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Help for ED after Prostate Surgery: The Basics

What’s the secret to having a good sex life after prostate cancer?  It’s very simple, says Johns Hopkins urologist Trinity Bivalacqua, M.D., Ph.D.  “You use prescription erection pills.  If they don’t work, you move to injectable medications.  If they don’t work, you get a penile prosthesis.  Also, having a loving and understanding partner always helps.”  There’s also the vacuum erection device (VED).   It is not a first-line treatment for ED because there’s a high drop-out rate, Bivalacqua says.  However, the VED can play a very important role in another aspect of surgical recovery: penile rehabilitation (see below).

First, the pills:  “When one of my patients leaves the hospital after a radical prostatectomy, he takes home a prescription for Viagra,” says Bivalacqua.  Does he take it every day, like a vitamin?  No.  Although some doctors prescribe the pills this way, it’s not what physicians call an “evidence-based” practice; that is, the medical literature doesn’t back it up conclusively.   Instead, Bivalacqua tells his patients to take it as needed.  “It is very difficult for me to tell a man that he should spend $600 a month to take a daily erection drug, because the evidence of a quicker return of erections is just not there.”  However, he adds, “taking a pill daily may provide a benefit, and a lot of prostate cancer patients want to take a proactive approach.  If that’s the case, then I encourage them to go ahead.”

Taking a pill like Viagra can boost confidence as well as help with erections, but even so, the first try might be frustrating.  “I tell men that it often takes three or four attempts with Viagra to have a true response that will allow penetrative sex.”  This doesn’t usually occur within the first couple of months after surgery, “but usually men see the most meaningful recovery around 9 to 12 months after surgery,” Bivalacqua notes.  Just to recap here:  Don’t be discouraged if the first time after surgery is not that great.

And don’t give up.

Hear these words:  “The penis works.  The blood supply to the penis is still good.”  So basically, it’s like a car that is having trouble starting.  What you may need is a jump-start to get it going.  That doesn’t mean you will always need this.  Your body is going to continue to recover.  It just means that at least right now, you might need a little help.

Now, here’s a question Bivalacqua asks all of his patients a couple months after surgery, when they are healing and are no longer having any problems with urinary leakage.  (Note: not every man has urine leakage after surgery, but some men do and it is usually temporary.)  “How important is it to you to have penetrative sex?”  If that is very important to the man and his partner, “then I ask how often he has tried Viagra over the last four weeks.”  If the man has tried it multiple times with no success, “I recommend that he start injection therapy immediately.”
Remember, the penis works.  “By injecting a medication will increase the blood flow to that area, the man has a very good chance to restore erections and get that important part of his and his partner’s life back.”

Injection therapy?  You mean, sticking a needle in the penis?  Well, yes.  But it’s a tiny needle, and your doctor won’t just hand it to you and say, “Good luck, buddy.”  You will be taught how to use it.  “Injection therapy allows a man to have sexual intercourse again,” says Bivalacqua.  Very important:  “We know that the more blood flow there is throughout the penis following a nerve-sparing radical prostatectomy, either with a pill like Viagra or with an injection of a pharmacological agent, the better the chances of regaining erections.”

Bivalacqua explains:  “If you don’t have enough blood flow within the penis after surgery, it becomes ischemic; it does not get the nutrients it needs to stay healthy.”

Let’s take a moment to think about rehabilitation – say, after a bad injury.  Maybe a man needs to learn to walk again, or use his hands, or how to talk again.  If that guy just sits around and hopes it will happen and gets frustrated when it doesn’t, you may agree that he’s not taking the approach most likely to guarantee success.  To put it bluntly, your penis needs rehab, too:  “By increasing the flow of oxygenated blood to the penis, whether it is from a pill or an injection, we are able to preserve the erectile bodies (called the corpora cavernosa; these are chambers where blood flows to provide a rigid erection), so they will respond once those nerves start to work again.”

