Why Do Erections Stop Happening after Prostate Cancer Surgery?
A common cause of ED is anything that damages, stretches or cuts nerves deep in the pelvis, which commonly happens during surgical or radiation intervention for prostate, colon or rectal cancer. It’s common for men with prostate cancer to have pre-surgical metabolic ED, yet prostate cancer therapies themselves cause ED (radiation therapy 43%; radical prostatectomy 58%), because the therapies damage nerves, blood vessels and/or clitoral components. Minimally-invasive surgical approaches may reduce complications right after surgery but still increase post-surgical ED.
The path of the pelvic plexus--the delicate nerves that carry sexual arousal information between the penis and the lower spine--curves around the prostate, colon, rectum and bladder. When surgery is performed on the prostate, or the prostate is completely removed, some nerves will be cut and some will be stretched. Even the most skilled and careful surgeon cannot avoid stretching the nerves. The stretched nerves become stunned, and although they are complete and in place, they cannot function until they recover. Nerves may return to function soon after surgery, but the time of recovery may take up to three years after the surgery.
In the meantime, when the nerves stop working, oxygen-rich blood will stop flowing to the clitoral body inside the penis, and scarring can occur. It’s important to keep blood flowing to the nerves, small blood vessels, and the clitoral body inside the penis, so that the oxygen exchange still happens and will work when nerve function recovers. Often we can’t tell when nerve recovery will occur, so it’s worth it to help blood flow to the penis for the whole three years after surgery. Fortunately, we have techniques that can help improve oxygen-rich blood flow to the penis even when the nerves can’t do the work.
Men who had trouble getting erections before the surgery will have more difficulty recovering after the surgery. This is a “double-whammy”: erectile trouble before surgery adds to the disturbance of prostate surgery and makes it harder to recover erectile function after surgery. Fortunately, penile rehabilitation helps men with any kind of erectile dysfunction, so even if there was trouble before the surgery, recuperation can be helped by penile rehabilitation.
First experience after surgery
From a man’s perspective, he will go into surgery with the penis length and function he is used to. When he wakes up after surgery, he will see that a urinary catheter has been placed inside his penis, both to help drain urine, but also to help keep the passage from his bladder to the penis open. This catheter also artificially stretches the length of his penis.
The clitoral bodies inside the penis won’t get any oxygen filled blood from the time of his surgery. The lack of oxygen, and the unavoidable nerve stretching, will cause the penis to shrink quite a bit, and when the catheter is pulled out (often right before hospital discharge) the penis will appear sometimes half of its length. Shocking as that is, remember the penis doesn’t have to stay that way, and penile rehabilitation (PR) is the process of regaining erectile function, erectile length and girth, and erectile hardness.
Goals of Penile Rehabilitation
The main goals of penile rehabilitation are to:
- Increase daily oxygen exchange to the penis, and
- Maintain length and girth of the penis such that full erection size and hardness are possible once the stunned-nerve period is over.
Regular daily blood flow keeps the erection nerves and blood vessels healthy by bathing them with oxygenated blood, and prevents scarring of the clitoral body inside the penis. If appropriate, medications (see pg. 6) should begin immediately after returning home from surgery. The physical portions of PR should be tried as soon as you feel physically comfortable enough to touch your penis, or by at least 2 months after surgery, whichever is sooner. During early recovery from surgery, there may be discomfort as internal scars heal. If discomfort happens, wait a few days, and start, or restart your program. However, there should never be any pain with PR. If there is pain, you should stop and consult your health care provider.
It’s important to remember: the sooner PR is started, the better the success. However, men who are within the three-year-from-surgery window will still benefit from PR, particularly if they occasionally have soft erections or erections when they wake up. Penile rehabilitation will help on-demand therapies work better (using PDE5-Inihbitors like Viagra before sexual activity), and can create erections hard enough for sexual penetration even when the nerves have been permanently damaged (Vacuum Erection Devices with constriction/cock ring).
For more information on the AWT Penile Rehabilitation Program, click here, or call and ask for a booklet.