Coping with sexual problems

Fatigue

During and after cancer treatment, many people feel tired and have no energy (fatigue). This fatigue, which is often not relieved by rest, may mean you have no interest in sex.

Tips
  • Plan your day so you have time to rest.
  • Don’t do more than you can comfortably do.
  • Eat well and drink plenty of fluids.
  • Take short walks or do light exercise.
  • Let other people help you.
  • Be intimate at the best time of day for you (e.g. in the morning when you feel refreshed).
  • Have shorter lovemaking sessions.

Losing interest in sex

Lack of interest or loss of desire for sex – low libido – is common because of fatigue, the effect of medications, or anxiety relating to treatment. Libido usually returns when treatment is finished.

Tips
  • Try different ways to get in the mood: shower together, have a weekend away, wear something sexy etc.
  • Show affection by touching, holding, hugging and massaging.
  • Watch a romantic movie, look at erotic magazines or DVDs, talk sexily with your partner, or create a sexy atmosphere with dim lighting and music.
  • Stimulate and help your partner to reach orgasm, even if you don’t want this yourself.
  • Physical activity can stimulate sexual desire by increasing energy and lifting your mood. Dancing is a good option.

Taking the worry out of sex

Many couples believe that sex should always happen on the spur of the moment with little or no advanced planning. After an illness, a couple may need to plan some relaxed time together and start their lovemaking slowly. Consider having sex in the morning when you are feeling fresher.

A relaxed way to practice for sex is to begin with self-stimulation. Masturbation is not a necessary step in resuming your sex life but it can be helpful. By touching your own genitals, and bringing yourself to orgasm, you can find out if cancer treatment has changed your sexual response without having to worry about frustrating your partner. It can also help you work out what you would like your partner to do to help you become aroused.

Changed body image

Having lymphoedema (swelling in the limbs) or losing a body part due to cancer treatment may affect your self-esteem. It will take time to get used to the changes. If you have lost a limb, it will take a while to adjust physically and emotionally.

Issues for women

  • Mastectomy – You may choose to use a breast form (prosthesis) or have a reconstruction. Both can help to improve self-esteem.
  • Vaginal surgery – You will usually have a vaginal reconstruction. Intercourse is possible but can be painful as no natural lubrication is produced.
  • Vulvar surgery – The genital area looks and feels different after surgery. Removal of the clitoris and lower vagina can affect a woman’s ability to orgasm. For other women, stimulation of their erogenous zones can bring them to orgasm, even if they don’t have a clitoris.
Tips
  • Remember that the removal of a breast or part of the vulva or vagina doesn’t make you less of a woman.
  • Allow your partner to be part of the decision-making process for how you want to deal with the changes.
  • Touch your genitals to find out if your sexual response has changed.
  • Explore other areas of your body that are sensitive to touch. Ask your partner to caress these areas.
  • Use a lubricant if it is safe to do so.

Issues for men

  • Testicular surgery – Surgery probably won’t affect your sexual ability, but you may not feel as desirable. A prosthesis placed in the scrotum can improve its appearance.
  • Penis surgery – Afterwards you are able to have penetrative sex or you can reach orgasm by stimulating the surrounding genital area.
Tips
  • Remember that the removal of a testis or the penis, or the inability to get an erection, does not make you less of a man.
  • Allow your partner to be part of the decision-making process for how you want to deal with the changes.

Painful penetration or intercourse

Sexual positions you enjoyed in the past may be painful after cancer treatment.

Women: Some women have vulvar pain or vaginal pain which may make sex difficult. Sometimes the muscles around the vagina tighten, causing pain on penetration. Sometimes intercourse becomes impossible. General pain can also be a distraction from feeling pleasure during sex.

Men: Radiotherapy to the penis can cause pain due to scar tissue. Irritation of the prostate gland or urethra from surgery or radiotherapy can also cause painful ejaculation.

Tips
  • Avoid sexual activity when you are tired or stressed.
  • Plan sexual activity for the time of day when your pain is lowest. If you are using pain medication, take it shortly before sex so it will have maximum effect.
  • Use positions that put minimal pressure on painful areas of your body and allow you to control the depth of penetration. Use pillows for support.
  • Try to focus on your feelings of pleasure and excitement rather than the pain.
  • Learn relaxation techniques to help stop muscles from tensing up.
  • Use a water-based lubricant if it is safe to do so.
  • Women may benefit from using a dilator to widen the vagina.

Trouble reaching orgasm

Cancer treatment does not usually affect the ability to orgasm.

