Dude, Where’s My Erection? Part I
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.
One of the most common sexual problems that survivors with penises experience are changes with erections (6,10). Unfortunately, erections don’t get a lot of air time during clinic conversations. For one thing, sexual side effects of treatments sometimes don’t show up right away, and over time survivorship concerns may no longer be on a provider’s radar (though they should be!). Another reason is that healthcare providers are just regular people too, often succumbing to their own personal discomfort and allowing embarrassment to prevent them from assessing sexual health. Fortunately, I rarely pass up an opportunity to dig into a dialogue about cancer and sex! So, let’s talk erections, shall we?
Erections are actually pretty fascinating and complex (as is everything related to sexuality and our bodies, in my opinion), so I have divided this discourse into a two-part series featuring the infamous anatomical appendage endearingly referred to as the penis (among other things . . .). Since I’m a total nerd for how stuff works, in Part I we will focus on the nuts and bolts of erectile function, which will help underscore why certain cancer treatments can negatively impact this phenomenon. Then, in Part II we will spend time exploring strategies to support and sustain your sex life when you’re dealing with unreliable erectile equipment.
Before getting into the nitty gritty, I have a couple of important clarifications to make regarding the terminology used for this topic:
Whew! So, you guys want to join me up here on my soapbox? The views are amazing! OK, let’s put the jokes aside. It’s time to get serious.
Is that a Banana in Your Pocket, or…?
For lots of young people with penises, erections often seem to just happen, popping up at opportune (and maybe, sometimes, at inopportune) moments. However, there’s a surprising number of behind-the-scenes physiological stuff that must occur for an erection to come to fruition. At the risk of oversimplifying, an erection is basically just trapping a bunch of blood inside a penis. However, coordinating this event requires the involvement of specialized nerves, chemical messengers, blood vessels, and penile structures that all work together in nuanced and intricate ways.
Penis Anatomy 101
The penis is an organ that’s larger than it looks. The portion that can be seen on the outside of the body is called the shaft, and at the tip of the penile shaft is the head or the glans. The structures of the shaft extend back inside the body and make up the root of the penis, which attaches to the internal pelvic structures. The purpose of the penis is to carry urine and ejaculate (semen) out of the body. This is accomplished by the urethra, a tube that connects the bladder and internal reproductive organs to the outside world via its opening (called the urethral meatus) at the glans of the penis.
There are three cylindrical structures composed of spongy erectile tissue that run lengthwise inside the shaft and give the penis its shape. The corpus spongiosum is on the underside of the penis and encases the urethra, and the two corpora cavernosa run parallel along the top of the penis. Most of the time the muscles that control the blood flow into the penis are contracted, preventing blood from filling these erectile bodies to capacity. It’s this mostly-empty erectile tissue that keeps the penis soft in its resting state.
Erective Function 101
Erections can happen for different reasons. Sexual erections happen in response to sexual stimulation, and non-sexual erections are a reflex of the body unrelated to sexual stimulation.
When the brain perceives sexually stimulating information (either from sexual thoughts or physical touch), it responds by sending signals down the spinal cord to specific nerve centers in the pelvis, which then carry the signals on to the penis (10). These signals trigger relaxation of the tissues and dilation of the blood vessels via the synthesis and release of certain chemicals, causing a sudden influx of blood flow and quickly flooding the corpora cavernosa. As the corpora cavernosa fill, they push against their tough outer fibrotic encasement, called the tunica albuginea. The force of the tissue expansion causes the tunica albuginea to be pulled taught, and the whole organ begins to feel more rigid or hard. The pressure of the swelling eventually compresses vessels on the outside of the penis, squeezing these veins closed and preventing the blood from escaping the tissue. How much the penis changes in size with erections varies from person to person.
