Restoring Erectile Function After Prostatectomy

In today′s world, the overall mortality for almost every cancer is falling. In many cases, the incidence of various cancers is also declining.

However, for prostate cancer, the incidence has been steadily rising since the advent of the Prostate Specific Antigen (PSA) test. 1

Considering that the American Cancer Society lists the 10 year survival rate for prostate cancer at 98 percent, this poses a problem. Is the 10 year survival rate due to excellent early detection and treatment, or was treatment not needed?

For many years, the medical paradigm for all cancer, including prostate cancer, has been to find and treat it early to effect a cure. It is well-known that prostate cancer can be very slow-growing and that some prostate cancer is of an indolent type that may never rise to a level of a significant problem.

Early detection and treatment of indolent prostate cancer that will likely never become life-altering are often more damaging than allowing natural disease progression. This is especially true regarding a man′s quality of life.

In autopsy studies of men that died from causes other than prostate cancer, many were found to have long-term, undetected cancer in their prostates. This overdiagnosis and overtreatment can cause more harm to a man than living with the disease.

This is not to say that some prostate cancer does not need treatment. Obviously, a large, aggressive tumor that has grown outside the prostatic capsule or metabolized to a distant area is cause for serious concern and potential treatment.

Treating Prostate Cancer

The most common treatment for prostate cancer is a radical prostatectomy. 2 In this surgery, the man′s entire prostate gland and some surrounding structures are surgically removed.

Men that are subject to this procedure should be made aware – before the procedure – that it can have a significant negative effect on post-surgical sexual function. Sex after prostatectomy will be different.

Unfortunately, this is not always the case. Many urologists tend to minimize sexual and other side effects, leaving the patient to believe they are truly minor occurrences.

The most common effect after the surgery is complete erectile dysfunction (ED). This occurs immediately after surgery in a high percentage of patients. Rates from 15 to 100 percent are typically reported in the literature. Subsequently, over a period of months, some men recover spontaneous erections, but most do not.

This wide span in outcome is associated with the skill of the surgeon at the conservation of neurovascular structures in and around the prostate, as well as the degree of involvement of cancer in these structures.

Unfortunately, many urologists minimize or do not fully discuss the side effects of the surgery. This often leaves a significant number of patients with unrealistic or optimistic expectations of sexual function after surgery. The second most common side effect of the operation is incontinence. In most cases, though, this is resolved in a month or two.

Understanding the Problem

The vast majority of men that are subject to a radical prostatectomy are over 60.

Many are already suffering from ED before their surgery. There are many common causes of ED, including disease, aging, vascular problems, and medications. People with diabetes are more likely to have ED because of poor blood flow and nerve function.

Recovery of erectile function in men following radical prostatectomy may only be possible if erectile function was viable before surgery. If a man has severe ED before or at the onset of surgery, there is little hope for him to recover spontaneous erectile function afterward without correcting the underlying cause.

If a man has viable erectile function before surgery, some surgeons attempt to preserve erectile nerves during radical prostatectomy. A man that values his sexual function should have a detailed discussion of nerve-sparing surgery prior to agreeing to the procedure.

The erectile nerves are almost always either traumatized or damaged to some degree during surgery. But, if the goal is to preserve them, it must be addressed up-front. In most cases, temporary nerve paralysis occurs in all surgery and results in almost 100 percent erectile dysfunction for all patients immediately after surgery.

However, for some, erectile function may recover spontaneously a few months after surgery, especially it the performing surgeon uses introduces post-surgical rehabilitation techniques.

During a nerve-sparing operation, the goal is to remove the prostate and cancer without totally destroying the erectile nerves. These surgeons are usually well-aware of the debilitating nature of ED on most men. They are usually well-versed in methods for recovering erectile function after surgery. 3

Surgically Induced Erectile Dysfunction

Unfortunately, many men have unrealistic expectations for sexual recovery after surgery. In many cases, treatment for prostate cancer, especially with radical prostatectomy, has permanent side effects.

Long-term and potentially permanent sexual dysfunction is a common consequence of radical prostatectomy. This can be a massive issue for both a man and his partner.

