side effects will also impact them so it is important that they can also ask questions or ask for support.
• You can also ask to be referred to a psychosexual counsellor so you can talk through any issues you may have. You can go alone or with your partner. This provides a safe space for you both to talk about any concerns you may have.

• Going along to a support group and talking to others about your concerns can be helpful for some. Visit our living with side effects page for more information about support groups (page will open in a new tab). There are general support groups as well as those that cater for:
  • Black and minority ethnic men with prostate cancer
  • Those from the LGBTQ community
  • Partners of those with prostate cancer.