This post is for all the men who have prostate cancer or are worried about prostate cancer. One of the most feared side effects of therapy for prostate cancer is the impact on sexual health.
Hopefully this will give men a better idea of what to expect and take some of the fear of the unknown away.
The prostate makes the liquid in the ejaculate. This is necessary for the sperm to work and therefore to have children. Other than having children, the prostate is of little use later in life and only causes problems with urination (BPH) and is a leading cause of cancer.
The “nerves” that go to the penis course very close to the prostate. They are only a few millimeters from the prostate and can be affected by surgery or radiation. These nerves are solely responsible for erections, or the ability of the penis to get hard.
The net effect of someone having his prostate removed is:
- He will lose the ability to have an ejaculate, and will be sterile. You can still have children with your own sperm by artificial means.
- He will maintain full sensation of the penis. With masturbation or other stimulation, he will still have the ability to have an orgasm.
- He will probably lose the ability to get a firm erection after surgery. I have had many patients who kept their erections with robotic surgery, but this is not the rule. With time he will hopefully get his erections back normally.
Factors that are responsible for the ability to get erections are:
- Preoperative function- Surgery can not help erections. If they are not that good to start, then they are less likely to come back.
- Age- The older the patient, the more they need the nerves working perfectly to have erections.
- Other medical problems- Illnesses that affect erections such as diabetes and high blood pressure will not help.
- Frequency of intercourse- The more sexually active the person is, the better the recovery rate.
- The ability of the surgeon to spare the nerves. If the cancer is such that the nerve shouldn’t be spared, erections are less likely to come back. If the cancer is such that the nerves are able to be spared, then technical factors such as how much tissue is saved, using less cautery in the areas of the nerve bundles, and stretching the nerves less all play a role in recovery.
The following video was from a surgery done at Newark Beth Israel and demonstrates the nerves being separated from the prostate. The da Vinci robot that was used for this procedure gives 10 times magnification of the anatomy and a near high definition, 3D picture.
October 2007 Update: I have a new post that may help men that are looking for insurance companies to help cover the cost of penile rehabilitation PDE5 medicines.
Comments
108 responses to “Sexual life after prostate removal”
I had my prostate removed in 2003 and it was not nerve sparing and I have never had a natural erection since.
Nerve sparing is of the upmost importance aside from getting rid of the cancer.
My husband had robotic (Da Vinci), nerve sparing radical prostate surgery almost 6 weeks ago. The cancer was diagnosed early and confined to the prostate. His surgeon perscribed Viagra 2-3 times a week as a healing aid – to help stretch tissues and to discourage formation of scar tissue while healing – as I understand it. It is early, of course, and there has not been much in the way of erection which is to be expected, I think. But here is the issue at present. Our insurance will not cover the cost of Viagra – it is an excluded product. We have appealed with a short letter from the Surgeon and a letter from ourselves stating that the Viagra is perscribed for medicinal reasons. They have written us and given us 5 days to furnish any supporting documentation before our request goes before a review committee. Can anyone give us a link to a study or information supporting that line of treatment? It makes sense, but that is not enough.
I will look through my files and get the exact abstract in the near future.
One paper showed that men that underwent daily dosing of viagra for 6 months after surgery had normal appearing penile tissue and those that didnt had scar tissue.
There arent any other great studies, but a few others that may relevant will be given as well.
The other thing is to split the pills in half (get the 100 of viagra and use 50 per day) since the pills cost about the same.
Dr Savatta
1) what are my chances for return of erection as it currently is if i can masterbate with a full erection but need viagra for intercourse?
2) i am 66 yr,gl=6, 3 out of 12 cores=10%, t1c, psa went from 2.5 to 5.7 in 6 mths
4)are you referring to frequency of intercourse pre or pos op? doe masterbation count?
Factors that are responsible for the ability to get erections are:
1) Preoperative function- Surgery can not help erections. If they are not that good to start, then they are less likely to come back.
2) Age- The older the patient, the more they need the nerves working perfectly to have erections.
3) Other medical problems- Illnesses that affect erections such as diabetes and high blood pressure will not help.
4) Frequency of intercourse- The more sexually active the person is, the better the recovery rate.
5) The ability of the surgeon to spare the nerves. If the cancer is such that the nerve shouldn’t be spared, erections are less likely to come back. If the cancer is such that the nerves are able to be spared, then technical factors such as how much tissue is saved, using less cautery in the areas of the nerve bundles, and stretching the nerves less all play a role in recovery.
(Frequency of intercourse- The more sexually active the person is, the better
the recovery rate.)
This is referring to the amount of sexual activity beforehand. I think any form of sexual function helps, including masturbation.
Nerve sparing has to be left up to the surgeon and I use the biopsy map (the report that shows the exact location of cores that are positive and where) to help decide. Most patients with T1c and gleason 6 should be nerve sparing candidates.
I use a SHIM form to assess pre and postop function. One of these can be found at:
http://www.njurology.com/_forms/shim.pdf
I would guess that people that have mild ED by the form have about 1/3 chance of keeping erections, but it usually will take longer to come back and viagra or a substitute will be needed for erections.
If the SHIM score is lower, than mild ED, than even less.
Although this isn’t great, the alternative therapy with radiation will also have a very negative effect on erections.
I would guess by 2-4 years more than 1/2 of the men will loose their ability to have erections even with viagra and more will loose it each year.
My best success story is a man who was 70 (72 now) who needed viagra before surgery. He was one of first 10 robotic patients, and I didn’t track SHIM scores formally at that time. He had diabetes and high blood pressure and had intercourse 2 weeks after surgery with viagra and still has them today.
I think the nerve sparing has to be perfect in those cases and sometimes the anatomy does not allow a perfect nerve sparing.
I had robotic surgery with unilateral nerve sparing. 6 weeks later have little or no bladder control. What are chances of regaining any erectile function?
Needing to remove one nerve significantly lessens the chance of regaining erectile function.
