Dude, Where’s My Erection? Part III

Dude, Where’s My Erection? Part III by Marloe Esch

Non-pharmacological Approaches to Managing Erection Challenges After Cancer

Warning: Mature Content

Disclaimer: This information is not a substitute for medical care. Always inform your healthcare team of any concerning symptoms you are experiencing, and consult with your provider before starting new treatments, therapies, or health routines.

We’ve made it to the final installment of this series! Part I highlighted how and why erection problems can occur after cancer, and Part II outlined some of the pharmacological options available to help improve erectile function for cancer survivors. However, not all erection issues require a prescription, and not all penises respond well to medicines.

Therefore, in Part III we’ll be exploring some mechanical and mindful management techniques that don’t require prescriptions, pills, or needles (oh my!). Also (and probably most importantly), we’ll round out the convo with some ideas about how to navigate the emotional toll of erection challenges as an AYA survivor. Because, you know, feelings.

NON-PHARMACOLOGICAL ERECTION AIDS

Devices

For people who cannot use erection-enhancing medications or choose not to, there are a variety of available devices designed to help you get and keep erections.

Vacuum Erection Devices

Vacuum erection devices (VEDs) work mechanically by stretching and pulling blood into the erectile tissues. A cylinder is placed over the penis and air is pumped out to create negative pressure, which then acts like a gentle suction to fill the tissues with blood. People often pair the use of a VED with an erection ring to help maintain penile firmness once it’s achieved (see below) (9). VEDs are pretty effective,9 and can be a good option for cancer survivors (5,6,7,11). Some people find that a VED works well to increase the firmness of a partially erect penis after some initial foreplay (2). The device may be covered by insurance if you have a prescription from your provider, but you can also purchase one online or from your local sexual health boutique on your own.

Erection Rings

If you can get erections but they don’t last very long, it may be because the vessels are allowing blood to leak out of the tissue too quickly. An erection ring or constriction band is a device that you place at the base of your penis once you achieve an erection. They work to trap blood inside the tissues by compressing the veins that would allow outflow. If you recall from Part I, this trapping mechanism usually happens naturally with spontaneous erections, as the swelling of the corpora cavernosa (erectile tissue) puts enough pressure on the penis veins to squish them closed temporarily. Sometimes, though, your body may need a little help. This is the same idea as using your (or your partner’s) hand at the base of your penis to gently squeeze and hold in the blood. Erection rings can be used with or without a VED (see above).

Only use erections rings that are easily removeable! This allows you to take the ring off quickly in the event that it is too tight. Erection rings can be made of stretchy, elastic-like materials, or they may use snaps or Velcro to allow adjustable constriction. For safety reasons, do not apply a VED or an erection ring for more than 30 minutes; this could cause damage to the penis tissue (3,9). When used correctly, side effects are minimal. Because the blood flow is trapped for a period of time, the penis may become cool to the touch and turn a darker or dusky color (10). Also, the constriction may actually close off the urethra and inhibit ejaculation. Orgasms can still occur, though, and the semen will leak out through the urethra when the erection ring is removed (8).

Vibrators

Sure, clitorises love vibrators, but penises dig vibration, too! This makes sense, because both organs are made out of the same type of erectile tissue and respond similarly to touch. The sensory stimulation that vibration provides causes a reaction that leads to increased blood flow into the genitals, and voilà, tissue engorgement and increased sensitivity! What’s awesome about using vibration is that this type of sensory stimulation can trigger an engorgement (swelling) response even if the arousal nerve pathways from the brain to the genitals are damaged (12). While full-on erections may not occur, the increased blood flow can make the area more sensitive to touch and might help augment or improve the effectiveness of PDE5 inhibitors, VEDs, or other erectile aids.

People with penises can try placing vibration on the underside of the base of their penis, scrotum, along the shaft or the glans (head), or really anywhere that feels good. Some erection rings come with built-in vibrator devices, which can be used for self-stimulation and/or partner-stimulation.

Surgical Options

Penile prostheses, also called penile implants, can be considered for cancer survivors who have not had success with other pharmacological and non-pharmacological options, but still desire to achieve erections (5,6,7). These are surgically implanted mechanical devices that can inflate to cause an erection. A sexual medicine specialist can review the different types of available implants and discuss whether this is an appropriate option for you. Surgery is, of course, an invasive procedure that comes with its own risks and potential contraindications. However, success rates are high and people who have completed surgery are typically satisfied with the results (5), although data is limited regarding use in the AYA population.

