Sexual Side Effects: Optimizing Sexual Function Outcomes

This summary is from the 2015 Prostate Cancer Conference where in his lecture, John Mulhall, MD, discussed Optimizing Sexual Function Outcomes. Dr. Mulhall is preeminent thought leader in sexual side effect treatment.  Here is the summary:

Optimizing Sexual Function Outcomes:

  • Achieving optimal outcomes requires informed consent before treatment - which requires a physician to give realistic expectations about the success and side effects of the treatment. 
  • Patient Support Mechanism needs to be in place to take care for “whole” patient
  • Average Medical Students get approximately only two hours of sexual medicine education 
  • Beware of doctors quoting “incredible” of erectile function preservation
  • If you have Erectile Dysfunction to start with, a surgeon might think it is not important to you.

Realistic Expectations: 

  • Referral pre-therapy to a sexual Medicine clinician
  • Discussion prevalence of Major sexual problems
  • Discussion of chronology of recovery
  • Discussion of strategies to minimize long-term effects
  • Discussion of strategies to treat adverse effects

Erectile Function Preservation Predictors: 

  • Degree of nerve sparing
  • Preoperative EF
  • Patient Age
  • Physician experience (250+)
  • Physician volume
  • Medical conditions (Diabetes, etc.)
  • Duration of ADT (beyond 4-6 months)
  • Vascular comorbidities
  • Pre-treatment testosterone levels (may have predictive value)

Radical Prostatectomy

Erectile Dysfunction:

  • Immediate effect
  • Nadir = 3 months after surgery
  • Recovery = 12-24 months (natural history of recovery of nerves any where in the body)
  • 20% get BTB (5% >60 years of age)
  • Rehabilitation = biceps & penis are the same. No exercise = degeneration/atrophy but PERMANENT!


  • No semen - dry orgasm
  • Should have orgasm: different
  • Painful (dysorasmia) = uncommon

Sexual Incontinence:

  • At orgasm (climacteric)
  • Arousal Incontinence

Penile Length Loss:

  • 70% men have documented loss
  • Causes
  • PDE5i protective (long way to preserving erection length)

Radiation Therapy

Erectile Dysfunction:

  • No clear data showing one type of radiation is better than the other (in the sexual disfunction arena)
  • Little effect within first 12 months = Nadir is 3-5 years out
  • Recovery: age, function, dose, ADT
  • ED rates between RP & RT are about the same at three years (hormone therapy excluded)


  • No semen - 70% @ 3 years, 90% @ 5 years- dry orgasm
  • Little data on orgasm

Sexual Incontinence & Penile Length Loss:

  • No data 

ADT (Hormone Therapy) 

Erectile Dysfunction:

  • Erectile tissue (muscle) degeneration
  • Permanent ED associated with _> 6 months use tissue
  • Leads to failure to respond to pills (PDE5i)


  • No semen - dry orgasm
  • Orgasm rare (5% will)


  • 90% of men, none
  • sexual neutrality ( sex drive = visceral (need testosterone) vs intellectual sex drive)

Penile Length Loss

Navigating Minefield of Deciding on Treatment

  • TAKE YOUR TIME, interview different physicians
  • Be clear on what is important to YOU!
  • If you have Erectile Dysfunction to start with, the surgeon might think it is not important to you
  • Ask about “active surveillance” - why is it not an option for me??
  • Have “The Talk” with your partner
  • Eyes wide open - Be completely informed - Realistic expectations BEFORE treatment
  • Understand “erectile function recovery” (variables)
  • Don’t rely on a single choice when choosing a physician
  • Understand recovery periods for the various treatments
  • Open vs Robotic RP - NO difference!! in Sexual Function recovery
  • Physician Experience Matters - For RP Surgeons *(250+) Surgical Expertise (don’t opt for a physician who has had open prostatectomy experience and has just changed to Robotic (DiVinci) *applicable to EMRT
  • Nerve sparing RP - How much of my nerves was removed/saved/etc.
  • ADT - most penis threatening factor - think of “Survival Benefit”
  • Get instructions/understand on how to use erection pills. NO nitrate oxide, need arousal, adrenalin is bad for erection, psychological effect, confidence restoration is crucial


Viagra generic - Revatio® (sildenafil) used in adults to treat pulmonary arterial hypertension (PAH). $2/20mg. Compounding pharmacy - NYC: Masterpharm 718-529-5500.

  • Window of opportunity 8-10 hours.
  • Before a meal, on an empty stomach.
  • Psychologically good to distance the pill from the act. 


