I lost my penis in the OR!!

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Dear Dr. Myrtle,

I had my prostate removed about 3 months ago because of prostate cancer, and well, 'Peter’ seems to have gotten lost in the OR. Even though my doctor told me that my erections would go away for awhile, I was more focused on living than I was thinking about sex. Now that I’m mostly healed from the surgery, my erections still haven’t returned, and I’m wondering if they’re ever going to return. Is there anything I can do to help this along? 

Before the surgery...

Sexual arousal and oxygenation of the clitoral caverns depends on the proper functioning of genital arousal structures (clitoral caverns), nerves (nitric oxide producing nerves of the pelvic plexus/arousal system), and several types of blood vessels. Healthy function dictates that the clitoris lightly swells and oxygenates the clitoral caverns about 4-6 times per 24 hours, which accounts for nocturnal and morning erections. It’s the body’s way to make sure that oxygen/blood flow makes it into the clitoris routinely for maintenance blood flow. Our nitrergic nerves produce nitric oxide that diffuses into little helicine blood capillaries of the clitoral caverns, and a bit of oxygenated blood puffs in then flows back out. (Women are usually much less aware of erection/swelling of the clitoris, so this effect happens but it is less obvious.) During sexual arousal, this process of engorgement and filling of the clitoral caverns is a more extensive version, where enough blood flows into the clitoral caverns to press the outflow veins shut, causing the caverns to swell and create an erection.

So, before the surgery, there were two processes happening: one revolving daily intermittent oxygenating erections, and the other of sexual arousal expanding the clitoral caverns to erections.

Where did Peter go?

Anything that changes the structure or function of these components will change the capacity of a person to experience either spontaneous or stimulated sexual arousal events. Prostate surgery is a common cause of temporary or permenant sexual dysfunction in men.

The reason is because the real estate in the lower pelvis is crowded. When surgeons perform removals, revisions or repairs, there often isn't much physical space to move one thing out of the way to get to another. Often, nerves and arteries get stretched or pressed on as different organs are moved for access. However, some of the smaller nerves are cut during organ removal, sometimes because the surgeon can't see the nerves and sometimes because a tumor is too wrapped around a nerve to spare it. If many nerves are cut, function of those nerves is very likely lost. During the process of removal of the tumor in the prostate, every attempt is made not to cut nerve bundles that course around the prostate, as long as the goal of tumor removal is maintained. When a surgeon can avoid the main nerve bundles, the surgery is called "nerve sparing". If the bundles need to be cut to take out the tumor, the surgery is called "NON-nerve sparing". 

Stretch and compression of the nerves cause an immediate slow down or work stoppage of communication along the nerves (technically this process is referred to as “immediate neurapraxia” or “grade 1 neuropathy”). Neurapraxia is a reversible process, but it takes time for function to return.

Depending upon what happened to the nerves in surgery, you might notice an immediate post-surgical change in genital sensation (numbness, tingling or muscle weakness) and/or function (no erection/engorgement/genital swelling). After prostate, rectal and some colon surgeries, often all forms of spontaneous erection/arousal will stop directly after surgery (includes nocturnal, morning and arousal erections). Sometimes, men use urinary catheters (a tube that drains the bladder), and because the tube can temporarily maintain the length of the penis, a man might not notice a loss of length of the penis until the catheter is removed right before he leaves the hospital. 

Eventually, if the nerves were functioning prior to surgery, function will return as long as they were not completely damaged during surgery. As the temporary nerve dysfunction resolves, the clitoris becomes more responsive to direct and cognitive sexual stimulation, and nocturnal erection/arousal activity heralds the return to spontaneous daytime erectile function .

So I should just wait for my spontaneous erections to return?

No. Your clitoral caverns need help while your nerves are recovering. At the time of surgery, the stretched, neurapraxic nerves of the pelvic plexus go on strike, and daily maintenance blood flow stops. The absence of clitoral cavern blood flow causes a cascade of things to begin:

  • lack of oxygen (hypoxia) causes the death of the smooth muscles which line the helicine (pigtail) arteries of the clitoris .
  • stagnation of hypoxic blood allows inflammation (usually a chemical reaction between nitric oxide and free radicals) to occur, enhanced by reduced blood flow .
  • shrinkage of the clitoris as the body’s healing processes increases the scarring/collagen process inside of the clitoris, reducing potential flexibility and shortening both the length and girth of the clitoral body .

