Penile Rehabilitation after Treatment for Prostate Cancer
Sexual function can change dramatically following treatment for prostate cancer. Many men experience a range of difficulties that can be disturbing and frustrating, and we have observed that a man has a greater chance returning to his pre-treatment function if penile rehabilitation begins soon after surgery. In fact, there appears to be a finite time period following surgery where rehabilitation can prevent long-term erectile dysfunction.
If it is possible to see a specialist before surgery, you can create a rehabilitation plan that will improve your chances of returning to presurgery sexual activity.
See the information below; the more you know the better your recovery will be.
What changes in sexual function may occur after a prostatectomy?
In the short term, all men will have some erectile dysfunction. Long-term, post-surgical erectile dysfunction is estimated to be 20% to 90%. However, the more closely and thoroughly men are followed, the higher the incidence appears to be! Note, that there is not much difference between the erectile function of men undergoing surgery and those undergoing radiation. However, clearly the radiation takes longer to damage erectile function.
In the acute phase (right after the surgery), many men will notice that their penis has shortened (or retracted more) into their body. This is not thought to be from actual shortening of the penis (which does not happen from the surgery!). When your body is under stress, it sends out signals through part of your nervous system called the sympathetic system. This is often called the “fight or flight” response. The sympathetic nervous system is responsible for all of the symptoms you have when you are anxious or angry e.g. sweating, increased heart rate, sweaty palms. In the penis, this causes the smooth muscle in your erection chambers to contract (which is why anxiety is not good for erections). This makes your penis retract. As your body heals, this acute shortening of your penis should improve.
However, you may notice permanent shortening of the penis post surgically that might be quite significant. The penis in its flaccid (unerect) state has very little oxygen. With erections, fresh oxygenated blood is brought into the penis. If you are not getting erections, either with sleeping (nocturnal erections) or with sexual excitement, then you are not getting enough blood and, ultimately, not enough oxygen into the penis. This results in fibrosis of the penis, loss of flexibility, and ultimately shortening of the penis. This fibrosis may be very difficult or impossible to reverse. Thus, it is important to try to avoid fibrosis by initiating regular erections as soon as possible after surgery.
For reasons that are not understood, up to 10% of men will develop scar tissue of the penile sheath after prostatectomy. This may lead to penile curvature when erect, penile pain and worsening erectile dysfunction. This seems to occur more frequently in younger men. Learn more about Peyronie’s disease and its treatment.
The prostate and the seminal vesicles, which produce much of the semen, will be removed at the time of the surgery. The vas deferens (the tubes that carry the sperm) will be interrupted (just like in a vasectomy). Thus, much of the production of the semen is stopped and the delivery of the rest of it is blocked.
This does not mean that you cannot have an orgasm, but you will not ejaculate. This often takes getting used to, but is, in and of itself, not a problem.
However, you may find that when you are sexually excited, sticky fluid continues to come out of the tip of the penis as it did before your surgery. This is the pre-ejaculate (or in popular vernacular "pre-cumm"). It is produced by the glands that line the urethra when a man in sexually excited. There are not sperm in the pre-ejaculate after a prostatectomy, and thus it could not initiate a conception in your partner.
Of course, this means that you cannot achieve a conception with a partner through intercourse. If you think there is a chance you will want children in the future, it is worthwhile to bank your sperm prior to the surgery. Your body collects the sperm in ducts, and thus there are usually more than 60 million sperm in an ejaculation. These sperm, if of adequate number and quality, could be used to put into a partner’s uterus, a process called intrauterine inseminations (IUI), to attempt a conception. If you do not bank sperm preoperatively, but decide later you would like a child, you are still usually making sperm. This is because even if your sperm ducts are blocked, you continue to make sperm, but cannot get them out through ejaculation. Sperm can be harvested (from the testis or its collecting ducts); however, because the body is not concentrating them naturally, only a few are retrieved. They will only be usable in a process called IVF/ICSI. This involves taking the eggs out of a woman’s body and then injecting a single moving sperm into each egg. This is, of course, more expensive and invasive than using sperm that had been frozen prior to your surgery.
After surgery, it may be more difficult to achieve an orgasm, or you may have diminished intensity of your orgasms. It is also not uncommon to have pain with orgasm. This is typically felt in the tip of the penis. With time and treatment, this will usually improve, as will the intensity of your orgasms.
