Coping with sexual difficulties
It is important to let your partner know if you have a changed attitude to sex after cancer treatment.
If you don't feel like sex
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It’s important to let your partner know if you don’t feel interested in sex. It can help to explain how you feel, so that they don’t feel rejected. You can also suggest what you would be happy with, such as `I don’t want to have sex but I’d love to have a cuddle’.
If your partner is feeling frustrated it may be helpful for them to reduce the frustration through masturbation, either with you or alone.
If you have fatigue (continual tiredness that isn’t relieved by rest) and don’t have much energy, it might help to have sex in different ways. Less energetic positions, where your weight is well supported, can reduce strain. You may also prefer quicker sexual contact rather than longer sessions. These are things you can talk about together.
If the tension is building between you, you may find it helpful to get support from a counsellor or sex and relationship therapist who specialises in offering help in these circumstances. We have a database of organisations that can help.
Pain during penetrative sex
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Pain during penetrative sex can occur after pelvic surgery or radiotherapy to the area. It may also occur if you’re taking medicines that reduce the production of natural lubrication.
Pain can reduce sexual feelings and desire. Often, an experience of pain can lead to a fear of pain, which can in turn lead to tension. Tension can be distracting and stop you from achieving arousal, prevent lubrication and cause further pain.
There are many reasons for pain during sex. It’s important to let your partner know what’s painful so that you can explore other positions or ways of having sex. Often, the cause can be treated simply. If you have pain during sex, tell your doctor or nurse. They can examine you to find out why and suggest possible solutions.
If you have pain or are worried about pain, it may helpful if you:
have sex after taking painkillers that have had a chance to work
learn some relaxation techniques to use before having sex
take control of the depth and speed of penetration
try to ensure you and/or your partner are close to orgasm before penetration
try different types of sexual contact, perhaps without penetration, that you don’t find painful
use pillows and cushions to help you feel more comfortable and supported
have sex side by side, to reduce body weight on a sore area.
Our section about controlling cancer pain might help.
Surgery, chemotherapy, hormonal therapy, or radiotherapy to the pelvic area, may cause vaginal changes. These changes can include dryness, narrowing, shortening, ulcers and infection, and they may lead to pain during penetrative sex.
This can be helped by a number of creams and gels that can be put directly into the vagina:
Replens MD® is a non-hormonal cream available from most chemists. It’s applied 2-3 times a week and works for about three days at a time. The cream binds to the vaginal wall and the water held within it reduces dryness and boosts the blood flow in the vagina.
Ovestin® and Ortho-gynest® are available on prescription from your doctor. They contain very small amounts of oestrogen and can be used as a cream or as a tablet that’s inserted into the vagina (pessary). The effect in the vagina is short-lasting. This product may not be appropriate for women who have a hormone-dependent cancer such as breast or endometrial cancer. It’s important to check with your specialist whether this would be a helpful product for you.
Vagifem®, also available on prescription, is a pessary that contains a small amount of oestrogen. It’s usually used daily for two weeks. A small research study has shown that Vagifem® can increase the amount of oestrogen circulating in the body. Because of this risk, Vagifem® may not be recommended for women who are taking aromatase inhibitors, such as anastrozole (Arimidex®), exemestane (Aromasin®), or letrozole (Femara®). Your specialist or breast care nurse can give you further advice and information about this.
Estring® is a vaginal ring that’s worn for three months at a time. It slowly releases a small amount of oestrogen and may help to reduce vaginal dryness.
Water-based lubricants such as Senselle®, Astroglide®, Sylk®, Vielle® or the range produced by Durex® can help to increase moisture levels, making sex easier. They can be bought at a chemist or some supermarkets. Some women prefer to buy lubricants online or to use glycerine, which is cheap and not embarrassing to buy due to its many uses. Other women prefer to use organic, natural lubricants, such as Yes® or V Gel, which are available to buy online.
This may happen after radiotherapy to the pelvis and sometimes after surgery. After your treatment you’ll usually be advised to use vaginal dilators. These are plastic tubes of varying sizes that can be inserted by yourself or as part of joint sexual touch. The dilators prevent the two side-walls of the vagina sticking together, and are used with lubricants. They’re available from your doctor or specialist nurse at the hospital. An alternative way to prevent vaginal narrowing is to have regular penetrative sex or to use a dildo, vibrator or your or your partner’s lubricated fingers.
After some types of pelvic surgery the vagina may be slightly shorter than before. While you’re still healing, you may prefer not to have penetrative sex or to be very gentle, controlling the depth of penetration. Try different positions to find out which ones are most comfortable for you.
Radiotherapy can also cause some areas of the vagina to become sore (vaginal ulcers), and these may bleed slightly. These can take weeks, or sometimes months, to heal. If you have any unusual bleeding after sex, you should tell your doctor and ask for an examination.