If allowed to continue for full effect, this inflammatory/hypoxic process will prevent the clitoris from responding to arousal stimulation even when the nitrergic nerves return to function. Fortunately, one can mechanically pump blood into the clitoral caverns even when the neurologic process of oxygenation isn't working. Vacuum pumped blood is not 100% oxygenated, but some oxygen is better than no oxygen, and the mechanical vacuum stretch of opening the caverns is useful for stretching the sides of the caverns, and pushing old blood out upon release of the vacuum.

The bottom line is that unless mechanical blood flow replaces the blood in the clitoris during early nerve dysfunction, the clitoris won’t be able to respond even when the nerves do.

Is there anything that can be done?

You should know that your level of function going into the surgery determines how much function you'll have afterwards. This is because men with erectile problems already have some injury to their erectile system. The surgery adds additional burden of injury to the system, and makes it that much harder to recover. Keeping this in mind, it would be ideal for men to improve their erectile function BEFORE they undergo the surgery, so that they have more capacity to recover after the surgery.

Another way to say this is: if your system was healthy before surgery, a healthy pre-op predicts healthy post-op. For example, 76% of men under the age of 65 with good pre-operative erectile function who had good nerve-sparing surgical outcome, had recovered effective function after 3 years . This is good news, indeed. On the other hand, if medication (sildenafil/Viagra), was required for successful erection prior to surgery--suggesting pre-surgical erectile dysfunction--successful erection was lower post-surgery .

Penile Rehabilitation

The gist of this process is to mechanically induce blood flow, thereby reducing the fibrosis and scarring of the inside of the penis. This allows the maintenance of length and girth by preserving the flexibility and function of the clitoral structure.

At home, four main techniques may be used separately, or in a coordinated program, depending on the effect and acceptability. To read indepth descriptions of the AWT Penile Rehabilitation program, click on the pdf brochure available in the education section of this website. The four at home techniques are:

  • Vacuum pumps with or without erection rings,
  • Phosphodiesterase 5 Inhibitors  (PDE5i)(sildenafil/Viagra)
  • Self massage of the penis, to enhance blood flow out of the penis, stretch the clitoral cavern walls, and keep normal sensory experience of touch to the genitals.
  • Pelvic floor muscle exercises, since two of the pelvic floor muscles contribute to holding blood in the penis during erections.

Each one of these techniques works on a different aspect of the erection/arousal system, and they all have supportive effects on the other techniques. (Doing one helps the others.) Some men cannot tolerate PDE5i's, while others can't or won't massage their genitals. We've found that men who embrace the whole program have better outcomes than those who engage with only a part of it.

Of all of the techniques, the one most responsible for maintaining length and girth of future erections is vacuum pumping. From 4 weeks post surgery, routine mechanical vacuum perfusion of the clitoris is important to minimize hypoxia-related scarring and cell death of the lining of the blood vessels. Vacuum pumping once or twice a day to low pressures mechanically holds the outer walls of the clitoris open so that blood can more easily fill the caverns. Vacuum pumping is so successful that between 52-60% of men with completely severed pelvic plexus nerves can achieve successful erections with the use of a vacuum pump and erection ring (cock ring) . Until you know for sure whether nerve function is going to return, maintaining routine vacuum blood flow will work in your favor.

It is important to note that high vacuum pressures are not important: in the early therapy exchanging the blood is important, not creating a complete erection. Vacuum pumps are very well tolerated, non-pharmacological tools, and risk occurs at high or prolonged vacuum pressures . If you use a constriction/cock ring, only wear it for 30 minutes, then take it off. You can re-pump new blood in there in a bit.

Your orgasmic capacity is also something to think about. A decade ago, when surgeons knew less about neurologic control of erection and so unknowingly cut through more of the pelvic plexus, 25% of men had normal post-operative orgasm, while 50% reported a decrease in orgasmic sensation. With today’s current surgical awareness, nerve-sparing surgery is much more actively pursued, with an astonishing 92% normal post-op orgasm reported. This underlines the fact that orgasm is not dependent upon erection, and men with incomplete erections are able to happily stimulate themselves to orgasm routinely after prostate surgery. Many men, unaware of this fact, become depressed at the slowness of return of erection, and don’t even try to stimulate themselves to orgasm.

