ED after prostate surgery, radiation and other pelvic surgery: what the guideline and the NIH say

The short version: if your erections changed after prostate cancer treatment or another operation in the pelvis, that is a recognized effect of the treatment, not a personal failing. The National Institutes of Health lists damage from pelvic surgery among the causes of erectile dysfunction (ED), and the American Urological Association (AUA) says prostate surgery, radiation and hormone therapy can all lead to some degree of it. This page walks through why it happens, what the guideline says about recovery, what the evidence shows for treatment, and what to ask your care team.

Can prostate or pelvic surgery cause ED?

Yes. The NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) lists “nerve damage or disorders, such as multiple sclerosis, spinal cord injuries, and damage from pelvic surgery” among the most common conditions that can lead to ED. It also lists “chemotherapy and hormone medicines” among the medicines that can have ED as a side effect (NIDDK, Symptoms & Causes of ED).

Prostate surgery is the best-known example, but it is not the only one. The National Cancer Institute (NCI) says surgery for penile, rectal, prostate, testicular and other pelvic cancers, such as cancers of the bladder and colon, “may affect the nerves, making it difficult to get and keep an erection,” and that nerve-sparing surgery can sometimes be used to prevent these problems (NCI, Sexual Health Issues in Men with Cancer). For the wider picture of how nerve conditions fit into ED, see our guide to nerve conditions and ED, and for the full map of physical, medical and mental causes, our guide to what causes erectile dysfunction. This page is part of our Causes and Conditions section.

Why does prostate surgery affect erections?

Because the nerves that control erections run right alongside the prostate. The AUA describes nerve-sparing surgery as techniques “that preserve the peri-prostatic penile nerve supply required for penile erection.” It explains that ED after prostate removal “principally involves ‘neuropraxia’,” meaning a temporary loss of nerve function from the trauma of surgery, which can happen even when the nerves are spared, or a complete loss when the nerves are cut or removed. Injury to nearby blood vessels and later changes in the erectile tissue itself can add to the problem (AUA ED Guideline, Statement 11 discussion).

Sparing the nerves is not always possible. NCI notes that nerve-sparing surgery “may not be possible in men with large tumors or tumors that are very close to the nerves,” and lists impotence among the possible problems after prostate cancer surgery, along with leakage of urine or stool and a shortening of the penis of 1 to 2 centimeters (NCI, Prostate Cancer Treatment (PDQ), Patient Version). Whether your surgeon was able to spare one side, both sides or neither is one of the most useful facts to know about your own situation.

Do radiation and hormone therapy for prostate cancer cause ED?

They can, though the pattern differs from surgery. The AUA says “clinically localized treatments such as RP and RT as well as systemic therapies used for advanced disease (e.g., hormonal therapy), result in various degrees of ED,” and that “many men will experience clinically significant ED as a consequence of prostate cancer treatment” (AUA ED Guideline). RP is radical prostatectomy and RT is radiotherapy.

Radiation. Surgery tends to affect erections right away. With radiation, the AUA describes “a delayed onset of ED that may occur 24 to 36 months after treatment and may worsen over time thereafter,” caused by radiation damage to the nerve and blood supply of the penis. It cites reported rates of new-onset ED of 36% and 38% at two and three years after radiation, while noting that changes in how radiation is delivered have improved erection preservation (AUA ED Guideline). NCI says radiation to the pelvis can make it difficult to get or keep an erection “if blood vessels or nerves are damaged” (NCI, Sexual Health Issues in Men with Cancer).

Hormone therapy. Hormone therapy for prostate cancer, also called androgen deprivation therapy, lowers testosterone or blocks its action. NCI lists loss of interest in sex and erectile dysfunction among its side effects, and notes that the risk of side effects rises the longer a man is on it. It also says most of the sexual side effects “will eventually go away if a man stops taking hormone therapy,” though for older men and those treated for a long time, testosterone levels may not fully recover (NCI, Hormone Therapy for Prostate Cancer). This is a different thing from testosterone therapy for low testosterone. The hormone therapy here is a cancer treatment, and whether to change it is a decision for your cancer team. Our guide to medications that affect erections covers the wider list of medicines involved, and our page on low libido in men covers changes in desire, which is a separate thing from erections.