Some women find that they’re prone to getting vaginal thrush infections while having radiotherapy or chemotherapy. This is because there are changes in the acidity in the vaginal area, which allow the normal organisms in the vagina to overgrow. You may have thrush if you notice a creamy-white discharge, or an itchiness in the vaginal area that gets worse if you scratch. This is easily treated with medicines that can be bought from your chemist. If you’ve had sexual contact, your partner may also need to have treatment.
If you’re not affected by any of these vaginal side effects, then penetrative sex is perfectly safe during radiotherapy and chemotherapy. You should use effective contraception if there’s any risk that you could become pregnant. Your doctor or nurse can advise you on the best method for your situation.
Many men have erection difficulties after cancer surgery or radiotherapy to the pelvic area, but the treatment may not be the only factor. Studies have found that men commonly have sexual problems after operations that have nothing to do with their genital area. Therefore your cancer operation may not be the cause of all your sexual difficulties. There may be psychological factors involved that you aren’t consciously aware of.
Some men find that they can have full erections with time. Even if they can’t, a half-erect penis can still be effective for having sex. The positioning for this may be better with the partner on top guiding the penis inside.
If you’ve had an operation that’s damaged the nerves that control erections, this need not be the end of your sex life. You don’t need to have a hard penis to give your partner pleasure. You may find it helpful to increase your range of sexual activity to include oral sex, mutual touching, increased masturbation or the use of sexual toys, such as a dildo or vibrator, to increase your pleasure and that of your partner.
Medicines, injections, pumps and implants
If you have problems getting or maintaining an erection, there are many options that can help you. Remember that these will give you a hard penis, but won’t necessarily increase your feelings of arousal. It’s worth trying different methods as some may work better than others.
Sildenafil (Viagra®) can help to produce an erection by increasing and sustaining the blood supply in the penis. It’s usually taken an hour before having sex, and then an erection will occur following direct sexual stimulation. Viagra should be prescribed by your GP. However, it may not be recommended for you if you have heart problems and/or are taking certain drugs, such as nitrates. It can cause side effects for some people, including heartburn, headaches, dizziness and visual changes. Another possible side effect is that occasionally the erection lasts for more than a couple of hours and there’s a danger of damage to the tissues of the penis.
Vardenafil (Levitra®) tablets are similar to Viagra®. They normally work within 25-60 minutes. The most common side effects are headaches and flushing of the face.
Tadalafil (Cialis®) tablets can also be used to help produce an erection. They can be taken up to 36 hours before having sex. Cialis® works by increasing the effects of one of the chemicals produced in the body during sexual arousal. It shouldn’t be taken by people who are taking certain heart medicines.
An injection of a drug such as alprostadil (Caverject®, Viridal®) or papaverine directly into the penis, using a small needle, causes an erection. The drug restricts blood flow and traps blood in the penis, causing an instant erection. Some experimentation is often needed at first to get the dose right. One of the possible side effects is that if too much of the drug is given, the erection stays for too long and there’s a danger of damaging the tissues of the penis. Some men who use these injections say that the head of the penis isn’t as hard as the shaft. The injections are prescribed by your GP. Usually this method is recommended to be only used once a week, which may not be enough for some men or their partners.
Pellets of alprostadil (MUSE®) can be inserted into the penis. The pellet melts into the surrounding area and, after some rubbing to distribute it into the nearby tissues, produces an erection. Some men find that the pellet is initially uncomfortable.
Vacuum pumps (sometimes called vacuum constriction devices) can also be used to produce an erection. The pump is a simple device with a hollow tube that you put your penis into. Pumps are either operated by hand or battery, and draw blood into the penis by creating a vacuum in the tube. Once the penis is full of blood, a rubber ring is placed around the base to keep the erection. The vacuum is released and the pump removed. The erection can be maintained for about 30 minutes. Once you’ve finished having sex the ring is taken off and the blood flows normally again.
The advantage of vacuum pumps is that they don’t involve inserting anything into the penis, but it does take a couple of weeks or so to get used to using one. They’re particularly helpful for people who aren’t able to use other methods of getting an erection. Your penis may feel slightly colder than usual because the blood is not moving around. The ring should only be worn for half an hour at a time. The pump can be used as many times as you want, providing you allow half an hour between each use so that the blood can flow properly. The pumps are available on the NHS or can be bought online.
Penile implants are sometimes used after all other methods have been tried. There are two main types, which have to be inserted during an operation. The first type uses semi-rigid rods that keep the penis fairly rigid all the time, but allow it to be bent down when an erection isn’t needed. The second type involves a hydraulic device that, when activated, causes an erection. Your doctor can discuss penile implants with you.
If you think any of these options might be useful to you, your doctor or nurse can give more information or you can contact the organisations on our database.
Urinary leaking (incontinence) or difficulty passing urine are occasional problems for both women and men after some cancer treatments. You may have to wear incontinence pads or have a urinary catheter, which may lead to feelings of embarrassment. You may feel unclean or unattractive and avoid intimate contact altogether.