I have patients regain function within 3 months saving 1 nerve, but many never will. Your surgeon should give you the best answer to your question.
After 3 weeks of prostate surgery and removal using the robotics do you
suggest using viagra before masterbation and should it be natural. The
nerves are still there and I am 65 and very active. What are your
thoughts on exend which is a product advertised to make the penis
larger. After surgery I have noticed the penis is somewhat smaller.
Thank you
My typical protocol for patients with good erections and nerve sparing surgery is to start them on medicines (viagra,levitra, or cialis) after the catheter is removed. I have my patients take 1 medium dose on Monday, Wednesday, and Friday evenings.
I have about 40-50% of patients have erections as soon as 4 weeks. I would wait at least 3 weeks for any sexual activity including masturbation. I do not think taking the medicines at the same time helps that much.
I ask patients to continue the 3 times a week maintenance until they are having decent erections, and then take it as needed as long as they will be having some sexual activity at least twice a week. I would continue this for 6 months if there are no results.
I do not recommend any pills or devices that are advertised to help penile size and recovery unless I know what is in them and they are monitored by the FDA (many supplements are not).
I am 61 years old and I had Robotic Laproscopic surgery on February 3, 2006. It was a 6 hour operation because the doctor was aware of my concerns about ED and he spent the extra time for the nerve sparing procedure. Everything went fine, I was out of the hospital in 2 days and I have very little or no incontinence. It is December 21, 2006 and I still have not had a normal erection. For the first 6 months I tried the various pills with no or little effect, other than a great deal of flushing and being uncomfortable until the drugs wore off. I did buy the battery automated vacuum pump that has worked sometimes. However, it is terribly uncomfortable for both of us. It is mechanical and that does not support a romantic event. Although I prefer not to use viagra, I try to use it on a Saturday and Sunday in the morning. That is probably the frequency of our sexual encounters. BEfore any sexual activity, the viagra has had to be in my system for at least a few hours, and the sexual activity to activate the erection works only a little, after 9 months. I then need to get up and work the vacuum device until that works, but by that time it is out of the mood and not comfortable and the rubber band hurts my partner. This frequency of our sexual events was the same before the operation and my partner does keep paritally clothed during our event, but that is the way it is. Does this seem to you that it will get better with time? Do you suggest trying something else? I am not sure that I want to inject anything into my penis and most certainly don’t want to have an operation to insert a device. I am open for all suggestions. I am not really happy taking the pills because of the flushing. I am aware that the frequency could be better. I would appreciate your response and I would be available for you to ask me any more information on the subject. Thanks. Joel
The important part of the last entry was the duration since the operation.
There can be dramatic improvement in the first year and some improvement for up to 2 years typically.
The best person to answer your question of the likelihood of erection recurrence is your surgeon, as the quality of the surgery and the preoperative function are important factors.
I do not consider penile implant surgery for at least 1 year if I thought there would be a reasonable chance of return of function.
I would recommend injection therapy. It sounds awful, but it is usually effective and not very painful usually.
I have been advocating injection therapy as soon as 1 month in patients whose erections are very important and do not have any significant response to the oral medicines.
Good luck and ask your surgeon what he thinks.
I had the robotic procedure on 11/27/06. At this point incontinence is minimal and erections are nonexistent. The pathology report revealed T2c and 3+4. The bladder neck was resected as it appeared abnormal. As it turns out the bladder margin did contain cancer. Insurance will not pay for Viagra. I have an appointment to listen to the sales pitch for a vacuum pump next week. The surgeon told me erections might return in 6 to 9 months if ever. That does not sound encouraging. Been married to the same woman for 35 years with sexually intercourse at least once a week. Comments and feedback welcome.
Hello Dale,
There are many factors that can help determine your probability of getting erections back. Your surgeon will probably be able to give you the most accurate estimate.
I think a vacuum pump is a decent idea at 1 month, and I used to recommend the vacuum or injections very early on, but I am stressing the injections more now. I read an article from a top ED doc who thought that the injections probably would work better since you are having blood come into the penis that is carrying oxygen as opposed to trapping venous blood in by using a vacuum.
So I am now recommending the injections first and then the vacuum for patients that can’t do the injections.
I have a patient of mine who took the makes of cialis to court and won his case to make them pay for the medicines for rehabilitation.
I had Da Vinci machine removal of prostate May 06. To date no sign of erection. I tried Viagra twice with no effect. My wife and I have always been pretty active and prior to procedure I had no problems with erection. My urologist indicated that it may take 1-2 yrs to get an erection. The question is should I be using Viagra with regularity to try and stimulate nerve regeneration? I thought viagra only worked on the chemical aspects of the erection and if the nerves are not there or have not regenerated then viagra is useless. Is there anything else that I(we) should be doing to move this process along? Thanks
The last comment discusses viagra. There was one study that looked at men’s penle tissue after 6 months of prostatectomy. It showed men on viagra had less scarring.
You do need some nerve tissue for viagra to work, but after nerve sparing dvP many men have some nerve function intact.
This is the main reason I use viagra (or levitra or cialis) regularly after dvP.
I am not sure of the ideal dosing and frequency, but I have been prescribing 1/2 of the maximum pill 3 times per week if there are no contraindications. I think this has some benefit and most men will have some erectile function as soon as 1 month. If they do, then I wait longer. If they do not, I recommend penile injection therapy. I think the vacuum pump is an OK option, but brings in venous blood, not oxygenated blood that viagra or injections will bring in.
Surgery was performed on 11/27/06. Very little problems with incontinence. Erections are another story. Doctor prescribed Viagra but insurance will not cover. What about generic Viagra? It’s a lot less expensive and if it will help prevent scar tissue it might be the way to go.
Is manual penis stimulation advised immediately after catheter removal? That is, stimulation not to orgasm, but continual tender rhythm. Also, frequency of two to three times a day help to stimulate erections while using 25mg dose of Viagra every other day?