Can erections recover after prostate surgery?

Recovery is possible when the nerves are spared, but it is gradual and often incomplete. In the AUA’s words: “When cavernous nerves are spared, a gradual recovery of erectile function is possible, although this recovery may be delayed for several months at a minimum. Commonly, the interval of spontaneous erectile function recovery occurs 12 to 24 months after surgery, although recovery may still be possible as much as 36 months after surgery” (AUA ED Guideline).

The guideline is also plain about the limits. It says that “relatively few men recover baseline erectile function, particularly those over age 60 years at the time of surgery,” and that when the nerves are not spared, “the expected effect is an unrecoverable loss of erectile function.” It cites a meta-analysis of studies with more than 12 months of follow-up that reported an erectile function recovery rate of 60% with nerve-sparing on both sides and 47% with nerve-sparing on one side (AUA ED Guideline). Those are averages pooled across many studies and surgeons. They describe groups of men, not what will happen for you, and your own surgeon is the best person to put them in the context of your operation.

Can ED be reversed after prostate surgery?

Sometimes it improves on its own, sometimes it does not, and the guideline does not promise either outcome. When the nerves were spared, the AUA describes spontaneous recovery commonly appearing 12 to 24 months after surgery and possibly as late as 36 months, while noting that “relatively few men recover baseline erectile function.” When the nerves could not be spared, it describes “an unrecoverable loss of erectile function” (AUA ED Guideline, Statement 11 discussion). Whether or not unassisted erections come back, treatments for ED that is present are still available, and they are the subject of the sections below. Our guide to whether ED can be reversed covers the causes that can improve when treated, across all types of ED.

Can surgery for an enlarged prostate cause ED?

It can. Surgery for benign prostatic hyperplasia (BPH), the noncancerous enlargement of the prostate, is a different operation from cancer surgery. NIDDK says surgeons may remove part or all of the prostate, using methods such as transurethral resection (TURP), laser surgery, electrovaporization or robotic surgery, and it lists “sexual problems, including ED, retrograde ejaculation, and infertility” among the possible complications of BPH surgery (NIDDK, Enlarged Prostate (BPH)). NIDDK also lists enlarged prostate itself among the conditions that can lead to ED (NIDDK, Symptoms & Causes of ED), so when erections changed, before or after the operation, is worth telling the clinician who evaluates you. Our guide to enlarged prostate and ED covers BPH, its medicines and its procedures in more detail.

Can a prostate biopsy cause ED?

The research points to a small, temporary dip rather than lasting ED. A 2021 systematic review and meta-analysis of nine studies that measured erectile function before and after a prostate biopsy found that the average score on a standard five-question erectile-function questionnaire fell by about 2 points one month after biopsy, then was no different from baseline at three and six months. The authors described it as “a mild, transient decrease” (Fainberg et al., J Urol 2021). A second meta-analysis, of seven studies, likewise found a significant drop at one month that resolved by three and six months, and concluded that men “should be counselled regarding the transient effect on erectile function post biopsy” (Mehta et al., Urology 2021). These are averages across studies; if erections have not returned to how they were within a few months of a biopsy, that is worth raising with your urologist.

Does taking an ED pill early after surgery protect erections?

The evidence so far says it may not. The idea of “penile rehabilitation” is to start treatment soon after prostate cancer surgery or radiation to protect erectile tissue while the nerves recover. The AUA’s Statement 11 says men who want to preserve erectile function after radical prostatectomy or radiotherapy “should be informed that early use of PDE5i post-treatment may not improve spontaneous, unassisted erectile function.” PDE5i means PDE5 inhibitors, the pill class that includes sildenafil and tadalafil (AUA ED Guideline, Statement 11).

