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Penile Rehabilitation after Prostate or Pelvic Surgery or Radiation

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:
  1.   Increase daily oxygen exchange to the penis, and
  2.   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.
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Self Pleasuring for People with Penises and Prostates

Download a free PDF version of this brochure

Self-pleasure, also known as masturbation, specifically refers to touching yourself sexually in a way that feels good.  There is no right way to masturbate, and as long as it doesn’t hurt, there’s no wrong way either.  You can do it alone, with a friend, or as part of sex play with a partner.  Pleasuring yourself, on your own terms, is a way to deepen your relationship with the most important person in your life—you!

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Anorgasmia and Anti-depressants

Why am I not having orgasms since I started taking antidepressants? I’m a lot happier since I started my antidepressant medication, but … it’s a weird thing … I can’t seem to have orgasms anymore. It’s not like I want to be depressed, but this isn’t a great trade-off. Any suggestions?

It’s important to distinguish between someone who has never experienced an orgasm (called primary anorgasmia), and someone who used to have orgasms, but now cannot have them as frequently, or at all (secondary anorgasmia). For people who have never experienced an orgasm, often it takes learning more about yourself, your anatomy, and how your personal arousal cycle functions.

The experience for people who once experienced orgasms, but later cannot, is a very frustrating one. There are many possible reasons for secondary anorgasmia. Often something has changed physically, emotionally, or medically, or certain medications/herbs are taken.

  • For a physical example, some women stretch their pelvic floor in the process of birthing a child. This lack of tone in the pelvic floor takes away some of the arousal pressure the pelvic floor exerts on the clitoris, making it harder to reach orgasm.
  • For an emotional example, some people find that they are not as emotionally comfortable with a new partner, or are uncomfortable touching themselves when they don’t have a partner.
  • For a medical example, some people experience lower blood flow to the clitoris due to the same process that causes hardening of the arteries. This decrease in blood flow makes clitoral erection and orgasm much more difficult.
  • Other people experience less sensation due to illness (like multiple sclerosis or diabetes), and although their blood flow is adequate, their nervous system isn’t cooperating as it used to.
  • For a medication-related example, some people who take SSRI-type antidepressants, beta-blockers, or hormonal contraceptives find they can no longer have orgasms as easily, or at all.

For you, it’s possible that the antidepressant you take is a contributing problem. Call your pharmacist, and ask if the medication that you are taking is a “SSRI” antidepressant. Trade names of some popular SSRIs are Prozac, Zoloft, or Paxil, to name a few.

In the medical literature, SSRIs are described as a potential cause of male impotence, but for women this side effect is more often manifest by difficult in achieving orgasms, although they may become quite aroused. Why? We speculate that there is a lengthening of time of the arousal cycle (probably in men and women), so it may take more time, stimulation, and patience to achieve orgasm.

If you think that this is complicating your pleasure, there are a couple of strategies that we can recommend. First, consult the person who has prescribed this medication for you, and ask whether you still need to be on it, and if so, whether you need to be on this particular dose. Some women notice that their orgasms are easier to achieve with lower dosages of SSRIs.

If you and your prescriber think it’s still a good idea for you to take it, don’t give up. You may find that you can have wonderful orgasms with more intense stimulation than you may have needed in the past. You may want to consider beginning to use a vibrator, or using a stronger vibrator than before. Our suggestion, based on our customer’s experience, is to try out a more intense vibrator like Magic Wandbecause the consistent vibration may increase your arousal over your orgasmic threshold. Finding the right strategy for you may be trial and error (because no one can know what will work for you but you), but we suggest that you take it on as a pleasant opportunity to learn more about yourself. (All homework should be this fun.)

Be happy and have your orgasms, too.

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Eager Ejaculation and what you can do

Download PDF brochure version.

Try as I might, I can’t seem to last as long as I’d like to. How can I prolong sexual penetration without coming?

In books and movies, our culture glorifies the mad, passionate rush to intercourse as the ultimate sexual experience.  Unfortunately, frenzied sexual experiences can sometimes be unsatisfying and difficult to control.  If ejaculation occurs before either partner wishes, it is often called “premature ejaculation.”

This makes it sound like a medical disorder, but it’s not.  Even the fastest ejaculation isn’t a problem if both partners prefer it that way.  Partners who are not particularly fond of intercourse, for instance, may prefer orgasm through oral sex or a vibrator, and may look forward to the fastest draw in the West.

The key is satisfaction, not endurance.  That said, you can learn to work with your arousal and gain more control  over when and how often you ejaculate, so that you can have prolonged, slow-to-climax interludes, “quickies,” or anything in between!  It’s a great opportunity to expand your sexual repertoire.

Things NOT to try.

Some folk remedies that don’t work very well:

Men sometimes drink alcohol to slow themselves down.  Alcohol can slow responses, but it may also make it difficult to get or keep an erection.

