Treatment Affected Intimacy

Sex changes physically after cancer treatment. The reasons are hormonal, mechanical and neurological. It is not a failure of desire. It is not something to wait out quietly. Chemotherapy, pelvic radiation, hormone therapy and surgery all affect sexual function directly. So do medicines taken alongside them. Opioids and several antidepressants lower desire on their own.

Most of what follows can be treated, or at least improved. Almost none of it gets raised unless you raise it.

Chemotherapy, hormone therapy and pelvic radiation often cause vaginal dryness. They also thin the tissue. Pelvic radiation can cause vaginal stenosis. That means a shorter, narrower, less elastic vagina. Scarring can make both sex and internal examinations painful.

Here is what can be offered.

• Lubricants and moisturizers are different products. Lubricant goes on at the time. Use a water- or silicone-based one. Skip the warming, scented and flavored kinds if you are sore. A vaginal moisturizer is used regularly, two or three times a week, whether or not you are having sex. It rehydrates the tissue itself.
• Dilators. You use these on a regular schedule after pelvic radiation. They keep the vagina open and reduce scarring. Ask when to start, how often, and for how long. Ask what to do if it hurts. This is standard aftercare, and it is routinely handed over with almost no explanation.
• Vaginal estrogen treats dryness and atrophy well. But if your cancer is hormone-receptor-positive, your oncologist decides whether it suits you. That matters even more if you take an aromatase inhibitor. Do not start hormonal products without asking, including ones you can buy over the counter.
• Pelvic floor physiotherapy helps with pain and tightness. It also helps muscles that have learned to brace after painful sex.
• Sudden menopause. Chemotherapy, ovarian removal or ovarian suppression can bring menopause overnight rather than over years. Hot flushes, broken sleep, mood change and dryness all arrive together. Ask what non-hormonal options exist for you.

Erectile difficulty after prostate or pelvic surgery comes from nerve damage. After radiotherapy it often builds slowly over months, as blood vessels and nerves are affected. Androgen deprivation therapy (treatment that blocks male hormones) lowers desire and function together. Chemotherapy can lower testosterone for a while.

There is a usual ladder of options. They are often combined, and sometimes started soon after surgery. The plan is called penile rehabilitation.

• PDE5 inhibitor tablets, such as sildenafil or tadalafil.
• Vacuum erection devices, which also help maintain tissue.
• Injections into the penis, or a small pellet placed in the urethra.
• Penile implants, either firm rods or inflatable devices, if other options fail.
• A testosterone test if desire has gone flat. Testosterone is not appropriate in every cancer.

Some effects are common and rarely flagged in advance. Dry orgasm after prostate removal. Leaking urine at orgasm. Changed sensation. A shorter penis after surgery. Ask about these, because most of them can be managed. During chemotherapy you may be advised to use condoms for a period, since traces of the drugs can be present in semen.

Fatigue is the single most common reason sex stops. Practical changes beat motivation. Plan for the part of the day when you have energy. Time your pain medicine so it is actually working. Choose positions that do not load a painful area. Treat touch without sex as a real option, not a consolation prize. Neuropathy (nerve damage) changes what touch feels like. Ports, lines, stomas and scars change what you want seen, and when.

Say it plainly at your next appointment. "Sex is painful." "I cannot get an erection." "I have no desire at all." Then ask for one of these: a sexual health or sexual medicine clinic, gynaecology or urology, pelvic floor physiotherapy, or a certified sex therapist. Fertility questions go to a fertility specialist. Ask before treatment starts if you can, but ask even if treatment has finished.

Clinicians often do not raise this. Partly it is time, and partly it is awkwardness. So the question usually has to come from you. It is a completely ordinary thing to bring to a follow-up.

• Call 911 or go to an emergency department if an erection is painful or lasts longer than 4 hours. MedlinePlus flags that duration for sildenafil, and it applies just as much to a penile injection or urethral pellet. Trapped blood damages tissue, so this is a same-hour problem, not an embarrassing one to sit out.
• Call 911 or go to an emergency department if chest pain starts during sex, or you feel faint or sick with it. MedlinePlus says to stop, call a doctor immediately, and avoid sexual activity until you are told otherwise. Chest pain is treated as a possible heart problem until someone rules that out, and PDE5 tablets change which heart drugs can be given, so say what you have taken and when.
• Call your care team within a day or two if intercourse or a dilator hurts every time, if there is bleeding afterwards, or if a scar, stoma or line site becomes sore or inflamed. Pain that keeps recurring is a referral question, usually to pelvic floor physiotherapy or a sexual medicine clinic.

• MedlinePlus — Sildenafil
• NCI — Sexual Health Issues in Men and Cancer Treatment
• NCI — Fertility Issues in Girls and Women with Cancer
• NCI — Fertility Issues in Boys and Men with Cancer
• NCI — Fatigue and Cancer Treatment