It’s no secret: “Erectile dysfunction (ED) is a common problem after prostate cancer treatment despite innovations to minimise the risk of side-effects.”^[i] That’s a common opening statement in a slew of journal articles, and they all contain the phrase “prostate cancer treatment.” For the most part, what they’re really talking about is radical prostatectomy (RP), a surgical approach to gland removal that cannot avoid disturbing the neurovascular bundles (NVBs) that control erections.

According to a 2017 paper by Emanu, et al., “While there is a large discrepancy in prevalence rates of ED after RP, several recent studies have cited rates as high as 85%.”^[ii] They note that robotic RP was hoped to significantly lower ED rates, but a 2021 study of sexual satisfaction after robotic RP revealed diminished satisfaction as far out as 36 months after treatment.^[iii] Compared with patients who had radiation, “men undergoing prostatectomy were more likely to have ED at 2 years, and at 5 years, with 78 to 87% experiencing insufficient erections for intercourse.”^[iv] Thus, of all treatment choices, RP has the most severe impact on sexual function. But new approaches to treating post-RP ED are more effective than ever.

Treating ED after RP

Separating the prostate gland from its pelvic cradle inflicts physical insults on the NVBs. The nerves are traumatized and need time to regenerate. It may be 2 or more years before spontaneous erections “wake up,” and sometimes never. The idea of boosting Mother Nature by means of medication-based penile rehabilitation after RP is attributed to pioneering work in 1997 by Montorsi, et al.^[v] Since then, pills and injections have been first line methods to keep blood flowing into the spongy tissue. This seems to keep tissues healthy, and to invite the nerves to regain function. (Vacuum erection devices, or VEDs, use mechanical means used for the same purpose, with or without medication.) Regular use is more effective during the recovery period than “as-needed” use.

Even so, it’s important to keep expectations reasonable. RP centers now prescribe immediate penile rehab. “Data suggest that 52–67% of men who use a penile rehabilitation strategy recover erections compared to 20% of men who do not utilize penile rehabilitation.”^[vi] When medication-based rehab doesn’t work, many men simply give up and resign themselves to impotence. This is sad not just for the patient, but for his partner as well, and can lead to emotional upheaval. Something more is needed.

In 2018, the American Urological Association issued revised guidelines for addressing post-surgery ED. To begin with, recognize that the couple (assuming an intimate partner) is the “customer.” Then, instead of simply prescribing pills or injections, “physicians should first counsel patients on all the options available, clearly laying out the benefits and risks of each, and let them decide what the first-line treatment should be. However, as part of that counseling, physicians should stress the importance of
lifestyle changes in improving sexual function that could negate the need for any potentially risky intervention. The same goes for the option of mental health referrals and sex therapy.”^[vii]

Note that there’s a difference between treating ED and curing ED. This is where forward-looking innovations come in, as researchers look for a way to address the root of the problem. Is there a way to regenerate unresponsive nerves that never wake up? Or to revitalize penile tissues that have gone unused and therefore have some degree of atrophy? Here are exciting avenues that are being explored:

A) For men with cardiovascular disorders (insufficient blood flow to the penis), a technique called extracorporeal shockwave therapy has shown some promising results in small clinical trials. However, since the devices are not FDA-regulated, many doctors and clinics have found a bandwagon to jump on, and a large audience eager for a miracle cure. You’ve probably heard or read ads touting a return to full function. Interested (and possibly gullible) men should steer clear of home-use devices, and only turn to reputable urologists or clinics for a thorough diagnosis before wasting time and money.

B) Stem cell therapy is also being tested for safety and efficacy. One expert cautions that as yet there “are no randomized, placebo-controlled trials for this therapy, and the human trials that do exist are very small. The AUA still considers stem cell therapy for ED as investigational, and physicians should be aware of legal nuances, as well as the feasibility and cost-to-benefit ratio for patients.”^[viii]

C) Platelet rich plasma (PRP) has been found to improve erectile function scores in a high level research trial, but “clinics often drastically overcharge for PRP injections, and the AUA still considers this therapy experimental.”^[ix]

Although B and C are not yet available, the point is that when RP is the right treatment for a PCa patient, there is more help for the patient and his partner than they may be aware of. In order to reduce the risks of post-RP ET, national PCa support organizations and foundations advise patients to seek physicians who are highly experienced, to ask questions, and to get second opinions. Find a doctor you feel good about who will advocate for you. Be prepared to adapt your sexuality, to be patient, and to get counseling if needed. RP treatment need not doom your sex life because there’s a lot you can do about ED if it happens after surgery.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Stainer V, Skews R, Aning JJ. Erectile dysfunction therapy after prostate cancer treatment. Prescriber. 2022 Feb:33(2); 15-22.
[ii] Emanu JC, Avildsen IK, Nelson CJ. Erectile dysfunction after radical prostatectomy: prevalence, medical treatments, and psychosocial interventions. Curr Opin Support Palliat Care. 2016 Mar;10(1):102-7.
[iii] Albers LF, Tillier CN, van Muilekom E, van Werkhoven E, Elzevier HW, van Rhijn BWG, van der Poel HG, Hendricksen K. Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study. J Sex Med. 2021 Feb;18(2):339-346.
[iv] Resnick MJ, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013;368(5):436–445.
[v] Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol 1997;158:1408-10.
[vi] Emanu et al. Ibid.
[vii] Khera, Mohit. “Changing Paradigm in the Diagnosis and Management of Erectile Dysfunction.” February 1, 2023. Accessed May 2023. https://grandroundsinurology.com/changing-paradigm-in-the-diagnosis-and-management-of erectile-dysfunction/
[viii] Ibid.
[ix] Ibid.