Some men’s partners take a hands-off approach, hoping that a lack of caressing and touching will allow their mates to last longer.  But if touching is not allowed, what’s the point of having sex?

Some men try to dissociate themselves by reciting baseball statistics or all 50 states in their heads.  This “focus-on-something-else” approach doesn’t take into account that arousal is an involuntary response.  Involuntary responses are nearly impossible to consciously control.  Think of what happens when someone asks you to stop focusing on your nose: if someone makes you think of your nose, it’s tough to focus on anything else!

All of these solutions can take you away from what you are doing and feeling, and are very unlikely to lengthen your sexual experience or heighten your pleasure.

In some cases, your doctor might prescribe an SSRI (Selective Serotonin Reuptake Inhibitor; commonly used as an antidepressant) to delay ejaculation.  Studies show that some SSRIs can delay ejaculation by about a minute, which gives you enough time to begin using the techniques explained here.  A word of caution: when you stop taking the SSRI, you may experience a quicker ejaculation than you did while you were taking it.  Be patient, and stay with it; the practice you gained while taking the medication can help you continue to work with and learn about your arousal levels.

What exactly happens in arousal?

Arousal is actually a part of our every moment.  Arousal keeps us breathing, increases when we need to concentrate on something important, and calms down to let us sleep.  The arousal system even has its own neurological pathway (the autonomic nervous system), separate from the nerves that make your fingers move.  But arousal cannot be controlled directly.  For instance, your heart beats without you deciding to make it beat.  Although you can slow your heart rate a little bit by thinking about it, it’s impossible to control your heart rate entirely with conscious thought.

Likewise, during sexual arousal, any person has room to tinker, particularly in the early stages.  However, one may reach the “point of no return”–the brink of the orgasmic threshold when it is no longer possible to slow down and delay orgasm.  Learning how to finesse your personal arousal is the key to choosing the satisfying sexual experiences you desire.

In men, it’s often assumed that orgasm and ejaculation are one and the same.  That’s not quite the case.  There are two stages of a man’s orgasm: the cognitive awareness of pleasure, and ejaculation.  These events happen two or three seconds apart.  During the contractions of the prostate gland, the arousal system sends pleasure feedback to the brain, which is experienced as an orgasm.  Men may experience the prostatic contractions as a pleasant fluttering or throbbing sensation.  The second stage, ejaculation, occurs as stronger muscle contractions propel semen down the urethra and out the tip of the penis.  The “point of no return” actually happens after the first part–the pleasure–and before the second part–the ejaculation.

Path One: Come and Come Again!

One strategy is to have a whole bunch of orgasms, rather than just one.  Who wrote that “only one” rule, anyway?  This is your sexual pleasure we’re talking about, and no one else decides when the curtain goes down on your party.  It’s okay to accept what is and have fun the way you are.  Does it have to mean the end of everything because someone ejaculates?  Nope!  Sometimes, it’s helpful to give yourself permission to have a big, long sexual session.

The multiple orgasms and multiple ejaculations technique is probably the easiest to learn.  The idea is to focus very consciously on the sensations that are arousing to you, do exactly what arouses you most, and don’t hold anything back.  Play around, and if you want to ejaculate again, go for it.  If you need a toy like a dildo or vibrator to increase the intensity of your erotic play, consider investigating the possibilities rather than holding back.

Having trouble getting an erection after ejaculating?  Try using a cock ring.  Cock rings are great when your body says “not yet,” but your desire is still flowing.  A cock ring is a flexible strap that can be secured around the base of the penis.  It works by allowing blood to flow into the penis, but not out.  You can put a cock ring on when you are soft or after you’ve gotten another erection.  While you shouldn’t leave one on for more than 30 minutes, there’s a lot you can do in that amount of time.

The major drawback to multiple ejaculations is that it can be hard to avoid post-ejaculatory stupor.  With several ejaculations, your arousal system will have exhausted itself, and you might not have the energy to go on without some sleep.

Path Two: Multiple Orgasms without Ejaculation

It’s possible to learn to stop every orgasm before ejaculating, and to orgasm several times without ejaculating at all.  Interestingly, it’s the ejaculation itself that is often experienced as exhausting, and some men who experience multiple orgasms without ejaculation notice an energizing effect.

The technique described below is essentially a prolonged session of playing “faster-slower.”  The goal is to stay somewhat aroused while you manipulate your arousal level.  Enjoy the feelings of both decreasing and increasing arousal.

Once you can do this, try masturbating to orgasm, and concentrate on the sensations of the prostate.

You need to learn what it feels like to experience the orgasm (for most men, the prostate fluttering) before you can know when to hold back from ejaculation.  Focus on the sensations, and see if you can experience the orgasm separate from ejaculation.