Keep up this great resource. best greetings!
To be honest my greater fear is incontinence. I understand that too is a risk with Prostate surgery.
You are correct, the biggest fear of surgery is incontinence.
I will work on a similar blog entry to help understand incontinence better.
Thank you,
Dr Savatta
My husband had robotic surgery on Mar 19. At the follow-up visit to the surgeon on Mar 26, the nurse removed the catheter and staples. Everything looks good! However, we won’t see the surgeon until Apr. 20. The nurse told us we shouldn’t even think about sex until the continence improves and that we’ll just see on the 20th how things are working. I’ve read so much about the importance of stimulating the penis to stretch the tissues and to discourage scar tissue formation; Viagra (or other) would certainly assist to do this. I think 6 weeks is too long to wait when there are tools like Viagra that could help now. What are your thoughts?
Thanks for the question Anne.
I agree that it is too long. This is just an opinion, as there are is not a definite consensus on what works and when it should be started.
I have this on my list of blog entries to get into my detailed thoughts, but the short of it is this:
Most nerves have some damage to them no matter who well the surgery goes. There have been studies that penile scarring may result if you do not have blood flow so even if the nerves recover later, the erection may not be as good.
If there is some nerve function left, PDE5 inhibitors should help augment the blood flow and I start them when the catheter is removed (usually 5-6 days).
By 1 month I offer penile injections or muse or vacuum pumps (vacuum probably will not work as well) if there is not a decent fullness to the penis. Some men wait until 3 months for this.
I have had men have intercourse as soon as 7 days after surgery, but I think it is best to wait 3 weeks to allow for healing.
I hope that helps.
Dr Savatta
Do you need to remove the whole prostate if I have prostate cancer surgery
This is one of the most common questions that patients ask me, especially if the cancer is confined to one area on biopsy. With robotic surgery I am able to remove part of a prostate if I want to, and…
I am a 43 year old who recently had a prosectomy (8/06)and get Lupron shots every 4 months for 2 years and casodex daily for 2 years, my question is I know that I have lost my ability to ejaculate but will I regain my ability to have an erection and even an orgasm?, I am a very positive glass half full kind of person so your anticipated positive response is greatly appreciated
Two years ago my PSA was 2.3, one year ago it was 2.6. A follow up two months later it was 2.8. I had a biopsy at that time which was negative and my prostate size was 63 grams. This past December my PSA was 3.2 and I had another biopsy. This time the biopsy came out positive. Prostate size was 79 grams, 1 of 10 cores was 60%. Gleason score was 6. Stage is T1C. I am having robotic surgery on April 13. Pre-surgery sexual activity was regular and quite satisfying. I think I have read enough regarding what I should expect time-wise on regaining continence and potency. what I have not been able to determine is how much the size of my prostate will affect the ability to do the nerve sparing surgery. Your comments on any of this would be appreciated. I am 54 and in good shape.
At 43, most men will regain sexual function after surgery. This also depends on their preoperative function and if nerves were spared or not. If they weren’t, the chances still go down significantly.
Most men on hormonal therapy will have erectile dysfunction to some degree.
Since there are many variables, your urologist should give you the best estimate.
Thanks for the question on big prostates.
With a small amount of cancer, you are definitely a candidate for a bilateral nerve sparing procedure.
In general prostates that are larger are more difficult. The nerves are stretched for a longer distance and I think they are traumatized more easily.
The other thing is that usually larger prostates are seen in older men, so not many prostates that size exist in young men.
Looking at my stats and limiting it to only men under 60, I performed 6 bilateral nerve sparing procedures in dvPs in your prostate size range (62-82 ccs) in men with normal sexual function. 4 men regained erections at 4,6,20, and 75 weeks. One man is 3 months out and not there yet, the other at 1 year and is close.
Given your young age you have a good chance of regaining sexual function.
Most of my men under 55 with normal erections regain function in a couple of months.
Good luck.
In my previous submission, I asked you questions about the size of my prostate and the ability to do nerve sparing surgery. My robitic assisted surgery was performed on April 13. I can report that my margins were negative and that my cancer was totally contained. My one month PSA is unmeasurable.
My catheter was in 2 weeks and 2 days. I am 95% continent with little or no leakage 2.5 weeks after the catheter removal. I am not yet confident enough to go without a pad but may try to go without one on the weekends. My urologist has put me on Viagra. He did not indicate any kind of frequency of use. I have taken Viagra twice in the last week. With stimulation, I do get enlarged but do not get an erection or anything close to being able to penetrate. Should I expect more at this stage? Should I be taking the Viagra more frequently to try to get back to normal even though the insurance provider will only fill the prescription once every 26 days? I have read that it is important intially to avoid scarring.
Thanks in advance for your comments.
There are different regimens for what medicines to try and when.
I think the best cost/benefit is to a viagra type medicine 3 times a week at the middle dose (50mg for viagra, 10 for cialis or levitra). I write scripts for the 100mg and have patients break them in half.
If you are getting some results at 1 month, I do not think it is necessary to try injections or other therapy unless you would like to have full erections right away.
I plan on writing something with more details on this in the near future.
My husband had robotic surgery May 4th and had one nerve removed – the cancer was totally removed and recovery has been good. He still had a bit of pain and is getting frustrated with a lack of an erection – he is 56 and in very good shape. Our sex life prior was very good and we wondered how long before he will have an erection – is a month too soon for him?
With one nerve spared there is still a good chance things will work well if they worked well before.
All of the factors that were mentioned previously still apply.
Most men with only 1 nerve spared rarely recover sexual function as soon as 1 month.
I would look into other options, my personal favorite for motivated men is penile injections which your urologist can teach you how to do.