Interestingly, erections can occur without the help of the brain as a spinal cord reflex that’s triggered by touch (1,11). This means that erections aren’t always related to sexual arousal, as anyone with a penis can probably attest to. Another example of non-sexual erection events includes the natural “puff” erections that are caused by cyclical increases in blood flow to the penile tissues (4). This spontaneous process might be the body’s way of keeping the erectile tissues healthy and in working order by occasionally bathing them in oxygen- and nutrient-rich blood. The side effect of increased blood flow to the genitals, though, is often a stiffer penis.
Cyclical patterns of increased blood flow to the genitals occur overnight during the REM (rapid eye movement) part of the sleep cycle (1,11). The REM stage of sleep is also the part of the sleep cycle we tend to wake up after, hence why people often awake in the morning with an erection (1). This phenomenon is all just a part of being a person with a healthy penis (7)! Not all of these cycles of increased blood flow are sufficient to achieve a full erection, and so they may go unnoticed throughout the day.
As far as trying to figure out the cause of erection difficulties, the presence or absence of these non-sexual erections can be helpful. For example, if you are having trouble attaining or maintaining an erection with partnered sexual activity, but you wake up with erections and/or you are able to get an erection in other situations (such as with masturbation), the cause is less likely to be physical and more likely psychogenic (related to feelings or emotions). Examples include stress, worries or anxieties about sexual performance, or problems with intimacy or your relationships.
However, if you aren’t able to achieve an erection with sexual activity, and you no longer notice erections when you wake up or in other situations, the cause is more likely to be physical. This could include damage to blood vessels, nerves, or altered hormone levels. A lot of the time, it’s a combination of both physical and psychogenic causes (see The Brain-Body Connection, below).
What Does Cancer Have to Do With My Penis, Anyways?
Well . . . maybe a lot!
Studies show that problems with erections are reported by young people dealing with all different types of cancers, including reproductive (testicular) and pelvic (bladder, colorectal) cancers, as well as brain and hematologic malignancies (9,12,13). Erection challenges have been associated with pelvic surgery and radiation, surgery and radiation to the brain or spinal cord, as well as chemotherapy and hematopoietic stem cell transplants (3,6,10,13). Some sexual problems may improve or even return to baseline over time, while other sexual issues can be long-term or worsen with time (6).
As we have seen, getting and keeping an erection is a surprisingly complex physiological phenomenon, so it’s no wonder that the impacts of some cancer treatments might derail the ability to get reliable erections. Let’s take a look.
Surgery for pelvic cancers (bladder, colorectal, prostate) can cause damage to the nerves and the blood vessel pathways that are responsible for erections. Even nerve-sparing surgeries are not 100 percent effective at preserving erectile function after cancer. Sometimes damaged nerves can heal with time, so if a person notices a loss of erections right away after a surgery, they may be able to recover some of that function as the nerves heal over the next year or two. A process called erectile rehabilitation (covered in more detail in Part II) might help with this (3). Brain and spinal surgery have also been found to be a risk factor for erection difficulties after cancer, due to either disrupting the brain’s role in the production of hormones associated with erectile function, or by disrupting the nerve signal connections from the brain to the genitals (13).
In contrast to pelvic surgery, where problems with erections are often immediate but may improve with healing over time; erection changes related to pelvic radiation often progress gradually as the affected tissues develop scarring with the healing process (10). Scarring can occur in the vessels that supply blood to the genitals, causing a loss of elasticity and the inability to accommodate the high volumes of blood flow needed for erections to occur. Fibrosis can also develop in the spongy erectile tissues (corpora cavernosa), inhibiting their capacity to stretch enough to stiffen the tunica albuginea and trap blood in the tissue. Further, damaged nerves may lose their ability to trigger tissue relaxation and vasodilation. Radiation to certain parts of the brain may also impact the production of hormones needed for erections, as well.
Because some chemotherapies lead to nerve damage (like peripheral neuropathies), it’s possible that the nerve pathways related to genital sensation and erectile function could also be impacted. However, the effects of chemotherapy on erections are most often related to the disruption of hormone levels in the body. Chemotherapies that are gonadotoxic can negatively affect testicular function and reduce testosterone production. Healthy levels of testosterone promote erections by helping maintain nitric oxide levels, one of the main chemical players that gets synthesized and released during the erection process (7). Nitric oxide in the penis acts to relax the tissues and promote vasodilation (7,11). Without adequate levels, erectile function is compromised.
