Erectile dysfunction (ED) is one of the most common and sensitive topics for people living with prostate cancer. Whether it appears before diagnosis or as a result of treatment, ED can affect relationships, overall health, and emotional well-being. Here are nine important facts to know about why ED happens with prostate cancer and what can be done to help.

1. Erectile Dysfunction Is Very Common

Having ED means being unable to get, or keep, an erection firm enough for sexual intercourse. It may happen occasionally or become a long-term issue. ED becomes more common with age, but it can develop at any point in adulthood. Prostate cancer itself can sometimes contribute to ED, but most ED is related to treatment.

ED happens when something disrupts either the physical or chemical processes that lead to an erection. A disturbance to blood vessels, nerves, hormones, or brain signals can make it more difficult to have an erection.

Common ED symptoms include:

• Trouble getting an erection
• Difficulty maintaining an erection
• Reduced firmness of erections
• Less interest in sex

Before prostate cancer treatment even begins, some people with prostate cancer already experience ED for several reasons. These other risk factors include, but aren’t limited to:

• Older age
• High blood pressure
• Diabetes
• Heart disease
• Stress
• Smoking
• Alcohol use
• Psychiatric or psychological issues

Adding on cancer treatment to this may worsen an already existing issue or create a new challenge.

2. Prostate Cancer Can Affect Sexual Function

Although prostate cancer typically develops slowly and may not cause symptoms early on, it can sometimes affect the structures that help with erections, leading to ED. The prostate sits below the bladder and close to the nerves and blood vessels that support sexual function. If the cancer grows beyond the prostate or causes inflammation in surrounding areas, it may interfere with these pathways.

Even before treatment begins, some people with prostate cancer notice:

• Weaker erections
• Shorter erections
• Less force during ejaculation
• Decreased sexual desire
• Anxiety during sexual activity

However, most ED related to prostate cancer happens because of treatment, not the cancer itself.

3. Surgery for Prostate Cancer Can Cause ED

The most common surgery for localized prostate cancer (prostate cancer that hasn’t spread) is called a radical prostatectomy. No matter how it’s done — robotic, laparoscopic, or open — it removes the entire prostate gland. While effective, it’s the treatment most commonly linked to ED.

Why can a radical prostatectomy cause erectile dysfunction? Tiny nerve bundles on each side of the prostate help control erections. During surgery, these bundles can be injured or removed. Even with nerve-sparing surgery, which aims to avoid these nerves, they can still be damaged or may need to be removed if the cancer is close by. The blood vessels that support erections may also be affected during surgery.

How Common Is ED After Prostatectomy?

Many people experience ED right after surgery due to trauma and inflammation around the nerves and blood vessels. Recovery can take months or even years, depending on age, nerve injury, and overall health. Some regain erectile function gradually, while others continue to have long-term ED.

Even when the nerves are spared, surgery can still irritate or temporarily damage them, so they may not work normally for a while. The process of nerve healing, called nerve regeneration, can be slow.

4. Radiation Therapy Can Lead to ED Over Time

Another therapy for prostate cancer, radiation therapy or radiotherapy, can cause damage that leads to ED gradually. Examples of radiation therapy include external beam radiation and brachytherapy. These may damage important structures, like nerves and blood vessels, that support erections. Unlike surgery, which has immediate effects on erectile function, radiation-related ED may develop slowly.

What should you expect with radiation therapy?

• Some people notice ED during treatment or within about six months after radiation begins.
• About 25 percent to 50 percent of people who undergo brachytherapy experience ED.
• About 50 percent of people who have standard external beam radiation experience ED.

Some people see improvement in ED after two to three years, but many don’t. Hormone therapy is sometimes combined with radiation, which increases the likelihood of temporary or long-term ED.

5. Hormone Therapy Lowers Libido and May Lead to ED

Prostate cancer often grows faster when there is more testosterone, a sex hormone, in the body. Hormone therapy, also called androgen deprivation therapy, reduces testosterone to very low levels, slowing or slowing the cancer’s growth and sometimes shrinking it. But testosterone is also important for sexual desire and erections.

If you’re on hormone therapy, you may experience:

• Decreased libido
• Difficulty getting or maintaining erections
• Decreased energy
• Emotional changes
• Smaller testicles and penis

Some people notice improvement in these symptoms once they’ve stopped hormone therapy, but recovery may take time. Not everyone regains their previous levels of sexual function.

6. ED Can Affect Emotions, Relationships, and Self-Esteem

ED can become an emotional problem, not only a physical problem. If you’re living with ED, you may feel:

• Less confident or embarrassed
• Frustrated
• Worried about disappointing your partner
• Disconnected from your relationship
• Depressed or anxious

Erectile dysfunction may also affect your partner, who may experience emotional stress and uncertainty. Open communication can help both people feel supported and understood. Many couples benefit from speaking with a counselor, therapist, or sexual health specialist about how prostate cancer has affected their sexual wellness.

7. Treatment for ED Usually Begins with Medications

Pills are often the first treatment option for ED, and they work well for many people. Medications such as sildenafil, tadalafil, and vardenafil help increase blood flow to the penis. These are often the first treatment recommended for anyone with ED, regardless of prostate cancer history.

These medications work best when some nerve function is still intact, blood flow is adequate, and the person taking them is sexually stimulated. About 75 percent of people who have undergone a nerve-sparing prostatectomy say these medications help them have erections.

Keep in mind that these medications don’t work for everyone, especially if there is significant nerve damage. These drugs may also take some time to work, so your urology or oncology doctor may encourage regular use early after your prostatectomy. These medicines must not be used with nitrates (often prescribed for chest pain) because they can cause a dangerous drop in blood pressure. If you know you have a heart condition, always talk with your doctor before trying these medications.

8. When Pills Aren’t Enough, Other Treatments Can Help

It’s common to need more than just medications to help with ED post-prostate cancer treatment. Fortunately, several effective treatments can restore sexual function over time.

Vacuum Erection Devices

A vacuum erection device (VED) is a plastic cylinder placed over the penis that creates a vacuum that draws blood into the penile tissue. A tension ring helps maintain the erection. VEDs may be very useful early after surgery. This device has an 80 percent success rate after prostate cancer surgery.

Penile Injections

Medications injected directly into the penis can cause increased blood flow and thus a firm erection. Often, these work within minutes, even when nerve damage limits your responsiveness to oral drugs.

Urethral Suppositories

A tiny medicated pellet placed inside the urethra can help increase blood flow. It can work even without sexual stimulation for some people.

Penile Implants

For those who don’t respond to other treatments, a surgically placed implant (inflatable or semi-rigid) can help give reliable erections. Satisfaction rates for people who get the implant and their partners are generally very high.

Pelvic Floor Physical Therapy

Strengthening pelvic muscles may improve blood flow and help with erections, especially after prostate surgery. Pelvic floor physical therapists may recommend exercises to do at home, like Kegel exercises (tightening and relaxing the pelvic floor muscles), to improve the ability to get an erection.

9. You Can Talk Openly With Your Doctor

It may feel difficult to bring up sexual concerns with your physician, but your healthcare team expects these questions. ED is one of the most common side effects of prostate cancer treatment, and doctors routinely help people manage it.

Feel free to ask your doctor:

• Why am I experiencing ED?
• How long is recovery expected to take?
• What treatment options are available?
• Should I see a sexual health specialist?
• Should I make any lifestyle changes?

Although ED is common after prostate cancer treatment, it doesn’t have to be your new normal. ED is treatable, and you deserve support. Talk to your doctor to develop a treatment plan for your sexual health.

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