I am a 41 yr.old who had the DaVinci robotic surgery. I am now coming up on a month since the surgery and I was curious alot of the quetions havebeen answered but w/ED and making a choice between a pump or a pill would you suggest the pump to see if an erection can be established and maintained I know that the pill is just a helper you must have some sort of stimuli-excitement to gain and maintain an erection. Will a pump show you if you can achieve,maintain,and if the size has changed drastically.Also if you are not erect and get a feeling of sensation of course without an ejaculation is it normal to get an uncomfortable feeling like a pain or pulling or shock making you stop IMMEDIATELY?? Will that jolt or pulling pass w/healing??GJL
I will need to write a good piece on why and how I do sexual rehabilitation which I plan on doing soon.
The important thing is that the oral medicines help some. If they are not causing some fullness, I usually perform injection therapy which is probably the most useful thing to help get better erections in the future. The pump may help prevent penile length if men are not having erections, but probably doesn’t help as much to bring back erections.
My husband had a DaVinci Laproscopic Proctectomy two weeks ago. The nerves on the left side were removed. The right was left in tact. Before surgery he could have an erection usually without too much trouble. I am wonder where do we go from here? Is it enough to have nerves on one side to have a decent sex life? Should we start trying to make love now? Does he need more time to heal? When is it safe for him to have an orgasm? And what will his chances of gettting an erection be? He has not been started on any medication as of yet. Thank You!
Is manual stimulation, masturbation, as good as Viagra for reducing scar tissue? Also where does scar tissue form?
I had a vasctomy about 35 yrs. ago and had a robotic assisted prostate done on July 13th. Does that mean that there is even less chance of having an erection or the feeling of climax? I’m 66 yrs old and in decent shape.
I do not think the vasectomy has any impact on erections or sensation of climax.
In October of 2005 my husband had prostate surgery. So far there is no erection. The viagra didn’t help. He feels the nerve fuction will not come back. Our sex life was quite active before surgery. I am not sure how to proceed. While I understand that this was a difficult period for him. It seems that the partners are left with little support as to how to proceed in the recovery. We do have intimacy but no intercourse. I don’t know what is available for me or even where to go from here.
I had a prostectomy using the daVinci robotic surgical system in May of ’05. I have spontaneous erections in the morning however I am still unable to achieve one for intercourse with normal stimulation without the use of an injection. For the first year I was not achieving erections of any kind. I seem to be slowly regaining the ability. Is this long period of time to gradually return to a point where erections can be achieved normal?
Recovery of erectile function is variable after prostate cancer surgery.
I expect men that have not recovered early on to continue to improve for 18-24 months. After 24 months, the chances of recovery are much less. If men are not having any erections at this point with the viagra type medicines, then it is unlikely he will recover function naturally or with viagra.
All impotence options should be explored including an inflatable penile prosthesis. I find that most couples with an open mind can do well with the various therapies, with the highest satisfaction rates being with surgery (inflatable penile prosthesis) and penile injections.
I had prostate surgery in December 2006 which was by lazer……….prior to diagnosed had been prescribed Viagra……..after the op was prescribed Cialis then developed a heart condition that requires me to take Isosorbride Mononitrate Tablets twice a day, this means if I took Viagra or Cialis this would “kill” me I was prescribed “Muse” 50mg and then 100 mg which had no effect. I saw my Uroligist yesterday and I am to be put on Vividal duo Injections…..this will be after my next visit at the end of Novemeber. I can not find any information about this new drug………has anyone had this treatment I would love to read more…… I am a 63yo male
I had a tumt procedure in dec of 06 which turned bad. apparently something went wrong with the precedure or with the machine, not sure which but left me with a fistula burned through my urethra through my rectum. I was on a catheter for six months and had a colostomy for diversion for seven months. I am now healed but I have erectile problems with no ejaculate and extreme pain on orgasm. MY doctor doesn’t give me any help> any thoughts on this??? Please help!!
Letters here are informative and many reflect my condition.
I still have questions and comments.
I had DiVinci prostate removal Aug. 9 2007. No erection as of yet. My concern is that the surgeon never suggested anything for the ED. I had to ask him for Viagra. He gave me Cialis samples. I saw the surgoen again Oct. 10 2007 ( 2 months ) He saw me for less than 5 minutes, asked how I was,have I had an erection yet, and how is my incontenence. Had a PSA less than 0.1 .He didn’t do anything I had to ask him for a script for Cialis. Personally, I don’t think he cares if I ever get an erection again, because he has never suggested any options. And never mentioned long term Scaring, Am I wrong ???
i am 57 years old i had robotic surgery April 19 07 its over 8 months and very little orgasem and no erection .do i still have a chance its that gona come back
Orgasms usually are present after surgery, just not the ejaculate.
Erections can be expected to improve for up to 24 months after surgery, but the operating surgeon should be able to give one the most educated guess at what the probablity would be.
after prostate cancer can you retreived sperm from the man to make babies?
Although men are sterile after prostatectomy, sperm can be retrieved directly from the testicles to have children. A urologist specializing in infertility can do this. In my office, one of my partners does this: Dr Seaman at
http://www.njurology.com/_physicians/seaman.php
My doctor thinks that my erectile dysfunction is do an inflammed prostate which in turn inflammes the cavernosal nerves which in turn caused ED. Is removing the prostate a viable option for someone like myself. I am 36, married, with kids. Thanks for you help.
I am 46 and had DaVinci prostectomy Dec 11,2007.
