Archive - Sex after Prostatectomy & How to Speed up Nerve Regeneration

Usually erections return slowly beginning as partial erections 3 to 6 months after surgery and continue to improve for 18 to 36 months. There is considerable variation. Usually, erections are not as firm as before surgery unless the patient had “perfect” erections to begin with. If the nerves can be partially or completely saved, Viagra and similar medications usually improve erections. If not, Tri-Mix injections, MUSE urethral suppositories, or a vacuum erection device must be used. Some patients prefer to solve the problem with a surgically implanted penile prosthesis. Also, see also Quest Articles on this topic posted on the website.

Normally, men have one or more erections daily. Therefore, the normal physiology of the penis is to have an infusion of well-oxygenated blood several times each day. It is probably not healthy for the tissues of the penis for men to go for months without having any erections – some experts have suggested that lack of erections can cause atrophy (wasting) of important anatomic structures in the penis, such as the valves that trap blood in the penis during erection, and also results in fibrosis (scarring) of the penile tissues.

Some experts recommend that patients induce artificial erections daily after radical prostatectomy to mimic the normal physiologic situation. My policy is to recommend that patients resume sexual activity as soon as they feel an interest and their urinary control is adequate for sexual activity. I usually suggest beginning with taking a Viagra (or similar) tablet two to three times per week about one hour before anticipated sexual activity – and then see what happens with sexual stimulation. Even if it does not produce a full erection, it should increase the blood flow. MUSE or intracavernosal (into the penis) injections of medicines that cause the blood vessels to dilate can also be used for this purpose. For Viagra to work, the nerves and blood vessels need to be functioning. MUSE and injections bypass the nerves, but require sufficient blood flow. If they don’t work, there may be a temporary or permanent deficiency with the blood vessels in the penis. The vacuum erection devices usually work well in most cases.

There are no specific physical exercises that I know of. Viagra does improve the blood flow to the penis in most men. Some experts believe that it is important for men to have frequent erections in order for well-oxygenated blood to keep the tissues in the penis healthy. Erections can be artificially induced with MUSE suppositories, vacuum erection devices, and intracavernosal injections of Tri-Mix, as well. Please see Quest Articles posted on this website for an article on obtaining and maintaining erections.

If the injections were performed correctly and they did not work, it is unlikely that Viagra will work. But are you certain you did the injections correctly? If injections do not work, I believe that the most effective options are the vacuum erection device (get it at a medical supply house or on the Internet) or consider a penile prosthesis.

It is complicated to mix Viagra with injection therapy. Viagra works by prolonging the effects of natural substances produced by your body, while Trimix contains drugs that directly cause the blood vessels to open up. Also, as nerves recover from surgery, there might be changes in the dosage of Viagra and Trimix needed to produce a rigid erection. In other words, you are working with a “moving target.” I would advise you to keep it as simple as possible. It is also less expensive that way.

Viagra is somewhat effective in patients who are receiving various forms of hormonal therapy – especially hormonal therapy with antiandrogens, such as Casodex, that do not lower the plasma testosterone level. This type of potentially “potency-sparing” hormonal therapy does not interfere with sexual desire or erections as much as more complete forms of hormonal therapy, such as Lupron, Zoladex, or removal of the testicles. However, even (some) patients on more complete forms of hormonal therapy have improved erections with Viagra. Their sexual desire is very low, and that also plays an important role.

As soon as the patient (and his partner) feel physically well enough and usually after the return of urinary continence.

Following nerve-sparing surgery, erections usually do not begin to return for 3 to 6 months. Then, they can improve for up to 36 months after surgery. Viagra usually is helpful in hastening recovery. If Viagra does not work, I usually recommend that the patient try a vacuum erection device, MUSE intraurethral suppositories, or injections into the side of the penis (please see the Quest article on return of erections following radical prostatectomy on this website). The other opinion is to have a penile prosthesis inserted. However, with more time, your erections may improve spontaneously.

It depends upon the dose of Lupron used and the extent of injury to the nerves from the brachytherapy. Usually, when the Lupron “wears off,” hot flashes diminish and libido increases. Viagra usually helps.

