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The myth is that prostate cancer treatment destroys men’s erections. The truth is more complicated.
Men facing treatment for this disease should prepare themselves emotionally for permanent erectile dysfunction (ED) that can’t be treated with erection medication. But after prostate cancer treatment, ED is not inevitable. And if you develop it, you can still enjoy a fulfilling sex life—including satisfying orgasms.
All Treatments Are Equally Effective
Most prostate cancer is diagnosed early, before it has spread outside the gland. With early detection, the prognosis is excellent. The American Cancer Society estimates 220,000 new diagnoses in 2015 and 27,500 deaths, a mortality rate of 12.5 percent. For comparison, breast cancer—232,000 diagnoses in 2015, and 40,000 deaths, a higher mortality rate of 17 percent.
Early-stage prostate cancer can be treated in three ways: surgical removal of the gland (radical prostatectomy), high-dose radiation from an external source (external beam), or insertion of a radioactive pellet (seed implantation, brachytherapy).
All three are equally effective. Researchers at M.D. Anderson Cancer Center in Orlando, Florida, reviewed outcomes for 2,991 consecutive men: 1,034 had prostatectomy, 785 had external beam radiation, and 950 had seed implantation, and 222 had combined external beam and seed. Five-year survival rates were 81 percent for prostatectomy, 81 percent for external beam, 83 percent for seeds, and 77 percent for combined therapy—statistical equivalence. An eight-year study of 1,682 men at the Cleveland Clinic also showed equivalent survival: 72 percent for prostatectomy, 70 percent for radiation (both kinds).
ED Risk After Treatment
Researchers with the National Cancer Institute followed 1,187 men for five years—901 had surgery, 286 had external beam. Sexual function declined in both groups, but ED was more prevalent in those who had surgery, 79 percent after prostatectomy vs. 64 percent after radiation.
Harvard researchers conducted a similar study in 987 men treated for prostate cancer. Two years later, surgery left 65 percent with ED. External beam radiation caused ED in 63 percent. And radioactive seed implantation caused ED in 57 percent.
Other researchers have reported somewhat different findings—rates of ED ranging from 60 percent to 82 percent. But almost every study shows that prostatectomy causes somewhat more erection impairment than radiation.
Risk Factors for ED After Treatment
However, these figures are averages. Depending on the man, post-treatment ED rates ranged from a high of 92 percent to a low of just 30 percent.
• Age. In healthy men, erection capacity declines with age. In some men, particularly smokers, this may start as young as 40, while most men notice erection decline in their early 50s. Erection capacity continues to decline with advancing years. The younger the man at treatment, the more likely he is to retain erection capacity.
• Type of treatment. All prostate cancer treatments cause considerable ED, but surgery causes the most. Type of treatment also affects how ED develops. After surgery, most men experience sudden erection impairment, but over time, some recover partial function. After radiation, fewer men report sudden ED. But over time, ED becomes more common.
• PSA. PSA, prostate-specific antigen, is a compound released by the prostate. Its use as a screening test for prostate cancer risk is controversial, but several studies show that the lower a man’s PSA before treatment, the more likely he is to retain erection capacity after.
• Pre-treatment sexual function. Compared with men who reported infrequent, unsatisfying sex beforehand, those who had regular, satisfying sex before treatment show better erection capacity after.
• Morning erections or partial erections. Young men often wake with morning erections. Some older men continue to wake with partial penile firmness. Compared with men who rarely or never wake with semi-erections, those who experience at least occasional firmness on waking are more likely to recover erection function after prostate cancer treatment.
Nerve-Sparing Surgery?
Why does prostate cancer treatment cause such a high rate of ED? Because the nerves involved in erection, specifically two nerve bundles, run very close to the gland. Surgery typically cuts these nerves, and radiation usually damages them.
For years, surgeons have strived to remove the prostate while leaving the nerve bundles intact (nerve-sparing prostatectomy) thus reducing risk of ED. Unfortunately, nerve-sparing surgery does not work miracles. At Fred Hutchinson Cancer Center in Seattle, researchers checked in with 1,291 men 18 months after prostatectomies performed in the mid-1990s. Among those who had ordinary surgery, 66 percent reported serious ED. Those who had nerve-sparing surgery reported less ED, but not much less—57 percent. In this group, age was a better determinant of sexual function than the type of surgery. Among men under 60, 39 percent could raise erections. For the men 60 or older, the figure was 20 percent.
More recent studies have reported somewhat better results. And recently, robot-assisted prostatectomy has improved erection retention rates. A 2012 Italian review of six studies showed that 12 months after surgery, 54 to 90 percent of men could raise erections.
However, these studies measure “any degree of erection.” Rates of erection sufficient for intercourse generally come in at 25 to 70 percent—according to surgeons. But ask the men who’ve been treated, and you get different numbers. Researchers at Memorial Sloan-Kettering Cancer Center in New York surveyed 180 men two years after nerve-sparing radical prostatectomy. Among those not using erection drugs, just 22 percent said their erections were back to baseline. Among those using the drugs, the figure was 43 percent—meaning that 57 percent had suffered a significant post-surgical loss of erection capacity.
Finally, if the tumor is located near a nerve bundle, nerve-sparing surgery may not be possible.
Bottom line: Compared with ordinary surgery, nerve-sparing surgery produces better results, but not much better. For best results opt for robot-assisted nerve-sparing surgery.
