Erections are not the simple operations they seemed to be when we were young. They usually begin in the head, with erotic stimulation. The mind sends messages through the nerves that cause the muscles inside the penis to relax, allowing additional blood to enter the corpora cavernosa (two parallel chambers inside the penis) and enlarge it. The penis remains that way as long as sufficient sexual arousal continues or until orgasm occurs. Failure of any one of these—the mind, the nerves, or the blood vessels—can lead to impotence (also called erectile dysfunction or ED).CAUSES
When erectile dysfunction follows treatment for prostate cancer, it is almost always caused by physical damage to the nerves and/or blood vessels that affect erections. It may be total or partial. Unless you know that the nerves were cut during a prostatectomy, you should not assume that you are impotent. If you functioned well before, there is a good chance that you will be able to function well again. And even if you are physically incapable of producing and sustaining an erection, there is an excellent chance that you will be able to do so with help from one of the treatments described below.
Resuming sexual activity. How soon sexual activity can be resumed depends in large part on the procedure you choose and the length of hormone blockade treatment. In any case, some specialists now believe that you should not wait more than a few months before trying to have sex, and they suggest using artificial techniques to produce erections. Men with any sort of sexual dysfunction should visit a good specialist not long after their procedure.
Even those who are not impotent for even a short time may find that things are not quite what they were. If there is no longer a prostate to produce the fluid, or if it has been sufficiently damaged, you will have dry ejaculations. These are otherwise not unlike normal ejaculations. If you had neoadjuvant hormone blockade, you will probably not recover your sex drive until your testosterone level rises.
Counseling. Even though impotence is not a hopeless situation, it does hit a man very hard. Losing the ability to produce an erection is traumatic, and no man should avoid seeking professional help—for both the physical and the emotional aspects. Be sure to include your partner in discussions, explananations, and decisions. (Ideally, you will have been doing this all through the process of dealing with the cancer.) And no matter how long it takes before you can resume sexual relations, you should not avoid intimacy.
Lack of desire. Many men experience a lack of desire following treatment for prostate cancer. Some are tempted to give up because they feel that they are "too old for sex." To make matters worse, some doctors seem to assume that older men no longer have sex anyway. (Any support group can shock you with a few stories about callous statements by doctors.) There may, however, be no such thing as too old for sex. According to a survey by the National Council on the Aging, about half of all Americans over 60 are still sexually active. And three-quarters of them said that they found sex at least as satisfying as it had been when they were middle-aged.
Lack of desire can also affect men who do not have erectile dysfunction. The roots may still be physical, such as infections or incontinence (leading to a fear of embarrassment during sex), or they may be emotional—general depression, for example. Whatever the reason, men who lack desire (but wish they did not) should visit specialists.
Other causes. Sometimes erectile dysfunction can be caused by something other than damage to the nerves or blood vessles. Drugs are often responsible for reduced libido or dysfunction. These include antidepressants (such as Prozac or Zoloft), antihistamines, anxiolytics, drugs for Parkinson's disease, and particularly drugs that lower blood pressure. Note that alpha blockers such as Hytrin or Cardura, which are often prescribed for urinary problems following prostate-cancer procedures, lower blood pressure. Proscar (finasteride) and Propecia (a hair-growth drug) also lower libido, as do the medications used in hormone blockade or thyroid treatments. Make a list of all your medications, prescription or not, for the specialist.
Don't be discouraged. The following descriptions appear to have a lot of negatives. This is mainly an effort to warn against as many potential problems as possible. Your doctor will know what to prescribe and what to avoid, but it is always a good idea for you to know what to expect or watch out for.
LINKS
Excellent coverage of potential side effects
A carefully researched list of links to most treatments (framed site)
List of clinical trials aimed at treating impotence
Sexual dysfunction in people with cancer, an overview
TREATMENTS
These are the treatments, from least-invasive to most-invasive:
PillsPILLS
External supports
Vacuum devices
Uretheral suppositories
Injections
Nerve transplant at time of surgery
Penile prothesesYohimbine (yohimbine hydrochloride). This drug, obtained from the bark of a tree that grows in Africa and India, has long been considered an aphrodisiac. Although it appears to work for some men whose impotence has a psychological basis, it is unlikely to help many who have had prostate-cancer procedures. Moreover, the American Urological Association states that its success rate is only slightly better than placebos. Journal of Urology, 1996; 156, 207-211
Upside: It may work for some men.
Downside: Yohimbine must be taken for two months before it can be determined whether or not it works. Side effects are unlikely but these have been reported: anxiety, dizziness, headaches, nausea, increased blood pressure, and tachycardia (increased heart rate). It contains methyltestosterone, so men who have prostate cancer should avoid it. Can be dangerous for men with stomach ulcers.