The guideline’s own meta-analysis of three trials comparing a PDE5 inhibitor with placebo after surgery found no difference in rates of restored erectile function, and it notes that early use did not improve later responses to the medicine either. The panel adds two caveats: the trials ran for 12 months or less, so a longer schedule might behave differently, and other approaches such as vacuum devices or injections have been tried in small studies that need more mature data. Its overall reading is that rehabilitation protocols “tested to date remain unproven” (AUA ED Guideline). That is a statement about protecting future unassisted erections. It is a separate question from treating ED that is present now, which the sections after the trial summary cover.

What did the penile rehabilitation trials find?

The largest placebo-controlled trials did not find that regular PDE5 inhibitor use after nerve-sparing prostatectomy brought back unassisted erections once the medicine was stopped, while one smaller early trial did. The trials measured erectile function after a drug-free “washout” period, so they were testing protection, not the pills’ effect while being taken. All four enrolled men who had good erections before nerve-sparing surgery (on both sides in three of the four), so they describe that group only.

Sources for the table: Padma-Nathan et al., Int J Impot Res 2008; Montorsi et al., Eur Urol 2008; Montorsi et al., Eur Urol 2014; Pavlovich et al., BJU Int 2013.

The REACTT authors did report that once-daily tadalafil improved erections while it was being taken and was associated with less loss of penile length at 9 months than placebo, and they suggested a “potential role” for early treatment, while stating plainly that unassisted function “was not improved after cessation of active therapy” (Montorsi et al., 2014). The AUA also notes small studies of early vacuum device use after surgery, with sample sizes it calls “extremely small,” and says more mature data are needed before those approaches can be called proven (AUA ED Guideline, Statements 11 and 13). Whether to use a rehabilitation plan, and which one, is a conversation for your urologist; our page on vacuum erection devices covers the device side, including its use after prostate cancer treatment.

Do ED medicines work after prostate cancer treatment?

They are studied in this group, with some differences from other men. The AUA says PDE5 inhibitors have been evaluated in men after prostatectomy and after radiation, with broadly similar results across the different medicines, but that men “who are post-prostatectomy have more severe ED at baseline and respond less robustly” to them. Men after surgery or radiation also reported higher rates of side effects than men in the general ED population, though the panel says it is not clear whether they have more side effects or report them more (AUA ED Guideline).

On a question many men ask, the AUA reviewed studies of PDE5 inhibitor use after prostate cancer treatment and interpreted them to indicate “there is no increased risk of prostate cancer recurrence associated with PDE5i use after prostate cancer treatment” (AUA ED Guideline).

The FDA-approved VIAGRA (sildenafil) label lists radical prostatectomy and transurethral resection of the prostate (TURP) among the groups included in its clinical studies. Across all trials, it reports improved erections in 43% of radical prostatectomy patients on sildenafil compared with 15% on placebo (VIAGRA prescribing information, section 14, DailyMed). Those are trial-group results. They do not predict how any one man will respond, and they do not replace a check of your heart health and other medicines first; our guide to sildenafil drug interactions covers the medicines that need a conversation first, including alpha-blockers.

Hormone therapy is a special case. NCI says ED drugs such as sildenafil “do not usually work for men undergoing hormone therapy because these drugs do not address the loss of libido (sexual desire) that is associated with a lack of androgens” (NCI, Hormone Therapy for Prostate Cancer).

What other ED treatments are options after prostate cancer treatment?

Pills are one option among several, and the AUA does not rank them as a required first step. The guideline’s starting principle is that men should be “informed of all treatment modalities that are not contraindicated, regardless of invasiveness or irreversibility, as potential first-line treatments,” using shared decision-making (AUA ED Guideline). Its statements say men with ED should be informed about:

• Vacuum erection devices, which the AUA says are effective in men after prostatectomy as well as in the general ED population, and should include a vacuum limiter (Statement 13).
• Intraurethral alprostadil, a medicine placed in the urethra (Statement 14).
• Penile injections (intracavernosal injections), which the AUA says have been reported effective in men after prostatectomy (Statement 16).
• Penile prosthesis implantation, a surgically placed device (Statement 18).

