By Melinda Fontaine
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.
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:
- 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