By: Dan Sperling, MD

Radical or whole-gland prostate cancer treatments include surgical removal (open radical prostatectomy or RP, laparoscopic RP or robotic assisted laparoscopic RP), external beam radiation therapy in its various forms including proton beam, brachytherapy or seed implants, and whole-gland ablation (cryotherapy or HIFU). Most patients considering a radical therapy are aware of the risk of temporary or even permanent erectile dysfunction (ED) after treatment. As used here, ED means the inability to achieve an erection sufficient for penetration. However, they may be less well informed about two other common sexual side effects of treatment: lack of ejaculate (dry orgasms) and changes in the anatomy of their penis, especially shrinkage.

It is important to distinguish ED from lack of desire. Post-treatment patients will still become mentally and emotionally aroused, but ED prevents them from having and/or maintaining stiffness. Men should be assured that even with ED, they can achieve orgasm (climax) which is controlled by nerve centers that are unaffected by treatment. However, most men with post-treatment ED find it psychologically difficult to achieve orgasm without an erection.

Nerve damage leading to ED

The introduction of nerve-sparing surgical techniques, including robotic-assisted RP, raised hope of better return to baseline sexual function after recovery from the operation. However, outcomes have been more disappointing than expected. During the past 17 years, according to a systematic analysis of 11 prospective randomized trials on penile rehabilitation after nerve-sparing RP, only 20-25% of men reported that their erectile function was not disturbed—nor had the rate of dysfunction diminished regardless of technique.[i] A 2008 study out of UCLA followed nearly 1300 prostatectomy patients for up to five years, and found that 78% still experienced ED at two years post-RP, while 72% reported ongoing ED at five years.[ii]

The causes of ED after treatment are mainly due to damage or injury to the neurovascular (nerves and blood vessels) bundles, but there are several complicating factors. A state called neuropraxia (a mild type of nerve injury) can develop from efforts to “tease” the nerve bundles away from the outside of the prostate capsule, and it leads to the inability of the nerves to transmit signals. When this occurs, messages from the brain that would normally trigger the start of an erection cannot be completed, and the penis remains limp. According to Jeffrey Albaugh, an expert on penile rehabilitation, “The nerves were never meant to be touched and this surgical manipulation leads to inflammation and neuropraxia (the nerves are there, but they don’t function).”[iii]Other causes of neuropraxia can be heat from cauterizing blood vessels to stop bleeding, or swelling and inflammation from surgical trauma. When neuropraxia occurs, the duration during and after recovery can vary widely from one man to another, and is not always dependent on the skill of the surgeon because nerve recovery is unpredictable. Even the most experienced surgeons cannot give a 100% guarantee that every patient will eventually regain spontaneous erectile function.

Change in penis anatomy

The longer ED due to neuropraxia continues, the greater the risk of damage to the internal tissues of the penis through hypoxia, a deficiency of the oxygenated blood that fills the spongy cavities during erection. If this becomes chronic, the internal structures of the penis begin to atrophy (cease to function). In addition, a condition called fibrosis (gradual thickening, hardening and scarring of connective tissue) may result in lack of elasticity needed to gain an erection, even if the nerves recover their ability to send signals. In turn, collagen build-up begins to occur so the resistance needed to hold blood in the spongy chambers (venous leakage) diminishes and results in insufficient erection. If all of these conditions become chronic, they culminate in penile shrinkage, often irreversible.

Dry orgasm

Because the prostate gland produces the seminal fluid to transport sperm out of the body during orgasm (the ejaculate), removing the gland means that a man’s orgasms will be “dry.” According to Harvard urologist Dr. Ravi Kacker, “Sometimes orgasm gets forgotten because everyone is so focused on erectile dysfunction… But for some—maybe most—men and their partners, achieving orgasm can be as important as erections—or even more so—for having a healthy sex life.”[iv]  Without the buildup of fluid prior to the release that occurs with orgasm, many men have to relearn the sensations in their bodies, and become comfortable with not having ejaculation as part of their (and their partner’s) sexual experience. Even when a man’s partner assures him that nothing has changed from their own viewpoint, a man may feel more insecure about his performance or less masculine in his identity.

Focal ablation for prostate cancer

Concern over sexual dysfunction following radical prostatectomy influences patient demand for an alternative. Newly diagnosed prostate cancer patients spend long hours on the internet searching for treatments that can reduce or even eliminate the risk of ED and other sexual side effects of treatment. Focal ablation, or targeted tumor destruction, is now a recognized standard of care for qualified candidates. Although there is not yet a treatment approach that is 100% curative with no risk of sexual impairment, image-guided focal ablation is a minimally invasive therapy that has rapidly gained appeal with both physicians and patients. It can be accomplished with extreme heat, as with focal laser ablation (FLA) such as that offered by the experts at the Sperling Prostate Center. It is not possible to predict if RP will ever become a surgery of the past, but it is possible to state confidently that focal ablation’s time has come as a way to spare men from the sexual side effects of radical therapy.

[i] Schauer I, Keller E, Müller A, Madersbacher S. Have rates of erectile dysfunction improved within the past 17 years after radical prostatectomy? A systematic analysis of the control arms of prospective randomized trials on penile rehabilitation. Andrology. 2015 Jul;3(4):661-5. doi: 10.1111/andr.12060.

[ii] Penson DF, McLerran D, FengZ, Li L et al. 5-year urinary and sexual outcomes after radical prostatectomy: results form the Prostate Cancer Outcomes Study. J Urol. 2008 May;179(5 Suppl):S40-4. doi: 10.1016/j.juro.2008.03.136.

[iii] Albaugh, J. “Life After Prostate Cancer Treatment: Sexual Healing.” Prostate Cancer Communication. Fall 2015 (Vol 31, No. 3):12-14.

[iv] http://www.harvardprostateknowledge.org/achieving-orgasm-after-radical-prostatectomy