Sexual dysfunction is the most commonly reported health-related quality-of-life outcome following treatment for prostate cancer. The impact of sexual dysfunction is complex, with wide-ranging physical and psychological effects for affected men, leading to depression, anxiety, sense of loss of masculinity, lack of sexual confidence, and potential avoidance of sexual activity. Additionally, sexual dysfunction related to treatment for prostate cancer differentially affects patients and partners, altering sexual performance, intimacy, and relationships in dramatic and unpredictable ways.

Although most men undergoing treatment for prostate cancer are rendered free from cancer, many experience long-term consequences of cancer treatment on their sexual health. The AUA2023 Plenary Panel Discussion, “Sexuality After Prostate Cancer Treatment,” included male sexual health experts Drs Jose Flores (Memorial Sloan Kettering Cancer Center), Sevann Helo (Mayo Clinic), Tobias Köhler (Mayo Clinic), and Chris Nelson (Memorial Sloan Kettering Cancer Center), and highlighted common concerns voiced by prostate cancer survivors: erectile dysfunction, penile length loss, and climacturia.

1. Erectile Function Recovery—Erectile function is adversely impacted by all surgical and nonsurgical prostate cancer treatments. Patient factors that can additionally modify erectile function include age, baseline erectile function, nerve-sparing status (for patients undergoing radical prostatectomy), and medical comorbidities, specifically diabetes, low testosterone, and sleep apnea. The pathophysiology of erectile dysfunction (ED) in individual patients may include arteriogenic insufficiency and/or neurogenic ED, both of which can progress to corporovenoocclusive dysfunction (CVOD) over time. The goal of penile rehabilitation therapy, using pharmacological or nonpharmacological options or both, is to limit the structural alterations, and prevent development of CVOD in order to maximize the chances of patients’ returning to their baseline presurgical erectile function level.¹ A recent meta-analysis by Motlagh et al included 22 randomized controlled trials to evaluate the recovery of erectile function to baseline in patients who had a nerve-sparing radical prostatectomy.² The study concluded that regular-dose and high-dose phosphodiesterase 5 inhibitors (PDE5i) use significantly increased erection recovery after surgery. The likelihood of returning to baseline erectile function with regular high-dose PDE5i, in particular, was almost double compared to placebo or no treatment.
2. Penile Length Loss—Penile length loss is reported in 15%-90% of patients after prostate cancer treatment. The temporal onset of penile length loss is earliest in men following prostate cancer surgery compared to nonsurgical treatment options, although overall prevalence is highest after androgen deprivation therapy. Men with severe ED, older age, and Peyronie’s disease are at increased risk of penile length loss. Accordingly, strategies for prevention of length loss include use of PDE5i and vacuum erection devices, as well as penile traction. Fortunately, most patients experience an improvement in penile length with time.
3. Climacturia—Involuntary loss of urine at the time of orgasm is reported by men more commonly following prostatectomy and less commonly following radiation therapy. The etiology of climacturia is not well understood. Penile length, adrenergic tone, and pelvic pain may all be contributing factors. Although climacturia is not harmful to patients or their partners, it is bothersome in 33%-45% of cases. Conservative management strategies, including voiding prior to intercourse, pelvic floor rehabilitation therapy, and use of venous tension loops, can all help with the frequency and degree of climacturia. Fortunately, climacturia improves over time in the majority of cases. However, for patients who continue to experience bother due to the involuntary loss of urine, surgical interventions with traditional slings and artificial urinary sphincter placement, as well as less-invasive options such as mini-jupette grafts, can offer dramatic improvement and complete resolution in the majority of cases.

Sexuality, and the restoration of sexual function, should be an integral goal of survivorship care for men with prostate cancer. Connecting patients to resources for sexual health, and ensuring that they continue to engage with and utilize these resources is of paramount importance in supporting their recovery. There is a growing body of evidence supporting the benefits of early psychological intervention as it relates to increasing sexual self-esteem, decreasing sexual bother, decreasing prostate cancer treatment regret, and decreasing the psychological impact of cancer. Urological practices can tremendously improve patient quality of life by developing the capacity to support sexual recovery for their prostate cancer patients and establishing referral pathways to qualified mental health specialists in their community.