Men undergoing surgery for prostate cancer often fear its side effects, including losing the ability to have erections. PCF-funded investigator Dr. Ashutosh Tewari, chairman of urology at the Icahn School of Medicine at Mount Sinai Hospital, and team have reviewed the latest research on strategies to improve erectile function that can be considered before, during, and after prostatectomy. In Part 2 of this series based on the publication, we summarize post-operative approaches.
Sexual and erectile function is a complex process, often involving a partner as well as the patient. Thus, it may be unrealistic to expect that post-operative sexual problems can be fixed with a single “magic bullet” (such as a dose of Viagra).
Tewari and team cite four main categories of interventions:
- Medicines and devices
- Hormonal assessment
Maintaining a healthy lifestyle through nutrition, exercise, and stress management is advised to maximize results. Open communication about your needs, priorities, and challenges with your healthcare team and your partner, if applicable, is essential.
Medicines and devices
In general, research suggests that starting these interventions early may lead to better recovery of erectile function. (Note, this should be done under the guidance of a clinician.)
- PDE5 inhibitors (e.g., sildenafil [Viagra], tadalafil [Cialis]). These medicines increase blood flow in the penis. Starting them earlier is linked to greater likelihood of recovery. For example, in one trial patients took sildenafil twice weekly after nerve-sparing prostatectomy, beginning immediately after catheter removal OR with delayed initiation. Patients who started early treatment were 3 times more likely to achieve complete recovery of erectile function. Regular use (i.e., daily) appears to be more effective than on-demand use.
- Penile injections. Again, starting early after surgery is linked to higher rates of recovering spontaneous erections. Think of the penis like your muscles – just as you need to get up and walking after surgery, even with a walker or cane, you’ve got to start using your penis, with whatever assistance is required. “Trimix,” which combines 3 medications, may be associated with less pain. Note: if you don’t have success at first with injections, make sure to get tips from a urologist or sexual medicine specialist on how to inject.
- MUSE (Medicated Urethral System for Erection). Alprostadil, one of the components of Trimix, can be inserted into the urethra. This approach has been in use for over 2 decades. In one study, MUSE combined with oral medications resulted in better penile rigidity and sexual satisfaction.
- Vacuum erection device (VED). This is another way to get your penis moving. Penile shortening can be a problem after surgery; early use of a VED can preserve penile length. VED combined with oral medication may have added benefit over medication alone. Be aware of drawbacks to VED use, including unnatural pivoting of the penis, a bluish color, and less warm erections.
- Pelvic floor muscle therapy (Kegel exercises). Do them after surgery to help regain urinary continence. Evidence also suggests a benefit to recovering erectile function. Even among patients with persistent erectile dysfunction (ED) after surgery, starting Kegels 12 months after surgery (vs. 15 months) was linked to better erectile function and less climacturia (leaking urine during ejaculation).
- Penile prosthesis. If you’re struggling after trying other interventions, you still have options. Although use of a prosthesis after prostatectomy is not common (about 2%), satisfaction rates are high. Read a patient’s story here.
Diagnosis and treatment of prostate cancer can lead to depression, stress, and anxiety, which can compound sexual problems. Therefore, understanding a patient’s psychological health and addressing those concerns is key to successful recovery of sexual function. For example, patients who participated in cognitive behavioral therapy had better self-esteem, satisfaction with orgasms, and increased sexual confidence.
Penile rehabilitation and recovery take time, patience, and persistence. Patients may “give up” on the process, which can lead to further anxiety, frustration, and a “cycle of avoidance” of both intercourse and the rehabilitation program. In this situation, one approach may be a type of therapy called Acceptance and Commitment Therapy (ACT). In one trial, participation in ACT led to increased use of penile injections and ability to better cope with ED. Partners should be involved in psychosocial interventions as well.
The role of hormones
An adequate level of testosterone is needed to have erections. Testosterone falls with age, so older men (the population at risk for prostate cancer) may already have this as a contributing factor to poor erectile function. After prostate cancer, patients (and their doctors) may be concerned about using testosterone supplements. However, more recent evidence shows that testosterone replacement is safe in patients treated for prostate cancer with no evidence of remaining disease. Ask your doctor about testing your hormone levels.
There are multiple therapies at various stages of investigation, from animal models to clinical trials in patients. These include: hyperbaric oxygen therapy, low-intensity extracorporeal shockwave therapy, use of stem cells, and nerve grafting. Be wary of online advertisements for ED treatments that are unproven: they may range from an ineffective waste of money, all the way to risky. If you are considering an investigational therapy, it is recommended that you do so only as part of a clinical trial. Speak with your doctor about whether a clinical trial might be right for you.
What this means for patients: Know that there are many options available to help regain erectile function after prostatectomy. Don’t suffer in silence: be as open as you can about any challenges so that your health care team can support you. Remember that sexual function is in the head and “heart” as well as the penis. Speaking with an individual therapist, couples therapist, or participating in group sessions may help with recovery. If you are in a relationship, involve your partner in your treatment plans both before and after surgery.
Read Part 1 on What You Can Do Before Surgery