NCI describes the same range for men after cancer treatment: medicines that increase blood flow to the penis, devices, and surgery to place “a firm rod or inflatable device” (NCI, Sexual Health Issues in Men with Cancer). NIDDK adds that your health care professional will teach you how to use an injection or suppository if you choose one (NIDDK, Treatment for ED). Each option has its own benefits, risks and burdens, which is why the AUA asks clinicians to discuss them one by one. Our overview of ED treatment options covers each in more detail.

How do the ED treatment options compare after prostate cancer treatment?

They differ in how they work, how invasive they are and how much evidence exists for men after prostate cancer treatment. The table below sets out what the AUA guideline and the sildenafil label say about each one in this group. It is a map for the conversation with your urologist, not a ranking, because the AUA treats every option that is not ruled out for you as a possible first choice (AUA ED Guideline).

Sources for the table: the AUA guideline statements named in each row, and section 14 of the VIAGRA prescribing information for the sildenafil figures.

Does Peyronie’s disease become more likely after prostate surgery?

It can. NIDDK says the chance of Peyronie’s disease, a curve in the penis caused by scar tissue, increases after surgery for prostate cancer, and that experts believe this is related to the ED that can follow the surgery (NIDDK, Penile Curvature (Peyronie’s Disease)). Our guide to Peyronie’s disease explains what to look for.

Is it normal to feel low or stressed about ED after cancer treatment?

Yes, and the guideline treats it as part of care. The AUA says that given the “suddenness and severity” of ED for many men after prostate surgery, “it is not surprising that men in this setting commonly experience depression, anxiety, and relationship stress.” It calls psychosocial support “an important strategy,” and says clinicians should educate men about the sexual effects of prostate cancer treatment and “set realistic expectations regarding functional recovery” (AUA ED Guideline). More broadly, the AUA says referral to a mental health professional should be considered for men being treated for ED (Statement 6).

NCI suggests sharing your concerns with people you are close to, and says a nurse or social worker can recommend support groups and counselors. It also notes that feeling close to a partner is probably still important even when energy or interest in sex has changed (NCI, Sexual Health Issues in Men with Cancer). Our guide to ED and performance anxiety covers how worry and erections can feed each other, and our page on counseling and sex therapy for ED explains what that kind of support involves.

What should I ask my care team about ED after treatment?

NCI points out that your doctor may raise sexual side effects with you, or you may need to ask. Its suggested questions include what sexual problems are common with your treatment, when changes might happen, how long they might last and whether any could be permanent, how they can be prevented, treated or managed, and which specialists you could talk with (NCI, Sexual Health Issues in Men with Cancer). NCI also lists the factors that shape your own outlook: the type of cancer, the type, dose and length of treatment, your age at treatment, how much time has passed and your other health factors.

A few questions follow directly from the guideline. Were the nerves spared on one side, both or neither? If you had radiation, could ED appear later even if things seem unchanged now? Which treatment options are not ruled out for you, and what are the benefits and burdens of each? Prior surgeries are part of the history the AUA asks clinicians to take for any man with ED (AUA ED Guideline), and NIDDK advises talking with a health care professional, for safety reasons, before using dietary supplements or alternative medicines for ED (NIDDK, Treatment for ED); our page on FDA warnings about tainted ED supplements explains why. Our guide to how ED is diagnosed walks through the evaluation itself, which doctor treats ED explains when a urologist is the right specialist, and talking to a doctor about ED covers how to start the conversation.

