INTERVIEW WITH AN EXPERT

Trinity Bivalacqua, M.D., Ph.D., the R. Christian B. Evensen Professor of Urology and Oncology, Johns Hopkins Medical Institutions

Rehabilitating Your Penis

Will your sex life be the same after surgery?  The absolute honest answer is, probably not, or at least, not for a while.  But the other absolute truth is just as important:  

You can have a good sex life after surgery.  

It’s essential to know these two facts, because a lot of men don’t hear the whole truth from their doctor – or maybe they do hear it, but then focus on statistics for younger men who have never had erectile dysfunction (ED) and think the results will be the same for everybody.  If you are in your sixties or older, have already experienced some ED, and maybe you also have some other health issues, like diabetes or heart disease, then most likely you will have some ED after surgery.  It happens after radiation, as well; the onset is more gradual, but the basic problem is the same – damage to the nerves and blood supply that control erection (see below).

“Erections are going to be altered from what you had before surgery,” says Johns Hopkins urologist Trinity Bivalacqua, M.D., Ph.D.  “Unfortunately, many doctors never provide this information; in fact, some men believe that if their erections before surgery are not as rigid as they would like, that a radical prostatectomy may actually improve them.  This is definitely not the case.  You may go on the Internet and find some doctor who says that 98 percent of his patients are continent and have excellent erections after surgery – but nowhere does that doctor tell you that he or she is just reporting on his youngest and best post-op cases, not on every single patient.  I can’t tell you how many men come to see me and expect the same results.  When they’re older and already have some trouble with ED, that’s just not going to happen.”

Bivalacqua cites a recent study in the Journal of the American Medical Association led by Harvard urologist Martin Sanda, M.D., based on data from 1,027 men with clinical stage T1 and T2 prostate cancer who had either radical prostatectomy or external-beam radiation therapy.  “For a 50-year-old man with good sexual function before surgery, the probability of having good sexual function 24 months after surgery ranged from 21 to 70 percent, depending on their pre-surgery PSA and whether the nerve bundles (see below) were spared.”  And for a man of any age with good sexual function before external-beam radiation therapy, “the probability of having good sexual function 24 months later ranged from 53 to 92 percent, depending on their PSA level and whether they received a short course of hormones along with their radiation therapy.”

The best “crystal ball” for what you can expect after surgery is to make an honest assessment of how things are for you right now, by answering a few questions on the Sexual Health Inventory for Men (SHIM) questionnaire.  Just answer them in your head, and add up the score.  “This is a validated questionnaire, and it accurately assesses erectile function.  If you score 22 out of 25 possible points total, it means that you consistently have rigid erections that are suitable for intercourse,” says Bivalacqua.  

Hold that thought.  

We need to take a very brief detour and have a mini-crash course in prostate anatomy.  On either side of the prostate – think of Mickey Mouse’s ears, except extremely tiny and hard to see – are two bundles of nerves.   They are called neurovascular bundles (that just means there are a bunch of nerves and blood vessels all clustered together).  Although these nerves are not in the penis itself, they are responsible for erection.  They’re like junction boxes that control the wiring in a different room.  Inside the penis are blood vessels; they’re like the plumbing.  Basically, the erection happens when blood flows inside the penis – think of a water balloon filling up.   If you have heart disease, and plaque in the arteries that can hamper blood flow, the penis (which depends on blood flow for erection) can be affected, too.  This has nothing to do with the prostate, or prostate cancer, or surgery or radiation.  This is just a problem you may already have.

In a nerve-sparing radical prostatectomy, if cancer is well confined within the prostate, your surgeon may be able to save one or both of those nerve bundles.  You can have an erection with just one bundle.  If you have both bundles removed, because your cancer is too close to that edge of the prostate, you can still have a sex life; you just will need some help with erections, and there are several options.

But first, back to your own situation:  “If you have strong erections already and the nerves that control erections are spared during surgery, your chances of achieving a full recovery are excellent,” says Bivalacqua.  “But if you score 21 or lower on the SHIM quiz before surgery, you already have mild ED.  This means that even if the nerves are spared, you will need some medication to help with erections after surgery.”

By medications, he means pills like Viagra, Cialis, or Levitra.  You can read more about those here.  Before we get into the specifics of sexual function after prostate cancer treatment, we need to talk about priorities:

“I always quote the legendary Johns Hopkins urologist Patrick Walsh in telling my patients that my first two goals, whether the surgery is done with a scalpel or a robot, are to control the cancer and preserve continence” (to have no urinary leakage), says Bivalacqua.  “Then erectile function is third.  This is because there are many ways to restore erectile function.”   

Now, what kind of cancer do you have?  If your doctor says you are a candidate for active surveillance, and you don’t have a family history of cancer and you are not of African descent, you may want to consider it, because it won’t affect your sex life or your urinary continence.  However, it is not fun to get repeat biopsies, and if you are the kind of man who will constantly worry about having cancer – even if it seems unlikely to progress – this may not be for you.  

If you are likely to choose surgery after a few years of active surveillance because you don’t want to live with the cancer and you want peace of mind, then please understand that your chances of recovery of potency are better when you are younger.  Younger men who are potent before surgery do better, for the reasons discussed above.

Next, and this is huge:  If you have cancer that is likely to progress beyond the prostate, you should get treatment now.  

Active surveillance is for a highly selected group of men with cancer that’s considered “safe.” It is completely different from not having surgery because you don’t want to have ED and hoping the cancer won’t spread.  

That’s actually more like denial than a good treatment strategy, and here’s why:

If you wait to have treatment, you might have more trouble than if you get treatment now.  Not just because you’re more likely to recover your potency if you’re younger, but because if you don’t get treated for prostate cancer when you need it, and if that cancer progresses, you will lose much more than the ability to have an erection.  If you have advanced cancer, the mainstay of treatment for metastatic disease is hormonal therapy, the shutdown of testosterone.  One of the most difficult side effects of hormonal therapy is that it causes loss of libido, or sexual desire.  (Note: Libido comes back if you stop taking the hormonal therapy, so a short course of hormonal therapy with radiation is different from taking it for the rest of your life.)

Terms to know from this article:

erectile dysfunction (ED)

An inability to have an erection of the penis adequate for sexual intercourse. Also called impotence.

urologist

A doctor who has special training in diagnosing and treating diseases of the urinary organs in females and the urinary and reproductive organs in males.

Radical prostatectomy

Surgery to remove the entire prostate. The two types of radical prostatectomy are retropubic prostatectomy and perineal prostatectomy.

Active Surveillance

Active surveillance is an option offered to patients with very low-risk prostate cancer (low grade, low stage, localized disease). Patients are monitored carefully over time for signs of disease progression. A PSA blood test and digital rectal exam (DRE) and prostate biopsy are performed at physician-specified intervals. Signs of disease progression will trigger immediate active treatment.

Hormonal therapy

Treatment that adds, blocks, or removes hormones. For certain conditions (such as diabetes or menopause), hormones are given to adjust low hormone levels. To slow or stop the growth of certain cancers (such as prostate and breast cancer), synthetic hormones or other drugs may be given to block the body's natural hormones. Sometimes surgery is needed to remove the gland that makes hormones. Also called hormone therapy, hormone treatment, or endocrine therapy.

Testosterone

A hormone that promotes the development and maintenance of male sex characteristics.

Libido

Interest in sexual activity; compare to impotency.

PSA

prostate-specific antigen (PSA): A substance produced by the prostate that may be found in an increased amount in the blood of men who have prostate cancer, benign prostatic hyperplasia, or infection or inflammation of the prostate.

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.

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