I have had adhesions at the tip of my penis after a visit to my doctor to open them. I have used a female catheter twice after the visit to open myself and I still urinate a ribbon thin and unpredictable stream. Could this be caused by my wifes manual stimulation from sticky seeman, or is it just scarring from the catheter? We have no problems manually getting an erection and trully enjoy a physical usage when cleared to do so. Thanks for any help, Lovin My Girl Everyday
Had nerve sparring surgery on 3/08/08. we started sexual activity after about 10 days and the third time i had an erection capable of penetration. It has not worked that well all the time but i am quite excited that i feel it will be back to normal or at least close to normal in a relatively short period of time
I had my De Vinci surgery June 16 of 2006 started pump therapy at 6 weeks had no problem with orgasm’s just not the romatic way to have orgasm’s started Viagra there after without any sucess tried Cialis with the no success rate, at 8 month, tried self injection that worked a little bit with it getting better after the first time it seem’s to help the return of more fuction if I could remember to to do it regular it does sting a little it’s not for everyone, a lucky man has a mate that would help and encourage with these things Iam now at 21 months seems better, but just keep trying that’s all you can do
I had never sparing prostate removal 5/04. Can get partial erection but must rely on injections or vacuum pump for intercourse. My problem is maintaining an erection when lying on my back. I assume this is venous leakage. It occurs even when using a tension ring. Does anyone know of a solution to this? Is a penile implant the only answer? I’ve heard the infection rate is higher that than what is usually posted on internet and can be disastrous. Has anyone had experience with the implant? Also, if anyone is concerned about the injections, it’s very easy and works well. Don’t be frightened to try it.
The last comment is unfortunately a relatively common occurrence. When we discuss high rates of sexual function after robotic prostatectomy we are selecting out patients with normal preoperative functions. Some of these men will never recover fully (even with a viagra) and will need other therapies.
After 2 years, I usually recommend the inflatable prosthesis. The infection rates are low with the newer devices (about 1%) and they are easier to use than past ones. Patient satisfaction is very high after these procedures.
Dr Savatta
I had prostate surgery about 2 years ago and it was cancer. I am unable to have a erection. Does masterbation harm you any way?
I am a 62 year old man and had my DiVinci procedure on March 14, 2008. The operation went perfectly and my surgeon said he couldn’t have hoped for a better result. My Gleason was a 6 but he said the cancer was totally confined to the gland itself and he was able to spare the nerves. My incontinence is virtually non-existent and my catheter was removed in just 6 days after the operation. My healing has been fabulous in every regard. However as most men have stated, my erections are non existent. My surgeon told me that they might return in 6 months to a year. He didn’t however mention the use of Viagra or Cialis to minimize the scaring I have been reading about. I have used a pump several times a week and have been able to achieve 5 or 6 “dry orgasms” as a result. There is significant urine expulsion during the orgasm however. I guess all in all I am satisified with the outcome of the operation and as many have already said, the best thing to do is just keep trying and hopefully a natural erection will return. One factor in my favor is the fact that I have always had a very active sex life prior to the surgery and I have been told that is one positive thing. Good luck to anyone who is considering this operation I have only positive things to say about my team and the Hospital where it was performed. The only thing that could have been better would have been never to have gotten prostrate cancer in the first place!
Dear Doctor: I am a 52 year old white male who had a PSA go from 1.9 to 2.85. My urologist had me get a prostate biopsy over a week ago. I thought it was extremely painful, I still have blood in my semen, I put my back out due to tensing up during the procedure. The results of the biopsy were “inconclusive.” Now the urologist wants me to have another biopsy in 3 months! This seems extreme to me. My 57 year old brother (who lives in another state) had an “inconclusive” biopsy and they waited 9 months before repeating the biopsy. Am I wrong to think this is extreme to repeat the biopsy in 3 months?
It really depends on the type of findings. “Inconclusive” can refer to high grade PIN, atypical cells, or other diagnosis.
At 52 years old It is a good idea to find cancer if it exists. The least worrisome of these findings is high grade PIN, which was once thought to be highly associated with prostate cancer, but with most urologists using 12 biopsies (instead of 6) the association with cancer is less.
A repeat biopsy for certain diagnosis in 3 months is reasonable.
Ways to minimize pain during the procedure include injecting numbing medicine into the prostate and sedation.
I am 48 years old, had my prostate removed 2.5 years ago with one side of my nerve bundle saved. I was able to have an erection within 3 or 4 months after the operation, but after about 1 1/2 years I started having pain somtimes with orgasm it is a 7 on a 1-10 scale at times. My family doctor said it could be a muscle strain it is painfull 1 out of 3 time I have sex. What could this be? My PSA is .099.
I had Divinci surgery april 14th. I have been using the pump from week four on. I had a lot of swelling and had the catheter in for the first three weeks or I was not able to void. I have two questions, first now that the prostate is gone, is it possible to leak urine while having sex. Second I had the biopsy on 12/31 and I had pain and slight bleeding when I ejaculated until the surgery. Is it normal not to heal after the biospy for so long?
This is very personal so I’d rather not use my real name. 1st I want to encourage the men (my husband had his surgery in 03)just let things happen naturally, don’t stress. The Cialis is best taken the evening before. Hubby had the DiVinci and is fine now. There is no ejaculation but so what, it is not necessary to achieve orgasm. In addition my husband found that masturbating in the shower prior to making love helped. Standing while having intercourse helps too. Have your wife lay on the edge of the bed (KY Jelly helps). It will work again, be patient with yourself and be thankful that this is available, it saves your life and there is more to life than sex.
I do have 1 question that has plagued me. Have any of the men (honestly now) felt that the removal of the prostate gland in any way changed the mental attitude of the men. I mean like when a woman goes thru menopause, hormone imbalance does many things. My husband seems to have a shorter fuse, seems to get angry for no real reason, even at our grown kids. This is not the same attitude before the surgery and it’s been over 5 yrs. Just seems out of sorts almost self-centered like a spoiled child; although his physical side affects are gone for the most part.
