A biopsychosocial approach to sexual recovery after prostate cancer treatment: Suggestions for oncology nursing practice

Lauren M Walker, Andrea M Beck, Amy J Hampton, John W Robinson


In the past decade there has been a surge of literature documenting the impact of prostate cancer (PCa) treatment-induced erectile dysfunction (ED) on intimate relationships. While there have been significant advances in the treatment of ED, with phosphodiesterase inhibitors, vacuum erection devices and intracavernous injections, patients and their partners continue to struggle to finds ways to maintain enjoyable sexual activity. Only half of PCa patients are willing to try ED treatments, and less than half of those patients, who find ED treatments helpful in improving erectile function, will continue to use them long-term.

While there are effective strategies that can be taught to patients for overcoming the barriers associated with the use of ED treatments, many patients struggle on their own with these challenges, become discouraged, and quickly give up. Nurses play a large role in patient education and counselling, both in preparing patients for PCa treatment, and in follow-up. Consequently, they are well positioned to play a significant part in promoting sexual recovery among PCa patients and, thus, increasing patients’ and partners’ experiences of success. Nurses are well versed in providing holistic biopsychosocial care, which is a much-needed approach to complement the use of biomedical ED treatments. 

We begin by providing suggestions for nurses to increase their competence in discussing, assessing and intervening in the area of sexual difficulties. We follow with specific suggestions, based on the PCa literature, to guide nurses in supporting patients receiving ED treatment. Guidance is offered regarding approaches to patient education that fosters the development of realistic treatment expectations. Not only should these suggestions help improve adherence to ED treatments, but they should also help patients think more broadly about the sexual recovery process, encouraging the development of goals in sexual recovery beyond restoration of erectile function. Flexibility in sexual practice is found to be a key in successful sexual renegotiation, therefore, non-penetrative sexual strategies—that are not dependent on erections—should be offered to patients, as a routine part of clinical practice. Additional suggestions regarding couple communication, persistence in the treatment process, and working through grief associated with sexual losses are also offered in addition to strategies for overcoming specific barriers such as loss of libido and demoralization associated with treatment failures.

Key words: prostate cancer, erectile dysfunction, sexual adaptation, counselling, patient education

Full Text:



Agency for Health Research and Quality (2001). Making health care safer: A critical analysis of patient safety practices. Evidence Report/Technology Assessment, No. 43.

Althof, S., & Needle, R. (2007). Sex therapy in male sexual dysfunction. In J. P. Mulhall, L. Incrocci, I. Goldstein & R. C. Rosen (Eds.), Cancer and sexual health (pp. 731-739). New York, New York: Humana Press.

Althof, S.E. (2002). When an erection alone is not enough: Biopsychosocial obstacles to lovemaking. International Journal of Impotence Research, 14(Suppl 1), S99–S104.

Anderson, B.L. (1990). How cancer affects sexual functioning. Oncology, 4(6), 81–88.

Annon, J.S. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral treatment of sexual problems. Journal of Sex Education & Therapy, 2(2), 1–15.

Arrington, M.I. (2004). To heal or not to heal? On prostate cancer, physician-patient communication, and sexuality. Journal of Loss and Trauma, 9, 159–166.

Badr, H., & Carmack-Taylor, C.L. (2009). Sexual dysfunction and spousal communication in couples coping with prostate cancer. Psycho-Oncology, 18(7), 735–746.

Barry, M.J., Gallagher, P.M., Skinner, J.S., & Fowler, F.J., (2012). Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of medicare-age men. Journal of Clinical Oncology, 30(5), 513–518.

Barsky, J.L., Friedman, M.A., & Rosen, R.C. (2006). Sexual dysfunction and chronic illness: The role of flexibility in coping. Journal of Sex and Marital Therapy, 32(3), 235–253.

Basson, R. (2005). Women’s sexual dysfunction: Revised and expanded definitions. Canadian Medical Association Journal, 172(10), 1327–1333.

