MEN IN THE BEDROOM: SEX AFTER PROSTATE CANCER
Prostate cancer can change a man’s image of himself. From the moment he hears the diagnosis his life may be altered. His prostate is deep within him, intricately bound up with his sexuality and intimately connected to his virility.
As well as triggering depression and a confrontation with mortality, the diagnosis can render him psychologically impotent. The sheer emotional stress of acknowledging the cancer and what it could mean can wipe out desire and sabotage performance. It may take sustained mental effort to get back on track sexually – if treatment allows it!
Treatment can affect sexuality, both psychologically and physically. Many view treatment as an assault on their genitals, their hormones and their sense of masculinity. The truth is that treatment usually does, in some way, reduce erectile function, alter ejaculation and impact on libido.
The big question for most men is whether impotence will be an inevitable consequence of treatment. It is not, although it must be remembered that 30 per cent of men with prostate cancer are impotent before any treatment commences; these men will remain impotent.
For the others, different treatments have different outcomes. After treatment some men lose their potency immediately, some lose it gradually and some regain it gradually.
The four main treatment options are surgery, radiotherapy, hormone therapy and watchful waiting (observing, but having no active treatment).
The prostate lies in the body beneath the bladder, surrounded by nerves and blood vessels. Removing it without damaging these nerves and vessels is difficult. The degree of damage determines the degree of potency after the operation.
Surgeons have to balance their enthusiasm for protecting nerves against the certainty of getting rid of the cancer. They don’t want to protect the nerves and leave some cancer behind. Sparing nerves is only possible in some patients.
The literature shows that after a ‘nerve-sparing radical prostatectomy’ (taking it out with as little nerve damage as possible) between 40 and 70 per cent of men could still be potent.
Each man’s potential potency depends on age, the number of nerves spared and erectile function before the operation. After surgery, erections take between 3 and 18 months to return and are not as strong as they were before. They are said to be 60 to 80 per cent as good, but in reality assessments of this kind are very subjective.
With radiation therapy, blood vessels are slowly damaged. After 5 months of treatment men may begin to notice an effect on their potency. About 50 per cent of men who have had radiation therapy will be impotent 5 years later. Ejaculation and orgasm are also affected, but the extent to which they suffer depends on how sexually healthy the man was before the radiation treatment began.
Hormone therapy is usually reserved for men with advanced prostate cancer and is essentially a form of chemical castration. It leads to loss of desire, impotence in 80 per cent of patients, decreased ejaculation and less intense orgasms.
Men who opt for watchful waiting have to live with the knowledge that they have this cancer and are not actively treating it. This influences their self-image and may affect their sexuality in the long term.
However, on a positive note, neither prostate cancer nor its treatment affects the skin of the penis, and sensations there remain the same. Furthermore, many men forget that orgasm is a mental event and can occur without ejaculation.
It is a myth that intercourse is the only real grown-up form of sex. Much gratification is possible without penetration and men suffering prostate cancer-induced impotence could try ‘outer-course’. This includes any form of sexual activity that is commonly thought of as foreplay.
Unfortunately, although foreplay satisfies many women, men often don’t regard it as real sex and their ‘outer course’ activities are limited. But people have ‘skin hunger’, and just like babies need to be held, so they need to be touched. There are numerous ways of feeding this hunger. Holding hands, lying together or massaging each other is a good way to start.
Men missing the closeness of intercourse could regain it using a technique described as ‘soft sex’. This requires the woman to sit astride the man and use her pelvic floor muscles to achieve partial penetration. This can give great pleasure to both partners but the woman does need to have a strong pelvic floor.
Following treatment for prostate cancer, men may initially lose their desire for sex and not feel like initiating it. But these men may feel more receptive when they realise how much they can still get out of it.
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