A topic that almost no one talks about
If your oncologist or surgeon hasn’t talked to you about sexuality or fertility, you’re not the only one. A recent study of people diagnosed with colorectal cancer before age 50 sums up these issues well with the phrase: “No one told me.” Although colorectal cancer treatment can have devastating consequences for sexual function and fertility, these issues remain underrecognized and are rarely addressed. This is neither a minor nor an embarrassing topic: it’s part of your quality of life, and you have the right to ask questions.
This guide is not a substitute for your healthcare team. It’s meant to help you understand what might happen, what questions to bring to your appointment, and what options are available in Spain today.
Male Sexuality: Erection and Ejaculation
The main cause of male sexual problems following colorectal cancer surgery is damage to the autonomic nerves in the pelvis surrounding the rectum. The main cause of postoperative sexual dysfunction is organic damage to the pelvic autonomic nerves during surgery, although neurotoxicity induced by radiation therapy and chemotherapy, as well as postoperative psychological factors, have also been reported to contribute.
There are two types of problems, as they depend on different nerve circuits:
- Erectile dysfunction: difficulty achieving or maintaining an erection. This depends on the parasympathetic nerves in the pelvis.
- Ejaculation problems: These can range from a “dry orgasm” (there is a sensation of orgasm but no semen is released) to retrograde ejaculation (semen flows into the bladder instead of being expelled). Some of the nerves that control ejaculation run near the lower part of the colon and are damaged during an abdominoperineal resection or a total mesorectal excision; in either case, this results in a dry orgasm. Retrograde ejaculation is neither painful nor dangerous, although it may come as a surprise the first time.
The risk varies depending on the type of surgery. When surgeons are able to preserve the nerves, the outcomes are better: in one study, among patients with no macroscopic nerve damage, only 2 out of 15 (13.3%) developed erectile dysfunction, whereas all 5 patients with incomplete nerve preservation developed erectile dysfunction. Ask your surgeon if the planned technique is “nerve-sparing.”
Recovery may be slow and partial. In a follow-up study after nerve-sparing surgery, the erectile function score dropped from 24.3 before surgery to 17.6 at 3 months, and improved progressively to 20.6 at 24 months, though it did not always return to the preoperative level. Abdominoperineal resection (with a permanent stoma) typically has a greater impact than a low anterior resection: even with a less radical technique such as low anterior resection, sexual function is affected, and studies show that 64% of patients experience a significant decline in the quality of their sexual life.
Sexuality in Women: Dryness, Pain, and Early Menopause
In women, the most common effects are different. For women who still have their ovaries, certain types of radiation therapy, chemotherapy, and hormone therapy can lead to ovarian failure, causing premature menopause, which is sometimes temporary but often permanent. This leads to hot flashes, vaginal dryness, and, as a result, discomfort or pain during intercourse. The vagina can naturally lose moisture and elasticity with age, and surgeries and cancer treatments can accelerate these changes.
If your treatment includes pelvic radiation therapy (common in rectal cancer), vaginal narrowing or fibrosis may occur. To prevent this, regular use of vaginal dilators is recommended after treatment. The prescribed vaginal dilators should remain inserted for at least 5 to 10 minutes, two or three times a week, for an indefinite period, depending on each patient’s needs, and the radiation oncologist should be the first to discuss this topic with the patient before starting radiation therapy. If no one has explained this to you and you are about to undergo pelvic radiation therapy, be sure to ask about it.
In abdominoperineal resection, the vaginal wall may also be affected if the tumor is very close to it, which can cause pain during penetration.
What Happens If You Have a Stoma
We’ve already discussed daily life with a stoma in detail in another guide on this website. Here we’ll focus on its effect on sexuality: it’s real, but manageable. In a study of 214 people with a stoma, 36.9% reported a decreased sex drive and 47.7% reported dissatisfaction with their body image. The cause is not usually purely physical: the creation of a stoma leads to a profound distortion of body image, accompanied by a loss of confidence in one’s own body, which acts as a major catalyst for sexual dysfunction, causing many patients to feel “asexual” or “unattractive.” The good news is that this improves over time and with support: closeness with a partner has been identified as a protective factor that promotes acceptance of the new body image and facilitates intimacy.