How injection therapy works:  As its name suggests, Tri-mix is actually three drugs (papaverine, phentolamine, and prostaglandin E-1).  “The specific formulation of these drugs is based on the type of erection achieved with test dosages in the doctor’s office,” says Bivalacqua.  “We teach the patient how to self-inject,” and understandably, this may take some getting used to.  “The medication is shot into the base of the penis with a small hypodermic syringe,” and it works pretty quickly – within five to 20 minutes.  What happens is that the Tri-mix causes the smooth muscle tissue in the penis to relax; it also dilates the main arteries and allows blood to fill the penis.  “The erection can last between 30 and 90 minutes, and it becomes more rigid with sexual stimulation.”  However, it may not always disappear right away after orgasm. (Note:  After prostatectomy, there is no ejaculation, because the organs that contribute fluid for semen are gone.)

How well does it work?  Pretty well; the success rate is between 70 and 80 percent.   However, the main cause of failure is poor blood flow to the penis, Bivalacqua says.  “Sometimes, although the shot produces an initial erection, it doesn’t last because the veins in the penis are damaged,” because of heart disease, diabetes, or other health problems, in addition to the surgery.

Each shot costs about $7, and even though it works, about half of men abandon it within a year.  Bivalacqua speculates that one reason is that these men didn’t get good or detailed enough instruction for them to feel confident injecting themselves.  Also, it may take two or three visits for an experienced urologist to determine the optimum combination and dosage of the medication.

The Vacuum Erection Device (VED) and penis-stretching:  One fact about the penis:  It needs activity.  The nerves in those neurovascular bundles are also responsible for nighttime erections (in your sleep), and those “are responsible for penile health and strength.”  Think of tiny push-ups happening in your sleep.  After surgery – temporarily if one or both nerve bundles (the nerves to the penis) are spared – these erections don’t happen.  If these bundles are damaged or removed during surgery, scar tissue can develop.  When any part of the body is injured, a scar forms.  This is because as it heals, tissue gets fibrosis (it hardens; this is the more rigid tissue that makes up a scar).  There is extra collagen in there, and this contracts over time.  This contraction can shrink the penis by as much as half an inch.  Now, before you say, “That’s it! I’d rather have the cancer!” or make any hasty decisions, please read this next sentence:  “The good news is that there is a way to prevent the loss of length in the penis: using a vacuum erection device,” Bivalacqua says.

Please note this important point:  We’re focusing on stretching, not shrinking.  

Briefly, the VED is what you might suspect; an actual vacuum.  The device costs between $200 and $500, and is available from the pharmacy with a prescription.  You place a clear plastic cylinder over the penis, and use either a manual or electrical pump to create negative air pressure (a vacuum).  It takes about two minutes to achieve an erection; then you slip a flexible tension ring from the bottom of the cylinder around the base of the penis.  This keeps the blood from flowing back out.  “No matter what is specifically causing the erection, the vacuum causes the vessels in the penis to fill with blood, just as they would during a normal erection.”  There’s a downside, though:  “The big complaint of all men using the VED is that the penis becomes cold and semi-rigid, and this makes intercourse difficult.”

Granted, it may not be the best way for you to have sex.  However, you may want to think of it more in the category of an exercise bike:  It can help you get back in shape.  A study from the Cleveland Clinic evaluated the early use of a VED after radical prostatectomy.  There were 109 men in the study.  “One group of 74 men used the VED at least twice a week, starting one month after surgery, for a total of nine months,” says Bivalacqua.  “The second group of 35 men did not receive any erection treatment.”  The study’s investigators found that “only about 23 percent of men who used the VED properly complained of decreased length and girth of the penis, compared with 85 percent in the group who did not use it as directed, twice weekly.  And 63 percent of the men in the control group – who didn’t use a VED at all – reported a decrease in the length and girth of the penis.  To sum up:  “What the VED does is stretch the penis.  It is this stretching that will prevent the penis from contracting, or shrinking, after surgery.”  

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Janet Worthington
Janet Farrar Worthington is an award-winning science writer and has written and edited numerous health publications and contributed to several other medical books. In addition to writing on medicine, Janet also writes about her family, her former life on a farm in Virginia, her desire to own more chickens, and whichever dog is eyeing the dinner dish.