Basson, R. & Schultz, W.W. (2007). Sexual sequelae of general medical disorders. Lancet, 369(9559), 409–424.

Beck, A.M. & Robinson, J.W. (in press). Sexual resilience in couples.

Beck, A.M., Robinson, J.W., & Carlson, L.E. (2013). Sexual values as the key to maintaining satisfying sex after prostate cancer treatment: The physical pleasure-relational intimacy model of sexual motivation. Archives Sexual Behavior, 42, 1637–47.

Beck, A.M. (2011). Couples’ maintenance of sexual intimacy after treatment for prostate cancer: A grounded theory study. University of Calgary, Calgary, AB.

Bergman, J., Gore, J., Penson, D., Kwan, L., & Litwin, M. (2009). Erectile aid use by men treated for localized prostate cancer. The Journal of Urology, 182(2), 649–54.

Berry, M.D., & Berry, P.D. (2013). Contemporary treatment of sexual dysfunction: Reexamining the biopsychosocial model. Journal of Sexual Medicine, 10(11), 2627–43.

Bober, S.L., & Sanchez Varela, V. (2012). Sexuality in adult cancer survivors: Challenges and intervention. Journal of Clinical Oncology, 30(30), 3712–3719.

Boberg, E.W., Gustafson, D.H., Hawkins, R.P., Offord, K.P., Koch, C., Wen, K., et al. (2003). Assessing the unmet information, support and care delivery needs of men with prostate cancer. Patient Education and Counselling, 49(3), 233–242.

Boehmer, U., & Babayan, R.K. (2004). Facing erectile dysfunction due to prostate cancer treatment: Perspectives of men and their partners. Cancer Investigation, 22(6), 840–848.

Brody, S. (2010). The relative health benefits of different sexual activities. The Journal of Sexual Medicine, 7(4 Pt 1), 1336–1361.

Brody, S., & Weiss, P. (2011). Simultaneous penile-vaginal intercourse orgasm is associated with satisfaction (sexual, life, partnership, and mental health). The Journal of Sexual Medicine, 8(3), 734-741.

Canadian Cancer Society. (2012). Sexuality and cancer. Canada: Canadian Cancer Society.

Carvalheira, A.A., Pereira, N.M., Maroco, J., & Forjaz, V. (2012). Dropout in the treatment of erectile dysfunction with PDE5: A study on predictors and a qualitative analysis of reasons for discontinuation. The Journal of Sexual Medicine, 9(9), 2361–2369.

Costa, R.M., & Brody, S. (2012). Greater resting heart rate variability is associated with orgasms through penile-vaginal intercourse, but not with orgasms from other sources. The Journal of Sexual Medicine, 9(1), 188–197.

Crowe, H., & Costello, A.J. (2003). Prostate cancer: Perspectives on quality of life and impact of treatment on patients and their partners. Urologic Nursing, 23(4), 279–285.

d’Ardenne, P. (2004). The couple sharing long-term illness. Sexual and Relationship Therapy, 19(3), 1468–1479.

Davison, B.J., Matthew, A., Elliott, S.L., Breckon, E., & Griffin, S. (2012). Assessing couples’ preferences for postoperative sexual rehabilitation before radical prostatectomy. BJU International, 110, 1529-–535.

Ezer, H., Chachamovich, J.L., & Chachamovich, E. (2011). Do men and their wives see it the same way? Congruence within couples during the first year of prostate cancer. Psycho-Oncology, 20(2), 155–164.

Fergus, K.D., Gray, R.E., & Fitch, M.I. (2002). Sexual dysfunction and the preservation of manhood: Experiences of men with prostate cancer. Journal of Health Psychology, 7(3), 303–316.

Fisher, W.A., Eardley, I., McCabe, M., & Sand, M. (2009). Erectile dysfunction (ED) is a shared sexual concern of couples II: Association of female partner characteristics with male partner ED treatment seeking and phosphodiesterase type 5 inhibitor utilization. The Journal of Sexual Medicine, 6(11), 3111–3124.

