Prostate cancer surgery: erectile dysfunction

Erectile dysfunction is the inability to achieve and maintain an erection. There are many causes of erectile dysfunction, and having surgery for prostate cancer is a common cause in over 60% of men.

For many men, erectile dysfunction problems improve within 12 months following surgery, but for others, the problem doesn’t get better. There are many treatments for the condition that can be tailored for each individual to guarantee good erectile function in the long term.

Here, King Edward VII’s Hospital Consultant Urologist Professor David Ralph discusses how surgery for prostate cancer can cause erectile dysfunction, and what can be done to treat it.

Why is surgery needed for prostate cancer?

If you have prostate cancer, it may be necessary to remove your prostate gland. This isn’t always the case, as some men can have their prostate cancer treated by radiotherapy without the need for surgery. Surgery to remove your prostate gland is called a radical prostatectomy, usually performed with the use of a robot.

If you do need your prostate gland removed, it’s because your doctor believes doing so will cure or control your cancer so that your life can carry on as normal as possible. In cases of advanced prostate cancer that has spread outside your prostate, your doctor may still opt to remove your prostate gland in order to slow down your symptoms and prolong your life.

Your doctor will discuss your options with you.

How does prostate surgery cause erectile dysfunction?

Surgery to remove the prostate is usually offered to men who have prostate cancer that hasn’t spread outside of the prostate, or has only spread a small way.

A radical prostatectomy procedure completely removes the prostate plus the tissues and lymph nodes that surround it. It also removes the seminal vesicles, the tubes that carry semen from the testicles. This means that although you’ll still be able to experience an orgasm after this kind of surgery, you won’t ejaculate as no fluid is now being formed.

It’s possible, if your cancer is confined to your prostate, to have a procedure called a nerve sparing prostatectomy. This means that your surgeon aims to leave the nerves that are either side of the prostate behind. These nerves are responsible for controlling erections. If they’re left undamaged, then there’s more chance that you’ll be able to achieve an erection unaided after surgery.

If the nerves are damaged or removed, then you’re likely to experience erectile dysfunction. In some men, this is permanent, in others they are able to achieve an erection within a few months, with or without medical help.

Can other treatments for prostate cancer cause erectile dysfunction?

Other treatments for prostate cancer, including radiotherapy and brachytherapy can also cause erectile dysfunction. Brachytherapy involves delivering doses of radiation therapy directly to the inside of the prostate rather than on the outside of the body as with normal radiotherapy.

Hormonal treatments, given as injections, tablets or a combination of the two, help to manage the progression of advanced prostate cancer by blocking the effects of the male hormone, testosterone. Testosterone helps prostate tumours grow, so blocking its action helps to prevent further growth of the tumour. It isn’t a cure, but is often used in conjunction with other treatments. This kind of treatment can also cause erectile dysfunction due to the loss of testosterone.

Cryotherapy, where cancer cells are killed by freezing them using tiny probes inserted into the prostate can also cause erectile dysfunction. This is because cryotherapy also may damage the nerves controlling erection.

What type of treatment you have for your prostate cancer will be determined by the stage and speed of growth of your cancer.

If you suffer with erectile dysfunction after treatment, how long this may last and how much it affects your life will also depend on your type of treatment and the severity of your prostate cancer.

Can erectile dysfunction be treated?

Having prostate cancer is an upsetting and stressful experience — having erectile dysfunction as a consequence of treatment to help treat your cancer can feel like a cruel twist of fate.

But the good news is, in most cases, erectile dysfunction can be treated, and often, erectile dysfunction will improve with time and require no further treatment.

There are numerous treatments for erectile dysfunction including:

• Tablets
• Creams
• Injections
• Pellets
• Vacuum pumps
• Implants

Tablets for erectile dysfunction include Viagra, Cialis, Levitra and Spedra. These drugs help relax the penile muscles and help improve the blood flow to the penis, and therefore  an erection. They need to be taken an hour or so before you plan to have sex and can work for up to 36 hours depending on the type of tablet offered. They won’t give you a permanent erection during this time as they only work when sexually stimulated or aroused.

Some of these medications have side effects that your doctor will discuss with you before prescribing them, including dizziness, headaches, facial flushing and indigestion.

Vitaros cream to help treat erectile dysfunction works by placing a small amount on the opening of the penis, up to half an hour before you plan to have sex.

Injections for erectile dysfunction, called Caverject, Viridal Duo or Invicorp, need to be injected into the penile shaft. Pellets need to be inserted into the opening of the penis. If you decide on these treatments, your doctor or a specialist nurse will give you full instructions.

Using a vacuum pump is a physical way of achieving an erection and can be particularly useful if you have had your nerves removed during prostate surgery. A pump is placed over the penis to encourage blood flow and then a plastic ring is put over the base of the penis to maintain your erection. Your doctor will be able to advise on where you can get a vacuum pump. This is often given to all patients to prevent any penile length loss that occurs soon after surgery.

If none of these treatments prove successful, you may be suitable for a short surgical procedure to insert an implant into your penis. Some implants are semi rigid and others are inflatable.

With semi rigid implants you will have a permanent erection, but you will be able to position your penis downwards and then upwards when necessary.

If you have the gold standard inflatable implant, your surgeon will implant a cylinder into your penis, a small reservoir of saline in your abdomen and a pump in your scrotum. To get an erection, you will need to squeeze the pump in your scrotum. This allows the saline into the cylinder which becomes rigid. To reverse your erection, you will need to press a valve in the pump to move the saline from the cylinder and back into the reservoir.

Erectile dysfunction clinics also offer penile rehabilitation. This is offered when the length and/or the width of the penis is reduced as a result of surgery or radiotherapy, leading to erectile dysfunction.

Penile rehabilitation includes a combination of tablets, creams, pellet injections, vacuum pumps, healthy lifestyle advice and counselling to help improve erectile dysfunction.

How you manage your erectile dysfunction will be individual to you. There are plenty of different treatments so don’t lose hope if one doesn’t work for you — another type of treatment may work instead.

What can I do myself to help my erectile dysfunction?

Eating well, not smoking, maintaining a healthy weight and exercising regularly can all help to improve erectile dysfunction. If you’ve lost interest in sex due to erectile dysfunction, the better you feel in yourself, the more interest you may develop, which can have a positive impact.

One of the best things you can do to help how you cope with your erectile dysfunction is to relax. Stress is a major issue and worrying about your erection could make things worse.

Talking to your partner might seem daunting, but it can also help to take the pressure off the situation. Keeping it to yourself can make matters worse with the addition of a mental problem too, in addition to a physical one.

You may also benefit from sexual counselling. Your GP or specialist can refer you for counselling on the NHS, or you can find a private counsellor in your local area.

More information

• If you’re concerned about erectile dysfunction or urinary incontinence after prostate cancer surgery, speak to our specialist team at The KEVII Prostate Cancer Survivorship Centre. They can help to put your mind at rest and discuss your treatment options.