About yohimbine hydrochlorideViagra does not initiate erections, it merely facilitates them. You have to supply the mental effort involved in an erection. Even so, the highly touted pill does not work for everyone. In a study of 800 men, Viagra led to successful intercourse 70 percent of the time. New England Journal of Medicine 14 May 98 However, if the drug does not work the first time, that does not mean it will never work. Dr. Francois Eid, M.D., director of the Erectile Dysfunction Unit at The New York Hospital-Cornell Medical Center suggests trying it three to six times before you give up on it.
According to Dr. Eid, Viagra is best taken three hours after a low-fat, alcohol-free meal or in the morning before breakfast. Expect about one and one-half hours before foreplay, and a "window of opportunity" of four to eight hours.
Before you try Viagra, make sure your doctor carefully assesses your physical fitness and reviews a list of all the medications you are taking. Problems have been reported in men who use nitroglycerin or nitrate-based medications for chest pains. Acting together, these drugs may cause sudden drops in blood pressure. It has also been reported that those who suffer from diseases of the retina may face permanent vision loss if they use the drug. About ten percent of the men taking a normal dose of Viagra report "bluish vision." It is suspected that the drug may result in overproduction of chemicals in that could destroy retinal cells. Headaches, flushing, and abdominal discomfort are more common side effects.
Upside: Reasonable success rate and easy to initiate.
Downside: Potential side effects, expense.
Viagra: FDA FAQ
Viagra: FDA Consumer InformationEXTERNAL SUPPORTS
Penile sheaths (or splints) are rigid or flexible supports that resemble condoms. They hold the penis erect during intercourse. Although the concept sounds unlikely, some people do say that they help. No prescription is needed, but not every pharmacy stocks them.
External penile rigidity devices, FDAVACUUM DEVICES
Pumps. These are properly called vacuum-constriction devices (VCD) or vacuum-erection devices (VED). The device consists of a tube, usually plastic and transparent, that is slipped over the penis and pushed up against the groin. The air inside is then pumped out by hand or battery. As the air pressure is reduced, blood is drawn into the chambers in the penis. The erection is maintained by an elastic ring that is moved from the end of the tube to the base of the penis, trapping the blood inside and maintaining the erection. An erection can last 20 to 30 minutes, but the ring must be removed after about 30 minutes to restore the bloodflow and avoid damage.
Sex shops offer cheaper versions of these devices, but prescription pumps are better made and may be covered by your insurance.
Upside: Quick and effective. Most side effects are not dangerous.
Downside: The pump can be difficult to use, which can destroy spontaneity. The constriction ring may impair or inhibit ejaculation. Leaving the ring on too long can damage the penis. (Don't fall asleep with it on.) Creating a vacuum too quickly may cause tiny surface blood vessels to rupture or trap the skin of the scrotum inside. The ring may also cause minor rupturing or make the penis blue and cold. One source warns against using the device if you have sickle-cell anemia, leukemia, or clotting diseases. Another mentions anti-coagulation therapy.
Using a vacuum pump (description by a patient)
External penile rigidity devices, FDAURETHERAL SUPPOSITORIES
M.U.S.E.—Medicated Urethral Suppository— also known as Muse and as alprostadil, is a tiny medicated pellet that is inserted in the urethra. The medication, prostaglandin E1, is absorbed by the erectile tissues, where it dilates the arteries. It takes about five to ten minutes to achieve an erection, which may last for about 30 to 60 minutes. In a study of 384 men who had undergone radical prostatectomies, Muse enabled 70 percent to achieve an erection sufficient for intercourse. (This was the rate in the clinic. When self-applied, the rate was lower.) The study concluded that "transurethral alprostadil is a well tolerated and efficacious method of treating erectile dysfunction after radical prostatectomy." Journal of Urology, October 1998
Upside: Fast-acting.
Downside: The tube must be inserted one inch or more. Prostaglandin is used in combination with other drugs to produce abortions, so Muse should not be used with pregnant females. Side effects may include pain in the penis, testicles, and groin, minor urethral bleeding, and burning in the urethra.
There have been studies of creams that contain prostaglandin or nitroglycerin, which are applied directly to the penis. These have had limited success (apparently absorption from the outside is even less efficient than from the inside). There are presently no plans to release such creams in this country.
INJECTIONS (Intracavernosal Injection Therapy)
This is a variation on the pellet and uses the same type of vasodilators, substances that increase the flow of blood into the penis. The introduction is by hypodermic needle, which is not as painful as it appears. The most commonly used are papaverine (Papaverine hydrochloride), phentolamine (Regitine), and prostaglandin E1 (Caverject, Prostin, or Alpoprostadil), which can be taken singularly or in combination. Erection usually begins within 15 minutes and may last several hours. Injections are effective for about 70 to 80 percent of men.