Be an active participant in your recovery.

The bottom line: none of us knows how well preserved your nerves were during the surgery. We do know that successful penile rehabilitation--including the use of vacuum pumps--can help to preserve normal erectile function. Taking a rehabilitative stance and mechanically reestablishing blood flow preserves function, and experiment on methods of stimulation to reestablish your orgasmic pathway can help maintain this important neurologic function.

Take Care,
Dr. Myrtle

References 1. McCullough AR, Sexual dysfunction after radical prostatectomy. Rev Urol. 2005 7S2:S3-10.2. Martinez-Salamanca et al, Orgasm and its impact on quality of life after radical prostatectomy. Actas Urol Esp. 2004 28(10):756. 3.McCullough AR, Sexual dysfunction after radical prostatectomy. Rev Urol. 2005 7S2:S3-10. 4.Dall’Era et al, Penile rehabilitation after radical prostatectomy: important therapy or wishful thinking? Rev Urol 2006 8(4):209. 5.Hong et al, Effect of statin therapy on early return of potency after nerve sparing radical retropubic prostatectomy. J Urol 2007 178(2):613. 6. Albersen et al, Preclinical evidence for the benefits of penile rehabilitation therapy following nerve-sparing radical prostatectomy. Advances in Urology. 2008. pg 1.7.Ciancio and Kim, Penile fibrotic changes after radical retropubic prostatectomy. BJU Int. 2000 Jan;85(1):101. 8. Munding et al, Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy. Urology 2001 58(4):567. 9. Gontero et al, A prospective evaluation of efficacy and compliance with a multistep treatment approach for erectile dysfunction in patients after non-nerve sparing radical prostatectomy. BJU Int 2005 95(3):359. 10. Rabbani et al, Factors predicting recovery of erections after radical prostatectomy. J Urol 2000 164(4):1929. 11.McCullough AR, Sexual dysfunction after radical prostatectomy. Rev Urol. 2005 7S2:S3-10. 12.Albersen et al, Preclinical evidence for the benefits of penile rehabilitation therapy following nerve-sparing radical prostatectomy. Advances in Urology. 2008. pg 1. 13.(pre sildenafil: Cookson & Nadig, Long-term results with vacuum constriction device. J Urol1993; 149(2):290); post sildenafil: Raina et al, Early use of vacuum contriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function Int J Impot Res 2006 18(1):77, Kohler et al, A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. BJU Int 2007 100(4):858. 14.Lowentritt et al, Sildenafil citrate after radical retropubic prostatectomy. J Urol 1999 162(5):1614. 15. Mullhall JP, Morgentaler A, Penile rehabilitation should become the norm for radical prostatectomy patients. J Sex Med 2007 4(3):538, Zippe CD, Pahlajani G. Penile rehabilitation following radical prostatectomy: role of early intervention and chronic therapy. Urol Clin North Am. 2007 34(4):601. 16. Hong et al, Effect of statin therapy on early return of potency after nerve sparing radical retropubic prostatectomy. J Urol 2007 178(2):613. 17. Shiri et al, Cardiovascular drug use and the incidence of erectile dysfunction. Int J Impot Res. 2007 19(2):208. 18. Becker et al, Plasma levels of angiotensin II during different penile conditions in the cavernous and systemic blood of healthy men and patients with erectile dysfunction. Urology 2001, 58(5):805. 19. Dorrance et al, 2002 20. Speel et al, Long-term effect of inhibition of the angiotensin-converting enzyme (ACT) on cavernosal perfusion in men with atherosclerotic erectile dysfunction: a pilot study. J Sex Med 2005 2(2):207, no significant difference from placebo. 21. Gontero et al, A prospective evaluation of efficacy and compliance with a multistep treatment approach for erectile dysfunction in patients after non-nerve sparing radical prostatectomy. BJU Int 2005 95(3):359. 22. Ganem et al, Unusual complications of the vacuum erection device. Urology 1998;51(4):627. 23. Koeman et al, Orgasm after radical prostatectomy. Br J Urol 1996 77(6):861. 24. Martinez-Salamanca et al, Orgasm and its impact on quality of life after radical prostatectomy. Actas Urol Esp. 2004 28(10):756.