By Melinda Fontaine, DPT, PHRC Walnut Creek
Meet Paul and Ashley. Paul and Ashley have an active sex life. They are taking the time to get to know each other’s bodies and pleasures as well as their own. They are trying new ways of being intimate and using toys. They are having fun and growing closer as a couple.
Paul and Ashley are not a new couple; they have been married for 35 years. Paul was diagnosed with prostate cancer last year and had a radical prostatectomy. Even though the surgeon is very skilled and Paul was in great health going into the surgery, he still wound up with some dysfunction after surgery. Paul and his partner are taking this challenge as a reminder to reevaluate their sexuality. Sexual desires and preferences change over time normally and even more so after an event like prostate surgery. After 35 years of doing the same things, it is difficult to make a change. Paul and Ashley are grieving the loss of spontaneous sex and welcoming Viagra and vibrators into their sex life.
Paul is not alone. Almost 60% of men who have prostate surgery have erectile dysfunction 18 months later.1 These men are often surprised by their impairments, uncertain about what to expect during recovery/rehabilitation, and not sure what to do to help themselves. As a pelvic floor physical therapist, I see many men after prostatectomy, and I may be the only one to ask them about their sex life and make suggestions and referrals. (To read more about pelvic floor physical therapy after prostatectomy, click here).
How prostatectomy affects desire, erection, orgasm, and ejaculation
Desire is most often still present after prostatectomy. It can be affected by things such as anxiety about your overall health, pain, or hormone treatments.
Injury or damage to the nerves that innervate the penis is the main reason for erectile dysfunction. Even in nerve-sparing surgeries, the nerves are still manipulated and injured and need time to heal. Healing can take up to 2 years. Better recovery of erections is associated with bilateral nerve sparing, good erections prior to surgery, and younger age. Poorer erections with or without prostate surgery are associated with heart disease, diabetes, smoking, and certain medications. There is no way to predict how much erection a man will have after 2 years. Growth of new blood vessels and the return of blood flow helps with healing, so many men participate in penile rehabilitation (see below).
A man’s orgasm has two stages: emission and ejaculation. Emission (aka the “point of no return”) is when the prostate, seminal vesicles, and vas deferens contract and produce semen where it is ready to be pushed out or ejaculated. (See Rachel’s blog on the male anatomy) After prostatectomy, semen is not produced or extremely little because the prostate is not present. Some men worry about the loss of semen because they would like to father a child. These men should speak with their doctor before surgery and consider banking some sperm. (Sidenote: sperm is still made in the testicles, but it just gets reabsorbed by the body instead of coming out and is not harmful.)
Ejaculation occurs when the muscles around the penis contract and relax rhythmically and push the semen out. Simultaneously, a message of pleasure is sent to the man’s brain, known as orgasm. Again, after prostatectomy, no ejaculate comes out when the muscles contract. Luckily, the signal for pleasure is still sent to the brain, and a man can experience a “dry orgasm” that can be just as intense as always. Many men and their partners get used to the “dry orgasm.” Some men report that their orgasm feels like “the string section instead of the whole orchestra.” Tips to improve orgasm include fantasy, foreplay, letting the excitement die down and rebuild, and orgasming with the firmest erection possible. Injury to the nerves that control arousal may mean that a man loses his ability to delay orgasm. This can be controlled by slowing down and/or using some antidepressant drugs.
Penile rehabilitation
Practice. Practice. Practice. Use it or lose it.
How do you work out a penis with erectile dysfunction? Anything that gets the blood flowing: fantasy, touching, intimacy with a partner, pelvic floor exercises (see these posts about the male kegel and pelvic PT), use of a vibrator, pills, penis pumps, etc. It doesn’t have to result in erection or orgasm (though that would be great) as long as you get the blood moving.
Immediately post-surgery, many surgeons will prescribe a daily low dose sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) to increase blood flow. A full dose is also recommended frequently to attempt sex (either solo or with a partner). These medications cause dilation of the veins and increase blood flow to the penis. They may not produce an erection, especially in the first 6 months of recovery, if the nerves are still healing from injury. These medications may interfere with other medications for heart disease, so discuss all treatments with your doctor.
A vacuum constriction device, or penis pump, also draws blood to the area and can help create an erection for sex. It is a plastic cylinder placed around the penis and a pump that pulls the air out. Consequently, the blood is also drawn up into the penis. A stretchy band can be placed at the base of the penis to maintain erection. Pumps can be used before or after foreplay.
Penile injections, used a few minutes before sexual activity, are very effective. They work in 80-90% of men2, but many men are afraid to try them. A doctor instructs a man how to deliver the injection into the side of the penis, and it doesn’t hurt as much as you would expect. When asked to rate the pain on a scale of 0-10 with 10 being the most pain, most men reported a 1/10 or 2/10.
Urethral suppositories are tiny tablets inserted in the urethra (the opening at the tip of the penis) and absorbed into the tissue of the penis. They don’t work as well as injections, but may be easier to use.