Gannon, K., Guerro-Blanco, M., Patel, A., & Abel, P. (2010). Re-constructing masculinity following radical prostatectomy for prostate cancer. The Aging Male, 13(4), 258–264.

Gilbert, E., Ussher, J.M., & Hawkins, Y. (2009). Accounts of disruptions to sexuality following cancer: The perspective of informal carers who are partners of a person with cancer. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 13(5), 253–260.

Gray, R.E., & Klotz, L.H. (2004). Restoring sexual function in prostate cancer patients: An innovative approach. Canadian Journal of Urology, 11(3), 2285–2289.

Gray, R.E., Fitch, M.I., Phillips, C., Labrecque, M., Fergus, K.D., & Klotz, L. (2002). Prostate cancer and erectile dysfunction: Men’s experiences. International Journal of Men’s Health, 1, 15–29.

Hawkins, Y., Ussher, J., Gilbert, E., Perz, J., Sandoval, M., & Sundquist, K. (2009). Changes in sexuality and intimacy after the diagnosis and treatment of cancer. Cancer Nursing, 32(4), 271–280.

Hordern, A. (2008). Intimacy and sexuality after cancer: A critical review of the literature. Cancer Nursing, 31(2), E9–17.

Irvine, J.M. (2006). Selling viagra. Contexts, 5(2), 39–44.

Johansson, E., Steineck, G., Holmberg, L., Johansson, J.E., Nyberg, T., Ruutu, M., et al. (2011). Long-term quality-of-life outcomes after radical prostatectomy or watchful waiting: The Scandinavian prostate cancer group-4 randomised trial. The Lancet Oncology, 12(9), 891–899.

Julien, J.O., Thom, B., & Kline, N.E. (2010). Identification of barriers to sexual health assessment in oncology nursing practice. Oncology Nursing Forum, 37(3), E186–190.

Katz, A. (2005). The sounds of silence: Sexuality information for cancer patients. Journal of Clinical Oncology, 23(1), 238–241.

Kirby, M.G., White, I.D., Butcher, J., Challacombe, B., Coe, J., Grover, L., et al. (2014). Development of UK recommendations on treatment for post-surgical erectile dysfunction. International Journal of Clinical Practice, 68(5), 590–608.

Klaeson, K., Sandell, K., & Bertero, C.M. (2012). Sexuality in the context of prostate cancer narratives. Qualitative Health Research, 22(9), 1184–94.

Klotz, T., Mathers, M., Klotz, R., & Sommer, F. (2005). Why do patients with erectile dysfunction abandon effective therapy with sildenafil (viagra®)? International Journal of Impotence Research, 17, 2–4.

Kotronoulas, G., Papdopoulou, C., & Patiraki, E. (2009). Nurses’ knowledge, attitudes, and practices regarding provision of sexual health care in patients with cancer: Critical review of the evidence. Supportive Care Cancer, 17(5), 479–501.

Lambert, S.D., Girgis, A., Turner, J., McElduff, P., Kayser, K., & Vallentine, P. (2012). A pilot randomized controlled trial of the feasibility of a self-directed coping skills intervention for couples facing prostate cancer: Rational and design. Health and Quality of Life Outcomes, 10, 119.

Laumann, E.O., Nicolosi, A., Glasser, D.B., Paik, A., Gingell, C., Moreira, E., et al. (2005). Sexual problems among women and men aged 40–80 y: Prevalence and correlates identified in the global study of sexual attitudes and behaviors. International Journal of Impotence Research, 17, 39–57.

Le, J.D., Cooperberg, M.R., Sadetsky, N., Hittelman, A.B., Meng, M.V., Cowan, J.E., et al. (2010). Changes in specific domains of sexual function and sexual bother after radical prostatectomy. BJU International, 106(7), 1022–1029.