Even when a man′s doctor is quite candid concerning reduced or non-existent sexual function, many men still expect improvements in sexual functioning one or more years after surgery. 4

It is a given that a man might be capable of recovering usable erections after surgery. However, it is also a given that sexual sensations after a prostatectomy will never be the same as they were before surgery.

In most cases, sensation after surgery is significantly altered. Therefore, if a patient′s expectation for success means recovery to the physical action and sensations prior to surgery, he is destined to be, at the very least, disappointed.

Loss of erectile function often causes a devastating blow to a man used to having sexual performance. Due to a lack of communication with his doctor, he may also be rather surprised about how total the loss is. This loss may also be perceived quite strongly by his partner.

Quite often, a man′s partner can foster psychological feelings of rejection due to misunderstanding of the nature of erectile dysfunction due to surgery. Thus, it is important to explain the side effects of the surgery to the partner as well as the patient.

Since complete surgical erectile dysfunction is a very real possibility, any man considering a radical prostatectomy, must, if he values his sex life, also consider other options very seriously.

Some men have little regard for their sexual functioning, and for such a man, a radical prostatectomy is one of the more efficient ways to resolve prostate cancer.

Recuperation After Surgery

Most doctors will begin procedures to recover erectile function almost immediately after surgery if a patient is clear that he desires such rehabilitation.

Progressive doctors might ask the patient to see a nutritionist or naturopath to improve diet and lifestyle. Nutritional deficiencies, especially if severe, can contribute directly to ED. However, it may take a few months for improved nutrition to have any effect, and the patient might have to learn to get serious about dietary and lifestyle changes.

The usual path for initial rehabilitation of erectile function is the use of ED drugs, such as Viagra, Sildenafil, Cialis, or Levitra. These drugs are not risk-free, but Cialis appears to have a profile that is least likely to cause disturbances with other body systems. 5

While erection problems can often be restored or improved, it may take two to three years for viable erectile function to return. If there is no noticeable improvement after several years, it is time to look for other solutions.

Many doctors simply use ED drugs (like Viagra) and evaluate periodically to see if there is any progress. However, rehabilitation takes time and effort and requires more than just waiting for it to happen.

An erection involves a combination of nerves and blood vessels, as well as appropriate chemical signaling. The penis is structurally composed of muscle and blood vessels. An erection is caused by nerves signaling muscles to contract and blood filling the erectile chambers.

Thus, both the muscles and vessels need to be healthy and viable. If you do not exercise these parts, they atrophy and do not function properly. The old adage “use it or lose it” is quite relevant.

Aware doctors have their patients start an exercise and rehabilitation routine almost immediately after surgery. In a healthy male, the body has a natural mechanism to avoid atrophy. This is the nocturnal or early morning erection. It produces one or more spontaneous, non-sexual erections during sleep or early morning awakening.

This mechanism circulates blood throughout the organ, nourishing it, and preventing atrophy. It often deteriorates with age and a decline in overall health and is almost always completely absent after surgery.

Exercising the penis immediately after surgery is called penile rehabilitation. A vacuum erection device (a.k.a. penis pump) is a simple device that applies vacuum to the penis causing it to fill with blood to produce an erection.

Using such a device regularly can simulate a nocturnal erection, helping to maintain penile tissue and structure. By providing blood flow and oxygen to the penile tissue, it can help prevent atrophy and permanent damage. It is an inexpensive, easily obtainable device.

To be effective, such a device must be used regularly. It also has added value in that, when used with an appropriate retaining ring, it can help a man with total erectile inability produce and maintain an erection of sufficient hardness and duration for vaginal penetration and intercourse. The devices typically come with all parts needed for both penile rehabilitation and sexual intercourse.

Men with no viable erectile function after prostate surgery often welcome the sexual ability they can obtain through the use of a vacuum erection device or other devices, or even a combination of several techniques while attempting the long process of rehabilitation.

Beyond Drugs and Rehabilitation

Sometimes, even with all the best efforts by the doctor and his patient, there is no improvement in erectile function over several years, and a man may decide it is time to review other methods.