The bottom line

ED after prostate cancer treatment or other pelvic surgery is a recognized, common effect, described by both the NIH and the AUA. After nerve-sparing surgery, gradual recovery is possible, commonly over 12 to 24 months, though few men return fully to how things were before, especially past 60. Radiation can bring ED on later, and hormone therapy can lower desire as well as erections. A prostate biopsy, on average, causes only a short-lived dip. The largest rehabilitation trials found that starting a pill early did not improve unassisted erections after it was stopped, but several treatment options exist for ED that is present, and a urologist can talk through which ones fit.

Sources

Every clinical statement on this page traces to a primary or guideline source:

• NIH NIDDK, Symptoms & Causes of Erectile Dysfunction (last reviewed October 2024): damage from pelvic surgery among the nerve-related causes of ED; enlarged prostate among the conditions; chemotherapy and hormone medicines among the medicines.
• NIH NIDDK, Treatment for Erectile Dysfunction (last reviewed October 2024): treatment options; instruction for injections and suppositories; talk with a health care professional before using dietary supplements or alternative medicines.
• NIH NIDDK, Enlarged Prostate (Benign Prostatic Hyperplasia) (last reviewed June 2024): types of BPH surgery; sexual problems including ED, retrograde ejaculation and infertility among the complications.
• NIH NIDDK, Penile Curvature (Peyronie’s Disease) (last reviewed August 2019): higher chance of Peyronie’s disease after prostate cancer surgery, believed to relate to ED after surgery.
• American Urological Association, Erectile Dysfunction Guideline (Burnett et al., J Urol 2018): Purpose (all non-contraindicated options as first-line); history including prior surgeries; PDE5 inhibitor efficacy, side effects and recurrence data in men after prostatectomy and radiation; Statement 6 (mental health referral); Statement 11 and its discussion (ED after prostate cancer treatment, nerve-sparing, neuropraxia, recovery timing, radiation onset, rehabilitation evidence, psychosocial support); Statements 13, 14, 16 and 18 (vacuum devices, intraurethral alprostadil, injections, prosthesis).
• National Cancer Institute, Prostate Cancer Treatment (PDQ), Patient Version (updated December 2024): nerve-sparing surgery and its limits; possible problems after prostate cancer surgery; radiation and impotence.
• National Cancer Institute, Sexual Health Issues in Men with Cancer (reviewed December 2022): effects of pelvic radiation, hormone therapy and pelvic cancer surgery on erections; factors that shape outlook; treatment options; support; questions to ask.
• National Cancer Institute, Hormone Therapy for Prostate Cancer (reviewed October 2024): sexual side effects of androgen deprivation therapy; ED drugs usually not working during hormone therapy; side effects after stopping.
• VIAGRA (sildenafil citrate) prescribing information, Pfizer, DailyMed: section 14, study populations including radical prostatectomy and TURP; 43% versus 15% improved erections in radical prostatectomy patients across trials.
• Padma-Nathan H, et al. Postoperative nightly sildenafil after bilateral nerve-sparing radical prostatectomy (Int J Impot Res, 2008): 76 completers; 27% vs 4% spontaneous erectile function; early stop.
• Montorsi F, et al. Nightly versus on-demand vardenafil after bilateral nerve-sparing radical prostatectomy (Eur Urol, 2008): 628 men; no difference after washout.
• Montorsi F, et al. Tadalafil and erectile function recovery after bilateral nerve-sparing radical prostatectomy, REACTT (Eur Urol, 2014): 423 men; 20.9%, 16.9% and 19.1% after washout; drug-assisted function and penile length findings.
• Pavlovich CP, et al. Nightly vs on-demand sildenafil for penile rehabilitation (BJU Int, 2013): 100 men; no difference between schedules.
• Fainberg J, et al. Erectile dysfunction is a transient complication of prostate biopsy (J Urol, 2021): 9 studies; about a 2-point drop at 1 month, back to baseline at 3 and 6 months.
• Mehta A, et al. Erectile function post prostate biopsy (Urology, 2021): 7 studies; significant drop at 1 month that resolved by 3 and 6 months.