Most men will have some urinary leakage with orgasm after their prostatectomy. However, most of the time, this will resolve during the first year. For about 20% of men, this will continue. However, this can be managed. The easiest thing is to use a condom. If this is not successful, then a specialized tourniquet can be placed around the penis. Medications also can be tried, to stop the urinary leakage.
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Mechanism of ED after Prostatectomy:
Nerve sparing radical prostatectomy is the current standard of care. However, due to certain characteristics of the cancer, either known before the surgery, or discovered at the time of surgery, this is not always possible. The ultimate goal of surgery is to make sure that all of the cancer is removed. If the cancer involves the nerves, then they cannot be spared. These nerves are the ones that innervate the penis, and they must be intact for you to get erections on your own. If these nerves need to be taken, or are taken by mistake, this does not mean that you will not be able to get erections with treatment, but you will not be able to get them on your own. Even in a nerve-sparing prostatectomy, the nerves may be stretched, damaged, or traumatized. Thus, they may be temporarily or permanently injured, even if spared.
Also, studies show that the nerves are not arranged in neat little bundles, but surround the prostate. Because of this, a very careful technique must be used in order to spare as many of them as possible.
A good blood supply is also necessary to get a good erection. In general, the blood supply to the penis is spared during a typical prostatectomy. However, many men have unusual blood vessels (called accessory pudendal arteries). These may supply much or even most of the blood flow to the penis. If these are interrupted by the surgery, there may be inadequate blood flow.
In order to get an erection, you have to get the blood into your penis and hold onto it. (The analogy I use for my patients is a bathtub. You have to turn on the water and put in the stopper in order to fill the tub.) If the penis does not get regular oxygenation (by getting erections) the tissue that traps the blood does not get enough oxygen over time and is damaged. This causes it to become less pliable and it cannot store the blood. Thus, even if an adequate amount of blood gets into the penis, it cannot be stored adequately, and a man will not be able to get and/or maintain a rigid erection.
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What Factors Affect Penile Rehabilitation after a Prostatectomy?
Sexual function before the surgery is a very important factor. Most men, who are having a prostatectomy, are not having erections of the quality and duration that they had when they were younger. Many are already encountering erectile dysfunction, which may or may not have responded to oral medications. Since a prostatectomy necessarily diminishes the quality of the erections a man will have after the surgery, the starting point is a very important prognostic factor.
The surgical technique is one of the most important factors. If the nerves are not spared, it is impossible to regain spontaneous erections (though remember, there are always ways to treat EVERY man with erectile dysfunction).
Studies consistently show that when all of the differences between patient risk factors are taken into account, the most important factor is the skill of the individual surgeon. As a surgeon (since I specialize only in sexual dysfunction and male infertility, I have not done a prostatectomy since my training), I can tell you that you should pick the surgeon, not the technique.
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Treatment: A Comprehensive Penile Rehabilitation Program
A commitment to penile rehabilitation is one of the most important factors in determining the quality of erections a man will have after healing from the surgery. A recent study of men who committed to a program of penile rehabilitation showed that 52% of them recovered unassisted functional erections (i.e. they could get and maintain an erection strong enough for penetration without medication.) This compared to a recovery of 19% in the group who did not participate in rehabilitation. In this same study, 64% (versus 24%) responded adequately to Viagra, and 95% (versus 76%) responded to injections.
In an ideal world, treatment of your potential erectile dysfunction would begin before your treatment for prostate cancer. This treatment is now often performed (and in my mind ideally so) by a urologist specializing in erectile dysfunction. Oncologic urologists (those specializing in urologic cancers like prostate cancer) will often not have the same level of expertise with erectile dysfunction as they have with cancer.
The treatment would include a thorough assessment of your current sexual function with you and your partner, if you have one. Studies have shown conclusively that the involvement of your partner (if you have one) is beneficial in making this process as smooth and successful as possible. Partner’s motivation and interest are often driving factors in the rehabilitation.
Studies have conclusively shown that the sooner a patient starts treatment after the surgery, the faster the recovery, and the better the final results will ultimately be. The incidence of post surgical venous leakage (as described above) increases as the amount of time without treatment increases—30% at 8 months and 50% at 12 months.
With a specialist, usually a comprehensive treatment program is mapped out. Ideally the specialist would have the expertise, time and interest in maximizing your recovery.
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What are the Different Parts of the Penile Rehabilitation Program?