PS He does at times have slight twinge or pain when having an orgasm, I think it must be something with the muscle, perhaps they do need to be exercised more. Thank you N
Dr. I had robotic surgery here in Nashville 5 weeks ago. Altho noone told me my penis would shrink up it has come back to about normal size. My wife and I started sexual activity after 2 weeks. By the end of week 4 I have been able to achieve orgasm 5 times. I am very encouraged by this even though I have no signs of erection. We we very sexually active prior to surgery and have sex every day. I’m still always in the mood and thank God I have a willing partner. How soon do you think I should explore items like the pump etc. I take the dosage you recommend of cialis 3 times a week. Thank you for this site. Bill
Dr. As an ecouragement to others I want to mention a significant event for me and my wife. Last night, just short of 7 weeks from surgery I had great response to our sexual activity. I was able to grow large enough to be inside the vagina and reach orgasm. However, after intercourse my penis actually grew larger, more firm and engorged with blood even tho still not really erect. This was after about 1 hour after the 50mg dose of Viagra. We are excited and looking forward to more improvement. Thank you for suggesting the medication at an early stage as my surgeon did not bring it up till the 6 week mark. I started Cialis at 2 weeks and tried Viagra last night for the first time. Thank you, Bill
I had nerve sparing robotic surgery 3 months ago. Sex is coming pretty good especially with therapy injection. But I now realize that there is visible small presence of semen at the tip of my penis after orgasm. Was it not supposed to remain dry after sex?
I have previously posted questions on your site. I had bilateral nerve
sparing robotic assisted prostetectomy on 04/13/07. My doctor has had
me on viagra several times a week since about one month after surgery.
That did not work so we tried muse. The muse did not work either.
About 4 months after surgery, my surgeon put me on injections The
injections work fine but I had to go from a trimix to a bimix solution
because of the pain. The bimix works fine. I use between 10 and 15
units for the injection depending on the age of the bimix. I get a
very good erection with the injection and it is not nearly as painful
as I would have thought. I am now out 14 months and do not experience
spontaneous erections. My surgeon says there is still time. I would
like to hear your thoughts. I am now 55, had a very good sexual life
prior to surgery. I am totally free of cancer with 0 PSA readings
since and i am totally continent. I had a prostate that measured 79.
Please provide me with your thoughts regarding spontaneous erections
based upon what you have seen. While I am very able to get erections
with what seems to be minimal amount of bimix injections, it would be
nice to regain natural erections.
The main ejaculate is gone, but you can have a small amount of fluid, the pre-ejacualte, that comes out of urethral glands that will still be there. Some men can have urine coming out as well, which doesnt sound great, but is not dangerous.
My husband had robotic protate surgury saving the nerves on 3/4/08. He now has sensation and if feels to him like he has an orgasm, but is hung up on the fact that there is no ejaculate. Is this a common hang up with most men. It has been almost 5 months since surgury, he has yet to get a hard on, although the Dr said this is normal. His Dr does not start prescription therapy until 6 months post op. Is this normal? Also his Dr has not mentioned Viagra or Cialis as far as discouraging scar tissue. What are your thoughts?
Most guys are OK with loosing the ejaculate, but arent happy about it. Most wives think it is a good thing.
Erections often come back for up to 18-24 months after prostate cancer surgery, but many factors depend on this. If both nerves are spared and patients have good preoperative sexually function, most of my patients are having at least partial erections by 6 months with viagra.
I am an advocate of using viagra, levitra, or cialis, but this is not universally accepted yet.
1/28/08 my husband had his
prostate surgically removed
being incontenent all of this time has totally worn him down. he sits so that he won’t have excessive leakage. actually, he won’t even go out, except to the doctors. once he had coffee before going out and it was a real urine problem. stink plagues him and too does the urin rash
i’m at a stand still. the heck with erections. what can be done to give this man
peace from leakage and odor?
my husband had a prostechtomy in May 2007. There was a miniscule amount of cancer found in one of the lymph nodes. He had 33 radiation treatments and a hormone implant until June 2008. We were told that nothing would work for him sexually until the hormone implant was removed. He had no interest, so it was not until recently that his libido has been returning. Now when he has an orgasm he experiences great pain. The urologist gave him muse, but he is hesitant to use it again, since he was in such pain at the doctor’s office. Will this pain go away eventually or should we give up and learn to enjoy each other in other ways? As a wife, it is difficult to respond sexually, knowing the pain my husband is undergoing.
Pain is not common after any form of therapy for prostate cancer, but can happen.
This case needs to be discussed with a physician and can not be answered in a simple way.
I am 53 and had nerve sparing surgery 10 months ago. During sexual activity there is some fluid on the penis. Is there ANY chance of getting my partner pregnant from this? At my stage in life I DO NOT want this. Do I need to use a condom?
After a radical prostatectomy (open, lap. or robotic) there should not be any possibility of having someone become pregnant. The tubes that bring sperm from the testicles to the penis are disrupted and removed.
Thanx Doc. I’m 53 years old and was found to have a “hard spot” on my prostate. Visit to the urologist confirmed and was told PSA was “Good” (whatever that might mean). I’m having a biopsy performed ( a little tentative) November 21st and I’m just looking for good info on what I need to know “just in case”. Any info or help would be greatly appreciated.
Typically only 1 in 6 men with an abnormal prostate exam and a normal PSA have prostate cancer. I usually tell men that need a biopsy to focus on the biopsy first since often it is not cancer.
Some helpful info about the biopsy can be found at:
Prostate biopsy side effects
Good luck.
Dr Savatta
I 63 and had dvP ( one side nerves spared ) in Mar/08 prior to this I had 2 – 3 month shots of Eligard the effects of this hormone blocker are starting to dissipate only now and slowly the androgen level increases , I really have not much desire for sex now but I had even less before
I have some lingering incontinence …no erection has been seen for well over a year , I had a great active sx life before that , I took a bit of viagra after the surgery but it is expensive and nothing seemed to happen so I have not kept it up
I am hoping that one day I can get all ducks in a row so that I may once again be somewhat active .
what I have noted during a very rare orgasm is a great deal of urine is expelled I worry about this for my partner in the future , is there any thing you can advise me on ?
thank you !
The best person to guide you is your surgeon.
One of the thinsg that you are reporting is a side effect that is more common than some people think. Some men have good control of their urine except for when they have an orgasm, as you mention. This often improves for the first year after surgery. I have had decent results with biofeedbacks, a type of urinary physical therapy that can help strengthen the urinary muscles.
