Sex After Prostate Surgery
What every couple needs to know

By Irwin Goldstein, MD

Over 230,000 men are diagnosed with prostate cancer each year, according The National Prostate Cancer Coalition.

Thanks to the effective screening, the vast majority will be cured. But the aftermath of this condition can be devastating: following a radical prostatectomy, four out of five men will have difficulty with erection or ejaculation, or complain of pain during sex.

Eighty-five percent of these patients, some as young as 30 or 40, have some form of impotence, according to a nationwide study by Leslie Schover in the December 2002 issue of the journal, Cancer.1

The good news is that we have a variety of ways to help these men regain a satisfying sex life.

Prostate cancer is generally slow growing and without any treatment, life expectancy is fifteen to twenty years. So I tell my patients, "We have time to consider the best approach for you."

The long-term survival rates are better for surgery than for radiation, so most men in their 40s to early 60s, are likely to choose a radical prostatectomy.2, 3

The most skilled surgeons can claim the lowest rates of incontinence. But no one can guarantee full sexual function. The nerves which run from the prostate to the penis are likely be affected, even with the latest robotic techniques which allow the surgeon to see more of the nerve network while operating. So-called "nerve sparing" approaches, however, only allow us to minimize the damage to this fragile area.4

The bottom line is this: While younger men (40 and under) have higher rates of potency post-operatively,5 all patients should be prepared for at least some change in their sexual response.

Treatment Options
A man can still have an orgasm even if he fails to ejaculate, so post-surgical treatments for sexual dysfunction focus on the initiation and maintenance of an erection.

After prostatectomy, first-line management of Erectile Dysfunction (ED) consists of a class of oral drugs called PDE-5 Inhibitors (phosphodiesterase-5 inhibitors). These drugs (Viagra, Levitra and Cialis) are designed to increase blood flow to the penis after sexual stimulation. These drugs require intact nerves to the penile erection chambers to achieve maximal blood flow increases. Studies show that oral PDE 5 inhibitors are only effective for post-radical prostatectomy patients approximately 20 percent of the time.1 The reason is that some degree of nerve damage to the penile erection chambers is likely after the majority of radical surgeries.

In one study after nerve sparing radical prostatectomy, patients were able to achieve a moderate-severe erectile dysfunction quality consistent with a baseline reading of 8 points out of 30, with 30 representing full sexual function. With the aid of a PDE 5 inhibitor, their score increased to 15 points out of 30, consistent with an improved but still a moderate erectile dysfunction quality. For comparison purposes, in separate study of men whose erectile dysfunction was unrelated to prostatectomy, baseline erectile dysfunction was 15 points out of 30 (moderate ED). After taking a PDE 5 inhibitor, their scores increased to 22 out of 30 consistent with minimal erectile dysfunction.6 The take home point is this: After prostatectomy, a man starts much lower on the potency scale and the PDE 5 inhibitor does not increase the function as much compared to having erectile dysfunction unrelated to prostate cancer surgery.

Many urologists and family doctors prescribe PDE 5 inhibitors with the expectation that these pills will manage the problem effectively - when they don't, many patients become discouraged.

Yet this is not the end of the story. It's simply time to move to our second-line treatment -- one which has proven more effective in patients after prostate cancer surgery. Penile self-injections have success rate of 50 - 70 percent. Compared to PDE 5 inhibitors which are taken orally, self-injections bring chemicals that cause penile blood flow directly to the penis.

Some men worry this approach will take the spontaneity out of sex, so we teach wives or partners how to give these injections and recommend that the couple consider them a part of foreplay.

A woman is still responsible for her partner's erection. When she says, "Honey, it's now time for your needle," she cues her mate that she's interested in having sex. The injection replicates the biological process of arousal. (Men who are single or dating may prefer to self-inject 10-15 minutes before they are ready to be intimate.)

The three vasodilator drugs used for self-injection therapy include papaverine, phentolamine and prostaglandin E 1. In men with ED following radical prostatectomy, the specific drug prostaglandin E-1 can produce pain in the penis. Since PGE 1 associated penile pain may also occur in men with ED secondary to diabetes and alcoholism, the explanation most commonly provided for PGE 1 pain is nerve damage. If pain occurs, the physician should lower the dose of PGE 1 and/or mix PGE 1 with papaverine and phentolamine. Usually some combination of vasoactive agents will yield an erection of sufficient rigidity without penile pain or discomfort.

Another second-line option is the vacuum pump, less popular because it is cumbersome, but which has a success rate of about 70 percent.7, 8

The pump is a hand or battery-operated device that increases blood flow to the penis. An elastic ring at the base of the penis keeps it fairly hard, but produces a somewhat floppy erection. There is no erection on the other side of the ring (the inside opart of the penis which extents to the pelvic bone near the anus and sit bones.

The pump is often chosen by older men who have been married for the same woman for a long time and who are extremely comfortable with their partners.