Next, you will need to become aware of your personal arousal and orgasmic cycle.  It’s helpful to rate your arousal on a scale from 0-10, with 9 or 10 indicating the point of no return.  Start by choosing a number in the middle, like 4 or 5, then practice masturbating to a fever pitch and slowing down as you reach that number.  You will still be aroused with minor stimulation, and you will learn what it feels like to be aroused to a 4.

Then, pick a slightly higher number on the scale–say, a 7.  It’s a little trickier here, but you really want to focus on lower arousal.  One thing to try is to take long slow breaths in, and let the breaths out quickly in a couple of bursts.  This helps disperse your sexual energy and take the tension out of your spine and lower back.

Another arousal-slowing technique is contracting your pelvic floor muscles.  Contract these by squeezing the muscles that run from your tailbone, around your anus, and all the way forward to the base of your penis.  When you are contracting correctly, the base of your penis will bob up and down slightly.  Next, incorporate pelvic floor contractions into your masturbation play.  Masturbate up to a 5, then contract for two seconds.  Slow and speed your self-play, and work on incorporating this PC flex into the ups and downs of your arousal cycle.

Similarly, you can control your ejaculation by pressing firmly on the perineum–the area between your scrotum and anus–while contracting your PC muscles.  This helps delay ejaculation by refocusing your attention on your arousal and interrupting the ejaculation reflex.

Perineal massage can be quite pleasurable, and some men think that it’s the greatest sexual technique they’ve ever experienced.  Perineal massage can be done by yourself or your partner, and can be performed at any time during self-play or penetration.

Okay, I’m having a blast here, but what about my partner?

With increased awareness of sexual arousal and physical cues, you can expand your practice to include partners. With a partner involved, you might have to relearn most or all of your cues.  Why?  Because it’s one thing to stop your hand, or turn off your vibrator when you need to ease off, but it’s a much greater task to communicate to your partner where you are on the arousal scale.

Fortunately, most couples report that the process of talking is in itself very satisfying, because they feel more connected than when they are silent.  Also, all of the techniques that you’ve been practicing work with partners, because none of them require that you pull out from penetration.  Your partner will have fun playing with you and your arousal, pressing your perineum and practicing your breathing techniques with you.  Learn more about your and your partner’s responses to sensation and practice expressing yourself.

Additional Resources:

The New Male Sexuality, by Zilbergeld

Male Multiple Orgasm, by Pokras

The Multi-Orgasmic Man, by Chia and Arava

The Multi Orgasmic Couple, by Chia and Chia, for hetero-

sexual couples interested in multiple orgasms for both partners.

Most of all … have fun!

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Penile Erectile Dysfunction

My friend told me that he has complete erectile dysfunction, and feels as though his sex life is over. Is there something that he can do?

Erectile dysfunction is a condition where a penis cannot get or maintain a hard enough erection for penetration. Due in part to cultural messages that suggest that sex equals penetration, many people and their partners feel that their sex life is over if they begin to experience erectile difficulties or dysfunction.

There are “things he can do,” but it’s wise to back up and ask, “Is there anything he wants to do?” Does the man want to change something for himself, or for his partners? Can he talk to his partner(s) about sex? What does sex mean to him? What it means to him to have “lost sex”?

Sex is intimate contact with oneself and/or between consenting adults. Penetration is one act of intimate contact, and many forms of mutual pleasuring (masturbation being one of them) are available to him that do not involve an erect penis. Sex does not have to stop, and intimate sexual contact can be re-initiated with some forethought and preparation, and less focus on penetration as the most desirable or only sex act available to him and his partner(s).

But what if penetration is really important to him?

If your friend wants to investigate his erectile difficulties, he needs more information. Is the cause medical? Hardening of the arteries (arteriosclerosis), high blood pressure, and diabetes are common diseases in the United States that can have a strong impact on the ability for a man’s penis to become erect. There are medical and surgical treatments for these conditions that can be prescribed by a health care practitioner. Non-pharmacological solutions involve instruction in the use of cock rings or penile vacuum pumps; erection rings work by keeping blood in the penis, while vacuum devices draw blood into the penis using suction. While some might want erections to happen “naturally,” few people will turn down the opportunity to have a fabulous pleasure opportunity with a fun suction device. For some couples, non-drug devices can mean the difference between having “sex” and not.

Sometimes, erectile difficulties do not have a direct medical cause. Is the hard erection of a man’s early life the only “erection” he thinks is real? For these people, understanding changes in the body as we age can make a huge difference in their confidence and erections. Some people or their partners need extra stimulation with hands or vibrators to maintain their arousal/erections. Accepting the challenge rather than quitting can mean hours of pleasurable play with fluctuating erections. Opening up to new possibilities can make changes happen all through our (sex) lives.