THE EMOTIONAL TOLL OF ERECTION CHALLENGES

At the risk of sounding like a broken record, let’s remember that the conditions required for erections to occur are complex. You need healthy hardware (erectile tissue), wiring (nerves and blood vessels), messengers (hormones and other chemicals), and a central station (your brain) primed to decipher and respond to sexually relevant signals. Plus, you gotta have an emotional environment that feels safe and sexy. With all these circumstantial caveats, it’s no wonder that erections don’t always work when you want them to; even for people who haven’t had cancer!

Erections and Emotions

How you are feeling can have a big impact on your erectile equipment. For example, if you are existentially stressed out or physically feeling unwell, there’s not much mental and emotional room for considering sex. But while your emotions affect erections, erections (or lack thereof) can also influence your emotions. For a lot of people, dealing with unreliable erections or erection problems is emotionally draining.

Experiencing a problem with getting or keeping an erection during a sexual encounter can be discouraging, frustrating, embarrassing, and disappointing. Your sexual self-confidence may be impacted, and self-doubt may creep in. What if this happens next time? Will my partner think I’m not into them if I can’t get an erection? Will they not be attracted to me, or will they be turned off or disappointed? These kinds of anxieties and fears can impact how you see yourself as a sexual person and how you feel about your sex life.

Changes in Relationships and Dating

Feelings like uncertainty and worry can make it difficult to feel excited about sex. Sometimes, the fears or concerns about having erection problems can lead to focusing only on trying to get or keep an erection during sex, rather than being able to enjoy the experience in the moment. Some people find themselves beginning to avoid any situations where sex might be a possibility in order to help prevent a potentially embarrassing sexual encounter. If you are in a relationship, this can impact your intimacy as a couple. If you are single, this can impact how you date and interact with potential romantic partners.

Exploring and talking about these thoughts and feelings can help. Some people feel better after disclosing their concerns to their sexual partner. When you are honest about your worries, this can give your partner the opportunity to better understand where you are coming from, and it also provides them with a chance to reassure and support you. Working together to problem-solve and find creative ways to enjoy one another sexually (with or without erections) can be really gratifying.

Cultivating the Right Mindset

Adopting a pleasure-focused mindset (versus the performance-based alternative) can give you the freedom and permission to enjoy sexual encounters just as they are, rather than feeling obligated to measure a “successful” sexual experience by some pre-determined endpoint.

Many people find that they benefit from exploring how to do this with a professional counselor or therapist. Mental health professionals are not only skilled at helping you sort out your thoughts and feelings, but they can also work with you to learn new patterns of thinking so that your worries and fears don’t get in the way of enjoying sex. For example, implementing mindfulness strategies7 can help you refocus your attention toward in-the-moment pleasure and sexual enjoyment, rather than worrying about what may or may not happen. Being mindful requires us to focus on the present moment without expectation or judgement, giving us less of an opportunity to catastrophize about some hypothetical future state. Instead, mindfulness provides the space for us to notice what’s nice and good and pleasurable about the here-and-now; something we often miss when we are too busy making assumptions about what we think is supposed to occur.

These mind management skills require practice and take time to learn. But once you do, you’ll find that approaching sex with an attitude of mindful curiosity and a willingness to go with the flow can elevate the fun, satisfaction, and fulfillment you feel with each encounter. Mindset matters, and you can use it to your pleasure advantage.

PUTTING IT ALL TOGETHER

Dealing with erection problems is best tackled with a combination of approaches, which often means taking advantage of multiple strategies available to support your erection function. This is because different treatments that work in different ways can complement each other to enhance response. Medications can be paired with devices; devices can be paired with other devices; and both medications and devices can be paired with the psychosocial support of a counselor or therapist to help increase the cognitive tools you have in your toolbox to deal with sexual challenges.

That said, when it comes to “fixing” erection problems, there’s no magic bullet. Interventions aimed to improve erections don’t always work equally as well for everyone, every single time. The effectiveness of any given technique depends a lot on your personal physiology and anatomy (cancer treatments, hormone levels), how your body heals, and other factors. Adopting realistic expectations can help prevent negative feelings from taking over when an option doesn’t produce the outcome that you’d hoped for. It can take some patience and some trial-and-error to figure out what works for you.

THE BOTTOM LINE

If your sex life is important to you (and it’s OK that is is!), it should also be important to your healthcare team. Don’t be afraid to talk to your oncology providers about your concerns regarding sexual response and any changes you’ve noticed in your erections, because that’s the only way they’ll know what you are experiencing. Speaking up might feel stressful, but getting the support you’re looking for will be worth the challenge.

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Erectile Rehabilitation

As we’ve discussed, erections require healthy nerves, blood vessels, and erectile tissues. Nerves can be damaged with pelvic surgery, leading to an immediate loss of erectile functioning. However, some recovery of function may occur over time.

