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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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Vaginal Renewal™

Download a free PDF version of this brochure

I am a cancer survivor in menopause. I don’t want to use estrogen but I am dry and sex is getting more painful. What can I do?


At A Woman’s Touch, we developed a program (beginning in 1997) for people with vaginas who are  experiencing dryness and discomfort or pain during vaginal penetration that is either diffused throughout the vagina or burning or tearing at the vaginal opening. Although originally developed for people who have had radiation therapy to the pelvis to treat different forms of cancer, people with less aggressive symptoms related to menopause also benefit from the Vaginal Renewal™ program.

We also helped manufacture vibrating wands for use in this program, which you can find by clicking on this link.

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Vaginal atrophy, dryness, and lack of flexibility

I am postmenopausal – I have vaginal penetration issues that are severe, tearing and extreme dryness as well as progressive desensitization. I am looking for ways to renew vaginal tissue and increase elasticity. Where do I begin…massage vibrator? moisturizer? kegel exerciser? estriol creams?


Begin with reading through the Vaginal Renewal program.

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Vulvodynia and Vulvar Pain

Why is my vulva so sensitive? I’ve been told I may have vulvodynia. What is vulvodynia? What can be done to treat it?


There are many potential causes for pain in the vulvar region, and the term “vulvodynia” is a word that describes a variety of conditions. Vulvodyina, or chronic vulvar discomfort, is characterized by burning, stinging, irritation or rawness of the vulva. Three different sub-types have been described, and have different treatment approaches:

  1. skin disease,
  2. inflammation of the vulvar opening, and
  3. irritation of the nerves that serve the vulva.

Vulvodynia is a diagnosis made after other diagnoses, such as vaginal infections, neuropathies, sexually transmitted infections, and other dermatological conditions are tested for and found not to be the cause. If you have an actual sore or scab patch on your vulva, you very likely need a series of biopsies to diagnose the problem. (One biopsy isn’t enough: it usually takes three biopsies minimum to determine a diagnosis.) Even when health care providers have extensive genital dermatological experience, the good providers will get a biopsy to confirm the diagnosis.

For skin-related vulvodynia, steroid ointments are used, often successfully, for treatment. (NOTE: Steroid creams, by definition, have alcohol in them, and should be avoided.) Although it is true that we need to be careful of using steroid ointments on the skin of the body (because it causes thinning), the vulva is relatively steroid insensitive, and use of steroids on the vulva does not cause the same problems that it can elsewhere.

Having said that, one should only use the very smallest amount prescribed, and ONLY on the areas where directed. Using more doesn’t make something better, and can cause it’s own problem if you become irritated by the base that the medication is in. Also, make sure to completely avoid the anal area unless your health care provider has instructed you to use the steroid there. The anus is very SENSITIVE to steroid ointments, and thinning can cause fissures and other skin problems you don’t need to add.

For women who experience inflammation of the vulvar opening, good attention to vaginal health may help. The skin at the opening of the vagina is just more sensitive than that of the lips, and often needs some healthy conditioning to help vaginal penetration be more comfortable. Look at the AWT Vaginal Renewal posts, and consider whether that may work for you.

We also find that strict attention to a low inflammation diet (see the AWT Good Sex Diet) helps dramatically with many types of skin inflammation disorders. Some women find relief with alpha-interferon injections, and others choose to pursue a surgical operation (vaginal advancement) when vestibular glands are infected or impacted for a long period of time.

The most severe cases of vulvodynia are those with neurologic irritation. Pain occurs wherever the nerves in the region receive too much sensation: the clitoris, vestibule (vaginal opening), urethra, perineum (skin between the vaginal and anal openings), and down the inner thighs. As in other cases of sensory neuropathies (diseases of the nerves), antidepressants and anticonvulsants may ease the pain in some cases by “resting the nerve” and allowing it to heal.

Other people may need an evaulation by a pelvic floor Physical Therapist, to determine whether a muscle spasm is causing compression on a nerve that you then feel as pain.

Vulvodynia can be a difficult condition. For many of the conditions, the cause is unknown, and the cure elusive. For some women, it’s a big breakthrough to know the name of this condition, and that this is not something “in their head”, or something to be ignored.

For more information, visit the website vulvodyniasupport or contact the National Vulvodynia Association (online at www.nva.org and ask for a referral for a gynecologist or genital dermatologist in your area who is familiar with vulvodynia.

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Vaginal Renewal after Cancer or Surgery

I have completed radiotherapy for cervical cancer, but I’ve noticed that my vaginal space isn’t as big or as flexible as it used to be. Is there anything I can do to help recover my previous abilities?


