Before Prostate Treatment: The Sexual-Function Questions to Ask

Sexual function is usually discussed once, briefly, during a consultation dominated by cancer. Men agree to a treatment, and the detailed conversation about erections happens a year later, when the situation is already fixed.

Ask the questions below before a decision is made, because several of them influence which treatment is chosen and how it is delivered. None of them displace the cancer question, which comes first.

Start with your own baseline

The strongest predictor of erectile function after treatment is erectile function before it. This sounds obvious and is routinely skipped.

Ask for a baseline measurement using a validated questionnaire rather than a general impression. It takes a few minutes, it gives you and your team a number to compare against later, and it prevents the common situation where a man cannot recall how things were before and attributes an age-related decline entirely to treatment.

The scale of that age-related decline is easy to underestimate. In ProtecT, which followed men randomized between active monitoring, surgery and radiotherapy, all three groups converged to between 13% and 17% reporting erections firm enough for intercourse by twelve years, including the men who were never treated.

If you already have some degree of erectile difficulty, say so plainly. It changes the realistic expectation, and it may change the recommendation.

Questions about the treatment itself

Is hormone therapy part of this plan, and for how long? Androgen deprivation is often given alongside radiation, and it affects desire more than it affects erections. Men who are not told this attribute the change to the radiation and misread their own recovery. Ask for a baseline testosterone level before it begins, because a proportion of men do not return to their previous level afterwards. We cover this in androgen deprivation therapy and sexual function.

If surgery: is nerve-sparing planned, on one side or both, and what would change that during the operation? Nerve-sparing is decided partly in advance and partly on the table. Understanding the conditions under which it would be abandoned is more useful than a yes or no. It also predicts what follows: venous leak after prostatectomy is far more common when no nerves were spared.

If radiation: does the plan constrain dose to the penile bulb and internal pudendal arteries? Dose to these structures is an active area of treatment planning. Ask what the trade-off against tumor coverage would be, and accept that coverage wins if the two conflict. The timeline of decline after radiation is set out in radiation therapy and erectile function.

What is the realistic expectation at two years and at five, for someone my age with my baseline and my other conditions? Diabetes, smoking, and vascular disease affect the answer at least as much as the treatment choice does. A general figure from a trial population is less useful than an estimate that accounts for you.

Questions about what happens afterwards

Who is responsible for sexual function once treatment ends? This falls between specialties more often than it should. The surgeon or radiation oncologist is focused on cancer control; sexual recovery may belong to a urologist, a sexual medicine clinic, or nobody in particular. Establish the answer before you need it.

When is the first review, and what will be assessed? Erectile function after radiation declines over two to three years rather than immediately, so a single check at six months will miss the trajectory.

What is offered, and in what order? The usual sequence runs from oral medication through vacuum devices and constriction devices to injections and implants. Knowing the sequence in advance makes the later conversations shorter.

If erections start but do not hold, what does that indicate? This distinguishes a retention problem from an inflow problem, and the two respond to different things. It is also the question most likely to be answered vaguely, which tells you something about who to ask next.

The question about the conversation itself

Ask whether your partner should be present for it. Sexual function after prostate treatment affects two people, and information delivered to one of them tends to arrive incomplete to the other. Partners who understand that reduced desire on hormone therapy is a drug effect generally interpret it correctly. Partners who do not, often do not.

What these answers will and will not give you

They will not give you certainty. Erectile outcomes after prostate treatment vary widely between men with similar disease and similar surgeons, and honest clinicians will say so.

What the answers do give you is a correct frame. Knowing that hormone therapy suppresses desire, that radiation-related decline is delayed, that surgical loss is immediate and partially recovers, and that baseline matters more than any of them, means you interpret your own recovery accurately rather than assuming something has gone wrong.

The 2018 AUA Guideline treats shared decision-making as central to erectile dysfunction care rather than following a fixed treatment ladder. That principle applies before treatment as much as after it.

Related reading

• Radiation Therapy and Erectile Function
• Androgen Deprivation Therapy: Desire, Erections, and What Returns
• Penile Rehabilitation After Prostate Treatment
• Supporting Sexual Function After Prostate Surgery

References

• Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. New England Journal of Medicine. 2016;375(15):1425–1437. https://www.nejm.org/doi/full/10.1056/NEJMoa1606221
• Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes 12 Years after Localized Prostate Cancer Treatment. NEJM Evidence. 2023;2(4):EVIDoa2300018. https://evidence.nejm.org/doi/full/10.1056/EVIDoa2300018
• Tal R, Valenzuela R, Aviv N, et al. Persistent erectile dysfunction following radical prostatectomy: the association between nerve-sparing status and the prevalence and chronology of venous leak. Journal of Sexual Medicine. 2009;6(10):2813–2819. https://pubmed.ncbi.nlm.nih.gov/19686421/
• Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633–641. https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-(ed)-guideline

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