• Prostaglandin (PGE-1): One of these can be direct penile injections. While most men initially balk at the thought of injecting a needle into their penis, once the psychological hurdle is overcome, it is a viable method that many men use successfully for years.
  
  Prostaglandin (PGE-1) is a hormone-like substance that has a strong effect on the penis. It relaxes the penile vascular smooth muscle in and around the corpus cavernous (erectile chambers) of the penis.
  
  This causes penile arteries to dilate and is instrumental in producing a natural erection. When injected, with or without other chemicals, directly into the penis, it will cause an erection, regardless of the man′s sexual arousal state.
  
  

• Vasodilator drugs: Other vasodilator drugs (drugs that open blood vessels and increase blood flow) are sometimes mixed with the PGE-1 to help enhance its effect. The resulting solution is called Bimix or Trimix. Either requires a valid prescription from a licensed medical practitioner.
  
  The drugs are injected directly into either side of the penis into the erectile tissue (coporus cavernous) of the penis. An erection is produced within a few minutes and can last for 1-2 hours.
  
  The disadvantage of this technique is that the man must give himself an injection directly into his penis before sex, and apply pressure to the injection site for a few minutes, which is not always conducive to a relaxed atmosphere for sex.
  
  

• Misoprostol: For men that are absolutely opposed to a penile injection, misoprostol (a synthetic PGE-1) can be inserted in liquid form into the urethra. This method requires that the user dissolve the misoprostol tablet in water, place a restrictive band on the head of his penis, and then insert, via an eyedropper or similar device, a measured solution of the chemical into his urethra. The restrictive ban is removed after allowing about 10-15 minutes for the chemical to take effect.
  
  Because the drug does not depend on functional erectile nerves, it can be very useful for men with nerve damage that does not respond to other ED drugs.
  
  

• Injection therapy: is quite effective and has a success rate of close to 90 percent, but the man using it needs to have a fair degree of manual dexterity to succeed with the injection. Some men have found that using low dose injection therapy along with a vacuum erection device can improve both their performance and satisfaction.
  
  

• Penile Implant: The final option for a man who cannot recover erectile function in any manner is called a penile implant. This is a surgical procedure in which the erectile chambers of the penis are replaced with inflatable implants. The implants are filled with saline solution from a reservoir embedded in the groin, producing an erection.
  
  A manually operated pump is located in the scrotum is squeezed to fill the inflatable implants, and when sexual activity is complete, a release button on the reservoir allows them to deflate, returning the penis returns to its pre-erect size and hardness.
  
  This is a major surgery with a recovery time of about 4-6 weeks as well as general risks of infection or complications. Insurance may or may not cover the procedure, but the major downside is that the surgery, of necessity, destroys the existing penile erectile chambers, and thus, cannot be reversed if the outcome is not satisfactory.

Conclusion

Radical prostatectomy in all its forms is the most frequently performed procedure for patients in the U.S. with localized prostate cancer and a life expectancy greater than 10 years. Compared to other treatment options for prostate cancer, it is relatively expensive. It is also major surgery with all its attendant risks.

A 2014 study from the University of Iowa compared costs for radical prostatectomy at 100 hospitals throughout the United States. The price varied wildly with the average price for standard open surgery around $35,000 and robotic surgery $6000 to 10.000 more.

Prostate cancer can be a serious disease. Prostate-Specific Antigen (PSA) was discovered around 1979 and first used to screen for prostate cancer in 1987. Around 1995 the PSA test gained FDA approval as a screening test. Since then, testing of older men has become ubiquitous, and today, prostate cancer is well-known to be subject to overdiagnosis and overtreatment. Any man advised to have a radical prostatectomy would be wise to seek a second or even third opinion, and to evaluate other options.

It is well known that ED is a long-term and often permanent complication of prostate surgery, even when nerve-sparing techniques are applied. A man considering this surgery should research it first to be sure he can live with this likely permanent side effect.

It is far easier to avoid the complication of ED than it is to try and ameliorate it after it occurs.