I would suggest two to three months.

In my experience, erections usually begin to return as partial erections 3 to 6 months after surgery and then continue to improve for about 36 months after surgery, as the nerves recover from the trauma of surgery. It is currently believed by some experts in erectile dysfunction that taking agents such as Viagra, Levitra, or Cialis will hasten the return of erections.The basis for this belief is that, normally, men have erections every day. Therefore, the normal situation for the penis is to receive an infusion of well-oxygenated blood every day. This infusion helps to keep the intricate anatomical structures in the penis healthy.I don’t know of any evidence to suggest that diet helps in this matter. Important factors are to take the erection enhancing medications on an empty stomach to allow them to become completely absorbed, to avoid smoking, alcohol, and, if possible, other medications that can interfere with erections. Keep diabetes under good control. Have regular sexual stimulation. And have patience.

I advise patients to begin sexual activity as soon as they are feeling up to it. I advise patients to avoid straining the abdominal muscles for 6 weeks after surgery. The importance of early sexual activity is to increase the blood flow to the tissues of the penis. Therefore, sexual activities that normally would produce sexual arousal and an erection would fulfill this requirement.

I believe they will improve substantially. It is still very early, and erections can continue to improve for up to 36 months after surgery.

The chances of recovering erections depends upon the patient’s age, how good his erections are before surgery, whether he takes medications for blood pressure or diabetes, how advanced the tumor is, the skill and experience of his surgeon, and whether or not he needs postoperative radiotherapy or hormonal therapy. Agents like Viagra are often helpful in speeding the return of erections.

There is a mixture of 3 drugs called Tri-Mix that, in my experience, many patients find considerably less painful than Caverject.

Thank you.

See other questions concerning the effects of radiation therapy on erections. There is about a 50% chance that the radiation would damage the preserved nerve. It is too early to say whether he will ever have spontaneous erections. There are other effective means of restoring erections such as vacuum pump, injections, suppositories, and a penile prosthesis. Please see Quest articles on this topic on this website.

Although I have limited expertise in this area, it is my understanding that all of the drugs you mentioned can adversely affect erections. You should consider stopping using them, in my opinion.

It sounds to me like you are right on track. Usually, erections begin to return as partial erections 3 to 6 months after surgery and can improve for 36 months. You might respond better to Viagra or other drugs as time goes by.

IMRT can deliver the radiation more precisely, but I agree that it is a stretch to call it potency preserving, if the bed of the prostate that does contain the neurovascular bundles receives a higher dose of radiation.

Normally, men have erections every night. Thus the normal physiology of the penis is to get a daily infusion of well oxygenated blood to keep the tissues healthy. After a radical prostatectomy, men usually have no erections for 3 to 6 months because of surgical trauma (manipulation and stretching of the nerves, sutures to control bleeders, etc.). Then erections begin to return as partial erections that gradually improve for up to 36 months. However, in interim it is believed to be important to get blood into penis at least 3 days per week to keep the tissues healthy. Blood flow is improved by several methods: 1) regular taking of Viagra-like medicines (I usually recommend Cialis 20 mg/day because it lasts longer, but this drug causes some men to have muscle cramps and they have to switch to another); 2) vacuum erection device; 3) injections into the penis of prostaglandin-like drugs that increase blood flow; 4) any sexual stimulation that causes erections normally. All patients should be encouraged to use one or all of these methods for sexual rehabilitation beginning about 1 month after surgery.

Men normally have daily erections with highly- oxygenated arterial blood (arterial blood contains 2.5 times as much oxygen as venous blood). Even male babies have erections every day. These infusions of well-oxygenated blood into the genital tissues keep these tissues healthy and robust and are critical for the propagation of the human species. Testosterone levels decrease with age, and if men are not having frequent erections, the genital tissues gradually undergo atrophy. This condition can be treated with testosterone- replacement therapy (if the blood testosterone levels are low) and with treatments that induce erections with arterial blood (oral Viagra-like medications or penile injections). I routinely incorporate this type of rehabilitation in my postoperative patients. See my article on erectile rehabilitation after radical prostatectomy in the Spring 2013 QUEST.