A penile implant is a balloon and pump system inserted surgically in the penis and scrotum that allow a man to “inflate” his penis using a tiny pump in the scrotum. The penile implant is usually considered after the above treatments have failed. The implant is very effective at creating an erect penis for penetration, but does not help with desire, sensation, or orgasm.
Erection does not equal sexual satisfaction
The goal of a man recovering from prostate surgery should be unselfconscious sex. This is going to look different for each man. This goal can be achieved with or without an erection. Sex does not have to involve penile penetration, but it can. The most important part is that he feels pleasure, and if he is with a partner, then he feels intimacy. After prostatectomy, it is perfectly normal to grieve some losses, perhaps of spontaneous sex, strong erection, ejaculation, penis size, etc. Be accepting of using sexual aides. Have good communication with your partner about your anxieties about sex. Experiment to find out what both you and your partner enjoy and what you need to have satisfying sex. The answers may surprise you!
How pelvic floor physical therapy can help post-prostatectomy
A pelvic floor physical therapist can help suggest strengthening and endurance exercises for the pelvic floor to also help with blood flow and rehabilitating the muscles responsible for erection. However, the most common reason I see men after prostatectomy is for urinary incontinence, which can also interfere with one’s sex life. While incontinence is not dangerous for a man or his partner, some people find it distracting or worry that it bothers their partner. The prostate provides support for the urethra (tube for urine in the penis ). After it is removed, the pelvic floor muscles have to make up for the loss of support by doing something they have never had to do before. Even if the muscles were working fine before surgery, they now have to go above and beyond the call of duty. Often, incontinence after prostatectomy can be eliminated with exercises and bladder retraining. See here for help finding a pelvic physical therapist near you.
Check out these other great websites on intimacy and cancer, and seek out professionals in your area:
American Association of Sexuality Educators, Counselors and Therapists (AASECT) SexHealthMatters
American Sexual Health Association (ASHA)
American Society for Reproductive Medicine (ASRM)
Fertile Hope (a LIVESTRONG initiative)
Gay and Lesbian Medical Association (GLMA)
______________________________________________________________________________________________________________________________________
Are you unable to come see us in person? We offer virtual appointments!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
References:
- Stanford JL, et al. (2000) Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: The prostate cancer outcomes study. JAMA 283(3):354-360. doi:10.1001/jama.283.3.354
- American Cancer Society. (2013) Sexuality for the man with cancer. http://www.cancer.org/acs/groups/cid/documents/webcontent/002910-pdf.pdf
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Interesting article thank you for writing it. My wife and I grew up Catholic so it has been difficult taking a relaxed attitude about sex after prostatectomy, and using sexual stimulation to aid in recovery from incontinence and ED without accompanying guilt feelings. This article helps. I am about to see surgeon for post op appt. after six months and am about 90% recovered from incontinence and about 70% from ED, without any aids like meds or the pump but just stimulation and pelvic exercises now. Just need to avoid nagging guilt left over from legalistic upbringing. Thanks again.
How old are you? Any other post-surgery complications/surprises?
Thanks for any insights. I am head in to surgery later this month (Oct 2017).
Any advice will help I have tried just about everything the pill the pump the injection please help my marriage is falling apart
Author Melinda Fontaine says:
Hi Ralph,
You are not alone. My first recommendation is to find a good sex therapist. Try the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) website to find one near you. It is common for couples to need a coach to help them find intimacy and pleasure in their sex life or relationship, especially after something has changed. After you start seeing a sex therapist, if you want to look into the medical side more, go back to your doctor and ask what other options may be appropriate for you. Surgical implants, for example, can help men have an erection firm enough for penetration. Lastly, use the American Cancer Society’s website to find a local support group to find people in similar situations to talk to. Take care.
I am 79 years old with a still-healthy libido. I underwent radiation treatments for stage one prostate cancer about five years ago, and recently, following orgasm, I experienced a lot of blood and clots in my urine. On three occasions since then, the clotting obstructed my urethra so that I could not urinate and had to rush to the ER of a local hospital and be catheterized and irrigated – sometimes overnight, sometimes for a few days. I am in the care of a urologist, naturally, but what I am finding out so far, is that there is no predictable cure or treatment for what I am diagnosed with – radiation cystitis. The uncertainty of if or when a flare-up and bleeding might occur is disconcerting enough, but being still blessed with a strong libido, I am worried that I dare not experience orgasm lest I wind up back in the ER, catheterized. Should I forego sex altogether, or forego it for a matter of months, or have sex up to the point of orgasm and stop, never having an orgasm again..? Is there any known treatment for this condition or any way of judging when or if to indulge in sexual activity? This is a very real quality of life issue for me and I have no intention of living my remaining years celibate if I don’t have to! I’ll be grateful for any info and advice you may offer, thank you!
Author Melinda Fontaine says:
Hi Dave,
I have only read about your condition in the literature. Ask these questions to your urologist, and ask if there are any treatments, such as bladder instillations, that would make it less likely for you to experience bleeding. Ask if waiting for some more bladder healing to occur would decrease your likelihood of bleeding. You deserve to have the most pleasurable sex life possible, but you do have to work around these hurdles. Speaking with a sex therapist near you may also help you get some more ideas.