  • Women – If the clitoris or vulva has been removed, women may still be able to orgasm by stimulation of other erogenous areas. This will probably be difficult at first and they will need to explore different ways to climax.
  • Men – After surgery to the penis, men still feel pleasure on the remaining skin and can learn how to reach orgasm in different ways.
  • Medication – Some medication, such as antidepressants, hormones, tranquillisers and narcotic pain medication, can interfere with the ability to orgasm. Talk to your doctor about this.
Tips
  • Think about pleasurable sexual experiences, watch romantic or erotic DVDs or read erotic literature.
  • Guide your partner’s hands or fingers to areas that arouse you.
  • Consider using an electric vibrator to give you extra stimulation to help you reach orgasm.
  • Focus on your breathing to help you relax and on the pleasure of the whole experience.
  • For women, tighten and relax your vaginal muscles in time with your breathing during penetration or while your sensitive areas are being stroked.

Incontinence

Incontinence is weak bladder or bowel control, causing leaking or increased frequency or urgency to urinate. It may be temporary or permanent.

Tips
  • Plan ahead for sex and ensure the bowel or bladder is emptied beforehand.
  • Use plugs for the bowel.
  • For indwelling catheters, tape the catheter to your skin, remove the bag and insert a flow valve or stopper.
  • Exercise the pelvic floor muscles.
  • An oestrogen cream or tablet inserted into the vagina may help improve the strength of the pelvic floor muscles.

Pelvic floor exercises

These exercises help tone the muscles in the pelvis to give you better bladder and bowel control, and, for women, more strength and sensation in the vagina.

Identify the pelvic floor muscles:

  • Pretend you are trying to stop the flow of urine or avoid passing wind. You should feel a tightening and lifting of muscles around your rectum (and vagina for women). These are your pelvic floor muscles.

Do the exercises:

  • While sitting, standing or lying, slowly tighten and lift the pelvic floor muscles, holding for five to 10 seconds.
  • Release and relax for 10 seconds.
  • Repeat the contractions up to 10 times, relaxing between each squeeze.
  • Then do five to 10 short, fast, strong contractions in quick succession.
  • Repeat the routine three times a day.
  • Your buttocks and legs should not move and you should be able to breathe easily.

Source: Adapted from Cancer Council Victoria’s Sexuality and Cancer: a guide for people with cancer.

More information

Contact the Continence Foundation of Australia.

Adapting to life with a stoma

Sexual activity with a stoma can be satisfying but may need planning.

Tips
  • Let your partner see or feel the stoma, if they want to, and give them time to adjust to it.
  • Change the appliance before having sex.
  • Cover your appliance with soft material if you don’t like the feel of plastic on your skin, and make sure it feels comfortable.
  • Wear a mini-slip, bathrobe or crotchless underwear if you feel uncomfortable showing the stoma.
  • Choose a position that keeps your partner’s weight off the stoma, or place a small pillow over the stoma so your partner is not lying directly on the appliance. You can lie on top or underneath your partner – you will not damage the stoma.
  • If you are worried about the stoma leaking, be intimate in the bath or shower.
  • Seek help if you are having trouble coping. Speak to your stomal therapy nurse or contact the Ileostomy Association of NSW – (02) 9568 2799 or the Colostomy Association of NSW – (02) 9565 4315.

Other issues for women

Reduced vaginal size

Vaginal narrowing from radiotherapy or surgery may make penetration uncomfortable.

Tips
  • Widen the vaginal entrance by using a dilator or have regular, gentle, penetrative sex.
  • Use a lubricant.
  • Try sexual positions that don’t involve deep penetration.
  • Talk to your doctor about further treatment, such as skin grafts, to widen the entrance to the vagina.

A dilator is shaped like a tube and is made from plastic, glass or rubber. It comes in different sizes and helps women to gently increase their vagina’s size over time. A dilator is different from a vibrator. A dilator is used to maintain the shape of your vagina, while a vibrator is used for sexual pleasure. Talk to your doctor or nurse about how to use a dilator.

Vaginal dryness

Dryness can make you more prone to vaginal infections, such as thrush, because the natural lubricating and cleaning process is not working. It can cause painful penetration.

Tips
  • Avoid soap, bubble bath and creams that irritate the genitals.
  • Talk to your GP about alternative contraception if your usual contraceptive device is irritating.
  • Try non-perfumed, water-based lubricants, available from chemists and supermarkets.
  • Make the application of the lubricant part of your sexual play
  • Take more time before and during penetration to help the vagina relax and become well lubricated.

Thrush

Thrush causes itching, burning and unpleasant discharge, and can make intercourse painful. It is common in women having chemotherapy, hormone therapy or antibiotics.

Tips
  • Treat thrush with prescription creams or, to soothe the genitals, use home remedies such as unsweetened, live yoghurt inserted into the vagina with a tampon.
  • Wear loose, cotton clothes. Avoid nylon pantyhose, tight jeans or trousers.
  • Avoid Vaseline or petroleum-based lubricants.
  • Use a condom to stop the spread of thrush to your partner.

Loss of sensation

Some women experience a loss of sensation in their vagina temporarily or permanently, depending on the type of treatment they have had. This can make sex uncomfortable or unsatisfying, or may cause low libido.