Letts, C., Tamlyn, K., & Byers, E. S. (2010). Exploring the impact of prostate cancer on men’s sexual well-being. Journal of Psychosocial Oncology, 28(5), 490–510.

Li, Q., & Loke, A.Y. (2013). A literature review on the mutual impact of the spousal caregiver—cancer patients dyads: ‘Communication’, ‘reciprocal influence’ and ‘caregiver-patient congruence’. European Journal of Oncology Nursing, 18(1), 58–65.

Lindau, S., Schumm, L., Laumann, E., Levinson, W., O’Muircheartaigh, C., & Waite, L. (2007). A study of sexuality and health among older adults in the United States. New England Journal of Medicine, 357, 762–74.

Lintz, K., Moynihan, C., Steginga, S., Norman, A., Eeles, R., Huddart, R., et al. (2003). Prostate cancer patient’s support and psychological care needs: Survey from a non-surgical oncology clinic. Psycho-Oncology, 12, 769–783.

Manne, S., Badr, H., Zaider, T., Nelson, C., & Kissane, D. (2010). Cancer-related communication, relationship intimacy, and psychological distress among couples coping with localized prostate cancer. Journal of Cancer Survivorship: Research and Practice, 4(1), 74–85.

Matthew, A.G., Goldman, A., Trachtenberg, J., Robinson, J., Horsburgh, S., Currie, K., et al. (2005). Sexual dysfunction after radical prostatectomy: Prevalence, treatments, restricted use of treatments and distress. The Journal of Urology, 174, 2105–2110.

McCarthy, B., (2001). Relapse prevention strategies and techniques with erectile dysfunction. Journal of Sex & Marital Therapy, 27(1), 1–8.

McCarthy, B., & Fucito, L.M. (2005). Integrating medication, realistic expectations, and therapeutic interventions in the treatment of male sexual dysfunction. Journal of Sex & Marital Therapy, 31, 319–328.

McCarthy, B., & Thestrup, M. (2009). Men, intimacy and eroticism. Journal Sexual Medicine, 6(2), 588–94.

Meston, C.M., & Buss, D.M. (2007). Why humans have sex. Archives of Sexual Behavior, 36(4), 477–507.

Mick, J., Hughes, M., & Cohen, M.Z. (2007). Using the BETTER model to assess sexuality. Clinical Journal of Oncology Nursing, 8(1), 84–86.

Mick, J.M. (2007). Sexuality assessment: 10 strategies for improvement. Clinical Journal of Oncology Nursing, 11(5), 671–675.

Montorsi, F., Adaikan, G., Becher, E., Giuliano, F., Khoury, S., Lue, T.F., et al. (2010). Summary of the recommendations on sexual dysfunctions in men. The Journal of Sexual Medicine, 7(11), 3572–3588.

Mulhall, J.P., Bella, A.J., Briganti, A., McCullouh, A., & Brock, G. (2010). Erectile dysfunction rehabiliation in the radical prostatectomy patient. Journal of Sexual Medicine, 7(4, Pt 2), 1687–1698.

Nelson, C.J., Scardino, P.T., Eastham, J.A., & Mulhall, J.P. (2013). Back to baseline: Erectile function recovery after radical prostatectomy from the patients’ perspective. Journal of Sexual Medicine, 10, 1636–1643.

Penson, D.F. (2001). The effect of erectile dysfunction on quality of life following treatment for localized prostate cancer. Reviews in Urology, 3(3), 113–119.

Perez, M.A., Skinner, E.C., & Meyerowitz, B.E. (2002). Sexuality and intimacy following radical prostatectomy: Patient and partner perspectives. Health Psychology, 21(3), 288–293.

Perz, J., Ussher, J.M., & Gilbert, E. (2014). Feeling well and talking about sex: Psycho-social predictors of sexual functioning after cancer. BMC Cancer, 14, 22–19.

