A friend, 62, recently underwent surgical removal of his prostate, followed by radiation therapy, for prostate cancer, after which his oncologist prescribed an anti-androgen medication for the rest of his life, which as I understand it, stops him from producing any testosterone, which he says has made it impossible for him to have an erection. He is very upset by the realization that he and his wife will never have genital sex again. What I find curious is that he did not research his options and appears not to be researching them today. The oncologist told him to start taking the med, he did, and now he’s coping with the consequences. I think his wife is upset, too, mainly for him but I’m sure for herself, too.
My questions are:
Is it indeed impossible for a man to have an erection if his testosterone level is permanently zero?
Would a penile implant be an option for genital sex in this medical situation?
If yes, is a man with zero testosterone able to have an orgasm?
I understand this individual cannot produce sperm, but could he produce any seminal fluid or does that, too, stop?
Clearly, these are questions my friend should take up with his oncologist and urologist, but he is very passive. I think he’s also very depressed. It’s not a good situation.
That’s correct. I may have a prostatectomy in my near future, at 48, and I was told that I would be left infertile and sans ejaculate but, hopefully, still able to achieve orgasms. It’s a roll of the dice – my father had a prostatectomy and was left completely impotent. Better than dead, though.
I have a pituitary tumour called a prolactinoma, the net effect is that my naturally produced testosterone is basically zero. Before starting hormone replacement therapy not only was I impotent, I had zero interest in sex at all. My T is back in the normal range and all is good and right in the world.
If there are prostate cancer cells that have spread beyond the prostate and can’t be removed surgically, testosterone will enable those cells to grow and spread further. The only way to prevent that is to starve them of testosterone.
I would never minimize the difficulty of dealing with the sexual side effects of this treatment, but it’s very literally a life or death situation. Genital penetration isn’t the only way to have satisfying sex, and if you’re close enough to your friend to have the conversation, you might encourage him to contact prostate cancer support groups and maybe ask his oncologist about whether counseling is available.
My cousin is 65 and had his prostate removed about three years ago. He still engages in sex and states that yes he can get an erections for prolonged periods but cannot climax. He doesn’t warn women about that point and they get frustrated when he just keeps going and going like the Energizer Bunny.
Hi! Kinda different perspective here - I’m a trans woman who was on antiandrogens for some years (spironolactone) and eventually had an orchiectomy (testicle removal.) I did not have and do not plan to have a vaginoplasty, as I rather enjoy having a penis.
Couple things - testosterone is unlikely to ever be zero. Cisgender women have some testosterone, and so do trans women who are on antiandrogens or who have had bottom surgery. Likewise, cis men and trans men on testosterone still have some estrogen. My understanding (which may or may not be accurate) is that some of these hormones are produced in the bloodstream - the majority comes from the gonads, but not all.
On to the main question - erection and penetrative sex are totally possible, as is orgasm. Certainly not guaranteed, but possible. Some trans women lose erectile function pretty much immediately. Others retain function indefinitely. The colloquial wisdom in the community is “use it or lose it.” Volume of ejaculate is certain to diminish enormously. Erection may be more difficult to achieve and may feel different, but it is entirely possible even with permanently suppressed testosterone.
Also, advise your friend to try a vibrator. They’re awesome whether or not you actually get hard. Sexual pleasure and orgasm can be achieved regardless of erectile function.
Well, new treatments with drugs like leuprolide plus abiraterone will often result in levels that are undetectable even in the most sensitive tests. The abiraterone component shuts down testosterone production elsewhere in the body (primarily the adrenal glands) while leuprolide does so in the testes. This is thought to give better outcomes in prostate cancer treatment. Testicular vs adrenal sources of hydroxy-androgens in prostate cancer - PMC
I knew this info vaguely when my patients were using the drugs for prostate cancer tx. I know it viscerally now since I’m having my prostate cancer treated with androgen blockers and radiation. My testosterone levels are now zero. Oh, I’m sure there are a few molecules of it still floating around, but not enough to do much.
For me, PIV sex is pretty much not an option, but enjoyable partnered sex with orgasm for us both still occurs. I must say that my reporting this seemed to surprise my urologist (a very well trained, experienced doc), who said it was rare for males on hormone blocker regimens to still achieve any sort of climax, and rarer still to retain significant enough erectile capacity for intercourse.
Libido is greatly diminished by this treatment, but for me desire is not gone. I’m grateful to have an enthusiastic and patient spouse. Lacking that, I’d probably not pursue any sort of activity beyond reminiscing about past fun times.
I plan to only stay on the hormonal treatment for a full 18 months (so 7 more months), which is the minimum recommendation. Up to 36 months on it is now a common treatment. It takes a year or more for testosterone levels to recover once hormone blockers are discontinued, and even then they often do not rise to normal, and erectile capacity may not return. Ejaculative capacity does sometimes return if the prostate hasn’t been removed. Papaverine injections can restore erectile capacity when there’s enough testosterone in the system to help facilitate this, but generally doesn’t work in the setting of extremely low androgen levels. Penile implants are also a possible workaround. Testosterone supplements can be trialed after hormone blockers are ended also, if native levels have not risen sufficiently.
If it is possible, please check out brachytherapy. I caught my prostate cancer early, and that was what I did. Done as an outpatient, no side effects, and the cancer is gone. It doesn’t work if the cancer has spread. Now, it seems I was an optimal case, but it is worth checking out. Heck, it worked so well that after the procedure I didn’t need to take any Tylenol for pain.
Thanks. I’ll ask the doctor about that. Right now I’m waiting on the results of genetic testing on the cancer cells to decide where to go from here. The urologist didn’t seem too super concerned about it right now, but did seem to intimate that something should be done down the line. It’s a small (3mm) tumor with a Gleason 7. Looking it up, brachytherapy is something we did briefly talk about, as I brought up radiation therapy, and they said that wouldn’t be good given my relatively young age, but did mention a mix of brachytherapy and radiation, in addition to just active surveillance for the timebeing. I’ll inquire more about that. The additional risk factor I have is that both my father and his twin brother had prostate cancer. My father survived. My uncle passed away a few years later from bone cancer. But my genetic counseling did not have any markers flagged for prostate cancer. (And I know my uncle did a genetic screening in the early 2010s, which also came up negative.)
I discussed brachytherapy with my urologist. It wasn’t right for me due to the aggressiveness of my prostate cancer. But in addition overall the treatment options for prostate cancer are moving away from brachytherapy due to a rising rate of bladder and rectal cancer for men who had the brachytherapy. There are still some folks for whom it’s considered appropriate, but its use is in decline.
The stats: After propensity-score matching, the 20-year incidence of bladder cancer was 6.0% for men undergoing brachytherapy and 2.4% for men undergoing prostatectomy. Likewise, the incidence of rectal cancer was 1.5% for men undergoing brachytherapy and 0.5% for men undergoing prostatectomy.