Erectile Dysfunction After Prostate Cancer
Nearly all men will experience some erectile dysfunction for the first few months after prostate cancer treatment. However, within one year after treatment, nearly all men with intact nerves will see a substantial improvement.
Following Nerve-Sparing Prostatectomy
Within one year, about 40 to 50% of men will have returned to their pre-treatment function. After two years, about 30 to 60% will have returned to pre-treatment function. These rates vary widely depending on the surgeon and how the extent of “nerve sparing” a surgeon can perform at the time of surgery.
Following Radiation Therapy
About 25 to 50% of men who undergo brachytherapy will experience erectile dysfunction vs. nearly 50% of men who have standard external beam radiation. After two to three years, few men will see much of an improvement and occasionally these numbers worsen over time.
Men who undergo procedures not designed to minimize side effects and/or those whose treatments are administered by physicians who are not proficient in the procedures will fare worse.
Men with other diseases or disorders that impair their ability to maintain an erection (diabetes, vascular problems, etc.) will have a more difficult time returning to pre-treatment function.
Management of Erectile Dysfunction
Oral medications relax the muscles in the penis, allowing blood to rapidly flow in. On average, the drugs take about an hour to begin working, and the erection-helping effects can last from 8 to 36 hours.
About 75% of men who undergo nerve-sparing prostatectomy or more precise forms of radiation therapy have reported successfully achieving erections after using these drugs. However, they are not for everyone, including men who take medications for angina or other heart problems and men who take alpha-blockers.
Men who do not recovery erectile function after treatment can try injectable medication that pharmacologically induced an erection. The most common drug used for this is Prostaglandin.
The vacuum constriction device creates an erection mechanically by forcing blood into the penis using a vacuum seal. A rubber ring rolled onto the base of the penis prevents blood from escaping once the seal is broken. About 80% of men find this device successful.
A three-pieced surgically inserted penile implant includes a narrow flexible plastic tube inserted along the length of the penis, a small balloon-like structure filled with fluid attached to the abdominal wall, and a release button inserted into the testicle.
The penis remains flaccid until an erection is desired, at which point the release button is pressed and fluid from the balloon rushes into the plastic tube. As the tube straightens from being filled with the fluid, it pulls the penis up with it, creating an erection.
Assuming the mechanics are working correctly, it is 100% effective, and about 70% of men remain satisfied with their implants even after 10 years. Because this procedure is done under general anesthesia, it is not available to men who are not considered good candidates for surgery because of other health reasons.
Erectile Dysfunction Following Radical Prostatectomy
Assuming the management of erectile dysfunction requires expert diagnosis and treatment.
Diagnosis includes sexual function history, general medical history, psychosocial history, medication history, physical examination, and appropriate laboratory testing.
Treatment follows diagnosis, and we provide a range of treatment options through the Clinic. Minimally invasive treatment options range from oral medications to medications administered directly to the penis to a mechanical vacuum device applied to the penis. Invasive treatments include implants or vascular surgery. We are particularly expert in the surgical treatment of patients with erectile dysfunction. The range of conditions we manage include penile prosthesis complications, penile vascular abnormalities, penile curvature, and abnormally prolonged erection consequences.
Psychological treatment is an important adjunct to managing erectile dysfunction. If our diagnosis suggests a psychological association with your erectile dysfunction, we may recommend that you pursue counseling with a qualified psychologist available through the Clinic.
For instance, there may be relationship problems that negatively affect sexual functioning with your partner. Referrals can be made to the Johns Hopkins' noted Sexual Behaviors Consultation Unit.
Erectile dysfunction following radical prostatectomy for clinically localized prostate cancer is a known potential complication of the surgery. With the advent of the nerve-sparing radical prostatectomy technique, many men can expect to recover erectile function in the current era.
However, despite expert application of the nerve-sparing prostatectomy technique, early recovery of natural erectile function is not common. Increasing attention has been given to this problem in recent years with the advancement of possible new therapeutic options to enhance erection function recovery following this surgery. Visit Dr. Burnett's Neuro-Urology Laboratory
This topic area was handled thoroughly in an article written by Dr. Arthur L. Burnett, entitled "Erectile Dysfunction Following Radical Prostatectomy," published in the Journal of the American Medical Association, June 1, 2005. Using a question and answer format, excerpts from this article are provided below.
What is the importance of preserved erectile function?
In considering the impact of the various treatment approaches for prostate cancer on their quality of life, many patients place paramount importance on the possibility of retaining natural erectile function. This matter is frequently important to young men who by age status are more likely to have intact erectile function than older men; however, for all men having normal preoperative erectile function irrespective of age, preservation of this function is understandably important postoperatively.
What are the current expectations with regard to outcomes after radical prostatectomy?
