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BackTable / Urology / Article
Female Sexual Health After Cancer: The Critical Role of the Urologist
Sam Strauss • Updated Apr 14, 2025 • 34 hits
For decades, conversations around female sexual health have been marginalized in clinical practice—often regarded as “too personal”, “too awkward”, or too complex to address in routine urologic care. While topics like erectile dysfunction have become standard components of male patient evaluations, issues of libido, arousal, pain, and orgasm in women have remained under-discussed and under-evaluated, despite their critical impact on quality of life.
For female patients undergoing treatment for urologic cancers, conversations about sexual health are especially important, as malignancies and cancer therapies can greatly limit sexual function. In this article, sexual medicine specialist Dr. Rachel Rubin and urologic oncologist Dr. Sara Psutka detail why sexual health is a critical part of urologic cancer care, and how urologists can approach female sexual health with the same clinical curiosity, confidence, and standardization as any other core system of the body.
The BackTable Urology Brief
• Despite increasing awareness, female sexual health remains insufficiently addressed in urologic practice, particularly in oncology settings where patients are at high risk for sexual dysfunction.
• Standardized assessment of female sexual function—including domains like libido, arousal, orgasm, and dyspareunia—is not commonly included in intake evaluations, leading to underdiagnosis and missed opportunities for early intervention.
• Normalizing sexual health discussions during the review of anatomical systems can improve clinical outcomes. This approach also mirrors established approaches to male sexual function (e.g., routine questioning about erections in prostate cancer patients).
• Cancer treatments such as radical cystectomy, chemotherapy, and pelvic radiation can significantly disrupt vaginal lubrication, pelvic floor function, and hormonal balance, contributing to sexual dysfunction that often goes unaddressed.
• There is no formal training pathway for sexual medicine in urology or gynecology, resulting in provider discomfort, underpreparedness, and inconsistency in how sexual side effects are managed or discussed with patients.
• Leading clinical voices in sexual health advocate for a systems-level shift, urging clinicians to incorporate sexual health screening, education, and treatment options as standard components of female urologic oncology care.
Table of Contents
(1) From Stigma to Standard: Making Female Sexual Health Part of Routine Cancer Care
(2) Cancer Treatment & Sexual Health: Counseling is Key
(3) Female Sexual Health as a Standard Across All Specialties
From Stigma to Standard: Making Female Sexual Health Part of Routine Cancer Care
Historically, the field of sexual medicine has marginalized female patients, treating their sexual health as secondary to other health concerns—or ignoring it altogether. Dr. Rachel Rubin notes that sex was long placed in the "vice category," something shameful or risky rather than a legitimate component of a standard healthy adult lifestyle. As a result, topics like libido, arousal, and orgasm have not been routinely addressed in clinical settings, particularly in urology. This cultural stigma has trickled down into medical education and practice, leaving generations of providers ill-equipped to engage in evidence-based, patient-centered conversations around female sexual function.
Dr. Rubin emphasizes that this neglect is not due to malice or lack of care, but to a broader system failure in how we train and support clinicians. Most physicians, she says, simply don't receive the tools or language necessary to guide these conversations confidently. Yet this is beginning to change. She argues that sexual health should no longer be seen as an "extra" or specialty topic, but as part of the foundational care patients receive—especially those undergoing treatment for urologic cancers. Reframing sexual health as a “vital sign,” Dr. Rubin calls for a new paradigm: one where asking about a woman’s libido is just as routine as asking a man about his erections.
This shift in perspective is being driven by a new generation of clinicians who want to meet the full spectrum of their patients' needs—but often don’t know where to start. As Dr. Rubin points out, the solution isn't necessarily more passion, but more preparation: giving providers scripts, language, and tools they can use confidently in daily practice. With the right education and normalization, these conversations can become just another part of good quality medical practice.
[Dr. Aditya Bagrodia]
I'll be the first to admit. My sexual health intake for most women coming in to see me, which is generally for urologic cancers, is limited to non-existent at best.
[Dr. Rachel Rubin]:
Call it what it is. It's piss poor. Let's call it what it is.
[Dr. Aditya Bagrodia]
I suspect that. We're going to change that. Maybe almost any female coming in, what should be almost like a review of systems that we're obtaining?
[Dr. Rachel Rubin]
…When I went to med school and y'all probably went to med school, sex was in the vice category. Do you smoke? Do you drink? Do you do drugs? Do you have sex? Right? It was something bad that you were doing. Instead, why don't you just have in your template, a review of systems that is actually appropriate for cancer patients? That should include a little bit more than, do you have sex with men, women or both? Right? We're urologists. We can talk about sexual health. We talk about erections, arousal, orgasm, libido, all day long, in men.