There are many options for erections if the viagra type medicines are not working for you. Your surgeon should be the best one to give you an estimate at recovery with viagra, which can take up to 2 years after surgery.
I am 53 and had my prostate removed on 12/18/08 using Da Vinci. My Gleason ranged from 3+3 to 3+4 on all right-side samples; no cancer detected on left side. Both nerves were spared. I am taking Cyalis about every 3 days (started 12/31/08). Today, I was able to produce almost a full erection with climax (Yes!). I have almost full bladder control with a small amount of leakage 2 to 3 times a day (e.g., getting up after sitting for a while). I expect my pathology report to be back this week including lymph nodes. I’ll provide an update in about 2 weeks.
Hello!
I am 70, I would like to inquire the time it takes normally to have erections after surgery. In my case I have been operated 5 months ago and I have very little erections even with 20mg Cialis. I was very busy sexually before surgery. Please tell me how long will I be waiting to have successful erections.
Thank you.
Your surgeon is the best one to answer this. The amount of nerve tissue that was able to be spared and how much the nerves were stretched are important factors.
In general, men over 65 take longer to recover sexual function and improvement can happen for up to 2 years after surgery.
I ma 66 years old and had the robotic surgery performed on October 31, 2008. It has been 15 weeks since the surgery and I am still incontinent and have no erections. Both nerves were spared. When can I expect the incontinence to disappear?
Return of urinary control depends on several factors:
The condition of the urinary musceles (sphincter) and bladder prior to surgery.
The ability of the surgeon to save the muscles (sometimes parts of these have to be taken to have better cancer control).
The patient doing exercises (Kegels) to help recover.
I have been performing extra surgery at the time of robotic prostatectomy (Reconstruction of the rhabdosphincter) which helps support the areas around the muscles that have to be cut during surgery. I sew these structures to the bladder. I have been doing this for 2 years and have seen less incontinence after surgery.
A patient can also do biofeedbacks, which is like urinary physical therapy. You may want to see if your urologist offers this in his office or can refer you to a biofeedback nurse.
Typically we expect urinary function to improve significantly for 6 months, then moderately the next 6, then minally after that.
My Husband [@ 50yrs old/african american] had robotic prostatectomy 10/22/07 gleason score 3+4 with nerves spared only left side. We were “extremely active” prior and continued as we do now several times a week just to stay in tune. He does have dry orgasums but w/urine expelled. We are “always” trying new things. He has tried oral aides [no effect/and cant afford even “with” insurance]. The pump merely pulls blood in. Injections [havent tried] may not be able to afford those either… It’s been 1yr and 3months. If a prosthetic is inserted, will “he” find pleasure and will “he” be stimulated? It’s no fun w/out him enjoying it as well….
My husband had partial nerve sparing robotic removal on 12/19/08. T3; 3+4. Lymph nodes were normal. PSA currently.01. The radiologist is recommending radiology after 2 months of PT. Surgeon is on the fence. We’re concerned about the side effects of the radiation vs. watchful waiting. My husband still has trouble with incontinence and erections are nearly non-existent.He just turned 49 and we had an active sex life prior to this. Is watchful waiting a viable option or does radiation benefits outweigh their risks?
It is a tough decision for you. There is a recent study that I will blog on that looks at T3 cancers and recommends radiation. I leave it up to the patient, but if the margins are negative and there is focal spread I would watch the PSA closely.
For men that havent recovered after 2 years, I think the surgery to place an implant is the best solution.
Sensation should be as good as before and the implant surgery gives the man the rigidity he is lacking.
Speak to your urologist about the risks and benefts, but I think it is a good idea.
My husband had a prostectomy almost one year ago and does not have erections even with Viagra or Cialis. He used the pump but it is not good enough. He ordered Tri-Mix in a gel form, didn’t work out. Could the injections work? Which is better Caverject or Tri-Mix or other? He is 60 and had good erections before the operation. Nerves were spare, but a prostate of 90, gleason score of 6. I have noticed difference in size, I think the mind is very important, he thinks the doctor cut the nerves but I have seen almost a full erection but goes down almost immediately when noticed. We want to try also hypnosis. What do you think? Nobody has asked about this. Please answer.
If a man has a decent erection it is a very positive sign, even if it does not last. The less that is needed for this to happen, the better.
If the erection is natural or with just an oral medicine and it hasn’t been that long since the surgery, he will probably recover.
Penile injections usually work well.
Patients and wives should discuss these issues with their urologist.
I do not have Cancer yet , Both dad and grand father have had, my grand father died of natural causes at 83 and was found to have it, my father got it at 70 , had the seeds in planted and has had good luck with the results, I am 52 and am enlarged, on Avadart but the loss of sexule desire is fustrating , Dr has a proceedure that could get me off of the Drugs , by reducing the prostrate around the tube , then I can go on some testoserone treatment , I have a very low count , I am looking to get back that Love’n feeling , Is this a good idea ?
This is a good idea in general. Speak to your urologist about the different ways he can do this. Ask what the chances of retrograde ejaculation are and what happens to your treatment options for prostate cancer as a result of the procedure he advises you to have.
Dr Savatta
I HAD ROBOTIC PROSTECTOMY 2/08. I’M 57. I HAVE HAD A VERY ACTIVE SEX LIFE ONLY WEEKS AFTER SURGERY, 3-5 TIMES A WEEK( A GREAT WIFE) BUT ONLY CAN HAVE SEXUAL INTERCOURSE VIA INJECTIONS OR PUMP. PILLS WORK BUT NOT ENOUGH FOR SI.WHAT HAS NEVER BEEN EXPLAINED TO ME IS HOW I CAN HAVE A DRY ORGASM.WHAT’S THE PHYSIOLOGY? IT IS SO DIFFERENT THAN BEFORE THE SURGERY. MY WHOLE BODY SHIVERS AND I CAN HAVE MULTIPLE ORGASMS ( AS MANY AS FOUR) W/I AN HOUR LONG LOVE MAKING ENCOUNTER. I COULDN’T DO THIS BEFORE. NOT COMPLAINING, BUT CAN YOU EXPLAIN THIS. MY UROLOGIST CAN’T?