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Using a Penis Pump

Penis pumps work to pull more blood into the penis than would normally be present during engorgement resulting from sexual arousal. The result is a slightly larger, firmer penis that is more sensitive to contact. This enlargement is not long-lived, and there is no evidence that a man can permanently enlarge his penis by repeated use of a pump.

However, you can maintain the enlargement and sensitivity longer by fastening a erection ring around the base of the penis after the pump has been used and the maximum amount of blood has been pulled into the penis. The erection ring will slow the blood flowing out of the penis, so the enlargement can remain longer. To prevent damage to the blood vessels, we do not recommend that you wear a erection ring longer than 30 minutes in this circumstance.

This method also works for a penis with a  less-firm erections due to medications or the effects of aging. Again, we recommend only wearing the erection ring for a maximum of 30 minutes, to avoid any damage.

There are stories of penises who have permanently damaged their penises from over-pumping, stretching out the skin and ligaments. As with anything, moderation is the best way to experiment with a penis pump.

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Diabetes and Erectile Dysfunction

My husband has recently experienced complete erectile dysfunction. We are both 34 years old, and he is diabetic. The problem started about a year ago and has grown increasingly worse – at this time he is unable to maintain an erection at all. To say the least, I am not taking this well and believe it to be psychosomatic; he believes it is medical. I have a hard time believing it’s a medical problem even though he’s diabetic, because he maintains his blood sugar within normal limits. What do you think?

First of all, diabetes (type 1 or 2) is one of the leading causes of erectile dysfunction in people with penises. Why? Well, think of erectile dysfunction as being caused by three major categories of things: blood-supply related, nerve-related, or emotional factors. We will talk about the emotional part below, but I want to focus on the medical causes first.

Any form of diabetes (as well as metabolic syndrome) has profound effects on both the neurological system and the blood (vascular) system. For people with diabetes, their chances of experiencing partial or complete erectile dysfunction is fairly high at some point in their lives. The fact that your husband is relatively young doesn’t mean much in the scheme of things, particularly if he has had diabetes for a number of years.

Good control of blood sugar levels is critical for staving off some of the blood vessel and/or nerve complications of diabetes, but this information really wasn’t available to people with diabetes until about 1994. Before that time, what healthcare providers thought “good blood-sugar control” was, was, in fact, much higher than the optimal levels we try to achieve today. Realistically, this means that despite your husband’s (and healthcare provider’s) best efforts, his blood sugar was probably allowed to be somewhat higher a few years ago than what we consider to be optimal by today’s standards.

High blood-sugar levels can make a mess of sensory nerves in particular. When your partner’s mind might be thinking, “I’m aroused now”, his penis may not be getting the message, literally. Does it mean that he doesn’t want to make love? No, it doesn’t, but his penis might not be able to respond to his brain’s arousal message. High blood-sugar levels also muck about with people’s arteries, so even if his nervous system says, “Hey down there, we’re aroused up here, so open up the gates!”, the flood gates of his penis might not open up enough to allow enough blood into the penis to make an erection possible.

I mentioned above that there are emotional reasons why men can have difficulty with their erections (performance anxiety among them). You might not realize that the tension that you are describing in your question (“I believe it to be psychosomatic, he believes it is medical”) may be adding to your sexual difficulties and frustrations. Your “not taking this well” may add another load of sexual performance stress to an already difficult situation.

There are medical tests that your partner can undergo which can help him discover the cause of his erectile dysfunction. But the bottom line is, he has a difficult disease, and he can’t make it go away. He has to deal with his diabetes in the best way that he can, and his erections may be altered by damage caused by the diabetes. Fortunately, there are solutions for underperforming erections (penis pumps or erection rings) and a program called Penile Rehabilitation may help him mitigate some of the problem.

I’m not saying that you shouldn’t be disappointed. You both may have some grieving to go through – each of your sex lives has changed, and not by choice. Does that mean that you should give up on having sex? Not at all. Just because a person doesn’t have blood in his penis, doesn’t mean that he has lost all sensation or desire for sex. Some couples have discovered a whole new world of sexual intimacy because they have gotten away from (willingly or not) society’s focus on “Sex = Penetration”. Does your husband feel the loss in the same way as you do? Does he want to try new things? Are you still in a place where you can work together as a couple to find solutions?

If you’re missing pleasure from your intimacy, there are strategies that will lead both of you to sexual fulfillment and satisfaction, but it means that both of you have to be in a place *as a couple* where you can work together, rather than needing to assign blame. For example, as a couple, you may want to discuss this with a certified sex therapist. You can take responsibility for your own sexual satisfaction. Beginning to play with sex toys may be the most satisfying decision you two have made, and with your pleasure being valued and provided for, the tension about his erections may become a thing of the past.

Many men who have talked with us in the store have been very satisfied with exploring their alternatives, both medical and non-pharmacological. There are many resources out there for you, so it’s up to you to start the conversation.