  • The “weekender”.
  • Takes 2-3 hours to kick in.
  • Long lasting drug - 24-36 hours.
  • Drug is covered by insurance for use with BPH.
  • Daily Cialis, 5mg per day, after 5 days, gives you an 8 mg dose in your blood which gives you as good an erection as 20 mg on demand. (1:00)


  • The “new kid”, spontaneity.
  • Takes 30 minutes to kick in, gone in 6 hours

Staxyn (vardenafil):  

  • FDA  approved drug. It is 10mg of Lavitra.
  • Oral dispensable tablet, put under tongue it dissolves, gets absorbed through the stomach, it does not get absorbed sublingually.
  • Marketing ploy by GSK, it flopped, not worth it, go straight to 20mg of Lavitra

Canadian Drugs: 

  • Distribution centers for drugs made in Indian and China.
  • We do not know what is in them, nor milligrams in each, etc.

Penile injections: 

  • Mental image distasteful.
  • Mosquito bite, middle of shaft - no where near head.
  • Erection in 5-10 minutes, rocket fuel, best erection you can get.
  • Most men get off the injections in the long term, it is used in the short term for rehabilitation.

Nocturnal Erections: 

  • We were developed to get orgasims (3-6) every night to to keep muscle working/functioning

Endothelial Preconditioning:

  • Pretreatment (two weeks).
  • No data available, but animal data is positive


  • Goal is to get erections.
  • Penetration hardness: 6-7 on a 10 point scale.
  • Keep muscle working/functioning.
  • Every patient getting a PDE5i, starts at the maximum dose:  100mg Viagra, or 20mg Cialias, or 20mg Lavitra.


  • Preserves penis length.

Venus Leak:  

  • Can not keep an erection.
  • Blood flows in but leaks back into general circulation.
  • When you stand up erection is good, if lay down, goes away. “valve broken”.

PDE5i & Melanoma: 

  • 17 year drug.
  • No good data that there is a link.
  • See Stacey Loeb, Swedish registry.
  • Wealthier people can afford it more, able to do vacations, more in sun, etc.

PDE5i & PSA (rising): 

  • There is not data showing a link between the two

Penile Prosthesis (3rd line therapy):

  • Implants are good for couples who want to have sexual intercourse.  
  • Couples are also happy with “outercourse” as an alternative option (more intimacy).  
  • All implants are good, no favorites.

Testosterone Replacement (TR): 

  • Testosterone does NOT cause prostate cancer.
  • Men with Gleason 6/7, organ confined, after prostatectomy.
  • Testosterone range of 150-750 cells are maximally activated.
  • MSK been using TR for 9 years.
  • People are getting it for no good reason and men who should have it have been scared off of it. Advanced/Castrate resistant different subject.  
  • See investigative work done by Abraham Morganthaler, MD, FACS, author of Testosterone for Life. 
  • Your PSA went up because your testosterone level was so low your body could not make any PSA.
  • By giving you Test. your body was able to make PSA- PSA response.

Addyi (fibanserin): 

  • (Sprout pharmaceuticals) - a novel, non-hormonal, multifunctional serotonin agonist antagonist (MSAA) for the treatment of hypoactive sexual desire disorder in premenopausal women.
  • Low sexual desire.  
  • HSDD is characterized by low sexual desire.
  • 100 mg tablets, FDA-approved on August 18, 2015.
  • First drug in this category, will open avenue up for more research and development (investigating for men).
  • Good first step in female sexual health.
  • Insurance coverage still unknown.


  • Be supportive.
  • If distressing for you, it is much more so for your partner.
  • Never emasculate.
  • We’ll work on this together.
  • Let’s go and fix this problem.

Let’s not solely focus just on adding years to life, but let’s also pay attention to adding life to years.

John Mulhall, MD

Dr. Mulhall is a board-certified urologist and a microsurgeon who specializes in sexual and reproductive medicine and surgery. As a microsurgeon he performs delicate procedures using operating microscopes and miniaturized precision instruments on the very small structures in the genirourinary tract. As part of Memorial Sloan Kettering Cancer Center’s Survivorship Initiative, they have established a Male Sexual and Reproductive Medicine Program, which is devoted entirely to the care of men who have suffered sexual difficulties or fertility problems as a result of their cancer or cancer treatment. He directs the sexual and reproductive medicine team, which includes a nurse practitioner, a nurse, and a psychologist.

This presentation summary was derived from the 2015 Prostate Cancer Conference. A DVD recording of the 2015 Conference is available for purchase. Click here to order, or call PCRI at 310-743-2116.