What are the common sexual side effects of prostate removal surgery?
Executive summary
Prostate removal (radical prostatectomy) commonly causes sexual side effects including erectile dysfunction, loss of ejaculate (dry orgasm), reduced fertility, and changes in orgasm and penile sensation, with severity varying by nerve preservation, age, and time since surgery [1][2][3]. Many sexual problems are at least partly reversible over months to years with rehabilitation and therapies—oral PDE5 inhibitors, devices, injections, or implants—but recovery timelines can extend up to two to three years and are not guaranteed [4][5][2].
1. Erectile dysfunction — the most frequent and variable outcome
The most commonly reported sexual complication is erectile dysfunction (ED): damage to the cavernous nerves during surgery often produces immediate difficulty achieving or maintaining erections, and up to the majority of men experience at least temporary ED after radical prostatectomy; outcomes depend heavily on whether nerve‑sparing techniques were possible and on surgeon experience [6][1][7]. Recovery can be gradual—many centers report improvements over 12–24 months and some patients regain function by two years, while others may need ongoing treatment; evidence for early “erection rehabilitation” (routine early use of PDE5 inhibitors) is still limited and partly empirical [4][5][2].
2. Loss of ejaculate and infertility — permanent, predictable changes
Because the prostate and seminal vesicles that produce most semen are removed, all men undergoing prostatectomy will have no ejaculate during orgasm (anejaculation), which is permanent and also renders natural conception via intercourse impossible unless sperm were banked beforehand or assisted reproduction is used [2][8][3].
3. Altered orgasm, penile sensation, and perceived penile length
Many men report changes in orgasm quality—often described as “dry” or different in sensation—and some note reduced penile sensitivity; a subset also perceive a loss of penile length after surgery, a change attributed to tissue remodeling, nerve injury, or scarring [2][9]. These effects vary between individuals and are influenced by age, baseline function, and how extensive the surgery was [10].
4. Psychological effects and relationship impact
Sexual side effects frequently carry emotional consequences: anxiety, depressive symptoms, and reduced sexual satisfaction are common and can themselves worsen sexual function, creating a feedback loop; cancer‑specific anxiety one year after surgery correlates with lower sexual satisfaction in cohort studies, underscoring the need for psychosocial support and couple counseling [11][12].
5. Urinary leakage during sex and bladder control interactions
Post‑prostatectomy men may experience urinary incontinence and sometimes leakage during sexual activity; while bladder control often improves over weeks to months, urinary side effects can complicate sexual activity and require pelvic‑floor rehabilitation or other interventions [5][3][8].
6. Treatments, timelines, and when more invasive options are considered
Management options include oral PDE5 inhibitors (sildenafil, tadalafil), vacuum erection devices, intracavernous injections, intraurethral agents, and ultimately penile prosthesis for refractory ED; response rates often increase as nerve recovery proceeds, and clinicians commonly wait up to 18–24 months before offering permanent surgical implants for potency issues [2][4][5]. Sperm banking and fertility planning should be discussed preoperatively because loss of ejaculate is permanent [8][13].
7. Determinants of risk and the importance of informed decision‑making
Risk of sexual side effects is not uniform: nerve‑sparing approaches reduce but do not eliminate ED risk, and whether nerves can be spared depends on tumor location and oncologic safety; younger patients and those with better baseline function fare better, while surgeon skill and center experience matter [1][6][5]. Reporting varies across studies and centers, and long‑term outcomes depend on follow‑up duration and rehabilitation practices [6][10].
8. Limits of reporting and alternative viewpoints
Clinical centers differ in how they present risks and in optimism about rehabilitation—Johns Hopkins and MSK emphasize that many patients recover function within two years and promote early rehabilitation while reviews and population studies document higher long‑term prevalence of sexual dysfunction, highlighting variability in outcomes and gaps in high‑quality comparative trials for some therapies [4][5][6]. Available sources do not settle exact probabilities for an individual; counseling must be personalized and grounded in surgeon experience and patient priorities [1][12].