This would include preoperative use of a PDE5 inhibitor (i.e. Viagra, Levitra, or Cialis) which is thought to protect the lining of the blood vessels. There are also studies that show that these medicines can actually increase the amount of smooth (involuntary) muscle in the penis. This muscle is responsible for trapping the blood during an erection.
There are three PDE5 inhibitors available at this point (though several more are being developed). I usually have patients use Cialis because it is the longest acting of them. Thus, there are constantly reasonable blood levels of the medicine in your blood stream, which is preferable for a protective medication. Cialis is approved for daily use, and is usually available through a pharmacy plan in the 5mg daily dose. However, depending on your medical condition, and the availability of the medication to you, 10mg per day can also be used.
Ideally, the Cialis is continued throughout the post-operative period. You will have to ask your surgeon when, or if, he wants you to stop it preoperatively, and when you can restart it postoperatively.
If rigid erections, adequate for penetration, using a PDE5 inhibitor alone, are not achieved, more aggressive treatment is then started one month after surgery.
You will be encouraged to use a modality that gives you good erections, adequate for penetration, while your penis is recovering. These may include vacuum-erection devices, penile-extension devices, intraurethral alprostadil, or penile injections.
One of the options available for the treatment of erectile dysfunction is the self-injection of medication into the penis. This often sounds scary to the patient and not particularly appealing. However, in reality, the technique does not involve a traditional syringe and does not hurt. Often, once a patient understands the reality of his treatment, he is willing to consider this highly popular and effective treatment technique.
The medication is delivered to the penis using a device that is similar to the ones used by diabetics. The use of this device is one of the most important ways to make this technique palatable to men. I am often referred patients who have been appropriately told to use injections post surgically, but who are unable to do it because they are too intimated by the prospect of putting a needle in to their own penis! A disposable syringe is placed on the injector, the device is placed against the side of the penis, and a button is pressed. A spring then pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis.
Men normally agree that the "injection" does not hurt. Most patients describe it as either painless or as if they have been flicked with a rubber band. The injection does not hurt for the following reasons. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). Additionally, since the side of the penis does not include many pain receptors, there is little sensation for pain as opposed to pleasure there.
The three most common medications used for injections are papaverine, phentolamine, and prostaglandin E1. All three act by relaxing the smooth muscles and causing the arteries to dilate. This brings more blood into the penis. This also activates the trapping mechanism, making sure the blood stays in the penis, yielding an erection. Prostaglandin E1 received FDA approval in 1996 for erectile dysfunction treatment. It is currently marketed and available in prescription plans under two brand names, Caverject Impulse and Edex.
The different medications have different characteristics.
Papaverine and phentolamine come in a liquid, do not need to be refrigerated, and have the least discomfort associated with them.
Prostaglandin E1 by prescription is a powder that is mixed with a fluid prior to use (this is due to the fact that it is stable as a powder at room temperature, but not as a liquid). It can also be premixed or added together to papaverine and phentolamine. Prostaglandin E1 can cause some men to have aching in their penis. Although it is not damaging in any way, it can be uncomfortable. However, in most cases, the discomfort is short-lived. Discomfort is experienced by approximately 20% of patients and is most common in patients who have neurological erectile dysfunction such as diabetes or post-radical prostatectomy.
The two main potential complications from the injections are the development of scar tissue and the possibility of a prolonged erection (priapism). This risk is significantly minimized when you are seeing a physician who is very experienced with this treatment option and the appropriate dosing levels. Also, the risk of scarring is greatly reduced if the penis is compressed for five minutes after the injection and the site of the injection is varied.
Penile injections were developed approximately 30 years ago and were the second method developed for the treatment of erectile dysfunction. The first treatment method was surgical and involved the insertion of a penile implant.
Experience suggests that many men are successfully treated post surgically with injectable medication. Their erections are often much stronger and more reliable than those from oral medications. In some ways, the injection is a more spontaneous solution for treating impotence since it can be used right before a sexual encounter. With foreplay and the medication, the individual gets a good, strong erection. The original study on this modality showed that two-thirds of men who used the injections on average twice a week recovered erectile function to the point where they could have intercourse without any outside help.
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Conclusion:
Only at 24-months post surgery will you know where you are going to end up, so it is crucial to stay motivated and on schedule.
Remember though, that not only are you rehabilitating your penis, but you are making sure that you have a satisfying sex life while waiting for things to improve.
Ideally, you would seek help from an expert even before your surgery, to maximize the speed of your recovery and to maximize your chances of ending up with the best erections possible after you have completely healed.
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