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To learn more about erections, such as what they are and how they form, see Cancer, Sex, and the Male Body.

This information is for adult males with cancer. If you are a transgender person, please talk to your cancer care team about any needs that are not addressed here.

Surgery effects on erections

Some types of cancer surgery can affect erections. (See Managing Male Sexual Problems Related to Cancer to learn more.) If any of these surgeries are part of your treatment plan, talk to your doctor before the procedure. Ask  doctor about how your erections might be affected by surgery and what may be the best way to manage the problem.

• Radical prostatectomy: Removal of the prostate and seminal vesicles for prostate cancer
• Radical cystectomy: Removal of the bladder, prostate, upper urethra, and seminal vesicles for bladder cancer. Removal of the bladder requires a new way of collecting urine, either through an opening into a pouch on the belly (abdomen) or by building a new “bladder” inside the body.
• Abdominoperineal (AP) resection: Removal of the lower colon and rectum for colon cancer. This surgery may require an opening in the belly (abdomen) where solid waste can leave the body.
• Total mesorectal excision (TME): ?Removal of the rectum as well as the tissues that support it (called the mesorectum) for treating rectal cancer
• Total pelvic exenteration: Removal of the bladder, prostate, seminal vesicles, and rectum, usually for a large tumor of the colon, requiring new openings for both urine and solid waste to leave the body.

Most men who have these types of surgeries will have some difficulty with erections (called erectile dysfunction or ED). Some men will be able to have erections firm enough for penetration, but probably not as firm as they were before. Others may not be able to get erections. There are many different treatments for ED that can help many men get their erections back. (See Managing Male Sexual Problems Related to Cancer to learn more.)

Nerve damage from surgery

The most common way surgery affects erections is by removing or causing injury to the nerves that help cause an erection. All of the operations listed above can damage these nerves. The nerves surround the back and sides of the prostate gland between the prostate and the rectum, and fan out like a cobweb around the prostate, which makes it easy to damage them during an operation.

When possible, “nerve-sparing” methods are used in radical prostatectomy, radical cystectomy, AP resection, or TME. In nerve-sparing surgery, doctors carefully try to avoid these nerves. When the size and location of a tumor allow for nerve-sparing surgery, more men recover erections than with other techniques. But even if the surgeon is able to spare these nerves, they might still be injured during the operation and need time to heal.

Even when the nerves are spared, research has shown that the healing process takes up to 2 years for most men. We don’t know all the reasons some men regain full erections and others do not. We do know that men are more likely to recover erections when nerves on both the left and right sides of the prostate are spared.

Other things that affect erections after surgery

A wide range of ED rates have been reported, even in men who haven’t had surgery. But for the most part, the younger a man is, the more likely he is to regain full erections after surgery. Men under 60, and especially those under 50, are more likely to recover their erections than older men.

• Strength of erections before surgery: Men who had good erections before cancer surgery are far more likely to recover their erections than are men who had erection problems.
• Other conditions, such as Peyronie’s disease: In some men, the penis can develop a painful curve or “knot” when they have an erection. This condition is called Peyronie’s disease. It’s most often due to scar tissue forming inside the penis, and has been linked to some cancer surgeries, such as surgery to remove the prostate (prostatectomy). Still, Peyronie’s disease is rarely linked to cancer treatment, and it can be treated with injections of certain drugs or with surgery. If you have painful erections, ask your doctor for help finding a urologist with experience treating this disease.

Early penile rehabilitation after surgery

As mentioned before, the recovery time for erections after surgery can be up to 2 years. If a man does not have an erection during this time period, the tissues in his penis may weaken. Once this happens, he will not be able to get an erection naturally. Some experts and doctors recommend different methods to promote erections starting within weeks or months after surgery to help some men recover sexual function. You may hear this called penile rehabilitation, or erectile rehabilitation.

Penile rehabilitation has 2 parts:

• Making sure you are getting regular erections that are hard enough for penetration. It’s best if you can have an erection 2 to 3 times a week. This will help keep the tissue in your penis healthy.

• Using a low-dose pill to help the blood flow around the nerves and help the nerves heal.

Medicines to help produce erections – pills such as sildenafil (Viagra^?), tadalafil (Cialis^?), or vardenafil (Levitra^?) ? are typically used in combination with other therapies or devices. Since the drugs might not produce an erection because they need the nerves responsible for erections to be healthy, penile injections or vacuum devices might be offered. See Managing Male Sexual Problems Related to Cancer to learn more.