What if you just did the same thing in your female patients? You could have a question. Hey, any issues with your libido? Are you sexually active? Do you have a partner? What does sex look like for you? Is penetration important to you? Is it something you would like to be important to you in the future? It's okay to ask those questions, and also to gauge from your patient how they feel about that. Then you can dig further. If it's important to your patient, it should be important to you. The worst thing is that when you're after surgery, after the fact, after something, and the patient is miserable because she said, well, I didn't know that was going to affect my orgasm, or I didn't know I wasn't going to be able to do X, Y and Z because you assumed that she's 70 and she's not interested in those things.
[Dr. Aditya Bagrodia]
…Sara, maybe I can ask you on what does this look like specifically in your cancer practice? Maybe we start out with a kidney cancer patient, preoperative, maybe they need a mass, they need a partial nephrectomy and you're intaking them. How does this practically work for a cancer patient?
[Dr. Sara Psutka]
…I think that one of the most important things, I love what Rachel said and I love how she just laid it out there, which is that we have to talk about sex. Sex is a very important part of quality of life. Our jobs as urologists and oncologists is to know our people and our patients and know what is important to them in terms of their quality of life. I think the first thing that I just do, and no matter who I'm seeing, whether I'm seeing someone for testicular cancer or kidney cancer or bladder cancer or penile cancer, the first thing I try to let patients know is that there is literally not a single topic that is off the table. That comes down to talking about sex. …I think one thing that I think is really critical is opening the door to conversations about this in a way where your language doesn't impart any judgment and doesn't let patients know that something's not on the table or that there's some implicit assumptions already being made.
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Cancer Treatment & Sexual Health: Counseling is Key
For patients undergoing cancer treatment, conversations around sexual health aren’t just important—they’re essential. Treatments like radical cystectomy, chemotherapy, and pelvic radiation can significantly impair sexual function in women, leading to decreased vaginal lubrication, pain with intimacy, and changes in the self-image of a patient. Yet these issues often go undiscussed in preoperative planning and survivorship care. When addressed proactively, sexual health counseling can help patients feel empowered, reduce post-treatment regret, and create a more transparent framework for recovery. It is also essential for the patient and the provider to be on the same page in terms of managing expectations post-treatment.
In many cases, the cancer itself—not just the treatment—can negatively impact sexual function. Tumors affecting the bladder, pelvic nerves, or reproductive organs may cause pain, pressure, or anatomical disruption that interferes with intimacy. For some patients, sexual changes begin before diagnosis, adding another layer of complexity to their emotional and physical recovery. Acknowledging this reality early can help clinicians provide more comprehensive support, both pre- and postoperatively. Dr. Psutka encourages clinicians to think beyond anatomy. She describes sexuality as multidimensional—impacted not only by nerve preservation or hormone levels, but by body image, relationship dynamics, and fear. In her experience, even patients who are medically “cured” of their cancer may carry significant emotional trauma related to sexual function. That’s why she believes the surgeon's role doesn’t end with tumor resection, for example. It includes laying the groundwork for long-term quality of life, including intimacy and identity.
For many patients, simply knowing that sexual function is a valid concern—and one their physician takes seriously—can be deeply validating. Dr. Rubin adds that these conversations don’t require deep expertise in sexual medicine to be effective. The important piece is ensuring that patients feel that they are in a “safe space” when discussing matters of sexual health. With the right framing, urologists can offer reassurance, guide expectations, and help connect patients to additional resources, even if they’re not the ones providing direct treatment.
[Dr. Aditya Bagrodia]
...I tell all my patients this, particularly for prostate cancer, that today, you're going to be interested in not dying of prostate cancer. In six months, you're going to wish that you had excellent erectile function and were ejaculating and things along those lines. This can be a dynamic process. For sure, I think for any patient dealing with a cancer diagnosis, that resonates.
..I really liked {the question}, “tell me about your sexual function”. That leaves it as existent, non-existent as first major paths, fork in the road. Then if it's existent, I think you talked about a couple of things between yourselves. Receptive intercourse. Is it painful? What's the frequency? Is it important to you?
[Dr. Sara Psutka]
What I usually do is I always ask patients about who they live with at home, who their partners are, and then I ask about their sexual function. I make the assumption. I just say, tell me about your sexual function. That opens the door for them to talk about it being either great or not great, important to them or not important to them, but it just opens the door and lets them know that I'm thinking about that, because it certainly matters for our kidney cancer patients, especially folks who are going to be going on systemic therapy or people who are going to have abdominal surgery. They want to know when they can get back to being with their partner in an intimate fashion. I just think, open the door, yes?
