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Erectile Dysfunction Or Impotence Post-Radical Prostatectomy

Impotence is simply described as the inability to achieve or maintain an erection suitable for sexual intercourse. Impotence affects 20 million American men or about 10% of the entire male population and 35% of the men over the age of 60. An erection is created when the penis fills with blood much like a tire fills with air. Blood is pumped into the penis and not allowed out, and the more blood that is pumped in, the firmer the erection. The reasons for lack of erections are either the lack of appropriate filling of the penis or inappropriate emptying.

For men who have had radical prostatectomy for prostate cancer, the nerves that control the flow of blood into and out of the penis may be cut or removed. These nerves do not control the sensation to the penis, nor are they responsible for the orgasm that occurs with sexual intercourse. Only the firmness of the penis is affected.

If nerve sparing was attempted during your procedure, the return of erections could take as long as 6 to 18 months. Partial erections may return earlier and may be a sign of subsequent complete return of function, although not a guarantee. Partial recovery is actually quite common and lends itself to some other options for treatment.

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Medical Treatment

Medical treatments for impotence after prostate surgery do not usually play a significant role. Unless pre-existing or current psychological problems have arisen, sex therapy is not often needed. Hormone treatments, usually testosterone, are often used in men with impotence. IT IS NOT TO BE CONSIDERED WHEN A DIAGNOSIS OF PROSTATE CANCER IS PRESENT. In most cases, the testosterone levels are normal after prostate surgery. Regardless, the use of testosterone has the potential of making any residual prostate cancer grow more quickly. Liver damage and high blood pressure are other problems too.

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Yohimbine

Yohimbine is a medication made from the bark of a tree that grows in India and Africa. Yohimbine acts on the nervous system and may also have some affect on increasing the male libido. It is considered homeopathic by medical doctors, that is, no definite uses are proven. The drug is very safe with uncommon side effects such as mild dizziness, nervousness, irritability, headaches and nausea rarely occuring. Some studies have suggested 10-20% of men will respond to the treatment with yohimbine, and it is necessary to take the medication for a full two months before knowing whether it is going to work or not. However, a task force of specialists sponsored by the American Urological Association has recently determined that Yohimbine is no more effective than placebo. After prostate surgery, Yohimbine has little or no effect.

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Injection Therapy

The drugs used today include: prostaglandin (PGE-1 or Prostin or Alpoprostadil or Caverject), Papaverine hydrochloride and phentolamine (Regitine). All of these drugs have been approved by the FDA for uses other than the treatment of impotence. Only Prostaglandin has been approved by the FDA for the treatment of impotence. Papaverine and phentolamine have not yet been approved by the FDA for this specific purpose, although these two drugs were the initial ones used for self-injection therapy. However, considerable experience has been obtained by urologists over the past decade and the all three drugs mentioned above are considered safe for self-injection therapy.

The disadvantages of self-injection therapy include the risk of infection, pain, bruising, scarring on the penis and episodes of "priapism" or a painful and prolonged erection, which requires injection of other medications to get rid of the erection. The injections are relatively easy to do, work within 10 to 15 minutes, and have a success rate of close to 70%. The erection could last anywhere from a half-hour to two hours. In some men, the erection achieved with injection therapy is still not adequate. Addition of a vacuum pump discussed below may give reasonable performance. The use of injection therapy could potentially cause scarring or fibrosis of the erectile bodies, particularly with repeated use of papaverine. This may make normal return of function impossible if nerve sparing was used.

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Urethral Suppositories

MUSE is the name of a new drug treatment and represents a unique approach for the treatment of erectile dysfunction. It is based on the discovery that the urethra (the tube in the penis for urine to pass from the bladder to the outside of the body) can absorb certain medications into the surrounding erectile tissues thereby creating an erection. The MUSE system uses prostaglandin E1, the same medication used in the self injection therapy, and has been approved by the FDA for the treatment of impotence.

An erection should begin within 5-10 minutes after administering MUSE. The duration of effect is approximately 30-60 minutes. However, the actual duration will vary from patient to patient.

The most common side effects that have been reported using MUSE are aching in the penis, testicles, legs and in the area between the scrotum and the rectum, warmth or burning sensation in the urethra, redness of the penis due to increased blood flow, and minor urethral bleeding or spotting due to improper administration.

MUSE was released in early 1997 and more experience will be gained over the first few years that it is available to the public through their physicians.