The basic premise of an erectile rehabilitation program is to promote the healing and recovery of these damaged nerves, and to keep the rest of the erection equipment (blood vessels, penis tissues) healthy while the nerve healing takes place.1,4 Erectile rehabilitation usually consists of some combination of techniques to promote blood flow to the genitals and to stretch and maintain the flexibility of the penile tissues. Strategies may include a daily low dose of a PDE5 inhibitor (if not contraindicated); stretching and massage of the tissues; use of a VED; and pelvic floor physical therapy exercises (4).

Most of what we know about the effectiveness of these programs is based on research with older survivors of prostate cancer, but it’s plausible that the same rationales apply for younger peeps whose erections have been altered by pelvic surgery for cancer, too. There’s been some critique that erectile rehabilitation programs rely too heavily on medical management (7). However, not all programs are created equal, so it might be worth exploring what would be available to you. If you are interested in learning more, check out the Penile Rehabilitation booklet from A Woman’s Touch, and talk with your care team.

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Great Erect-Spectations

When it comes to conversations about dealing with erectile difficulties, there’s always a lot of focus on how to get your erections back. And sometimes, that’s just not possible. Or maybe it’s only partially possible. Maybe semi-rigid is the new normal, or maybe sometimes it’s up, and other times it’s not. Living in this space of unpredictability can be hard.

It’s important to remember that a lack of erections doesn’t have to mean a lack of sex life. You get to choose how you want to actively participate in your sexual wellness. You get to decide whether or not unreliable erectile function is going to prevent you from enjoying all the other ways you can share a sexual experience with a partner (or yourself!). You have the final say in how to define sexual pleasure and satisfaction, and it definitely doesn’t have to hinge on a hard penis. Softening your erect-spectations is the first step to reclaiming your sex life, regardless of erectile function.

REFERENCES:

1. American Cancer Society, “How Cancer Can Affect Erections,” (2020). https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/fertility-and-sexual-side-effects/sexuality-for-men-with-cancer/erections-and-treatment.html. (Accessed July 19, 2023.)
2. American Cancer Society, “Managing Male Sexual Problems Related to Cancer,” (2020). https://www.cancer.org/cancer/managing-cancer/side-effects/fertility-and-sexual-side-effects/sexuality-for-men-with-cancer/sex-problems.html. (Accessed July 19, 2023.)
3. A Woman’s Touch, “Erectile Dysfunction in Men,” (2013). https://sexualityresources.com/wp-content/uploads/ErectileFunction13.pdf. (Accessed July 19, 2023).
4. A Woman’s Touch, “Penile Rehabilitation,” (2019). https://sexualityresources.com/wp-content/uploads/PR-Booklet-longform-18-1.pdf. (Accessed July 19, 2023).
5. Bernal, J., Venkatesan, K., & Martins, F. E., “Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options.” Journal of Clinical Medicine, 12(7), 2697 (2023). https://doi.org/10.3390/jcm12072697.
6. Carter, J., et al., “Interventions to Address Sexual Problems in People with Cancer: American Cancer Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline,” Journal of Clinical Oncology, 36(5), 492–511 (2018). https://doi.org/10.1200/JCO.2017.75.8995.
7. Dizon, D. S., & Katz, A, “Overview of Sexual Dysfunction in Male Cancer Survivors,” UpToDate (2022). https://www.uptodate.com/contents/overview-of-sexual-dysfunction-in-male-cancer-survivors. (Accessed July 19, 2023.)
8. Khera, M, “Patient Education: Sexual Problems in Men (Beyond the Basics),” UpToDate, (2022.) https://www.uptodate.com/contents/sexual-problems-in-men-beyond-the-basics. (Accessed July 19, 2023.)
9. Khera, M, “Treatment of Male Sexual Dysfunction,” UpToDate, (2022). https://www.uptodate.com/contents/treatment-of-male-sexual-dysfunction. (Accessed July 19, 2023.)
10. Schover, L. R., Sexuality and Fertility After Cancer, Wiley; 1st edition (September 30, 1997).
11. Sukhu, T., Ross, S., & Coward, R. M., “Urological Survivorship Issues Among Adolescent Boys and Young Men Who are Cancer Survivors,” Sexual Medicine Reviews, 6(3), 396–409 (2018). https://doi.org/10.1016/j.sxmr.2017.12.007.
12. A Woman’s Touch, “Erectile Function,” (2013). https://sexualityresources.com/wp-content/uploads/ErectileFunction13.pdf. (Accessed July 19, 2023.)