Erectile dysfunction (ED) happens when your penis cannot get hard enough to have sex. Learn why this happens after some prostate cancer treatments and what you can do about it.

Almost every kind of prostate cancer treatment, including surgery, radiation therapy (radiotherapy) and hormone therapy, can cause changes to your sexual function. Most men will experience erectile dysfunction, or ED, during and after their treatment. Although you may feel aroused or in the mood for sex after prostate cancer, chances are it can be difficult getting an erection.

Surgery to remove your prostate (radical prostatectomy) affects the nerves and blood supply around your penis. Your penis needs a healthy blood flow to get an erection. Without this, your penis will not become as hard as it did before surgery.

During surgery, your entire prostate is removed. The nerves that help create erections run down the left and right side of the prostate. Your surgeon can usually take out the prostate without causing permanent harm to the nerves on either side. But if your cancer is too close to the nerves, they may need to be removed.

Depending on where the cancer was within the prostate, your surgeon may have been able to avoid cutting the nerves. This is known as "nerve-sparing" surgery. However, even with nerve-sparing surgery you’ll likely have some trouble getting a hard erection right away after surgery. And some people may not get back their full erectile function. It is important to understand that surgeons cannot see the nerves during the surgery, so they use their knowledge of anatomy to attempt to avoid cutting nerves.

Sometimes the bundles of nerves on both sides of the prostate must come out (non nerve-sparing surgery). Damaged nerves can often recover; however, cut nerves cannot regrow. People who have this kind of surgery will not be able to have erections firm enough for penetration without an erectile aid, such as medications or devices.

Even though radiation treatment is focused on the prostate, it can cause scarring in the tissues around the prostate, including the nerves that control erections.

After radiation treatment, erections gradually become less firm. This can happen soon after treatment, or years later.

Hormone therapy lowers the amount of the sex hormone, testosterone, in your body. It also disrupts blood flow to the penis which causes erectile dysfunction.

ED usually starts within six weeks of treatment. If you have to stay on hormone therapy long-term, ED may be permanent. If your therapy is short-term, you may see recovery of erections about six months after stopping treatment.

You’ll likely have trouble getting a hard erection immediately after surgery. It may take up to 3 years to improve.

Some of these you can work on, like staying active and keeping a healthy weight. Others are a little more out of your control. All are things you can talk to your doctor about and ask for recommendations that can help.

Remember, you can still get pleasure from sexual intimacy. If you're comfortable, you can try the following suggestions.

There are different types of sexual aids you can try, all with their own set of pros and cons. Every person is unique so you may need to try out a few options, a number of times and perhaps in combination to settle on the best solution for you. You can find out more here.

You might want to experiment with different sex positions that can help with blood flow to the penis. Depending on how you like to have sex, consider:

Before surgery, you may have relied on erections as a way to initiate sex. Without spontaneous erections, think about who will initiate and how.

After surgery, you may find that penetrative sex is difficult or impossible. It can help to explore different sex acts that give you both pleasure. For example:

Hear from someone who’s been there:

This will depend on what type of sex you’re having, and what your role is with your partner.

If you’re having sex with a partner who has a vagina, it’s safe to attempt intercourse as soon as your catheter is removed. This usually happens about two weeks after the surgery. Achieving erections so soon after surgery, however, is unlikely. So, be patient and understand the body takes time to heal.

If you are the “top” partner during anal sex, it’s physically safe to have sex and to attempt anal intercourse as soon as your catheter is removed. This usually happens about two weeks after the surgery. Achieving erections so soon after your surgery, however, is unlikely. So, be patient and understand the body takes time to heal.

If you are the “bottom” or receiving partner during anal sex, it’s physically safe to engage in non-penetrative sex as soon as your catheter is removed. It’s probably best to avoid anal sex for a period of 6 weeks after surgery, to let your internal pelvic region heal. Importantly, it is wise to be cautious and talk to your surgical oncologist about when you can re-engage in sexual activity and be on the receiving end during anal sex.

Overall, a lot of men are not interested in sex when they are getting over the immediate effects of the surgery. However, there may be an increased need for physical affection for both you and your partner. At this early stage of recovery, you will most likely need to use injections to have erections firm enough for penetration.

You can have sex during and after radiation treatment, as long as you feel physically comfortable to do so. Your anal tissue can be sore during radiation treatment so you will want to avoid anal sex until the soreness is gone, usually about 3 to 4 weeks after treatment.

If you’re having internal seed radiation (brachytherapy), you will need to wear a condom during sex. This is because the seeds can become loose and come in out in your semen. Talk to your doctor about how long you need to wear a condom for.

If you’re having external beam radiation, there is no radiation risk to your partner.

As always, if you’ve got questions about ED after prostate cancer and ways to improve, talk to your doctor or care team for support.