Not Hard, but Not Unhappy: Living Without Penetrative Intercourse

February 4, 2023

Andrew Siegel MD   2/4/2023

Although this entry is intended mainly for men with sexual dysfunction following prostate cancer treatments, it is equally applicable to all men with sexual dysfunction of any cause. This is also intended for the partners of men unable to achieve penile erectile rigidity.

Image by Peggy from Pixabay

When prostate cancer is diagnosed and treated on a timely basis – most commonly with surgery, radiation, and/or hormonal therapy — it has an extremely high survival rate.  Once concerns and fears about the cancer are diminished or absent, side effects that affect quality of life rise to the forefront.  Although the initial grieving process concerned the diagnosis of prostate cancer, after the disease is addressed, a new grief can surface for patient and partner—anxiety, distress, frustration, despair and even depression over the resulting impairment of sexual function.  Not all men experience erectile dysfunction, but most men will, particularly in the immediate post-treatment period for men who under radical prostatectomy and on a delayed basis for men who undergo radiation therapy. For many men it can take a prolonged time for erectile function to resume, and for some men erectile function will never return.

Impaired erectile rigidity and durability and dry ejaculation are the most common adverse sexual effects experienced after prostate cancer treatment.  Other sexual issues that may be encountered, particularly after prostatectomy, include urinary leakage with foreplay, ejaculation of urine at the time of sexual climax, altered sensation and possibly discomfort with sexual climax, and penile anatomical changes including shortening, deformity, and Peyronie’s disease.

The psychological impact of sexual side effects following prostate cancer treatments cannot be understated.  These repercussions further compound the psychosocial and interpersonal burdens that are already associated with the cancer and its treatment. Impaired sexual functioning can result in a profound compromise of masculine identity and self-esteem, impacting not only the patient but his partner, as well as his relationship with his partner. Clearly, prostate cancer is a couple’s disease and men need to recognize this and keep communication channels with their partners wide open. “It takes two to tango” and the prostate cancer patient needs to understand that the problem and the burden of the cancer and its sexual ramifications is not strictly his, but is shared with his partner.

Most partners are grateful for the fact that their significant other is alive and well and are less concerned about sexual function since the state of being alive clearly trumps and prioritizes the ability to participate in penetrative sexual intercourse.  Nonetheless, partners have their intimacy needs that should not be neglected.  Intimacy comes in many flavors, including touching, hugging, cuddling, snuggling, kissing, and fondling, which can be highly satisfying and end up in mutual orgasm.  Many men and their partners are surprised to discover that ejaculation and orgasm can occur without having an erection, although after radical prostatectomy ejaculation is dry. Many body parts can substitute for an erect penis — fingers, tongues, etc. — and there are an abundance of available sexual aids including toys, vibrators, etc., that can help the process and help provide partner satisfaction.

It is the urologist’s responsibility to prepare and inform the patient and his partner prior to cancer treatment of the sexual impact of the treatment so as to avoid the consequence of decisional regret. It is also the urologist’s responsibility to recognize the importance of sexual dysfunction as a side effect of prostate cancer treatment and guide the patient and partner through the available management options if sexual dysfunction occurs. There are numerous solutions available to erectile dysfunction including pelvic exercises, pills, urethral suppositories, penile injections, penile pumps, penile implants, etc. If a patient chooses one of these options, his sexual recovery can benefit from shared experiences, i.e., the partner can assist with the penile pump, urethral suppository placement or injection therapy.  Understandably, not all men and their partners are enthusiastic or interested in these less-than-natural means of helping to provide erectile rigidity, but they are available to help men achieve penile rigidity.

The bottom line is that a rigid penis is certainly a nice accessory, but is by no means a necessary requirement for pleasurable and gratifying sex and intimacy. Humans are incredibly creative and adaptable. Life goes on.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro AreaInside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, one of the largest urology practices in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food