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OBJECTIVE: To determine the effect of treatment choice radical prostatectomy (RP) with or without nerve sparing or pelvic irradiation (XRT) on sexual function and sexual bother after controlling for sociodemographic and clinical factors. METHODS: We studied 131 men (mean age 64 ± 6.7 yrs) from the CaPSURE™ database, a longitudinal prostate cancer registry. Patients had undergone either RP or XRT and had a minimum of one year of follow-up with health-related quality of life (HRQOL) information. Covariates and sexual bother are measured with the UCLA Prostate Cancer Index on 0–100 scales (higher scores representing better outcomes), then regressed against selected independent variables. RESULTS: Multivariable regression analysis showed that sexual function scores were significantly lower in the RP groups than in the XRT group (p < 0.001) three months after treatment. Improvement in sexual function over time was better in those undergoing RP with nerve sparing, compared to non-nerve sparing group showed a trend toward greater improvement in sexual function compared to XRT (p=0.12) Younger age was a significant predictor of sexual function and post-treatment improvement, but disease stage was not. No significant differences were found in sexual bother scores among the three treatments. CONCLUSIONS: Significant differences in sexual function are found between patients undergoing RP versus XRT for prostate cancer. Men undergoing nerve sparing RP showed greater improvements in sexual function than either XRT or non-nerve sparing RP patients. Sexual bother from dysfunction may be explained by non-treatment-related variables.