How does a history of prostate cancer affect ejaculation in a male patient over 50?

Ejaculation After Prostate Cancer Treatment

Men treated for prostate cancer will experience anejaculation (absence of ejaculate) after radical prostatectomy, while the ability to achieve orgasm is typically preserved even without an erection. 1

Impact of Different Treatment Modalities on Ejaculation

Radical Prostatectomy

• Complete loss of ejaculation (anejaculation) occurs universally after surgery due to removal of seminal vesicles and disruption of ejaculatory ducts. 1
• Orgasm capability remains intact in most men despite the absence of ejaculate—this can occur even without achieving an erection. 1
• Climacturia (urine leakage at orgasm) affects a significant proportion of men, particularly within the first year post-surgery, and can be managed by emptying the bladder before sexual activity or using condoms during intercourse. 1

Radiation Therapy

• Radiation does not immediately eliminate ejaculation like surgery does, but progressive damage to ejaculatory structures occurs over time. 1
• Ejaculatory dysfunction develops gradually due to ischemic tissue changes including fibrosis and necrosis affecting the seminal vesicles and ejaculatory ducts. 2
• The delayed onset of sexual dysfunction after radiation (6-36 months) contrasts with the immediate effect of surgery. 1, 2

Androgen Deprivation Therapy (ADT)

• ADT combined with radiation therapy causes temporary to prolonged loss of libido and erectile function, which indirectly affects sexual activity including ejaculation. 1, 2
• The demasculinizing effects of hormonal treatment can significantly impact body image and sexual self-regard. 1

Psychosocial Considerations

Partner and Sexual Orientation Factors

• Men who have same-sex partners are significantly more bothered by loss of ejaculate than heterosexual men and face greater risk of depression or anxiety. 1
• Partners' sexual function and satisfaction directly affect the survivor's erectile function recovery and overall sexual satisfaction. 1
• Many couples do not recover their sexual relationship without professional support or counseling. 1

Body Image and Psychological Impact

• Men experiencing loss of ejaculation, penile shortening, or hormonal treatment side effects benefit from discussing these issues with their primary care clinician. 1
• Some survivors feel regressed and child-like when dealing with persistent bowel or urinary symptoms alongside sexual dysfunction. 1
• Referral to supportive counseling should be offered when patients express distress about body image changes or loss of sexual function. 2

Clinical Management Approach

Pre-Treatment Counseling

• Counsel all men before treatment that prostate cancer therapy will cause anejaculation (if surgery) or progressive ejaculatory dysfunction (if radiation), along with potential infertility, erectile dysfunction, and urinary/bowel problems. 2
• Pre-treatment counseling must explicitly state that orgasm ability is often preserved even without ejaculation. 2
• Discuss sperm banking before treatment for men of reproductive age who wish to preserve fertility options. 2

Post-Treatment Support

• Open the door to sexual recovery discussions during routine clinical care by directly asking about sexual function concerns at regular intervals. 1, 2
• Address climacturia management: recommend bladder emptying before sexual activity and condom use if urine leakage at orgasm is bothersome. 1
• Include partners in survivorship care discussions, as their distress and sexual function significantly affect the patient's recovery. 2

Referral Pathways

• Refer to a urologist or sexual health specialist when patients express persistent distress about sexual dysfunction or when first-line interventions fail. 1, 2
• Mental health professionals trained in sex therapy can help couples develop a new sexual paradigm based on current function rather than pre-treatment expectations. 2
• A multidisciplinary approach involving primary care, urology, and mental health support is most effective for comprehensive sexual recovery. 2

Common Pitfalls to Avoid

• Do not assume that preserved erectile function means preserved ejaculatory function—these are separate physiologic processes, and surgery eliminates ejaculation regardless of erectile recovery. 1
• Avoid dismissing climacturia as trivial; this symptom causes significant distress and embarrassment but has practical management solutions. 1
• Do not overlook the heightened psychological impact on men who have same-sex partners, who require specific attention to loss of ejaculate concerns. 1
• Failing to counsel patients pre-treatment about anejaculation leads to unrealistic expectations and greater post-treatment distress. 2