Erection Drugs Might Help
Several studies show that in some men, Viagra and other erection drugs may help restore erection after prostate cancer treatment. But this depends on nerve function.
Erection medications work by coaxing more blood into the penis. But if a man doesn’t have enough nerve function for erection, the amount of blood in the penis doesn’t matter. Damaged or severed nerves mean iffy or no erections. However, with nerve-sparing surgery, much or all of nerve function remains, and erection drugs can help.
Italian researchers analyzed 11 studies of erections in men who took Viagra after prostatectomy. After conventional surgery, erection medication helped from 0 to 15 percent of men. (Conventional surgery sometimes accidentally spares some nerves.) After surgery that spared one nerve bundle, the drugs helped 10 to 80 percent of men. When both nerve bundles were spared, Viagra helped 46 to 72 percent of men.
Bottom line: For best chance of sexual function, have bilateral nerve-sparing surgery and use erection medication.
Penile Implant?
Penile implants are nested rods surgically inserted into the penile shaft along with a squeeze bulb and fluid reservoir inserted into the scrotum. Squeeze the bulb and the fluid fills the rods, hydraulically extending them to produce erection.
However, there are two major problems with implants. Insertion surgery may leave the penis looking deformed. And implants can malfunction, necessitating more surgery for repairs.
As a result, only a small proportion of men opt for implants after prostate cancer surgery.
Great Sex and Satisfying Orgasms Without Erection
All the attention on erection after prostate cancer treatment obscures a key fact: Men don’t need erections to have satisfying sex and orgasms. In an erotic context—candle light, music, and an erotically-motivated woman who turns a man on—vigorous penile stimulation can trigger orgasm even if the penis is flaccid. If a man develops ED from prostate cancer treatment, he can still enjoy a fulfilling sex life and have orgasms that feel just as pleasurable as those he used to have when he could raise erections.
Different nerves control erection and orgasm. Even if a man’s erection nerves are damaged or severed, chances are that the nerves that govern orgasm remain intact. It’s an adjustment to have a flaccid penis stimulated to orgasm. But it’s not all that difficult—and after prostate cancer treatment, most men say they’d rather have orgasms without erections than erections without orgasms.
How do men have orgasms without erections? The regular way—with direct, sustained penis stimulation by hand, mouth, or sex toy, or any combination. It may take several months after treatment to return to orgasm, but if you work at it, either solo or with a lover, you can enjoy fulfilling orgasms with a flaccid penis.
For individual help with sex after prostate cancer, consult a sex therapist. To find one near you, visit the American Association of Sex Educators, Counselors, and Therapists, the Society for Sex Therapy and Research, or the American Board of Sexology.
References:
Alemozaffar, M. et al. “Prediction of Erectile Function Following Treatment for Prostate Cancer,” Journal of the American Medical Association (2011) 306:1205.
Christian, JN et al. “Back to Baseline: Erectile Function Recovery After Radical Prostatectomy from the Patients’ Perspective,” Journal of Sexual Medicine (2013) 10:1636.
Ficarra V et al. “Systematic Review and Meta-Analysis of Studies Reporting Potency Rates after Robot-Assisted Radical Rrostatectomy,” European Urology (2012) 62:418.
Kupelian, PA et al. “Radical Prostatectomy, Extermal Beam Radiotherapy, Permanent Seed Implantation, or Combined Seeds/External Beam Radiotherapy for Stage T1-T2 Prostate Cancer,” International Journal of Radiation Oncology, Biology, and Physics (2004) 58:25.
Kupelian, PA et al. “Comparison of Efficacy of Local Therapies for Localized Prostate Cancer: A Large Single Institution Experience with Radical Prostatectomy and External Beam Radiation,” Journal of Clinical Oncology (2002) 20:3376.
Megas, G et al. “Comparison of Efficacy and Satisfaction Profile Between Penile Prosthesis Implantation and Oral PDE5 Inhibitor Tadalafil Therapy, in Men with Nerve-Sparing Radical Prostatectomy Erectile Dysfunction. BJU International (formerly British Journal of Urology) (2013) 112:169-76.
Montorsi, F and A. McCullough. “Efficacy of Sildenafil (Viagra) in Men with Erectile Dysfunction Following Radical Prostatectomy: A Systematic Review of Clinical Data,” Journal of Sexual Medicine (2005) 2:658.
Montorsi, F. et al. “Effects of Tadalafil Treatment on Erectile Function Recovery Following Bilateral Nerve-Sparing Radical Prostatectomy: a Randomised Placebo-Controlled Study (REACTT),” European Urology (2014) 65:587.
Noldus, J et al. “Patient-Reported Sexual Function After Nerve-Sparing Radical Retropubic Prostatectomy,” European Urology (2002) 42:118.
Potosky, AL et al. “Five-Year Outcomes After Prostatectomy or Radiotherapy for Prostate Cancer: The Prostate Cancer Outcomes Study,” Journal of the National Cancer Institute (2004) 96:1358.
Shimizu, T et al. “Erectile Dysfunction Following Nerve-Sparing Radical Retropubic Prostatectomy and Its Treatment with Sildenafil,” International Journal of Urology (2005) 12:552.
Sivarajan G, et al. “Ten-Year Outcomes of Sexual Function After Radical Prostatectomy: Results of a Prospective Longitudinal Study,” European Urology (2014) 65:58.
