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Improving Erectile Function, Part 1: What You Can Do Before Surgery

If you’ve been diagnosed with localized prostate cancer and are considering having surgery (radical prostatectomy), you may be concerned about potential side effects, including loss of erectile function.

About 40% of men lose some erectile function after surgery. This can have a major impact on quality of life for both the patient and his partner. However, there are ways to improve erectile function, especially if multiple strategies are combined and are personalized to the patient. A team led by PCF-funded investigator Dr. Ashutosh Tewari, a urologist and chairman of urology at the Icahn School of Medicine at Mount Sinai Hospital, reviewed the latest research on strategies used before, during, and after prostatectomy. Here, we summarize key considerations before surgery.

Planning Before Surgery

The area around the prostate has delicate nerves and blood vessels needed for erections. It’s important for your surgeon to have as much information as possible before surgery about your anatomy and the extent of the cancer. Your doctor may use MRI combined with other information (such as PSA, grade group, number of positive cores on biopsy). This can help to guide a custom-tailored approach during surgery.

It’s also important to know about your baseline erectile function: one questionnaire is called the International Index of Erectile Function (IIEF). Your erections after surgery can only be as good as they were before surgery. Men may have some degree of erectile dysfunction (ED) before surgery due to other factors such as age, diabetes, or cardiovascular disease. Research is underway to develop better methods of predicting a patient’s risk of ED after surgery.

What You Can Do Before Surgery

You’ve probably heard of rehabilitation: care and activities to help get back to baseline after illness or treatment. “Prehabilitation” means optimizing your health before treatment to potentially improve your outcomes. Some studies suggest that using multiple approaches, both before and after surgery, may support recovery. More research is needed to better define effective prehabilitation in prostatectomy.

  • Adopt a Healthy Lifestyle: What’s good (or bad) for your heart is good (or bad) for your penis. As noted above, factors such as cardiovascular disease, diabetes, obesity, smoking, and high cholesterol can affect erectile function. They can also affect recovery of erectile function after surgery. If you smoke, get support from your doctor to quit.
  • “Kegels”/Pelvic Floor Muscle Training: Kegel exercises involve squeezing your pelvic floor muscles for a few seconds, then relaxing. They are an important part of treatment for incontinence. Doing Kegels before radical prostatectomy may be helpful in recovery of erectile function, although the effects seen in studies are small.
  • Medication and a Multi-Pronged Approach: Medications called PDE5 inhibitors (e.g., Viagra, Cialis) are commonly used for ED, and are also used after prostatectomy. In one study, men received tadalafil (plus the supplement L-citrulline) daily for 2 weeks prior to nerve-sparing robot-assisted surgery, and continued this after surgery. They were instructed to use other erectile aids (vacuum erection device daily and penile injections as needed), and received advice on a healthy diet, exercise, and sleep. More men in this group reported return of erectile function after 1 year compared to men who did not participate in the pre-operative program (56% vs. 24%).

It Takes Two: The Partner’s Role

For men with a partner, it’s important to consider his partner’s sexual function, aspects of the relationship, and expectations about returning to sexual activity. For example, the partner’s expectations about sexual relations, and their willingness to participate in penile rehabilitation, may affect the patient’s sexual desire and motivation after surgery. Thus, Tewari and colleagues encourage a complete assessment of the partner’s sexual function as part of prehabilitation.

 What this means for patients: Before you have surgery, ask your doctor if there are any other tests you should have that would help plan for the procedure. Talk to your care team about what you can do before surgery to help maximize your ability to have erections after surgery. Make a pro-active plan for your post-surgical rehabilitation. Research suggests that starting interventions earlier can lead to better recovery.

 Read Improving Erectile Function, Part 2: What You Can Do After Surgery

Becky Campbell
Becky Campbell develops medical content at the Prostate Cancer Foundation. She has previously worked in outcomes research and in science education.