Pelvic radiation therapy effect on erections

Prostate, bladder, colon, and rectal cancer are sometimes treated with radiation to the pelvis. This can cause problems with erections. The higher the total dose of radiation and the wider the section of the pelvis treated, the greater the chance of erection problems later. If radiation therapy is part of your treatment plan, talk to your doctor before it starts. Ask how your arteries and nerves might be affected by radiation therapy so you know what to expect.

Artery damage from radiation

As the treated area heals, the blood vessels lose their ability to stretch due to scar tissue in and around the vessels. They can no longer expand enough to let blood speed in and create a firm erection. Radiation can also lead to hardening (arteriosclerosis), narrowing, or even blockage of the pelvic arteries.

Nerve damage from radiation

Some men who get radiation will notice that their erections change for the worse over the first year or so after treatment. This change most often develops slowly. Some men will still have full erections but lose them before reaching climax. Others no longer get firm erections at all.

As with surgery, the older you are, the more likely it is you will have problems with erections. And men with heart or blood vessel disease, diabetes, or who have smoked heavily seem to be at greater risk for erection problems. This is because their arteries may already be damaged before radiation treatment. Doctors are looking at whether early penile rehabilitation could help after radiation therapy, too. (Penile rehabilitation is discussed above, in the surgery section.)

Radiation given for prostate cancer

Some men will have issues with erections (erectile dysfunction or ED) within a few years of external beam radiation for prostate cancer. Some of these men may have erections that allow penetration, but only a small portion report their erections are as good as they were before treatment.

Some men with early-stage prostate cancer have a choice between radiation and surgery to treat their cancer. When looking at how men’s erections are affected by prostate cancer treatment, there does not seem to be much long-term difference between the two. Men who have had radiation may see a general decrease in the firmness of their erections over time (up to several years after radiation). In contrast, after surgery most men have erection problems right away and then have a chance to recover erections in the first 2 years following the surgery. About 4 years after either treatment, the percentage of men reporting ED is about the same. Treatments can often help these men get their erections back whether they’ve had surgery or radiation.

Hormone therapy effects on erections

Hormone treatment is commonly given for prostate cancer. Men given androgen deprivation therapy (ADT) are at a high risk for sexual problems, including loss of sexual desire and erectile dysfunction. Erections may or may not recover when ADT is stopped. Erectile dysfunction drugs do not usually work in these cases because they don't help with the loss of sexual desire.

Chemotherapy, targeted therapy, and immunotherapy effects on erections

Other types of treatment for other types of cancer sometimes affect sexual desire and erections because certain drugs slow down testosterone output. Whether chemotherapy, targeted therapy, or immunotherapy drugs cause problems with erections depends on the type of cancer being treated and the type of drug or drugs being given. Some of the medicines used to prevent nausea during chemo can also upset a man’s hormone balance. But hormone levels should return to normal after treatment ends.

Nerve damage from chemotherapy

Some chemo drugs like cisplatin, vincristine, paclitaxel, bortezomib, and thalidomide can damage parts of the nervous system, usually the small nerves of the hands and feet. (This is called peripheral neuropathy.) These drugs have not been found to directly injure the nerve bundles that allow erection. But some people have concerns because the drugs are known to affect nerve tissue, and there are many nerves involved in sexual function.

Infertility after chemotherapy

Some types of chemo can also cause short-term or life-long infertility. (See Fertility and the Male Adult with Cancer for more information.)

Stem cell transplant effects on erections

Stem cell transplant (also called bone marrow transplant) involves getting very high doses of chemotherapy drugs. One complication of a transplant is graft-versus-host disease. Men who have had graft-versus-host disease are more likely to have a long-lasting loss of testosterone. In some cases, these men may need testosterone replacement therapy to regain sexual desire and erections.

Psychological effects of cancer treatment on erections

Many men report disappointment, fear, and distress when they have trouble with erections. They report they feel that something important is missing. Men may report a general unhappiness with life and depression when they have problems with erections. These feelings are a natural part of coping with erection problems. And most men, if they are able find effective treatments to help with their erections, will start to feel better. If these feelings are severe or persist, most men find it very helpful to see a mental health professional who specializes in sexual issues or a psychiatrist who can help address these feelings.

Worries about self-image and performance can sometimes lead to erection problems, too. Instead of letting go and feeling excited, a man may focus on whether he will be able to function, and fear of failure might make it happen. He may blame the resulting problem on his medical condition, even though he might be able to have an erection if he were able to relax.

A therapist or mental health professional who specializes in helping patients with sexual issues can often assist in the treatment of erection problems caused by anxiety and stress. Any treatment for an erection problem should be based on the results of a thorough exam, which should include both medical questions (history) and certain medical tests.