Potosky, A.L., Davis, W.W., Hoffman, R.M., Stanford, J.L., Stephenson, R.A., Penson, D.F., et al. (2004). Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: The prostate cancer outcomes study. Journal of the National Cancer Institute, 96(18), 1358–1367.

Rabbani, F., Schiff, J., Piecuch, M., Yunis, L.H., Eastham, J.A.,

Scardino, P.T., et al. (2010). Time course of recovery of erectile function after radical retropubic prostatectomy: Does anyone recover after 2 years? The Journal of Sexual Medicine, 7(12), 3984–3990.

Reese, J.B., Keefe, F.J., Somers, T.J., & Abernethy, A.P. (2010). Coping with sexual concerns after cancer: The use of flexible coping. Supportive Care in Cancer, 18(7), 785–800.

Regan, T.W., Lambert, S.D., Kelly, B., McEdluff, P., Girgis, A., Kayser, K., et al. (2014). Coping with cancer: Cross-sectional relationship between dyadic coping and anxiety, depression, and relationship satisfaction for patients with prostate cancer and their spouses. Patient Education and Counselling. Epub ahead of print.

Rivers, B.M., August, E.M., Gwede, C.K., Hart, A., Donovan, K.A., Pow-Sang, J.M., et al. (2011). Psychosocial issues related to sexual functioning among African-American prostate cancer survivors and their spouses. Psycho-Oncology, 20(1), 106–110.

Robinson, J.W., & Lounsberry, J.J. (2010). Communication about sexuality in cancer care. In D. Kissane, B. D. Bultz, P. Butor & I. Finlay (Eds.), Handbook of communication in oncology and palliative care (pp. 409–424). New York, N.Y.: Oxford Press.

Sadovsky, R., Basson, R., Krychman, M., Morales, A.M., Schover, L., Wang, R., et al. (2010). Cancer and sexual problems. International Society for Sexual Medicine, 7, 349–373.

Salonia, A., Burnett, A.L., Graefen, M., Hatzimouratidis, K., Montorsi, F., Mulhall, J.P., et al. (2012). Prevention and management of postprostatectomy sexual dysfunctions part 2: Recovery and preservation of erectile function, sexual desire, and orgasmic function. European Urology, 62(2), 273–286.

Salonia, A., Gallina, A., Zanni, G., Briganti, A., Deho, F., Sacca, A., et al. (2008). Acceptance of and discontinuation rate from erectile dysfunction oral treatment in patients following bilateral nerve-sparing radical prostatectomy. European Urology, 53(3), 564-570.

Schover, L. R., Fouladi, R. T., Warneke, C. L., Neese, L., Klein, E. A., Zippe, C., et al. (2002). The use of treatments for erectile dysfunction among survivors of prostate carcinoma. Cancer, 95, 2397-2407.

Schover, L.R., van der Kaaij, M., van Dorst, E., Cruetzberg, C., Huyghe, E., & Kiserud, C.E. (2014). Sexual dysfunction and infertility as late effects of cancer treatment. EJC Supplements. Epub ahead of print.

Schover, L.R., Fouladi, R.T., Warneke, C.L., Neese, L., Klein, E.A., Zippe, C., et al. (2004). Seeking help for erectile dysfunction after treatment for prostate cancer. Archives of Sexual Behavior, 33(5), 443–454.

Shindel, A., Quayle, S., Yan, Y., Husain, A., & Naughton, C. (2005). Sexual dysfunction in female partners of men who have undergone radical prostatectomy correlates with sexual dysfunction of the male partner. Journal of Sexual Medicine, 2(6), 833–841.

Steginga, S.K., Occhipinti, S., Dunn, J., Gardiner, R.A., Heathcote, P., & Yaxley, J. (2001). The supportive care needs of men with prostate cancer (2000). Psycho-Oncology, 10(1), 66–75.