The difference, and sometimes the danger, with this type of erection is that it does not end directly after orgasm. The erection cannot end until the agent has been metabolized or diffused. Extended erection, called priapism, can be painful and damage the penis. (If an erection lasts more than four hours, get to a hospital emergency room.)
Needless to say, sticking a needle into one's penis goes against all male instincts, and tends to dampen the mood. Therefore, it may be best to have your partner do it for you. Side effects may include headaches, nausea, and transient hypotension. When papaverine is used alone, it may cause liver problems, so users should have liver-function tests. These are all reasons why initial injections are given in a doctor's office and the patient remains until the erection has subsided. (Follow-up visits are also required until the proper dosage can be ascertained. You will also have to return every several months to be checked for scarring of the corpora.)
Penile scarring and deformity can also occur, so few men use the needle for very long. This treatment can be valuable in helping to maintain the penis during the early part of impotence.
A study using prostaglandin E1 found that 62 percent achieved complete erections and another 24 percent had erections that were sufficient for sexual intercourse. They observed no severe side effects. Journal of Urology, 1989 Feb;141(2):323-5 Other studies have found that as many as 75 percent respond well. New England Journal of Medicine, 1996; 334, 873-877
Upside: Erections usually last an hour or more. Topical anesthetics can reduce the discomfort of the injection.
Downside: After a certain number of times, scar tissue makes it difficult to continue the injections and may even deform the penis. If the injection is not done correctly, it increases the likelihood of scarring. Injections should not be given more than once every several days. Infections are possible. The medicine is expensive.
NERVE IMPLANTS AT THE TIME OF SURGERY
Techniques for replacing damaged nerves are being developed in several places. However, the replacement surgery must be done at the same time as the prostatectomy.
An Associated Press report in September of 1999 stated that urologists and plastic surgeons at Baylor and M.D. Anderson Cancer Center in Houston, Texas, have collaborated on a number of successful operations. Four of their initial 14 patients can now have sexual intercourse and seven others have achieved partial erections. (The nerves require from 14 to 18 months to regenerate.)
Once the prostate has been removed, a plastic surgeon removes a segment of the sural nerve from the back of the patient's ankle and sews it to the ends of the severed nerve. This allows the original nerve to regrow itself over the neural "bridge". The transplant does not harm the foot, but does leave a small area without sensations. Plastic surgeons have successfully transplanted other nerves in the past, but these are parasynthetic nerves, a complex type involved in organ control. This is apparently the first instance of parasynthetic nerves being regenerated.
PENILE PROTHESES
These are devices that are implanted in the penis by a surgeon. There are two basic types: rods and inflatables. Both types enable a man to have satisfactory sex. The surgery is done with anaesthesia and is not particularly unpleasant. However, installation of either type of device necessarily destroys the erectile tissue inside the penis, so other impotence treatments will not be possible afterward.
Flexible. One type is constructed of rods made of braided wires inside a silicone covering. (The silicone is solid and does not present the risk to the body that breast implants did.) The other is a nested set of tiny cups held together by a wire. Both types have two rods, one in each of the chambers in the penis. Both types can be bent in any direction, and both slightly increase the diameter of the penis. There is very little risk of infection as a result of the operation.
Upside: Erections on demand. Rods or cups cost less than pumps and are unlikely to break or malfunction.
Downside: Although the rod can be pointed straight down, the penis is always extended, which may make it difficult to wear shorts or embarrassing to go naked in a locker room. Although it is unlikely to create problems, the silicone has been reported to shed particles that can migrate to the lymph nodes.
Inflatable. These also come in two varieties. Both types contain inflatable tubes in the corpora. One employs a squeeze pump (usually hidden in the scrotum) that moves a fluid into the tubes. The other type is engorged by squeezing the penis. It is deflated with a release valve. In both cases, the surgery does not take long and is often done as an outpatient procedure. However, it is necessary to wait four to six weeks before taking a test drive. Both types usually use a harmless saline solution as the fluid, so there is no danger if it escapes.
A study of 2,354 patients by the University of North Carolina Medical School reported that 86 percent of the men who had received pump implants said they were satisfied. International Journal of Impotence Research, 10:1-4, 1998
Upside: Erections on demand—and they go away when you want them to. Unlike the rod, the pumpable penis appears natural in both the flaccid and erect states, which provides considerable psychological benefits.
Downside: Infection is a small possiblity during installation. The device is unlikely to function well for more than ten years and may break down much sooner. It can, however, be replaced. The cost is likely to be at least $10,000 and possibly twice that—which on an annual basis will probably amount to considerably more than Viagra.