Tips
  • Focus on other areas of your body and genitals that feel pleasurable when touched.
  • Experiment with different sexual positions to see whether this affects sensation.
  • Use a vibrator to enhance sensation in the vagina and surrounding area.

Early menopause and osteoporosis

If you go through menopause, you will no longer be able to have children and you may worry that your partner finds you less attractive, less sexually appealing or less feminine. Oestrogen loss in menopause can cause hot flushes, mood swings, weight gain, insomnia, tiredness, vaginal dryness and lowered libido. Early menopause may cause osteoporosis.

Tips
  • Use relaxation techniques and light exercise to reduce irritability, anxiety, insomnia and fatigue.
  • Eat a healthy diet with lots of fresh produce and wholegrains.
  • Eat low-fat dairy products and other high-calcium food.
  • Exercise regularly. Walking, dancing and weight training help reduce the rate of bone loss.
  • Get vitamin D from fortified foods or regular, safe sun exposure.
  • Talk to your doctor about medication or vitamin and mineral supplements for osteoporosis.

Other issues for men

Erectile dysfunction

Many men experience erection problems after cancer treatment, but this isn’t always because of the surgery or radiotherapy. The condition also affects many men at different stages of their lives for different reasons (e.g. ageing, illness, smoking, high alcohol intake, or emotional distress, such as anxiety or depression). If anxiety is causing erection problems, talking to a sex therapist or your family doctor may help. Counselling can also help if you’ve lost sexual confidence after cancer treatment.

Tips
  • Take time to get aroused and focus of enjoying the pleasure of sexual play, rather than worrying about an erection.
  • You can have sex and an orgasm with a half-erect penis. This works best with the partner on top guiding the penis inside.
  • Help your partner reach orgasm without penetration. Experiment with other sexual activities, such as oral sex, masturbation or all-over touching.

Other options to help you get an erection include:

  • Tablets that increase the blood flow to the penis. These medications can cause headaches, nausea, blocked nose and facial flushing. Ask your doctor what is best for you.
  • Injections to the penis, which you can learn to do yourself. A substance is injected into the penis, causing the blood vessels to expand and the penis to become erect. This treatment works well in most men but some experience pain after injecting and scarring of the penis tissues.
  • A vacuum pump device that draws blood into the penis, where it is trapped with a rubber ring placed around the base of the penis. When you have finished having sex, the ring is taken off and the blood flows normally again. A pump may be an option if injections or tablets have not worked, or if you don’t want to take more medications.
  • A penile ring can help men maintain an erection by keeping the blood in the penis.
  • Implants surgically placed in the penis. A pump is placed in the scrotum and squeezed to inflate the penile implant and produce an erection.
More information
  • Speak to your doctor.
  • Call the Impotence Australia Helpline on (02) 9280 0084 or the national free call number 1800 800 614.

Ejaculation difficulties

A dry orgasm is common after prostate cancer surgery. It may feel different and no semen will be ejaculated, but you should still feel some pleasure. Another form of dry orgasm is retrograde ejaculation. This occurs when a valve between the bladder and prostate does not close properly, making semen travel into the bladder instead of through the urethra. It is harmless. Premature ejaculation may be a problem, but this is caused more by anxiety than by cancer treatment.

Tips
  • Try to enjoy sex without worrying about ejaculating.
  • Talk to your partner about the problem. Even if you feel you ejaculate too quickly or you are worrying about having a dry orgasm, your partner may be satisfied with your performance.
  • Increase the frequency of ejaculations, perhaps by masturbation, to help delay ejaculation.
  • Avoid rushing through foreplay, as your partner may not have sufficient stimulation for penetration.
  • Join a support group where you can talk openly with men who are experiencing the same or similar difficulties.

What else might help?

Hormone therapy

Most men continue to produce enough testosterone, even after age 50 or 60. Hormone therapy is helpful for men who have damaged testes or low testosterone levels from large doses of radiation or chemotherapy. This helps to restore sexual desire and erections. As prostate cancer is influenced by testosterone, this is not a safe option for men with this diagnosis.

Women can also have testosterone therapy if their ovaries have been removed or efforts to improve their libido have not worked.

Talk to your doctor about this option.

Complementary therapies

Complementary therapies may help you cope better with side effects and feel as well as possible. Examples of complementary therapies include:

  • counselling
  • relaxation therapy
  • massage
  • acupuncture
  • yoga and meditation
  • aromatherapy
  • art and music therapy.

Relaxation and exercise

Some people find relaxation and exercise helps them feel better by releasing tension and anxiety, and reducing depression. Creative activities such as painting, playing music, furniture restoration and reading can also be relaxing.

Ask the hospital social worker about relaxation, exercise or creative therapy programs.

The amount and type of exercise will depend on what you are used to and how you feel. Start by making small changes to your daily activities, such as walking to the shops or using the stairs instead of the lift or escalator. Even gardening can be helpful. If you want to do more vigorous exercise, ask your doctor what is best for you.

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