Background for Fast Fact #517: Sexual function is commonly impacted in patients with serious illnesses like cancer, cardiovascular disease, and organ failure. For example, about 95% with prostate cancer report sexual dysfunction, 51% with testicular cancer experience ejaculatory difficulties, and 81% with coronary disease experience erectile dysfunction (1-3). Disease progression, treatment side effects, and psychosocial factors contribute, often reducing quality of life (1-4). This Fast Fact is a companion piece to #511 and will focus on erectile dysfunction and ejaculatory disorders in patients with serious illness.

Erectile dysfunction (ED): defined as an inability to attain or maintain an erection adequate for desired sexual activity. It is often multifactorial and may be associated with malignancy, vascular dysfunction, neurologic disease, endocrine disorders (notably hypogonadism and diabetes), or psychological disorders. Antidepressants (particularly SSRIs), opioids, and anti-androgen medications are frequently associated with ED (5-8). Substance use (alcohol and tobacco) can contribute as can iatrogenic factors like prior surgeries, chemotherapy, and radiation. When assessing for ED in a patient with serious illness, focus on the onset of symptoms (including temporal relationship to comorbidities and medication changes, particularly antidepressants), situational factors (e.g. psychological stresses and relationship issues), and the presence or absence of nocturnal/morning erections (9,10). 

• Non-medication management: Before prescribing a medication, explore how ED is impacting their mood, self-worth, and relationships. Discuss reasonable expectations of treatment as not all cases will be fixable in the context of a life limiting illness. Patients and their partners may need extra counseling to cope with these profound changes. Address psychosocial factors and refer to psychology and/or sex therapists as necessary, especially if prognosis is estimated to be months or more.  Encourage lifestyle changes like smoking/alcohol cessation and comorbidity optimization (e.g., weight loss, blood pressure control) if appropriate.
• Medication management: Phosphodiesterase type 5 inhibitors (PDE5i) are the mainstay (7,11). Common agents include sildenafil (25-100 mg PRN) and tadalafil (5 mg daily and/or PRN dosing, maximum of 20 mg daily). PDE5is are contraindicated in patients on nitrate-containing medications and should be used with caution in patients with severe renal or liver disease or unstable cardiovascular status, but are otherwise safe in heart failure, frailty, and serious illness (5). In frail or hypotension-prone patients, start with low doses and monitor closely. Common side effects include headache and flushing (5,11). Urology referral is recommended if symptoms persist despite a trial of a PDE5i. Interventional approaches such as injections or penile prosthesis may be considered (7).  For SSRI-induced ED, bupropion should be considered as an alternative treatment (12).

Ejaculatory dysfunction (EjD): includes both premature ejaculation (PE), ejaculation that occurs sooner than desired, and delayed ejaculation (DE), delayed or inability to ejaculate despite adequate stimuli (13). Both PE and DE can be lifelong or acquired. EjD is common after cancer treatment or neurological injury. It is also associated with chronic pain, diabetes, cardiovascular disease, and depression (13-15).  

• Non-pharmacologic management: Mental health and/or sex therapy referral if appropriate, focusing on improving interpersonal communication and behavioral approaches. For PE, pelvic floor physical therapy (PFPT), behavioral techniques such as “the squeeze and hold” technique, and acupuncture can be beneficial (7,13,16). For patients with DE, behavioral approaches such as masturbation retraining and modifying sexual positions may help (13,16).  A sex therapy referral is often warranted to properly counsel patients on these behavioral strategies (13,16).  

• Pharmacologic management: For patients with advanced illness, medical therapy may be preferred over behavioral techniques. For PE, topical anesthetics (e.g. lidocaine/prilocaine creams) applied 5-10 minutes prior to sexual activity, SSRIs (particularly paroxetine taken on demand 3-6 hours prior to sexual activity), tramadol, and alpha-blockers have all been shown to be effective in some patients (7,13,16). For DE, no FDA-approved medication exists nor is there a well-established off-label medication (13). Management focuses on the replacement, dose adjustment, or staged cessation of medications that contribute to DE with SSRIs, opioids, and anti-androgens being common culprits (7,13,16,17). Normalizing testosterone levels may help as may PDE5i therapy if ED is present (13).

Communication:  Sexual health and intimacy are often overlooked in serious illness care, despite many patients expressing a desire to discuss these topics (10). Barriers include stigma, shame, time constraints, provider assumptions, and a lack of training in managing sexual health concerns (10). The American Society of Clinical Oncology recommends that clinicians proactively initiate and revisit sexual health discussions throughout the course of illness (1). Several validated tools and frameworks like the PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy) can help clinicians navigate sexual health concerns (18). Broad themes that emerge from these frameworks are: 

• Normalize the topic via open-ended, nonjudgmental questions: “Many with your condition experience changes in sexual health. Is it ok if we discuss any sexual concerns you might have?” 
  Explore patient expectations and goals—many prioritize intimacy over function, and penetrative intercourse may not be their primary objective (5-7).
  Discuss ways to redefine and prioritize intimacy, especially when prior sexual function cannot be restored. This may include physical expressions such as hugging, kissing, handholding, or using sex toys, as well as non-physical forms of intimacy like emotional, spiritual, or intellectual connection. Social workers, chaplains, therapists, and the multidisciplinary team are helpful in addressing the social and spiritual impact of sexual dysfunction for patients and partners.