Our final option is the implant. We consider this the last line of treatment because it is the most invasive, but it's also the most effective, with about a 90 per cent success rate.

An implant can restore size and bulk, give the man the most control of his sexual response, put spontaneity back into his sex life, and provide the most natural-looking erection.

About 20,000 men have implants each year, according to the Erectile Dysfunction Institute. Nearly 600,000 men have had this surgery since implants were first invented in the 1970s.

There are now three types to choose from: three-piece inflatable implants (chosen by 75 per cent of ED patients), two-piece inflatable implants (chosen by 15 percent) and semi- rigid malleable rods that can be positioned by the man or his partner (chosen by 10 percent).

Costs range from $15,000 to $35,000 though most health plans, including Medicare will cover the procedure according to The Erectile Dysfunction Institute. The surgery generally takes an hour or less, and recovery takes three weeks to a month.

Here's how the three-piece implant works: Inflatable cylinders are placed inside the penis, a pump is positioned in the scrotum, a reservoir of saline solution is implanted deep in the patient's abdomen. A man gently squeezes the concealed pump in his scrotum. The saline solution then flows into the cylinder and the penis becomes erect and firm. When deflated, the penis appears soft and natural.

With the two-piece system, the reservoir is not a separate component but is included into the pump or is included into the back of the cylinders . The pump is inflated by repeated pumping to the scrotum, which fills the cylinder in the penis with fluid. Erections are less rigid wit the two-piece implant, since there is less fluid transferred to the cylinders.

The malleable implant consists of two bendable rods that can be positioned according to the patient's needs. (The disadvantage is that the penis remains fairly rigid, even in the "down" position.")

There are no major complications with the implants. The chance of getting an infection is low - about as much as getting one from a hip implant: around 1 to 2 per cent. While implants have no effect on sensation or on a man's ability to have an orgasm, they can have a big impact on his performance, his overall enjoyment of sex and his self-esteem. I tell patients who have this operation, "From now, it's about relaxing and learning to have fun."

The Importance of Counseling
After prostatectomy, a man shouldn't have to just forget about being intimate with his partner. Men with younger partners are the most likely to seek treatment for sexual dysfunction, though there's no reason for an older couple to give up a satisfying sex life.

The problem is not every urologist is qualified to deal with these issues. Only 5 to 10 percent have any training to deal with male sexual dysfunction. So it's important to find a physician with a background in sexual medicine. That said, a man has also to feel distressed about the loss of sexual function, before he considers any of the options presented in this article.

Many men in long-term marriages discuss this with their wives then decide that it's okay to simply let their sex lives wind down. Post-menopausal women often report a diminished a level of desire, and so they may be unconcerned about changes in their husband's sexual performance.9

Other men come to me and say, "I'd like to get the implant, but how to I convince my wife to be interested and give me her support?" This is a decision hat has to be made by the couple, and counseling can help them to address their needs. To find a qualified clinician, I recommend contacting the American Association of Sex educators, Counselors and Therapists (www.AASECT.org).

More information about sexual potency after prostate treatment can be found on the following sites:
The National Institutes of Health
Irwin Goldstein MD


REFERENCES

1. Schover, L.R., et al., The use of treatments for erectile dysfunction among survivors of prostate carcinoma. Cancer, 2002. 95(11): p. 2397-407.
2. Yan, Y., et al., Primary treatment choices for men with clinically localized prostate carcinoma detected by screening. Cancer, 2000. 88(5): p. 1122-30.
3. Moul, J.W., Radical prostatectomy versus radiation therapy for clinically localized prostate carcinoma: the butcher and the baker selling their wares. Cancer, 2002. 95(2): p. 211-4.
4. Van der Aa, F., et al., Potency after unilateral nerve sparing surgery: a report on functional and oncological results of unilateral nerve sparing surgery. Prostate Cancer Prostatic Dis, 2003. 6(1): p. 61-5.
5. Stanford, J.L., et al., Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA, 2000. 283(3): p. 354-60.
6. Keating, G.M. and L.J. Scott, Vardenafil: a review of its use in erectile dysfunction. Drugs, 2003. 63(23): p. 2673-703.
7. Marmar, J.L., T.J. DeBenedictis, and D.E. Praiss, Penile plethysmography on impotent men using vacuum constrictor devices. Urology, 1988. 32(3): p. 198-203.
8. Sidi, A.A. and J.H. Lewis, Clinical trial of a simplified vacuum erection device for impotence treatment. Urology, 1992. 39(6): p. 526-8.
9. Avis, N.E., et al., Is there an association between menopause status and sexual functioning? Menopause, 2000. 7(5): p. 297-309.

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Irwin Goldstein, M.D.
Director, Institute for Sexual Medicine
Editor-in-Chief, The Journal of Sexual Medicine
mobile: 617 543-8928
New e-mail: irwingoldstein@comcast.net
URL: http://jsm.issm.info

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