[Dr. Sara Psutka]
Especially for patients who don't have partners at the time of, that's actually a really important key point because it's easier to have the conversation, you have the decision tree that you go down. I do always ask patients, do you have a partner? Then I still ask them how their sexual function is irrespective of that, because they could very well have opportunities or it just is an important thing that they preserve the potential. I think it's really important, especially. We're here to talk about female sexual function after bladder cancer care. It's super important to understand the role of menopause and how women are feeling about their sexual function and their pelvic health, and try to get a sense for where they're at with that.
Female Sexual Health as a Standard Across All Specialties
Despite the well-documented impact of sex (and therefore, sexual dysfunction) on quality of life, most physicians receive little to no training in how to assess or address it—particularly for female patients. While sexual health is foundational to wellbeing, it’s often treated as peripheral, optional, or “someone else’s job.” Many urologists and oncologists, and even primary care physicians assume that addressing vaginal dryness or arousal concerns falls under the purview of gynecology or sexual medicine, when in reality, these issues emerge directly within the scope of their own cancer care.
Dr. Rubin argues that empowering urologists to prescribe vaginal estrogen or DHEA, offer guidance on hormone therapies, and initiate conversations about arousal and orgasm is not only appropriate, but it’s necessary. “You prescribe hormone therapy for prostate cancer all the time,” she points out. “You can prescribe vaginal estrogen.” These aren’t fringe interventions; they’re basic, evidence-based tools that dramatically affect recovery, body image, and patient satisfaction.
Change requires structure. At present, there are no formal sexual medicine fellowships in urology or gynecology, and few medical education programs offer comprehensive training in these topics. As a result, providers are often left to refer their patients to sex therapists, seek out information independently, or avoid the subject altogether. Dr. Rubin and Dr. Psutka both advocate for a culture within medicine that treats female sexual health with the same clinical curiosity, urgency, and confidence already applied to male patients.
[Dr. Aditya Bagrodia]
I think as the sexual medicine field gains traction, as there's guidelines, as there's increased awareness, I personally have very little problem. If I just get a hint that there's something to be done, because pelvic health, sexual health, libido, hypo orgasmia, it's complicated, it's intricate, it's related to say, hey, I've got an awesome partner over here that can really help you sort out your sexual health, your pelvic health. Is that fair, just engage other people early?
[Dr. Rachel Rubin]
How many oncology fellowships are there? How many urologic oncologists are we training? There is one fellowship in the entire country that even acknowledges women's sexual health {as a specialty}. Just one, right? There was not even a fellow last year.
There are so few of us, nor are we able to keep up with the demands of the way medicine is currently running because we can't do sexual medicine in 10 minutes, right? I can't get to know you. What do you care about? What are your goals? What do you want sex to look like? What's the dynamics here in 10 minutes? Until we invest in quality of life medicine and what it means for women, because I think the system is very focused and very more efficient on the male side of things. Yet we are taught to think, ooh, women are whiny. They have feelings. I don't want to ask about this because it opens up Pandora's box. It's more of a limitation of what we are taught, instead of saying, oh, well, we actually have to take a little bit different of an approach here.
[Dr. Sara Psutka]
To that point though, one resource I rely on a lot are actually either sexual health nurses or sex therapists that we have relationships with, because we don't have the same thing. I wish our multidisciplinary team had a sexual medicine specialist on it, because that's really what we need, right? As bladder cancer specialists, that would be amazing. Just like you have a pelvic floor physical therapist, you can help your patients to learn to use their neobladders and to really facilitate their recovery after prostate cancer surgery. It'd be great to have a formally trained sexual medicine specialist on our multidisciplinary cancer teams. That's critical.
Oncofertility and sexual health in oncology, that's a really important part of the cancer center healthcare practice. We definitely don't have the same thing. We just need more people. There are people I have in the community who I do refer people to. Then like we were just talking about, I've definitely made myself get super comfortable with prescribing things like vaginal estrogen, which I never used to do. Now I do every day.
Podcast Contributors
Dr. Rachel Rubin
Dr. Rachel Rubin is a urologist and sexual medicine specialist in North Bethesda, Maryland.
Dr. Sara Psutka
Dr. Sara Psutka is an associate professor and urologic oncologist at UW in Seattle, Washington.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 29). Ep. 139 – Gynecologic-Sparing Cystectomy & More: Prioritizing Female Sexual Health [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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