One of the most dreaded complications of surgery for prostate cancer is impotence. I have had several patients tell me that they will never consider prostatectomy because they refuse to “say goodbye” to their sex lives. Given what they read on the internet and hear from friends, many men feel that in order to treat their prostate cancer, they need to give up on ever having sex again. In truth, while impotence is one of the most common side effects of surgery for prostate cancer, it can be overcome. Men facing impotence after prostatectomy have many options that will help them have a satisfying, albeit different, sex life. The purpose of this post is to shed some light on impotence after prostatectomy and to explain the methods available to overcome it.
Studies have demonstrated that approximately half of men undergoing surgery for prostate cancer suffer from impotence after the surgery. Men with good erections prior to surgery have a higher chance of maintaining them than those men with some level of impotence prior to surgery. Also, older men undergoing prostatectomy appear to have a higher chance of impotence after surgery as well. The reason why impotence is so common after surgery has to do with the nerves that are responsible for creating and maintaining erections. These nerves are located on both sides of the prostate and are basically stuck to it. During surgery, attempts are made to push and tease the nerves off of the prostate to preserve them (nerve sparing). However, these nerves are often damaged in the process. This damage is what leads to postoperative impotence. The situation is even worse for men with aggressive disease that pushes its way outside of the prostate. During surgery for this type of cancer, the surgeon often removes the tissue around the prostate on the side of the cancer to ensure that the prostate cancer is completely removed. In so doing, the surgeon sacrifices the nerves on that side, often removing them completely.
As a result of this nerve injury, most men will have some level of impotence immediately following surgery. While we occasionally see men that have erections a few days after surgery, most will not see any erections for weeks to months. This difference in timing has to do with the extent of damage done to the nerves, the health and vitality of the patient, and the preoperative potency. For some men , the erections never come back naturally. Fortunately, these men have many options from which to choose in tackling erectile dysfunction. I divide these options into Plan A and Plan B:
Plan A
1) Viagra and company: The mainstay of treatment for erectile dysfunction after prostate surgery or otherwise has been a class of drugs called Phosphodiesterase 5 (PDE5) Inhibitors. These drugs, including Viagra, Levitra, and Cialis, work by blocking the breakdown of a compound in the penis responsible for creating an erection. For all intents and purposes, Levitra and Viagra are interchangeable, although I do have patients that swear by one or the other. Cialis is a little different in that it lasts much longer than the other two( half life 18 versus 4 hours). Most men with erection problems after surgery are prescribed one of these medicines after surgery to help with erections. Of course, these medicines are not for everyone. Men with heart disease and particularly those who take heart medicines called Nitrates can have a heart attack or even die by taking the PDE5 Inhibitors. Men with other conditions such as liver disease, low blood pressure, HIV, and many others also need to be very careful when taking these medicines. Still others may not tolerate the side effects of the drugs. Commons side effects reported by patients include rapid heartbeat, flushing of the face, headache, stuffy nose, visual changes, and the erection that wont go away(more on this later). Of course, a careful discussion with a physician should always be carried out prior to taking any of these drugs.
2) Injections: I like to describe injectable therapy for erectile dysfunction as “turbo-charged Viagra”. Rather than taking the medicine by mouth, you inject it directly into the base of the penis. Yes, I did say that YOU actually INSERT a NEEDLE into the side of your PENIS. While I know this sounds very unpleasant and daunting, it is actually quite easy and tolerable. You use a tiny needle like one you may have seen during a TB test. The whole process lasts a few seconds and the erection is usually achieved within 15-30 minutes. From what my patients tell me, the injection does not really hurt very much, especially once they have gotten over the anxiety of doing it for the first time. These injections tend to be more reliable than the pills and work faster. They also seem to work despite factors, like full stomachs and stress, that often decrease the efficacy of the pills. Like the pills, injectable medicines are also contraindicated in some men. For example, men on blood thinning medications like Coumadin may experience bleeding during injections. Also, the medicine can sometimes cause a decrease in blood pressure making it less than optimal for men with existing heart problems and those taking Nitrates mentioned above. Side effects of these injections include pain or tingling in the penis, scar formation at the site of injection (leading to some curvature of the penis), a drop in blood pressure, and the erection that does not go away(more on this later).
3) Vacuum Erection Device(VED): Those of you who watched the Austin Powers movies are probably familiar with the novelty form of this, actually, very useful tool for treating impotence. The device is a cylinder into which the penis is placed. Through a vacuum effect blood is brought into the penis to create an erection. The device is then removed and the erection is maintained through a ring which is placed at the base of the penis. When sexual intercourse is completed, the ring is removed and the erection goes away as the blood is allowed to drain from the penis. The VED is nice in that it works for most men and, so, there are few contraindications. Men that really should not use these devices are those with severe curvature of the penis (Peyronies Disease), those men on significant blood thinners and those with a history of the erection that wont go away(more on this later). Most men are very happy using the pump. The only complaints I get are that it is somewhat cumbersome to use and that it takes away some of the spontaneity of the sexual experience. Other minor complaints include minor pain and coldness at the tip of the penis.
