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

Questions & Answers

What is the pattern for return of sexual function after prostate surgery?

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.

Can you recommend specific exercises that may help with obtaining or increasing erections? For example, I have read that leg presses increase blood flow to the penis. Is there any literature on this subject?

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.

Can you recommend specific exercises that may help with obtaining or increasing erections? For example, I have read that leg presses increase blood flow to the penis. Is there any literature on this subject?

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.

After prostate surgery, what is the best thing for an erection. We have tried the injections they seem not to work. Do you think Viagra will work better?

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.

I had a radical prostatectomy about six months ago. To treat the resulting ED, I began Viagra therapy one month after surgery and injection therapy four months after surgery. I am using a TRIMIX cocktail. I have been surprised by how exact the dosage level must be in order to achieve adequate rigidity without having the erection continue for several hours. If I took Viagra an hour before injection, might I be able to take a lower dosage of TRIMIX and have a wider range of what will be successful? As it is, a slight underdose or a slight overdose is very unsatisfactory, though the second is to be preferred.

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.

Tell me about the use of Viagra for a prostatic cancer patient who is taking hormone treatments and Casodex.

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.

When can sexual intercourse start after a prostatectomy?

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

Eight months ago I underwent a nerve sparing prostate surgery. I recovered well and my last PSA count was <0.03. But till now I cannot get an erection although I used several times 100 mg Viagra. Please advise.

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.

My husband had Lupron injections twice before a seed implant to reduce the size of the prostate. He is doing well, now, 7 weeks after the implant. When is it reasonable to expect potency to return. Does Viagra help?

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.

How soon after brachytherapy can I resume normal sexual relations?

I would suggest two to three months.

I am a 57 year old man who had a RRP 6 months ago. I currently have sex 2-3 times per week using prostaglandin injections and Viagra. Can you give me an estimate as to when most men see a substantial and noticeable improvement in erectile function? Also, are there any foods or supplements that can promote the nerve regeneration process, and are there foods to avoid that might help the healing process?

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.

How soon can a man resume sexual activity after a retropubic prostatectomy? What activities are to be avoided and for how long? What activities are the best to help a man start to regain his sexuality?

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 had nerve sparing radical prostatectomy nearly ten months ago. My PSA is in the undetectable range and I am fully continent. At the moment I can achieve reasonably rigid erections on my own but not with my partner. In fact, my problem is that my erections are the result of massaging for a long time, not a reaction to sexual simulation, as it was before prostatectomy. Will the old erections through sexual stimulation gradually come back to replace the need for long, mechanical massaging?

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

After a RRP, when and what are the possibilities for return of erections? Is an agent like Viagra or Cialis required to start or help in the recovery?

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.

I have used Caverject impulse penis injections 5 mg doses but it gives me severe pain in my penis during and after use. I was wondering is there any of type of injection medication that can be used that doesn’t cause so much pain.

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

You recently received a question about pain during and after a PI induced erection via Caverject. You recommended the Tri-mix as a possible solution. I have tried both Caverject and three different formulas of Tri-mix and find the discomfort similar, but would offer this suggestion: to avoid about 90%(or more) of the discomfort all I need to do is remain lying down following an orgasm until detumescence is complete. It is the standing up (including walking around) that needs to be avoided after sexual activity to greatly minimize discomfort. Once this has been documented in your own mind by personal experience any negative sensation during sexual activity seems to be easily minimized and overlooked, knowing that you will not be uncomfortable following sex as long as you stay lying down for a while. I normally prefer the Tri-mix, but it has to be refrigerated so the Caverject is the way to go when on vacations, etc.

Thank you.

My husband is 57 and had a radical prostectomy . The seminal vesicles had cancer in them. The lymph nodes were negative. Only the nerves on the right side were spared. He is scheduled to undergo 35 radiation treatments as a precaution. His PSA 6 weeks post-op was less than 0.1. Will his radiation treatments destroy the nerve bundle that was spared? Will he ever have an erection again? So far Viagra has not worked.

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.

I had RP 8 months ago and still haven’t be able to gain an erection. I understand that drugs like smoking cigarettes and marijuana and excessive alcohol consumption could cause permanent damage to your nerves in the penis and cause delay of normal erections. My question is can nicotine from chewless tobacco cause the same affect as smoking cigarettes? I’ve noticed that if I smoke marijuana before injecting Tri-Mix, I don’t get an erection or one sufficient enough for intercourse.

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.

I had retropubic radical prostate surgery about six and a half months ago. I am sixty-five years old. I am nearly dry, but still wear a light pad during the day. More for peace of mind than leaks. Sexually I have both mild erections and orgasms, but have yet to achieve satisfactory penetration. Am I still on the mend, and might things continue to improve? It is interesting to me that my spontaneous erections are nearly as intense as those I achieve with medication such as Viagra.

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.

How can IMRT be claimed to be a potency preserving salvage PC treatment (Int J Radiat Oncol Biol Phys. 2002 Sep 1;54(1):101-6) while delivering a higher dose of radiation to the prostate bed, the place where the post-RRP nerves are located?

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.

I underwent a nerve-sparing radical prostatectomy 4 months ago. All went well, and my recovery has been excellent. When can I expect erections to return (none yet and I have been using Cialis 10MG for about 5-6 weeks)?

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.

What causes the penis and testicles to draw up into the body 6 years after prostatectomy?

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.

I have just re-ordered my next refill on Cialis (tadalafil) and have questions concerning erectile dysfunction medications. At my physical examination this past summer, my primary care physician seemed a bit surprised that I was taking 20 mg Cialis daily. Am I doing something wrong? He seemed concerned about the dosage. Also, my new prescription just cost me $230. Many of these drugs seem to be reaching ‘generic’ stage. Shouldn’t the costs be coming down? Also, I seem to have a sex drive that is reduced.

You can now get tadalafil (Cialis) through GoodRx at less than $1 per 20 mg pill. If you are taking this drug daily, because of its longer half-life in your body, the recommended dose is only 5 mg; whereas, for “on-demand” use, the dose is 20 mg.

Sex drive is usually related to the blood testosterone level. You should have an early morning blood draw for testosterone. Visit my website at www. and search the terms “testosterone,” “libido,” and “erectile dysfunction” for more information.

The Bi-mix injections that I am using for erectile dysfunction (Bimix, papaverine 30 mg/mL phentolamine 5 mg/mL) at 40 units are not giving me good results. Is it possible to increase to a stronger formula?

You could increase the amount of Bi-Mix 30-5 that you inject up to 100 units (1 mL). There is a 100 unit syringe with the same ultrafine 31 gauge as you have been using on the 50-unit syringe. Other options include Tri-Mix, Quad-Mix, or Super Quad- Mix. All of the latter include a drug called alprostadil that causes aching after injection in about 15% of patients.

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