How Bladder Cancer Affects Your Sexual Health

There are about 624,490 bladder cancer survivors in the United States, according to the American Cancer Society. Bladder cancer is the fifth-most common cancer in the U.S., and it disproportionately affects men; it is three times more common in men than in women.

In recent decades, there has been growing emphasis on the oncological effects, that is, how they relate to the study and treatment of tumors. But it's also important to investigate the quality-of-life ramifications after diagnosis and treatment because bladder cancer is known to have a potentially detrimental effect on the patient's genitourinary and internal sexual organs.

Treatment of bladder cancer

The treatment of cancer depends on the tumor's clinical stage, which includes how deep it has grown into the bladder wall and whether it's spread to nearby structures or tissues and other organs. Other factors, such as the size of the tumor, the grading of the cancer and the aggressiveness of this type of cancer, can also affect treatment options.

For muscle-invasive bladder cancer, the standard treatment is radical cystectomy, a procedure to remove the entire bladder. For non-muscle-invasive bladder cancer, which accounts for 70 percent of newly diagnosed bladder cancer, there are intravesical treatments such as the Bacillus Calmette-Guerin (BCG) vaccine, intravenous chemotherapy and radiation therapy.

"Immunotherapy with BCG helps prevent recurrence in 70 percent of the patients if it is noninvasive bladder cancer," said John Kaspar, M.D., a urologist practicing with the Associated Urologists of North Carolina.

Current European Association of Urology guidelines recommend that standard radical cystectomy in men should include removal of the bladder, prostate, seminal vesicle, distal ureters and regional lymph nodes. For women, the guidelines recommend the removal of the bladder, uterus, entire urethra and regional lymph nodes.

Male sexual dysfunction after bladder cancer

Erectile dysfunction (ED) is historically known as a significant primary complication after surgery.

"Sexual dysfunction goes beyond that of just erectile dysfunction," Kaspar said. "There are plenty of deformities that can occur in a man's penis that can affect an erection. Importantly, there are also other effects on orgasm or ejaculation that's extremely prevalent in men following surgery to remove the prostate and bladder."

ED often results from surgical effects as vital nerves or blood vessels can potentially be injured inadvertently due to the complexity of the anatomy and close proximity. The neurovascular bundle, which innervates the penis and runs laterally to the prostate and the bladder, can easily get damaged during surgery.

In simple terms, when a man is aroused, the brain sends messages to the nerves in the penis, and the nerves that innervate the penis release nitric oxide, which allows the blood vessels to relax and widen so blood can rush into the penis and cause an erection.

However, when these nerves are injured, they do not release nitric oxide, affecting the blood flow to the penis and resulting in erectile dysfunction. This particular effect can occur after the treatment of bladder cancer.

Intracorporeal injection of medications or oral ED drugs can be prescribed to dilate blood vessels and enable blood flow to the penis.

Finding a sustainable way to treat and manage ED can lead to long-term positive outcomes and ongoing relationship happiness. For a lot of men, a wearable device proves helpful. Eddie^® is an FDA-registered Class II medical device designed to treat erectile dysfunction and improve male sexual performance. In 2021 clinical trials, Eddie proved effective in treating men with physically, psychologically and pharmacologically induced ED. Of the study participants, 95 percent of men who used Eddie reported a beneficial effect on their sex lives.

"Penile implants can also be a good option if the men are unresponsive to the blood dilators," Kaspar added.

Female sexual dysfunction after bladder cancer

Women do worse than men after diagnosis of bladder cancer, said Gregory Quayle, M.D., a certified urologist in Mississippi and an expert on the bladder and sexual health.

"Due to the anatomical differences, diagnosing bladder cancer in women itself is harder," Quayle said. "It could take longer, and by then, the cancer is likely to have spread, making the condition worse. Additionally, women are prone to UTIs often, and UTIs have the same symptoms as bladder cancer. So misdiagnosis is common, and often, the cancer diagnosis comes at a later stage where the cancer is harder to treat."

One physical cause of sexual dysfunction in women is related to hormones and how the intact nervous system directs blood flow to the vagina.

"Following different surgical procedures and radiation therapies, they can develop impairment in blood flow, innervations resulting in vaginal dryness and inhibited sexual desire," explained Aleece Fosnight, M.S.P.A.S., a sexual health counselor and educator at Aeroflow Urology in Brevard, North Carolina.

A survey conducted by John Hopkins Medicine with urologists who practice bladder cancer care asked whether or not the care providers had conversations about sexual health with their patients. The survey found about 21 percent of women have never had a discussion about baseline sexuality at the time of surgery.

"There is a gap in care for women with bladder cancer and, most particularly, with women who have providers who don't discuss nerve-sparing [treatment], which is done to protect sexual function," Fosnight added. "Obviously. treatment for bladder cancer is recommended, but conversations around sexuality-preserving measures should be actively discussed with the patients."

A radical cystectomy may shorten the vagina, and in these cases, vaginal dilators can be used to stretch the vagina or vaginal reconstruction surgery can lengthen the vagina. A physical therapist can also help with releasing tension by prescribing different pelvic exercises. The most common treatments are lubricants and hormonal therapy, which include low-dose vaginal estrogen.

Addressing the problem

"Most of the time, if caught early with a lower grade of bladder cancer, options other than surgery are available, such as resection of the tumor under general anesthesia and chemotherapy bladder instillations afterward, which are associated with less sexual dysfunction," Fosnight said.

Having bladder cancer certainly doesn't mean an end to your sex life. If you've undergone some of the more radical treatments, which make sex difficult, the most important factor is communication with your partner. Counseling from a sex therapist who can provide you with options to help you restore your sexuality is helpful, too.

"People with cancer mostly worry about burdening their partner and don't talk about their problems," Fosnight said. "When they stop talking, they start withdrawing from one another, and when that happens, people begin to lose emotional intimacy, making it tougher for a way back to pleasure. It is not just the person's body and treatments, but also the emotional health and the health of the relationship that can be a barrier in restoring sexuality."