With any of the options of “Plan A”(less so the VED), there is a risk of a condition called priapism, which is the erection that wont go away. I am sure that many if not most of you have seen commercials for Viagra or the other impotence drugs which end with the warning to seek medical attention if the erection does not go away in 4 hours. The reason for this warning is that some men respond to these treatments with a painful erection that just will not go away despite having an orgasm and ejaculating. The reason for this is that the blood gets trapped in the penis and cannot come out. This condition needs to be treated within the first few hours because, following this window, scarring can occur in the penis preventing the ability to have any future erections. Treatment for this condition includes draining the penis of the trapped blood, injecting medicine to counteract the effects of the erection producing drugs and, occasionally, performing surgery to bring down the erection. Men using any treatments for erectile dysfunction need to be aware of priapism and what to do in case they get it.
The 3 options mentioned above provide an excellent “Plan A” for those men that experience erectile dysfunction after prostatectomy for prostate cancer. In my practice, over 90% of men are able to experience erections suitable for intercourse using one of the three options mentioned above. For a small minority of men, however, “Plan A” does not work. Those men require a little more help. This is when we turn to “Plan B”.
Plan B
As mentioned above, some men do not respond to any of the “Plan A” strategies for impotence after prostatectomy. Fortunately, we do have a “Plan B”. While this strategy is certainly more invasive and risky, it is often successful when everything else has failed. “Plan B” involves the surgical implantation of a prosthesis into the penis. There are two types of such prostheses:
1) Semi-Rigid Prosthesis: This prosthesis is literally two plastic rods that are inserted into the parts of the penis that get engorged with blood during an erection. As a result the penis is always hard. One obvious advantage of this type of prosthesis is that it is always working, making sex potentially more spontaneous. In addition, this prosthesis is fool-proof and does not require any particular dexterity or manipulation by the patient as may be needed with injections or the VED. The semi-rigid prosthesis does have some risks. As with any surgery, implantation of the prosthesis has a risk of bleeding, infection, and the risks of anesthesia. More specifically it also carries a risk of damage to the urethra, the tube in the penis which carries urine. Long term, there is a 5% risk of the rods of the prosthesis eroding out of the skin or into the urethra tube and a 5% risk of infection of the prosthesis. Both of these complications require surgical removal of the device.
2) Inflatable Prosthesis: This prosthesis is much more complicated than the semi-rigid prosthesis. The device is actually composed of three interconnected parts. The main part of the device is comprised of two inflatable cylinders that are placed in the same location within the penis as the rods of the semi-rigid prosthesis. These cylinders are connected to a reservoir (containing fluid) that is implanted in the abdomen and a pump that is implanted in the scrotum. At baseline, the cylinders within the penis are deflated and, so, the penis is flaccid. However, when the patient pushes on the pump within the scrotum (which can be manipulated through the skin), fluid from the reservoir is transferred to the cylinders in the penis which inflates them and causes an erection. When the patient wants to deflate the cylinders, he, again, pushes the pump in the scrotum and the fluid is transferred back from the cylinders to the reservoir. The whole process is carried out via hydraulics. The obvious advantage of this prosthesis is that it does not require the patient to walk around with a constant erection. There are some drawbacks, however. First, any man that wants an inflatable prosthesis needs some level of manual dexterity that will allow him to operate the pump in the scrotum. In addition, as with all machines, the device can and does break down, requiring the parts to be removed or replaced through further surgery. The surgical risks are a little more extensive than those associated with a semi-rigid prosthesis because there are more surgical sites and the surgery takes longer. The risk of erosion, however, is smaller because of the lack of the constant pressure on nearby tissue as caused by the rods of a semi-rigid prosthesis.
These prostheses can bring new life into an otherwise dead sex life of a man with impotence after prostate cancer surgery. As mentioned, these devices usually work even when all of the mainstream approaches of “Plan A” fail. So why not resort to these devices in the first place? First, the surgical and device risks mentioned above make many patients wary of trying it. Secondly, although these devices give you an erection, they do not give you a natural feeling erection. Because no blood is flowing through the penis during an erection produced by the devices, the erection feels more artificial. While most men who have either device implanted are happy with the fact that they can have intercourse, they often admit that sex does feel a little different. This is why I encourage my patients to try the options from “Plan A” first, if appropriate.
As should be evident by now, treating prostate cancer does not need to be a death sentence for your sex life. While many men undergoing prostatectomy do experience some level of erectile dysfunction, most, if not all, of them can again be sexually active. Some of the treatments mentioned in this post are certainly more involved than others and all make sex a little less spontaneous and natural. However, with the right attitude and approach, sex can again be possible and enjoyable for men undergoing prostate cancer surgery.
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