References:  

1. Carter J, Lacchetti C, Andersen BL, et al. Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline. J Clin Oncol. 2018 Feb 10;36(5):492-511. doi: 10.1200/JCO.2017.75.8995. Epub 2017 Dec 11. PMID: 29227723. 
2. Apostolo A, Vignati C, Brusoni D, et al. Erectile dysfunction in heart failure: correlation with severity, exercise performance, comorbidities, and heart failure treatment. J Sex Med. 2009 Oct;6(10):2795-805. doi: 10.1111/j.1743-6109.2009.01416.x. Epub 2009 Aug 11. PMID: 19674255.
3. Melisko ME, Narus JB. Sexual Function in Cancer Survivors: Updates to the NCCN Guidelines for Survivorship. J Natl Compr Canc Netw. 2016 May;14(5 Suppl):685-9. doi: 10.6004/jnccn.2016.0193. PMID: 27226515.
4. Bober SL, Varela VS. Sexuality in adult cancer survivors: challenges and intervention. J Clin Oncol. 2012 Oct 20;30(30):3712-9. doi: 10.1200/JCO.2012.41.7915. Epub 2012 Sep 24. PMID: 23008322.
5. Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018 Sep;200(3):633-641. doi: 10.1016/j.juro.2018.05.004. Epub 2018 May 7. Erratum in: J Urol. 2022 Mar;207(3):743. doi: 10.1097/JU.0000000000002389. Erratum in: J Urol. 2022 Mar;207(3):743. doi: 10.1097/JU.0000000000002436. PMID: 29746858.
6. Denlinger CS, Carlson RW, Are M, et al. National comprehensive cancer network. Survivorship: sexual dysfunction (male), version 1.2013. J Natl Compr Canc Netw. 2014 Mar 1;12(3):356-63. doi: 10.6004/jnccn.2014.0037. PMID: 24616541; PMCID: PMC4465261.
7. Salonia A, Bettocchi C, Boeri L, et al. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol. 2021 Sep;80(3):333-357. doi: 10.1016/j.eururo.2021.06.007. Epub 2021 Jun 26. PMID: 34183196.
8. Sadovsky R, Basson R, Krychman M. Cancer and sexual problems. J Sex Med. 2010 Jan;7(1 Pt 2):349-73. doi: 10.1111/j.1743-6109.2009.01620.x. PMID: 20092444.
9. Leemans C, Van den Broucke S, et al. Sexual Dysfunction in Patients with Chronic Non-Genital Physical Disease: An Umbrella Review. Int J Environ Res Public Health. 2025 Jan 24;22(2):157. doi: 10.3390/ijerph22020157. PMID: 40003383; PMCID: PMC11855788.
10. Kelemen A, Cagle J, Chung J, et al. Assessing the Impact of Serious Illness on Patient Intimacy and Sexuality in Palliative Care. J Pain Symptom Manage. 2019 Aug;58(2):282-288. doi: 10.1016/j.jpainsymman.2019.04.015. Epub 2019 Apr 22. PMID: 31022442.
11. Shamloul R, Ghanem H. Erectile dysfunction. Lancet. 2013 Jan 12;381(9861):153-65. doi: 10.1016/S0140-6736(12)60520-0. Epub 2012 Oct 5. PMID: 23040455.
12. Whooley MA. Diagnosis and treatment of depression in adults with comorbid medical conditions: a 52-year-old man with depression. JAMA. 2012 May 2;307(17):1848-57. doi: 10.1001/jama.2012.3466. PMID: 22550199.
13. Shindel AW, Althof SE, Carrier S, et al. Disorders of Ejaculation: An AUA/SMSNA Guideline. J Urol. 2022 Mar;207(3):504-512. doi: 10.1097/JU.0000000000002392. Epub 2021 Dec 28. PMID: 34961344.
14. Pizzol D, Trott M, Grabovac I, et al. Ejaculation Disorders in Male Patients with Cancer: A Systematic Review and Meta-Analysis of Prevalence. J Urol. 2021 Dec;206(6):1361-1372. doi: 10.1097/JU.0000000000002136. Epub 2021 Jul 21. PMID: 34288714.
15. Loh-Doyle JC, Stephens-Shields AJ, Rolston R, et al. Predictors of Male Sexual Dysfunction in Urologic Chronic Pelvic Pain Syndrome (UCPPS), Other Chronic Pain Syndromes, and Healthy Controls in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. J Sex Med. 2022 Dec;19(12):1804-1812. doi: 10.1016/j.jsxm.2022.08.196. Epub 2022 Sep 28. PMID: 36180370; PMCID: PMC10916540.
16. Martin-Tuite P, Shindel AW. Management Options for Premature Ejaculation and Delayed Ejaculation in Men. Sex Med Rev. 2020 Jul;8(3):473-485. doi: 10.1016/j.sxmr.2019.09.002. Epub 2019 Oct 23. PMID: 31668585.
17. Sanchez Varela V, Zhou ES, Bober SL. Management of sexual problems in cancer patients and survivors. Curr Probl Cancer. 2013 Nov-Dec;37(6):319-52. doi: 10.1016/j.currproblcancer.2013.10.009. Epub 2013 Oct 22. PMID: 24331239.
18. Arends SAM, van Rossum CE, Eeltink CM,et al. Feasibility and effectiveness of communication tools for addressing intimacy and sexuality in patients with cancer: a systematic review. Support Care Cancer. 2024 Jan 17;32(2):109. doi: 10.1007/s00520-024-08308-6. PMID: 38231322; PMCID: PMC10794301.

Conflicts of Interest: None to report.
Authors’ Affiliations: 1University of Utah School of Medicine, Salt Lake City UT; 2University of Louisville School of Medicine, Louisville KY.
Version History: First electronically published in August 2025; originally edited by Sean Marks MD.