Sexuality for the Man With Cancer

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How pelvic surgery to treat cancer can affect erections

Surgery types

Some types of cancer surgery can interfere with erections. These include:

  • Radical prostatectomy – the removal of the prostate and seminal vesicles for prostate cancer
  • Radical cystectomy – the removal of the bladder, prostate, upper urethra, and seminal vesicles for bladder cancer. Removal of the bladder requires a new way of collecting urine, either through an opening into a pouch on the belly (abdomen) or by building a new “bladder” inside the body. (See “Urostomy, colostomy, and ileostomy” in the “Special concerns linked to certain cancers and their treatment” section to learn more about the opening and the pouch.)
  • Abdominoperineal (AP) resection – the removal of the lower colon and rectum for colon cancer. This surgery may require an opening in the belly (abdomen) where solid waste can leave the body. (See “Urostomy, colostomy, or ileostomy” in the “Special concerns linked to certain cancers and their treatment” section.)
  • Total pelvic exenteration – the removal of the bladder, prostate, seminal vesicles, and rectum, usually for a large tumor of the colon, requiring openings for both urine and solid waste to leave the body. (See “Urostomy, colostomy, or ileostomy” in the “Special concerns linked to certain cancers and their treatment” section for more on this.)

These operations can interfere with erections in different ways, mainly by damaging nerves or blood vessels. We will go into more detail about this below, and also talk about other factors that can affect erections after surgery.

Most men who have these types of surgeries will have some difficulty with erections (called erectile dysfunction or ED). Some men will be able to have erections firm enough for penetration, but probably not as firm as they were before. The good news is that today there are many different treatments for ED that can help most men get their erections back. It might take some time, but if you are willing to try the different options, you’ll most likely find one that will work.

Damage to the nerve bundles that cause erections

The most common way surgery affects erections is by removing or injuring the nerves that help cause an erection. All of the operations listed above can damage these nerves. Damaging the nerves is like fraying a telephone wire – the message to start an erection is either weakened or completely lost. The nerves surround the back and sides of the prostate gland between the prostate and the rectum, and fan out like a cobweb around the prostate. During surgery the doctor may not be able to see the nerves, which makes it easy to damage them.

When possible, “nerve-sparing” methods are used in radical prostatectomy, radical cystectomy, or AP resection. In nerve-sparing surgery doctors remove the prostate or rectum while carefully avoiding the nerves around it. When the size and location of a tumor allow for nerve-sparing surgery, more men recover erections than with other techniques. But even if the surgeon is able to spare these nerves, they are still injured during the operation and need time to heal.

Some men do regain erections after surgery, but it can take up to 2 years. Even when the nerves are spared, research has shown that the healing process takes about 2 years for most men. We don’t know all the reasons some men regain full erections and others do not. We do know that men are more likely to recover erections when nerves on both the left and right sides of the prostate are spared. The healing and growth of new blood vessels may also help restore blood flow to the penis. This healing takes time, which could help explain the delay in the return of erections.

Other things that affect erections after surgery

Age: For the most part, the younger a man is, the more likely he is to regain full erections after surgery. A wide range of ED rates have been reported even in men who haven’t had surgery, from as low as about 1 in 4 men under age 60 to as high as about 3 in 4 men over age 70. Men under 60, and especially those under 50, are more likely to recover their erections than older men.

Erections before surgery: Men who had good erections before cancer surgery are far more likely to recover their erections than are men who had erection problems.

Other conditions, such as Peyronie’s disease: In some men, the penis can develop a painful curve or “knot” when they have an erection. This condition is called Peyronie’s disease. It’s most often due to scar tissue forming inside the penis, and has been linked to some cancer surgeries, such as surgery to remove the prostate (prostatectomy). Still, Peyronie’s disease is rarely linked to cancer treatment and it can be treated with injections of certain drugs or with surgery. If you have painful erections, ask your doctor for help finding a urologist with experience treating this disease.

Early sexual rehabilitation after surgery

Studies have been done in which doctors tested different methods to promote erections starting just weeks after surgery. The results of these studies suggest that these methods can help some men. You may hear this called penile rehabilitation, or erectile rehabilitation.

Penile rehabilitation

The idea is that producing erections within weeks or months of surgery can help men recover sexual function. Any kind of erection is thought to be helpful. An erection pulls oxygen-rich blood into the tissues of the penis, helping keep this tissue healthy. As mentioned before, the recovery time for erections after surgery is about 2 years. If a man does not have an erection during this time period, the tissues in his penis may weaken. Once this happens, he will not be able to get an erection naturally. The idea of penile rehabilitation is to use some type of medicine to be sure that a man is getting regular erections while his nerves are healing. This helps keep the tissue in the penis healthy. Most studies have suggested using medicine to get an erection hard enough for penetration about 2 to 3 times a week. The erections do not need to be used for sexual activity, the goal is to keep the tissue in the penis healthy.

In penile rehabilitation, medicines to cause erections – pills such as sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®) − are tried first. But these drugs may not produce an erection because they need the nerves responsible for erections to be healthy. In fact, the pills only work in about 10% of men in the first few months following surgery. If the pills don’t work, penile injections or vacuum constriction devices are tried. .Most sexual medicine specialists suggest using penile injections before the vacuum devices. (You can read more about these treatments in the section called “What treatments are available to help with erections?”)

The other part of penile rehabilitation is taking a pill (again, usually sildenafil [Viagra], tadalafil [Cialis], or vardenafil [Levitra]) at a low dose (about a quarter of tablet) on the days you are not getting an erection. This low-dose pill will not be strong enough to help you get an erection, but it will help increase the blood flow around the nerves that help cause erections. This increased blood flow helps the nerves heal.

Putting this all together, penile rehabilitation has 2 components:

  • First, making sure you are getting regular erections that are hard enough for penetration. It’s best if you can have an erection 2 to 3 times a week. This will help keep the tissue in your penis healthy.
  • Second, using a low-dose pill to help the blood flow around the nerves and help the nerves heal.

Talk to your doctor about how your nerves were affected by surgery and whether penile rehabilitation is right for you.

Last Medical Review: 08/19/2013
Last Revised: 08/19/2013