Can prostatectomy cause erectile dysfunction (ED)?

Erectile Dysfunction After Prostatectomy

Yes, prostatectomy commonly causes erectile dysfunction (ED), with rates ranging from 24% to 76% depending on patient age, surgical technique, and preoperative erectile function. 1

Mechanism and Prevalence

Erectile dysfunction after prostatectomy occurs primarily due to:

• Direct damage to the cavernous nerves during surgery
• Neuropraxia (temporary nerve injury) leading to:
  • Penile hypoxia
  • Smooth muscle apoptosis
  • Fibrosis
  • Veno-occlusive dysfunction

The prevalence varies significantly based on several factors:

• Age: Younger patients (<60 years) have better recovery rates (up to 76%) compared to older patients (>65 years) with rates as low as 7.5% 1
• Nerve-sparing technique: Bilateral nerve-sparing procedures have better outcomes (68% recovery) than unilateral nerve-sparing (47% recovery) 1
• Preoperative erectile function: Men with strong baseline erectile function have better recovery potential 1
• Time since surgery: Recovery may continue for up to 2-4 years after surgery 1

Recovery Timeline and Expectations

Unlike the immediate urinary side effects that typically improve within weeks to months, erectile dysfunction follows a different pattern:

• ED is typically immediate after surgery
• Recovery is gradual and may take 1-2 years 1
• Some men may experience continued improvement for up to 4 years 1
• Even with nerve-sparing techniques, early recovery of natural erectile function is uncommon 2

Treatment Options

Treatment should begin early after surgery (penile rehabilitation) to preserve tissue health and improve long-term outcomes 3:

1. First-line treatment: PDE5 inhibitors

   • Tadalafil 5-20mg
   • Sildenafil 50-100mg
   • Vardenafil 10-20mg
   • Multiple trials (4-6 attempts) may be necessary before establishing efficacy 3
   • FDA data shows tadalafil significantly improves erectile function in post-prostatectomy patients (41% success rate vs 19% with placebo) 4

2. Second-line options (if PDE5 inhibitors fail):

   • Vacuum erection devices
   • Intraurethral alprostadil (MUSE)
   • Intracavernosal injections 3, 5

3. Surgical option for refractory cases:

   • Penile prosthesis implantation 5, 6

Important Considerations

• Orgasm vs. erection: The ability to achieve orgasm is often preserved after surgery but without ejaculation (anejaculation) 1
• Climacturia: Urine leakage during orgasm may occur, especially within the first year after surgery 1
• Penile shortening: Some men experience penile length reduction after prostatectomy 1
• Partner involvement: Including partners in discussions about sexual recovery is essential 3

Practical Advice for Patients

1. Begin penile rehabilitation early after surgery
2. Try PDE5 inhibitors as first-line treatment, with multiple attempts before determining efficacy
3. Empty the bladder before sexual activity to reduce risk of climacturia
4. Understand that orgasm is still possible even without erection
5. Consider referral to a urologist or sexual health specialist if initial treatments fail

Common Pitfalls to Avoid

• Delayed treatment: Untreated ED after prostatectomy can lead to penile atrophy and further diminished function 5
• Inadequate trials: PDE5 inhibitors require multiple attempts and proper dosing before determining effectiveness 3
• Overlooking psychological impact: The emotional aspects of ED can compound the physical issues 1
• Assuming immediate failure is permanent: Recovery can continue for years after surgery 1, 2

The significant impact of post-prostatectomy ED on quality of life makes early intervention and comprehensive treatment essential for prostate cancer survivors.