Erections and pelvic surgery to treat cancer

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 the “Urostomy, colostomy, and ileostomy” 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 aspects of some cancer treatments” 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 aspects of some cancer treatments” section for more about 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.

How surgery can affect erections

Damage to nerve bundles that allow blood flow to the penis

All of the operations listed above can damage the nerves that control blood flow to the penis. 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.

There are different ways to do all of these surgeries. For example, some doctors use surgical methods that try to remove the prostate while sparing the nerves around it. Some surgeons have even tried to locate the nerves more quickly by using a mild electric current to find the spot where stimulating a nerve will cause an erection. This method has also been used to test the nerve bundles to be sure that they still worked after removal of the prostate. But ongoing study suggests that this method is not a reliable measure of potency after surgery.

When the size and location of a tumor are right for nerve-sparing surgery, more men recover erections than with other techniques. When possible, nerve-sparing methods are used in radical prostatectomy, radical cystectomy, or AP resection. Doctors are now also trying to repair or graft nerves when they cannot avoid cutting them during surgery. This is being studied to find out whether it helps preserve erections.

Reduced blood flow to the penis

Some of the problems with erections after these operations may be caused by a loss of blood flow to the penis. The surgeon must seal off some of the small arteries that feed into the 2 main blood vessels involved in erection. Blood flow is then slowed, like a river after the streams that run into it have been dammed. Usually a man has partial erections after such surgery. His penis swells when he feels excited, but the penis may not become firm enough for penetration. Skin sensation and the ability to feel an orgasm should be normal.

Some men do regain full erections after surgery, but it can sometimes take up to 2 years. We do not know all the reasons why 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.

The type of surgery affects the outcome

Some operations cause more sexual problems than others. For instance, it is not known that any man has regained full erections after having total pelvic exenteration (the total removal of all organs in the pelvis). But this surgery is so rare that statistics are not available.

At least 15% of men who have standard surgery to remove the bladder or the prostate have full erections again. But surgeons report better erection recovery rates if they are able to spare the nerve bundles during these surgeries. After AP resection (removal of the lower colon and rectum), the ability to have erections returns more often than it does after surgeries that also remove the prostate.

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. Men under 60, and especially those under 50, have much higher erection recovery rates than older men. For instance, some cancer centers that do many radical nerve-sparing prostatectomies (taking out only the prostate and trying not to injure the nearby nerves) report impotence rates as low as 25% to 30% for men under 60, and as low as 10% for men under 50. But other doctors have reported higher rates of impotence in similar patients. Impotence happens in about 70% to 80% of men over 70, even if nerves on both sides are not removed or cut.

Erections before surgery: Men who had good erections before cancer surgery are far more likely to have a full sexual recovery than are men who had erection problems.

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.” The idea is that ensuring erections within weeks of surgery can help men recover sexual function. Any kind of erection is thought to be helpful, including sleep erections. The thought is that they keep the tissues of the penis healthy and help prevent tissue changes that can make erections almost impossible.

Men who have at least one intact nerve bundle may be helped by phosphodiesterase inhibitors (also called PDE-5 inhibitors) like sildenafil (Viagra^®), tadalafil (Cialis^®), or vardenafil (Levitra^®). (For more about these drugs, see “Is there a pill that will cure sexual problems?” in the “Dealing with sexual problems” section.) Other treatments, such as pellets in the urethra, penile injections, and vacuum devices have been used, too. No single method has been shown to help all men. Talk to your doctor about how your nerves were affected by surgery and whether penile rehabilitation is right for you.