There are 3 different parts to the sexual experience. The nerves affected by surgery are responsible for obtaining a hard erection.
Different nerves are responsible for sensation and an orgasm. Neither of these are affected by surgery. Many men have much worse or much better sensations whole having an orgasm. Nothing comes out since the prostate makes the ejaculate, but an orgasm is still felt. I do not know why this is and I can not predict how orgasms will change for individual patients.
I hade a robotic nerve sparing sergery 3 month ago. My sex was very good 4 times a wk.I am 64 now I try viagra cialis it is not working yet.I really like to have my sexual life again.
I ker in 88 am radio in Boston group they do help having reular sex no operation no nothing in 1 hour you gain your sexual life Is this really.
I think they teach patient how to do injection therapy. Most urologists should know how to do this and can teach you if you are interested. I usually bring it up with my patients at the 1 month visit if things are working well.
I am 57 and had prostate removal on july 27, using the Da Vinci method my PSA was 50.3 and 3 weeks after surgery it is down to 0.6
The biggest problem I have so far is the urine leakage I do ok sleeping or sitting but standing and walking is a problem how long will this be a problem I do the exerise daily also I have to get up every 3 hours during the night bladder feels full and usualy is about half.
Also what should I be doing about erections and sex?
Reading some of the comments in this entry gives you an idea of how some people heal, but the recovery after surgery has a lot to do with how things are working beforehand, how the surgeon does the surgery (sometimes the type of cancer forces a surgeon to remove extra tissue), and surgeon technique.
Things can be done by your urologist after surgery that may help the recovery in the urinary and sexual departments. The specifics need to be discussed with your surgeon.
I had diVinci prostatectomy in November 2007. I am now 57. I was 10th diVinci procedure for my doc. I had constant infections for about three months post-surgery. Catheter was in for about two-three weeks due to leaks where urethra was reattached. Still have moderate incontinence even after physical therapy. Wife and I had an active sex life before surgery. Since have ED and no treatments have worked. Tried the vacuum pump and discovered I developed severe Peyronie’s disease. (No issued pre-surgery). Doc feels bad but has no recommendations except for implant. As it is not covered under insurance, we can’t afford it. Of course, this now results in severe depression. Had I known of the complications, I wouldn’t have had the surgery. I don’t know where to turn, so hope you can make a suggestion on improving the incontinence and a cure for the Peyronie’s and ED.
I had have robatic surgery nerve spearing. I was very active sexually I am 62. Now I have been takeing viagra and breaking it in half it goes up very little very short time. I hope that in long run we all get it back. Other wise I also like very much eating apple and rare Filetmignon…..
Ihad prostate surgery about 6motha ago iam on cialis 5mg a day i have been on for 6 month now but still no hard on and i still have leakage how long will i have to take this before i have a hard on and what can i do about the leaks and will it ever stop and how long will it take for me to get a hard on THANKS AKORA
As we discuss above, there are many factors that lead to an answer to this question. Your surgeon should know best what factors are important in your situation and answer your question best.
prior to benign (non-cancerous) prostat removal in April 2009 a 3 mm stone was detected in left kidney which the physician left untouched. Post-prostate removal the physician detected urine crystals in the urine and had suggested cat scan which I did not undergo as I also did not feel any discomfort except the fact that in August 2009 I had noticed blood discharge during my sleep twice which was also without any sensation or pain or awareness. This blood discharge has been happening at regular interval of 18 months since 1995 whereas I had underwent vasectomy in January 1994.
I would like to know any repurcussions or treatment required as the prostate presumed to be cause of blood discharge during nights is no more and the prostate was benign (non-cancerous).
Blood in the urine should be evaluated by assessing the bladder, ureters, and kidneys. A small stone can be followed, but may grow and would likely cause pain if it was trying to pass. If there is blood in the urine a person should make sure they get a full assessment from a urologist with a cystoscopy and IVP or CT scan or maybe ultrasound to assess the kidneys. Urine tests are also done to assess for abnormal cells.
This question may seem odd – My husband had prostate surgery 2 years ago and we weren’t sexually active for over a year but we are now. His urologist told him recently that at his age (56) and because of the prostate cancer he shouldn’t be having sex more than twice a week. I have not seen any advice like that in any reputable web site. I’m skeptical because this doctor never told him about using viagra during the months after surgery, which seems to be a standard of good treatment and probably would have made his recovery easier. Is there any reason to limit sexual activity 2 years after surgery? (My husband had high blood pressure but it is under control with medication). Does my husband need a new urologist?
I am not familiar with any limitation on sexual intercourse frequency. In general, the more frequent a man has sexual function, the better it is to promote penile well being. I would recommend asking your urologist for a reference.
Good luck,
Dr Savatta
I had the robotic surgery in November of 2009, very successful, both
nerves spared. Unfortunately, the preoperative physical discovered a
lymphoma, and I followed up the surgery with 4 months of chemotherapy.
My urologist says I should regard my recovery as starting at the end of
the chemo. As well, I have extremely low testosterone, 40ng/dl. I’m
told I can get suplements starting a year from the surgery.
From that perspective, I guess I’m on schedule, I get floppy erections
just before climax. The big problem is that climax is painful, like
somebody is driving a spike into the base of my scrotum. Is there
anything I can do to prevent this pain?
I have had a significant amount of patients (maybe 3-5%) that complain of pain during an orgasm.
I have not read anything that explains why this would happen or how to treat it. Usually the pain lasts for a short period of time- seconds or minutes.
Most patients have less pain over time, but it doesn’t always go away.
Please post back on your experience if possible for other patients.
Dr. Savatta,
I too have discomfort during orgasm. Five years after surgery, instead of pain, I experience a somewhat of a burning sensation which does go away quickly.
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