Prostatectomy and impotence

Male impotence or erectile dysfunction is usually described as the consistent inability to achieve or sustain an erection with sufficient rigidity for sexual intercourse.  There are usually degrees of impotence ranging from a partial decrease in rigidity to complete failure.  Unfortunately this information is not often common knowledge in both the lay public and with physicians.  Often times people believe that erectile dysfunction is an all or nothing phenomenon when, in fact, it is a process.

Imagine the number of nerves and muscular complexity that must come together in order to raise a finger or speak some words.  This is same amount of complexity goes into the apparent automatic erection which happens with sexual arousal.  Each time it requires muscular, nervous and arterial and venous blood flow coordination to achieve a sufficient erection to last through sexual activity.

Erectile dysfunction can result from endocrine,  vascular, nervous dysfunction or even drug-induced or related injuries or illnesses.  Some men may also suffer from age-related or disease related factors such as a man who experience diabetes or cardiovascular disease.  Impotence is also a common result after pelvic surgery. A prostatectomy is one of those surgeries.

The physiology of an erection is a complex procedure that requires intact nerves, arteries and veins which are localized anatomically as bundles and paired along the lateral pelvic fascia outside the prostatic capsule.  The entire process requires intact communication to allow the penis to become engorged with blood and then drain after sexual activity.

Statistics indicate that approximately 50% of the men over age 40 in the United States suffer some degree of erectile dysfunction.  For many years it was assumed that men who experienced a radical prostatectomy for the treatment of prostate cancer would suffer impotence.  In fact early reports find the rate at 90 to 100% after surgical treatment of prostate cancer.  The reason for this high rate was as a result of nerve damage to the bundles necessary to achieve an erection.

Since 1983 surgeons have pioneered the use of a nerve sparing prostatectomy and henceforth the incidence of impotence after radical prostatectomy has decreased.  Some research findings report the incidents between 28% and 42% as opposed to the 90 to 100% reported using traditional surgical methods.

Although these statistics are lower this particular surgical intervention does not completely negate post operative impotence in all patients, even when both nerve bundles are preserved.  This suggests that post operative impotence can be due to other factors other than nerve injury and has led to further research.

Fortunately, men who have experienced a radical prostatectomy for the treatment of prostate cancer also have options available to them to treat erectile dysfunction following the surgery.  Treatments available will include both invasive and noninvasive protocols.  Some men find that the new erectile dysfunction drugs such as Viagra or Cialis, are helpful in their treatment while other men must use penile implants or penile vacuums.

The most important thing to remember when considering postoperative treatment for men who have had a radical prostatectomy and may be facing erectile dysfunction is that treatment is available and often very successful for these men.  Ignoring a problem with erectile dysfunction in men who are in stable relationships will often lead to destabilization of the relationship and potentially a divorce.  The importance of a good sexual relationship within a marriage cannot be overlooked and should be addressed by the surgical team or a psychologist who interacts with the patient and the postoperative period.

RESOURCES

Weill Cornell Medical College: Prostatectomy and Erection Problems
https://www.cornellurology.com/clinical-conditions/erectile-dysfunction/prostatectomy-and-erection-problems/

Cancer REsearch UK: Radical Prostatectomy
http://www.cancerresearchuk.org/cancer-help/type/prostate-cancer/treatment/surgery/radical-prostatectomy

Urology: Renewing Intimacy: Advances in Treating Erectile Dysfuncion 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2615103/

Department of Urology George washingon University: Management of post-prostatectomy Erectile Dysfunction
http://www.canjurol.com/pdfs/HOW/HOW-DrJamal.pdf

Prostate Cancer Treatment Guide
http://www.prostate-cancer.com/prostatectomy/side-effects/prostatectomy-side-effects.html

American Cancer Society: Post Prostatectomy Impotence
http://csn.cancer.org/node/136191

Medscape Today: Majority of Men Experience Impotence Following Radical Prostatectomy
http://www.medscape.com/viewarticle/411468

British Medical Journal: Impotence after Prostatectomy
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1662342/
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