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Vacuum Devices

External penile vacuum therapy is relatively new and is a nonsurgical, mechanical way of producing erections. The penis is placed within a hollow plastic cylinder, and a slight vacuum is created with a mechanical or electric pump. The vacuum and the negative pressure causes blood to flow into the penis. A rubberband-like device is then placed over the shaft of the penis at the base, trapping the blood in the penis. The erection can be used for up to 25 to 30 minutes. While serious injuries are rare, bruising, soreness or numbness of the penis is not uncommon. The device can usually be tried in the office at no charge and most manufacturers provide a money back guarantee. As mentioned above, this technique could be used in conjunction with self-injection therapy.

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Penile Prostheses

Penile prosthetic implants can also be used for treating impotence and have been available since 1970. There are three types of prostheses that can be used. The simplest is the semi-rigid or malleable prosthesis. The implants which come in pairs are placed into the penile shaft giving the penis a modest erection which is unchanged. The rods are malleable so that they can be bent into certain positions for concealment, but the major problem with this type of prosthesis is the difficulty in concealing the prosthesis. The inflatable prosthesis is a more complicated surgical device in which two inflatable balloon cylinders are implanted within the penis, along with a pumping mechanism in the scrotum and a reservoir placed under the muscles of the abdomen. To obtain an erection, the pump is squeezed, pushing fluid from the reservoir into the hollow penile cylinders thereby creating an erection much like the patient's normal erection. A release valve allows the fluid to go back into the reservoir when the erection is no longer desired. This prosthesis is the most natural in some ways because it mimics normal activity, but there is a chance of mechanical breakdown or leakage of fluid that can occur at any time, and it requires a surgical procedure to implant the prosthesis. Self-contained implants are designed somewhat like the rigid prosthesis, but have an actual pump at the tip and a reservoir at the rear of the self-contained cylinder, which allows for an erection without the necessity of multiple other connected devices. These prostheses, while easier to implant, do not give the quality of erections or flaccidity of the multi-unit, implantable prosthesis.

Concerns recently about the safety of silicone products have been raised, including such thoughts as causing cancer and affecting the immune system. The liquid silicone used in breast implants caused enough concern for the FDA to remove them from the market. The solid silicone used in penile prostheses most likely does no cause harm and have been used for many decades with safety. Silicone is used in pacemakers, brain shunts and other prosthetics. The FDA, which tends to be extremely conservative has not suggested that they will take silicone products out of circulation. But, only time will tell how safe silicone really is.

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What Is New?

Another new development is in pill form. The drug called Sildenafil or Viagra has been studied in England and seems to improve erections in men who have no known cause for difficulty with erections. Studies on men with known causes, such as surgery or diabetes, have not been completed. The drug has been available since early 1998. Early studies show very few side effects. The drug does not directly cause erections, but enhance erections caused by sexual stimulation. It works by partially blocking an enzyme in the penis that is responsible for normally reversing erections. Some studies have shown 60-80% effectiveness in selected patients with difficulty maintaining erections. About one in 25 men discountinued therapy from side effects, which included headache, indigestion, visual distrubances, and flushing. Viagra, which comes in three different dosages, has an onset of action which begins within 60 minutes. The effect lasts for four hours. Only one dose per day is recommended. Diabetics and men who have had radical prostate or bladder surgery have a lower success rate with Viagra.

Important Note: Patients who take or need nitroglycerin or nitrates for heart disease CAN NOT use this drug. A number of heart attacks, some causing deaths, have been reported since the introduction of Viagra. These appear to be due to the exertion of sexual intercourse or to the use of nitroglycerin with Viagra against doctors' orders. Patients with significant heart disease, whether using nitroglycerin or not, should be counseled about the risk of heart attack.

What Does Not Work

At this point there is no evidence that nutritional supplements or vitamins have any significant bearing on sexual performance. The Food and Drug Administration has currently banned the sale or advertising of all nonprescription products for the treatment of male impotence because none had been scientifically shown to be effective. Yohimbine does not usually work after prostate cancer surgery or irradiation treatments.

Vascular surgery, a technique used rarely in men with known blood vessel abnormalities is not to be considered in post-prostatectomy impotence. Impotence is a treatable problem, which is not the inevitable consequence of aging, but is brought on by the surgical removal of the prostate or by radiation treatments. A multitude of treatment choices are available to assure that each patient has a good chance of a successful outcome.

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Reprinted with permission from Dialogue Medical, dialogmedical.com.

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