Sexual Wellness Resource Center
For Adults over 50.

But, Doc, what happened to my manhood? (after prostatectomy for cancer)

By Michael Bates, M.D.

Manhood, what it means to be a man, is the ability to obtain and maintain erections sufficient for penetration. Having sex is integral to being a man. Sexual performance is a symbolic expression of masculinity. Is there a risk of losing your manhood following prostate surgery?

You chose prostatectomy to treat your prostate cancer. You may or may not have been aware of the risk of loss of the ability to get a spontaneous erection. You may have been aware of the risk, but not the statistics of just how common that loss is. You may not have cared, thinking the loss of sexual function was a reasonable price to pay for life. My attitude as a surgeon confronting my own diagnosis of prostatic cancer was to cut it out. My optimism made me think that the nerve sparing techniques would probably work, that I would continue to be the same sexual being. I was 55 years old. This is what I learned.

Nerve-sparing surgical techniques provide hope, but how successful are the results? It turns out, often not what they are touted to be. A significant proportion of men receiving surgery are troubled by sexual dysfunction, reports range between 29-75%.

There is an erroneous assumption that sex is an isolated function, rather than an integral component of men’s identities. Sex and life are far more intertwined. A seemingly strait forward decision often results in an unexpectedly complex and painful recognition of loss of manhood, the inability to perform sexually, often causing embarrassment, a loss of confidence, a change in self worth, and even changes in one’s identity as a man.

There are treatments for post op erectile dysfunction, upon which I report in My Story about Impotence article. Many result in effortful, awkward, non spontaneous and mechanical sex, disrupting the natural flow of events leading to intercourse.   The absence of ejaculation with orgasm is another change, which lessens the intensity and pleasure of sex.

The loss of manhood is more than impotence, it is also a change in everyday functioning with women. In most day-to-day interactions between sexes there is a subtle undercurrent of sexuality. Men think about sex many times daily, they experience pleasure seeing an attractive woman, they fantasize. With the loss of manhood, with knowledge that they no longer can sexually perform, men imagine themselves less often as potential sexual partners, there is less arousal by an attractive woman, there is less fantasy. Men find themselves on new footing with respect to the women in their lives. These changes can cause intense psychosocial and emotional responses, leading some to clinical depression.

So, how do men adapt?

  • Attempting to reinstate one’s level of functioning to the best of modern medicine and technology's ability.
  • Humor, trying to make light of the changes.
  • Minimization, efforts to downplay the importance of sex in a long term relationship, to attribute the changes to aging, not only to surgery.
  • Exploring “outercourse,” lovemaking techniques outside of erection and penetration to maintain intimacy.

It is particularly helpful if one’s partner is a participant in the adaption. For younger, single men sexual dysfunction is harder to deal with, especially in the context of a new relationship when leading up to the moment of disclosure.

So, where I am I going with this report? Before making the decision of whether to treat prostate cancer or not, and how to treat it, men and their partners need to talk about their sexual lives, their sexuality, and how important that is to them, with each other and with their physicians. Physicians should address two issues as they discuss treatment options, first the realistic risk of loss of erections satisfactory for intercourse. Second, the related changes in daily issues of manhood, fantasy, and female interaction outside of intimacy.

Resources: Sexual Dysfunction and the Preservation of Manhood: Experiences of Men with Prostate Cancer, Journal of Health Psychology, 2002. Sexuality after Treatment for Early Prostate Cancer, Journal of General Internal Medicine, 2001.