Testicular damage and low levels of testosterone (called hypogonadism) may be temporary or permanent. Although a full discussion on hypogonadism is beyond the scope of this article, it’s important to talk with your provider about this possibility. There are also some non-chemotherapy medications that can impact hormone levels (11). Your provider or pharmacist can help determine if you are on any meds that might be contributing to erection problems.
The Brain-Body Connection
Although we have been reviewing a lot of ways that cancer treatments physiologically impact erectile function, we cannot forget the brain-body connection when it comes to erections. As noted earlier, sexual erections are triggered by the brain sending signals down to the genitals, leading to a cascade of events that results in an erection. These signals are the brain’s response to some sort of stimulation that it perceived as sexually relevant. You might recall that the brain tends to ignore these types of signals when it’s overwhelmed or otherwise occupied with other (more pressing) matters. For instance, thoughts related to cancer.
Cancer sucks! It’s stressful, scary, anxietyprovoking, and exhausting. Unsurprisingly, these negative thoughts and feelings tend to display themselves front-and-center in people’s emotional landscapes, leaving little room for anything else. This hijacks the brain’s attention, preventing it from “seeing” stuff as sexy and telling your body to respond accordingly. It’s no secret that the distress related to the diagnosis and day-to-day living with cancer can impact your mental health, and it’s been found that depression and anxiety are associated with erection problems in young men (13). Further, some of the medications that are used for treatment of these mood disorders (especially a group called selective serotonin reuptake inhibitors, or SSRIs) are known to negatively affect sexual response for many people taking them (8,13).
Experiencing distress and anxiety about your illness is a totally legit and logical (not to mention, normal) reason for difficulty with erections. Giving yourself a little grace can go a long way. Over time, you may find that your focus can once again turn toward the sexier aspects of life. In Part II, we will take a closer look at the importance of curating a healthy headspace when it comes to navigating some of the mental roadblocks that cancer creates, and we will identify some of the psychosocial strategies for successfully adjusting to erection changes.
The Bottom Line
Having trouble with erections after cancer is a real thing, and it’s often related to a complicated combo of altered erection hardware and negative emotional overload. But that doesn’t mean that you will never enjoy sex again. Knowing a little bit more about how your body works might make it easier for your brain to get on board with some of the options for overcoming sexual challenges related to erections. Coming up, we will dive into the medications, mechanical aids, and mental approaches available to help maximize the erectile equipment you are working with. Stay tuned!
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TRUE OR FALSE: Orgasms Require Erections?
This is one of my favorite factoids ever. Turns out that the nerves responsible for causing erections are separate from the nerves responsible for orgasming (2). This means that people don’t need to have an erection in order to experience an orgasm! Who knew?!
The reason I love busting this myth is because knowledge is power, and this little gem of knowledge sort of feels like a huge middle finger to the misguided cultural imperative that penetration is somehow the best—if not the only—kind of sex worth having. I mean, using penis performance as the measure of successful sex totally undermines the sexual relevance of all the penis-owners whose erection equipment doesn’t swell, but who are still, obviously, sexual people with sexy thoughts, feelings, and attractions, and the ability to feel pleasure.
Thankfully, our bodies can experience pleasure in so many ways that don’t require rock-hard penises or penetration of any sort. No matter where a penis lands on the spectrum between soft and stiff, it can still participate in sexual play and bring sexual pleasure your way, if you are willing to explore the possibilities.
For inspiration, consider checking out the third episode of a three-part podcast series by Death, Sex & Money, called “Hard: Softening Expectations.” The first two episodes are great as well, but this one explores sex beyond erections, and it’s well worth your time!
This article was featured in the March 2023 Unseen Challenges of Survivorship issue of Elephants and Tea Magazine! Click here to read our magazine issues.
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