First, I’d like to address the health part of your question. This part of your body has been through a lot, and needs some recuperative attention. This first information really doesn’t have as much to do with “having sex”, as it does with helping your body heal again.

Healing Step Number Two

Healing step Number One, of course, was that you had treatment for a serious medical threat. Congratulations! Now that you’ve been through the radiation, your body will naturally scar some to try to heal the damage that was inadvertently done while the radiation was zapping those cancer cells. One way to help to soften the scar tissue (inside and outside) is to massage your skin with a moisturizing lubricant of your choice.

The way to do the massage is to make a plan for yourself. I often suggest that you put the bottle of moisturizer by your toothbrush, so that when you brush your teeth morning and night, you also do your massage morning and night. A reminder: this doesn’t mean that you are “ready, honey!” for sex. If you need to lock your bathroom door, by all means do. This is really a self-care issue.

Put a dime-quarter size dab of lubricant on your fingertips, and massage your entire vulva (the outside of your vaginal area), your clitoris, the vulvar lips … by using a press-and-release technique, not a friction massage. Your goal is to bring new blood to your skin with these strokes, and to push old blood and fluid out of the skin. You are not trying to stretch your skin; rather, you are trying to increase your skin’s flexibility. You don’t need to feel “wet” when you are done, but do use enough lubricant that your massage feels somewhat slick, so that you know that you are using enough to moisturize.

If you feel comfortable, go ahead and massage the lubricant into the opening of the vaginal canal, using these same circular strokes. Most women find that they can accomplish this in about five minutes, so you don’t need to feel that you’ll be spending the rest of your life doing this. I usually suggest that women who are at your stage of recovery do this massage for about two weeks before progressing to the next step.

If you forget an evening, or go away for a weekend – don’t worry about it. Your teeth don’t fall out if you don’t brush your teeth once, and your vulva isn’t going to fall off if you forget to do this massage. Just get back to your routine when you are ready or able to do so.

Healing Step Number Three

The next step is to use a smooth-surfaced vibrator (something that can be inserted into the vagina) to help slowly and comfortably massage your inner vaginal skin, and help you massage lubricant far up into your vagina. We recommend using one of the Vaginal Renewal Massage Wands for this part of the process. You can start by just coating the wand with lubricant and inserting it as far as is comfortable. If you’ve had radiation, you may be instructed to push it firmly as far as it can go, so that you break up the developing scar tissue before it gets too thick. You can then turn on the vibrator to a vibration level that feels comfortable, and let it run in place for 5 – 10 minutes.

You’ll want to find out what size will work best for you at this point in your recovery. The best way to tell which size to get is to see how many fingers you’re comfortable being penetrated with when you’re not sexually aroused. Once you know this, you can get a wand that is approximately the same width across as your finger(s). Start with one that is right for you now, rather than something you want to “work up to.” To know when you’re ready to move to a wider wand, you will want to try gently inserting a lubricated finger alongside of the wand. If you can do so comfortably, you’re ready for the next size.

Again, the goal here is to bring blood to the area; to exchange blood/lymph fluid; and to increase the flexibility of your skin. (It isn’t that you’re “too tight” – we don’t want flabby vulva lips here! It’s that we are trying for increased flexibility so that your skin can adjust to penetration if you so choose.)

Healing Step Number Four

The next step is to evaluate yourself with regard to your orgasmic potential. Are you able to bring yourself to orgasm currently? (Could you before, or could you ever?) This is important, because I think the radiation may also have an effect on your blood vessels, which can make orgasm more difficult. If you are able to bring yourself to orgasm, you have my prescription to bring yourself to orgasm at least once a week (for the rest of your life). This is really preventive maintenance of your body. If you are not able to orgasm now, or have never been able to orgasm, check out one of our articles on this site about how to learn to orgasm, or pick up a good book on the subject. If you haven’t tried to orgasm since all of this radiation stuff, please attend to your “homework” and find out if you can still have orgasms.

It’s important to continue to have sexual pleasure, because I have met and spoken with many women who say that the *first* thing they thought of was life/death and surviving, and that they de-prioritized this “sexual pleasure” part. Then, as the years roll by, some of that scarring has already occurred, and it’s difficult for some women to experience orgasmic release. It seems to be an easier road to maintain the system/process than to recover it (although recovery is possible too).

From Here?

The road going forward depends on the process, rather than an endpoint. The path you travel from here may take you to continued daily massages, with intermittent orgasms; or you may find that you can take vacations from the massage/orgasm schedule, and restart the program when you need to. Listen to what your body needs, first and foremost.