Following a series of anatomical discoveries of the prostate and its surrounding structures about 2 decades ago, changes in the surgical approach permitted the procedure to be performed with significantly improved outcomes. Now after the surgery, expectations are that physical capacity is fully recovered in most patients within several weeks, return of urinary continence is achieved by more than 95% of patients within a few months, and erection recovery with ability to engage in sexual intercourse is regained by most patients with or without oral phosphodiesterase 5 (PDE5) inhibitors within 2 years.
Why is there increasing concern at this time regarding erectile dysfunction issues following radical prostatectomy?
The reality of the recovery process after radical prostatectomy today is that erectile function recovery lags behind functional recovery in other areas. Patients are understandably concerned about this issue and, following months of erectile dysfunction, become skeptical of reassurances that their potency will return.
Why does it take so long to recover erections after the very best surgery?
A number of explanations have been proposed for this phenomenon of delayed recovery, including mechanically induced nerve stretching that may occur during prostate retraction, thermal damage to nerve tissue caused by electrocoagulative cautery during surgical dissection, injury to nerve tissue amid attempts to control surgical bleeding, and local inflammatory effects associated with surgical trauma.
What determines erection recovery after surgery?
The most obvious determinant of postoperative erectile dysfunction is preoperative potency status. Some men may experience a decline in erectile function over time, as an age-dependent process. Furthermore, postoperative erectile dysfunction is compounded in some patients by preexisting risk factors that include older age, comorbid disease states (e.g., cardiovascular disease, diabetes mellitus), lifestyle factors (e.g., cigarette smoking, physical inactivity), and the use of medications such as antihypertensive agents that have antierectile effects.
Are there any surgical techniques that have been developed to improve erectile function outcomes?
At this time, there are several different surgical approaches to carry out the surgery, including retropubic (abdominal) or perineal approaches as well as laparoscopic procedures with freehand or robotic instrumentation. Much debate but no consensus exists about the advantages and disadvantages of the different approaches. Further study is needed before obtaining meaningful determinations of the success with different new approaches.
Is another treatment option better for preservation of erectile function?
The growing interest in pelvic radiation, including brachytherapy, as an alternative to surgery can be attributed in part to the supposition that surgery carries a higher risk of erectile dysfunction. Clearly, surgery is associated with an immediate, precipitous loss of erectile function that does not occur when radiation therapy is performed, although with surgery recovery is possible in many with appropriately extended follow-up. Radiation therapy, by contrast, often results in a steady decline in erectile function to a hardly trivial degree over time.
What current options exist to treat erectile dysfunction after radical prostatectomy?
Options include pharmacologic and nonpharmacologic interventions. Pharmacotherapies include the oral PDE-5 inhibitors (sildenafil [Viagra®], tadalafil [Cialis®], and vardenafil [Levitra®]), intraurethral suppositories (MUSE®), and intracavernous injections (prostaglandin E1and vasoactive drug mixtures). Non-pharmacologic therapies, which do not rely on the biochemical reactivity of the erectile tissue, include vacuum constriction devices and penile implants (prostheses).
Men who have undergone nerve-sparing technique should be offered therapies that are not expected to interfere with the potential recovery of spontaneous, natural erectile function. In this light, penile prosthesis surgery would not be considered an option in this select group, at least in the initial 2 year post-operative period, until it becomes evident in some individuals that such recovery is unlikely.
Can erection "rehabilitation" be applied to improve erection recovery rates?
A relatively new strategy in clinical management after radical prostatectomy has arisen from the idea that early induced sexual stimulation and blood flow in the penis may facilitate the return of natural erectile function and resumption of medically unassisted sexual activity. There is an interest in using oral PDE5 inhibitors for this purpose, since this therapy is noninvasive, convenient, and highly tolerable. However, while the early, regular use of PDE5 inhibitors or other currently available, "on-demand" therapies is widely touted after surgery for purposes of erection rehabilitation, such therapy is mainly empiric. Evidence for its success remains limited.
Are there new strategies in the near future that may be helpful in improving erection recovery after surgery?
Recent strategies have included cavernous nerve interposition grafting and neuromodulatory therapy. The former, as a surgical innovation meant to reestablish continuity of the nerve tissue to the penis may be particularly applicable when nerve tissue has been excised during prostate removal. In the modern era of commonly early diagnosed prostate cancer, nerve-sparing technique remains indicated for the majority of surgically treated patients.
Neuromodulatory therapy, represents an exciting, rapidly developing approach to revitalize intact nerves and promote nerve growth. Therapeutic prospects include neurotrophins, neuroimmunophilin ligands, neuronal cell death inhibitors, nerve guides, tissue engineering/stem cell therapy, electrical stimulation, and even gene therapy.