Can prostate cancer cause erectile dysfunction?

Can Prostate Cancer Cause Erectile Dysfunction?

Yes, prostate cancer itself can cause erectile dysfunction, though the cancer treatments—surgery, radiation, and hormone therapy—are far more commonly responsible for ED than the disease itself. 1

Direct Effects of Prostate Cancer

• Prostate cancer by itself reduces sexual desire and the frequency of sexual intercourse, even before treatment begins 2
• Men on active surveillance (no active treatment) have higher rates of sexual problems than matched peers without prostate cancer 3
• At least one-third of men already have sexual problems at the time of prostate cancer diagnosis, often related to age and comorbidities 3

Treatment-Related Erectile Dysfunction

All prostate cancer treatments can affect men's erectile function, making treatment-related ED far more significant than disease-related ED. 1

Radical Prostatectomy (Surgery)

• ED occurs rapidly after surgery due to nerve injury from intraoperative nerve traction, thermal injury, ischemic injury, and local inflammatory reactions 2
• The absence of nocturnal penile tumescence after surgery causes persistent hypoxia of the corpus cavernosum, leading to secondary anatomical and functional changes 2
• Erectile function may improve gradually, with some patients recovering function up to 2-4 years after surgery 1
• Surgery increases the rate of erectile dysfunction to 80% compared to 45% in watchful waiting groups 1

Radiation Therapy

• ED after radiation is delayed in onset, typically appearing 6 to 36 months after treatment, in contrast to the immediate effect of surgery 1
• The worsening appears as a slow decline due to local neurovascular changes from small vessel obliteration and endarteritis 4
• Radiation causes ischemic tissue changes including fibrosis and necrosis affecting erectile structures 4
• Anejaculation rates increase from 16% at 1 year to 89% at 5 years post-radiation, demonstrating progressive tissue damage 4

Androgen Deprivation Therapy (ADT)

• Men on ADT have the worst rates of sexual dysfunction among all prostate cancer treatments 3
• Even after 3-4 months of ADT, sexual desire decreases and irreversible damage may occur to erectile tissue 3
• Erections do not recover in approximately one-half of men, even if ADT is discontinued 3
• ADT in combination with radiation therapy has at least a temporary negative impact on libido and erectile function 1
• Serum testosterone requires 9-12 months off ADT to recover with intermittent therapy, but permanent ED still occurs in half of men 3

Clinical Management Approach

Initial Assessment and Counseling

• Men should be counseled before treatment that prostate cancer therapy may cause sexual dysfunction, infertility, bowel and urinary problems 1
• Pre-treatment counseling must include information that orgasm ability is often preserved even without ejaculation 4
• Sperm banking should be discussed before treatment for men of reproductive age 4

Treatment Algorithm for Post-Treatment ED

First-line: Trial of PDE-5 inhibitors (sildenafil) in appropriate candidates 1, 4

If PDE-5 inhibitors fail or patient is not a candidate:

• Referral to urologist or sexual health specialist for advanced options 1
• Treatment options include:
  • Intraurethral dissolvable prostaglandin pellet
  • Intracavernosal prostaglandin injection
  • Vacuum erection device
  • Penile prosthesis 1

Combination therapy (e.g., sildenafil and vacuum constriction) may improve erectile function but should be managed with urology collaboration 1

Important Clinical Pitfalls

• Do not assume ED treatment discussions have occurred—12% of men were not told that ED was a risk factor of prostate cancer treatment 5
• Do not wait for patients to bring up sexual concerns—primary care clinicians must proactively ask about sexual function during routine follow-up 4
• Do not give up on PDE-5 inhibitors too early after surgery—some patients recover erectile function up to 2-4 years after surgery, making it worth revisiting 1
• Do not conflate anejaculation with erectile dysfunction—these are separate issues requiring different management approaches, though they often coexist 4

Multidisciplinary Support

• A multidisciplinary approach is important and effective for sexual recovery 1
• Partners should be included in survivorship care, as they are often distressed and their sexual function affects recovery 1
• Referral to supportive counseling should be offered when patients express distress about body image changes 4
• Mental health professionals trained in sex therapy can help couples develop a new sexual paradigm based on current function 1

Quality of Life Considerations

• Patients value sexual function so highly that they are often willing to choose a therapy that offers shorter life expectancy but better potency 6
• Function and perceived bother may not be correlated—patients may express satisfaction despite loss of sexual function 6
• Approximately 50% of men use ED treatment during the 5 years following prostate cancer diagnosis, with modest improvement in sexual function compared to those not receiving treatment 7
• A fifth of men (21%) are not offered any ED management, and 23% are not satisfied with how healthcare professionals address their ED concerns 5