Sexual Dysfunction

Erectile dysfunction (ED) is a risk with every type of treatment for prostate cancer, but the exact risk is very specific to each patient. The better a man’s erections are before prostate cancer treatment, the better chance he has of preserving function. However, even in the hands of the finest surgeons only about 15% of men will have undiminished erectile function two years after the operation. 

Changes in Ejaculation and Orgasm

Men will no longer ejaculate after their prostate is surgically removed. After radiation, many men will also develop dry orgasms. Hormone therapy will decrease the volume of ejaculate. Changes in the sensations associated with orgasm occur at about the same frequency with radiation or hormone therapy as with surgery. Anorgasmia and delayed orgasm are treatable. Problems with painful orgasm will usually resolve over time.

Penile Size and Shape Changes

One of the most devastating consequences of prostate cancer treatment involves the change in penile size: penile shrinkage. This involves not only a reduction in length, but also a decrease in girth. It is estimated that about 70 percent of men will observe a change in the size of the penis after surgery. On average, there is about a 1 cm loss of length. Recent evidence suggests that the loss of penile length can be offset with regular use of Viagra or Cialis.

Libido Changes

One of the common causes of decreased libido is a low testosterone level. If levels are too low, discuss with your physician whether you can take testosterone. 

Managing Erectile Dysfunction

There are multiple ways that men can increase their erections. First-line treatment for men who have a decrease in erectile function is oral medication with Viagra, Levitra, Cialis, and Stendra. How well this works depends on how badly the nerves were damaged from treatment. Men who do not initially respond to pills should at least try them every now and then. Over time, the nerves can heal. Some men who, for example, did not respond well to the Viagra type medications immediately after surgery, will become responsive later. As with any pill, there are side effects and contraindications. You cannot, for example, use them if you are taking certain medications such as nitrates. 

One effective approach to correct ED is to use “intracavernosal injections” (ICI). This involves using a small needle (much smaller than anything you would have ever seen used for drawing blood, for example) to inject medicine that causes erections directly into base of the penis. While this may initially be anxiety-provoking, it has proven to be very effective. There are many formulations of medications and countless dosing regimens, so it is essential that your physician be familiar with all the options. You must also have a detailed discussion with your physician—and preferably have something written out to refer to if you ever develop a prolonged erection, known as “priapism.” While uncommon, priapism is a urologic emergency, so you must understand what to do in case this occurs. 

Another option for increasing erectile rigidity and longevity is a vacuum erection device (VED). This involves inserting the penis into a plastic tube, which uses negative pressure to draw blood into the penis, and then slipping a ring around the base of the penis to keep the blood from draining out. As with any other erection aid, there are benefits and risks, include discomfort caused by the ring pinching the penis, and the risk that the penis could turn “cold and blue.” However, it is a relatively inexpensive approach compared with medications, and it does not involve using needles or the potential side effects of the oral medications.

The final treatment for ED is surgical. The inflatable penile prosthesis (IPP) can be used in men who do not achieve satisfactory erections using any of the previously described treatments. The IPP involves surgically inserting inflatable “balloons” into the penis. 

These balloons are connected by a small tube to a fluid-filled reservoir and pump, located in the abdomen and scrotum, respectively. The pump draws fluid out of the reservoir and into these balloons to produce an erection. When sex is over, a separate “deflate” button causes the pump to drain the balloons and let the fluid go back into the reservoir. Obviously, because this is the most invasive treatment for ED, it should be considered last. There are risks inherent in any surgery, including infection. Mechanical failure of the pump, with the need for further surgery, is also a risk.  

Penile Rehabilitation

Penile rehabilitation (PR) entails taking a small dose of a Viagra type medication every day (usually a quarter of the maximal dose – one pill split up into four parts), and taking a maximum dose (one full pill) once a week. As yet, there is no conclusive research published to support our claims that this policy improves outcomes. Some doctors take this as evidence that PR is not worth the time or the money. In our expert opinion, however, everything a man can do to keep his penis healthy is worth doing. The most important goal is to find a healthcare provider who appreciates how critically important sexual side effects are and has the knowledge and skills to manage all forms of dysfunction.

Conclusion

Sexual dysfunction after a man is diagnosed with prostate cancer takes many forms. Although we know that the vast majority of men will see some decline relative to their baseline erectile function, we have ways to treat this. The most important goal is to find a healthcare provider who appreciates how critically important sexual side effects are and has the knowledge about preventative care and the skills to manage all forms of dysfunction, and to choose an experienced surgeon or radiation therapist with a proven track record of successful treatment.

Kelly A. Chiles, MD, MSc is an assistant professor of urology specializing in all areas of Male Sexual and Reproductive Medicine as well as being an experienced urologic microsurgeon. Dr. Chiles received her Bachelor’s degree from Pennsylvania State University in Microbiology, and a Master’s degree in Biotechnology from Johns Hopkins.  After completing medical school at Pennsylvania State University, she went on to complete her internship and residency at the University of Connecticut.  Dr. Chiles completed an intensive two year fellowship in Male Sexual and Reproductive Medicine at Weill Cornell Medical College and Memorial Sloan Kettering Cancer Center prior to joining The GW Medical Faculty Associates.   

John P. Mulhall, MD is Director of both the Male Sexual and Reproductive Medicine Program and the Sexual Medicine Research Laboratory at Memorial Sloan Kettering Cancer Center. In addition, he is Professor of Urology in the Department of Urology at Weill Cornell Medical College. Professor Mulhall has more than 250 papers published in peer-reviewed journals, and has published numerous books, such as Contemporary Management of Urologic Emergencies (1999), Sexual Function In The Prostate Cancer Patient (2009) and Saving Your Sex Life: A Guide For Men With Prostate Cancer (2008). He has contributed in excess of 30 book chapters and has also edited textbooks, such as Cancer and Sexual Health (2011) and Fertility Preservation in Male Cancer Patients (2012).  Professor Mulhall has been editor-in-chief of Current Sexual Health Reports (2003– 2008) and an associate editor of Reviews in Urology (2006–2010). He is currently editor-in-chief for the Journal of Sexual Medicine. Professor Mulhall is the recipient of numerous awards, including the Career Development Award from the VA (1998), the Robert P. Nelson Award from the Sexual Medicine Society of North America (2001), the Young Investigator Award (2000) and the Jean Francois Ginestie Award (2002) from the International Society for Sexual Medicine. In 2005, he was honored with the Gold Cystoscope Award from the American Urological Association.