Steinsvik, E.A., Axcrona, K., Dahl, A.A., Eri, L.M., Stensvold, A., & Fossa, S.D. (2012). Can sexual bother after radical prostatectomy be predicted preoperatively? Findings from a prospective national study of the relation between sexual function, activity and bother. BJU International, 109(9), 1366–1374.

Stephenson, R.A., Mori, M., Hsieh, Y.C., Beer, T.M., Stanford, J.L., Gilliland, F.D., et al. (2005). Treatment of erectile dysfunction following therapy for clinically localized prostate cancer: Patient reported use and outcomes from the surveillance, epidemiology, and end results prostate cancer outcomes study. The Journal of Urology, 174(2), 646–50.

Straus, S.E., Tetroe, J., & Graham, I. (2009). Defining knowledge translation. CMAJ, 181(3-4) 165–168.

Tal, R., Alphs, H.H., Krebs, P., Nelson, C.J., & Mulhall, J.P. (2009). Erectile function recovery rate after radical prostatectomy: A meta-analysis. The Journal of Sexual Medicine, 6(9), 2538–2546.

Ussher, J.M., Perz, J., Gilbert, E., Wong, W.K.T., & Hobbs, K. (2013). Renegotiating sex after cancer: Resisting the coital imperative. Cancer Nursing, 36(6), 454–462.

Walker, L.M., & Robinson, J.W. (2011a). A description of heterosexual couples’ sexual adjustment to androgen deprivation therapy for prostate cancer. Psycho-Oncology, 20(8), 880–888.

Walker, L.M., & Robinson, J.W. (2011b). Sexual adjustment to androgen deprivation therapy: Struggles and strategies. Qualitative Health Research, 21, 444–53.

Warkentin, K.M., Gray, R.E., & Wassersug, R.J. (2006). Restoration of satisfying sex for a castrated cancer patient with complete impotence: A case study. Journal of Sex & Marital Therapy, 32, 389–399.

Wassersug, R.J. (2009). Mastering emasculation. Journal of Clinical Oncology, 27(4), 634–636.

Wassersug, R.J., Walker, L.M., & Robinson, J.W. (2014). Androgen deprivation therapy: An essential guide for prostate cancer patients and their loved ones. New York: Demos Health.

Wiegner, E.A., & King, C.R. (2010). Sexual function after stereotactic body radiotherapy for prostate cancer: Results of a prospective clinical trial. International Journal of Radiation Oncology, Biology, Physics, 78(2), 442–448.

Wittmann, D., Carolan, M., Given, B., Skolarus, T.A., An, L., Palapattu, G., et al. (2014). Exploring the role of the partner in couples’ sexual recovery after surgery for prostate cancer. Supportive Care Cancer. Epub ahead of print

Wittmann, D., Chang, H., Coelho, M., Hollenbeck, B., Montie, J.E., & Wood, D.P. (2011). Patient preoperative expectations of urinary, bowel, hormonal and sexual functioning do not match actual outcomes 1 year after radical prostatectomy. The Journal of Urology, 186, 494–499.

Wittmann, D., Foley, S., & Balon, R. (2011). A biopsychosocial approach to sexual recovery after prostate surgery: The role of grief and mourning. Journal of Sex & Marital Therapy, 37(2), 130–44.

Wittmann, D., Montie, J.E., Hamstra, D.A., Sandler, H., & Wood, D.P. (2009). Counselling patients about sexual health when considering post-prostatectomy radiation treatment. International Journal of Impotence Research, 21(5), 275–284.

Wrosch, C., Miller, G.E., Scheier, M.F., & de Pontet, S.B. (2007). Giving up on unattainable goals: Benefits for health? Personality Social Psychology Bulletin, 33(2), 251–65.

Wrosch, C., & Scheier, M.F. (2003). Personality and quality of life: The importance of optimism and goal adjustment. Qualitative Life Research., 12(Suppl. 1), 59–72.


  • There are currently no refbacks.