The impact of cancer on male sexual function

When a man finds out he has cancer, sex doesn’t tend to be the first thing on his mind. Survival is.

But that’s not to say that the impact of a cancer diagnosis on sex, and more particularly on his ability to achieve and sustain an erection, should be disregarded. For many men, sex remains important throughout life – and that includes after a cancer diagnosis.

With cancer more and more becoming a chronic disease, which people often live with for many years, the sex lives of men living with cancer is increasingly worthy of consideration. So, what types of cancer can result in erectile dysfunction? Why do they do so? And how severe does that “ED” tend to be?

Many people know of the link between prostate cancer and ED. But fewer understand that a wider range of cancers – mainly those located in the pelvic region, for obvious reasons, but others too – are implicated as well.

ED rates among men newly diagnosed with cancer are higher than among healthy men of the same age, suggesting cancer itself could have a negative impact on erectile function. Notably, ED rates deteriorate further after treatment. This is because the necessary courses of treatment – principally surgery, but also radiotherapy – can damage the blood vessels and nerve cells needed to achieve and sustain an erection.

Prostate cancer and erectile dysfunction

Let’s take a look at prostate cancer first. Prostate cancer is the most commonly diagnosed type of cancer in men worldwide. Within Europe, it accounts for almost one in four cancer diagnoses in males.

Thankfully, most men with prostate cancer will not develop ED as a result of the condition. Often, if the cancer is at an early stage and thought to be growing slowly, the patient is advised to “watch and wait” or take an “active surveillance” approach (where tests are taken at regular intervals).

However, if the cancer is thought to be more aggressive, a radical prostatectomy might be necessary – meaning removal of the whole prostate gland. Due to the prostate’s proximity to penile tissue, this type of surgery can cause damage to the nerves and blood vessels needed for normal erectile function.

Worldwide, some 1.5 million men a year are diagnosed with prostate cancer, according to the Global Cancer Observatory, around half of whom are in Europe and North America. At least a third go on to need a radical prostatectomy.

Nearly all men who have this operation will experience ED to some extent in the months after surgery. For many, things then settle down. A year after surgery, around half – estimates vary widely – will have regained their pre-treatment sexual function. There’s good evidence that PDE5 inhibitors like sildenafil can help men achieve an erection after prostatectomy and might even assist in the healing process if started soon enough.

But for the half (or so) of men who still experience ED a year after prostate surgery – translating to at least 200,000 per annum in Europe and North America alone – the picture is not so rosy. These men often experience ED that is more severe (as measured by erectile function scores) than that caused by other medical conditions, such as diabetes or heart disease. For them, PDE5 inhibitors are usually not enough to counteract the problem, because the surgical damage to penile nerves and blood supply has been too serious. An additional complication is that, after surgery, the nerves serving the penis can be so badly affected that the man no longer experiences normal, nocturnal erections – which are necessary to maintain the health of penile tissue. This leads to fibrosis, thus initiating a vicious circle that prolongs the ED.

Surgery is not the only type of treatment that can result in ED. According to Johns Hopkins Medicine, around half of men who have external beam radiotherapy for prostate cancer experience ED, while the corresponding figure for those who’ve had brachytherapy (where radioactive beads or wires are placed as close as possible to the tumour) is a quarter to a half.

“After two to three years, few men [who’ve had such radiotherapy for prostate cancer] will see much of an improvement and occasionally these numbers worsen over time,” Johns Hopkins Medicine reports.

Remedies do exist for men with severe ED who don’t respond to drugs like sildenafil, but they tend to be cumbersome. Mechanical devices like vacuum pumps and inflatable penile implants are one option, while injections into the penis with erection-inducing medicines are another. Blue Cell Therapeutics is working on an alternative, for instance, using allogeneic stem cells to restore normal vasculature and nerve structures to the penis.

Other cancers and erectile dysfunction

A systematic review and meta-analysis, published in the British Journal of General Practice (BJGP) in 2021, found ED was around twice as common in men diagnosed with cancer compared to healthy men of the same age. Rates were even higher among men who had undergone treatment for their cancer.

Besides prostate cancer, ED prevalence was particularly high in men with colorectal cancer, cancers of the anus and rectum, bladder cancer, and colon cancer. Once more, rates were higher after treatment than at diagnosis – reflecting the impact of surgery and radiotherapy on normal erectile function. Given treatment for all of these can involve surgery in the pelvic region, with its potential disruption to penile tissue, that is unsurprising.

More surprising were the high rates of ED among men with some other forms of cancer, where tumours are not typically located close to penile tissue. For example, around three-quarters of men with blood cancers reported ED after treatment, while the figure for men with lymphomas was almost 50%. The authors of the paper also noted that other malignancies, including lung cancer – one of the most common types of cancer globally – and head and neck cancers, were also associated with higher rates of ED.

Of course, the overriding concern of men having treatment for cancer will usually be for their lives. But, as the BJGP authors themselves noted, the benefit of maintaining sexual function after finding out one has cancer should not be underestimated.

“Sexuality and intimacy are important aspects of quality of life and may also reduce some of the psychosocial distress associated with the cancer diagnosis,” they wrote. “Maintaining normal sexual function in males with cancer can be important to help relieve suffering.”

About the author

Søren P. Sheikh MD, PhD, HD, is CEO of Blue Cell Therapeutics. With more than 35 years in Danish and US academia and healthcare, Sheikh specialises in gut and neuropeptide biology, stem-cell fate determination, and cellular differentiation. His work covers molecular signalling pathways, transcriptomic and proteomic analyses, and AI-driven research in prostate cancer. He founded both the Danish Centre for Regenerative Medicine and the Centre for Vascular Regeneration, where he integrated stem-cell therapies into clinical settings. Most recently, Sheikh directed the Department of Clinical Biochemistry & Pharmacology at Odense University Hospital for 15 years, managing a team of 280 staff, including 35 dedicated scientists.