Sexual Desire: What Affects Everyone Equally
Beyond surgery, there are factors common to both men and women that reduce the desire to have sex during treatment. Sexual desire, pleasure, satisfaction, and the frequency of sexual relations all decrease throughout the course of the illness. Fatigue, nausea, pain, anxiety, or an altered body image weigh just as heavily—or even more so—than the physical damage itself. It’s not “your fault”: it’s to be expected, and it usually improves once the most intensive treatment ends.
Fertility: What May Be Affected
Chemotherapy can damage reproductive capacity, sometimes temporarily and sometimes permanently. Cancer treatment can affect fertility in both sexes, either temporarily or permanently, or manifest in women later on as early menopause; chemotherapy can be gonadotoxic for both sexes. The extent of the impact depends on the drug, the dose, and the person’s age.
Surgery can also play a role. An abdominoperineal resection can also affect fertility by damaging nerve or vascular structures involved in reproduction. In women undergoing pelvic radiation therapy, the ovaries may fall within the radiation field: In colorectal cancer, the effects on fertility are determined by surgery, chemotherapy, and pelvic radiation therapy, and oocyte vitrification or ovarian transposition may be considered if radiation therapy is to be used.
An important point: it is not recommended to try to conceive during active treatment. In general, women are usually advised not to become pregnant during treatment and, depending on the treatment and individual circumstances, to wait before trying to conceive afterward. For men, the advice is also to use contraception: the risk of birth defects if a man fathers a child during or after treatment is not entirely clear, but many doctors advise using contraception and not trying to conceive during treatment.
Preserving Fertility: Options and How to Access Them in Spain
If you want to have children in the future, this should be discussed before starting treatment, provided the treatment schedule allows it. If your treatment may cause fertility issues, you may want to consult a fertility specialist before treatment to discuss your options.
For men
The main option is to freeze semen (sperm banking) before starting chemotherapy. Sperm banking is an effective method of fertility preservation for men and is generally offered before cancer treatment to those who want to have children in the future, although doctors sometimes fail to mention this option. The results are good: sperm collected before treatment is just as likely to result in a pregnancy as sperm from a man without cancer. If this option hasn’t been offered to you and you’re interested, ask to be referred to a sperm bank before your first chemotherapy session.
For women
The available techniques include oocyte vitrification (egg freezing) or, in some cases, embryo freezing, and in specific situations, ovarian tissue cryopreservation or surgical relocation of the ovaries outside the radiation therapy field.
Is this covered by public health insurance?
Yes, under certain conditions. The National Health System’s portfolio of services expressly includes this benefit. It covers the preservation of gametes or pre-embryos for deferred autologous use based on medical indication, intended to preserve fertility in situations associated with specific pathological conditions. The eligibility criteria are defined as follows: the cryopreservation of gametes or preembryos for deferred autologous use is performed in patients at potential risk of losing their reproductive capacity due to exposure to gametotoxic treatments or pathological conditions with a proven risk of premature ovarian failure or primary testicular failure, which is precisely the situation of those who are about to undergo chemotherapy.
In practice, access and waiting times vary by autonomous community and hospital. Request a referral to the fertility clinic as soon as possible: these procedures (especially ovarian stimulation) take a few days or weeks, which can sometimes conflict with the urgency of starting cancer treatment. Your oncologist and the fertility team must coordinate to determine if there is enough time.
What You Can Do
- Ask questions without waiting to be asked. Many professionals don’t bring up the topic out of respect or due to a lack of time—not because it isn’t important.
- If fertility is important to you, say so as soon as possible—ideally before your first round of chemotherapy or pelvic radiation therapy.
- Use lubricant if you experience vaginal dryness; it’s a simple and effective way to relieve discomfort during intercourse.
- If you’ve been prescribed vaginal dilators after pelvic radiation therapy, use them as directed; they prevent narrowing, which is harder to treat later on.
- Talk to your partner. Silence often creates more distance than the physical problem itself.
- Seek psychological help or a sex therapy consultation if the discomfort persists; it’s not about “putting up with it”—it’s another symptom that can be treated.
When to Consult Your Healthcare Team
Notify your oncologist, surgeon, or nurse if you notice: new or severe pain during intercourse, unusual vaginal bleeding, a complete lack of desire that concerns you, or questions about contraception during treatment. None of these issues is “trivial” or something you should have to deal with on your own.