Coping with incontinence
Although it may seem too embarrassing, it’s a good idea to discuss the incontinence with your sexual partner. Be honest with them - tell them that a little urine may leak during sex. You may want to let them know that urine is sterile and it won’t cause an infection for them. It can also help to have towels and tissues handy in case there’s any leakage. Maintaining good personal hygiene will help you feel more confident.
It’s a good idea to avoid drinking too many fluids for about an hour or so before you have sex, and to pass urine beforehand so that your bladder is as empty as possible. It’s sometimes possible to make sure that your bladder is empty by putting in a catheter, and your nurse or a continence adviser can discuss this with you. You may also want to have a shower or bath before having sex, which you can do alone or with your partner.
Some women find that penetrative sex makes the incontinence worse. If this happens you can explore other ways of getting sexual pleasure, such as foreplay, massaging and oral sex. Trying different sexual positions may also help.
After prostate surgery, some men find they lose a small amount of urine at the point of orgasm/climax. This is known as climacturia. If this loss of urine is distressing to you or your partner, you may wish to wear a condom to contain the loss. Pelvic floor exercises may help you to increase urinary control, and a technique called bulbo-urethral massage can reduce the urine likely to be expelled in this way. Your specialist nurse or urology team can give you further information.
Your doctor or specialist nurse can give you advice on different ways of coping with incontinence. They can also refer you to a continence adviser for further support.
If you have a catheter
Sex is still possible if you have a urinary catheter in place. Your nurse or a continence adviser can discuss this with you. In some situations it may be possible to remove the catheter during sex, and the nurse or adviser can show you how to do this.
Women can tape the catheter out of the way on their leg or hip. It’s worth experimenting with different sexual positions to find ways that are more comfortable for you and that don’t put pressure on the catheter.
Men can fold the catheter back along the penis using surgical tape and cover it with a condom to keep it in place. Extra lubrication may be needed. To avoid the catheter getting blocked with semen, you may need to flush out the bladder after sex. Your nurse or a continence adviser can discuss this with you.
Loose bowel motions (diarrhoea) and needing to open the bowels with very little or no warning (faecal incontinence) can sometimes be a side effect of cancer treatment, especially pelvic radiotherapy. These effects may be temporary but can sometimes be permanent. Having problems with your bowels can have a huge impact on your life. It may make you feel less interested in sex but can also make you feel embarrassed and affect your confidence. You may feel unclean or unattractive and avoid intimate contact.
You can discuss any bowel problems with your doctor or specialist nurse, or with a dietitian. They may be able to reduce the side effects using a combination of medicines, dietary changes and exercises, and can help you cope with how the problems are making you feel. Other things you can do that may help include:
being aware of which foods trigger the diarrhoea or make it worse, and avoiding them for several hours before you have sex
emptying your bowels just before you have sex
maintaining good personal hygiene, which will help boost your confidence
burning scented candles, which may help if you are concerned about smells
letting your partner know that you may have to rush to the toilet, and making sure that you can get there quickly and easily
having tissues and towels handy during sex
using an anal plug (available from the Bladder and Bowel Foundation).
Body image is the mental picture we have of our own appearance. This image is drawn from what our body actually looks like, and also from how we think we look. Throughout our lives, our body image is constantly changing. Our body image can be altered whether or not a cancer or its treatment causes changes to our appearance.
Changes in body image can cause feelings of distress that go far beyond the physical effects of a cancer and its treatment. When there’s been a change in body image that’s sudden and dramatic, you may feel abnormal. You may also have feelings of shame, embarrassment, inferiority and anger. When the change is a visible one, these feelings can be reinforced by the reactions of other people.
Some people adapt well to body changes caused by cancer and its treatment over time. However, others can become anxious, less confident or depressed. They can withdraw from relationships and from social activities they enjoy.
The effect on a person is not always related to the size, severity or visibility of the change. For example, a small, hidden scar can still affect a person’s mood, confidence and sexuality.
We have a section about the effects of cancer and its treatment on body image.
If the change can be hidden under clothes, for example a colostomy or mastectomy, a fairly common reaction is to pretend that everything is normal. You might hide the change, avoid looking at it, and conceal it from others. However, avoidance can lead to increasing feelings of anxiety about the thought of someone finding out.
Changes such as having a stoma or having a breast removed are likely to cause a significant change in the way you feel about your body. If this is true for you, you could try having sex partly dressed or in your underwear, rather than completely naked. Changing the lighting level during sex can also help to build your confidence about how your body looks. It may help to lie on your side to prevent pressure on scars or stomas. Facing away from your partner, not towards, may also help.
Talking about your feelings around body image
It’s important to tell someone your fears, rather than hiding them and letting them grow into something bigger. The more you’re able to face the things you’ve been avoiding, the better. It might be important to spend some time thinking through your worst fears, and planning a way of managing them to help build your confidence.
If you’re the partner of someone who has changes in their real or perceived body image, it may also take you time to adjust to and accept the changes. You may need to talk through your own fears with someone.