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Dear Dr. Myrtle,
I had my prostate removed about 3 months ago because of prostate cancer, and well, ‘Peter’ seems to have gotten lost in the OR. Even though my doctor told me that my erections would go away for awhile, I was more focused on living than I was thinking about sex. Now that I’m mostly healed from the surgery, my erections still haven’t returned, and I’m wondering if they’re ever going to return. Is there anything I can do to help this along?
 The Anatomical Structures of Erection.
As we develop during gestation, the female clitoral structure appears first. If the embryo is a genetic female (XX), this clitoris will continue to develop into a female shape, and female reproductive organs will develop. If the embryo is a genetic male (XY), the Y chromosome will cause production of testosterone at 10 weeks gestation, and the female-shaped embryonic clitoris will re-form and re-shape into a male version, and the male will develop male reproductive organs. This transformation is roughly complete by 14 weeks gestation. Therefore, technically the female was formed first, not from a rib, while the male re-shapes into the male form. Also, although we are used to the Latin term corpus cavernosa for the male erectile structure, it was a clitoris first in form and function, and therefore I use this term in both genders.
Erection of the Clitoris.
Erection of the clitoris relies upon healthy functioning nerves to relay stimulation signals between the lower spine and clitoris. Special arousal nerves (myelinated parasympathetic “nitrergic” nerves) course through a diffuse nerve bundle known as the pelvic plexus (aka inferior hypogastric plexus). The pelvic plexus can be visualized as a massive switchboard that includes some of the nerves which control autonomic function of many pelvic structures (such as the clitoris, bladder outlet, rectum and internal anal sphincter muscles).
To the naked eye, the pelvic plexus looks like a fine spider web of small delicate nerves, intermixed with larger bundles (called neurovascular bundles). Nerve-sparing pelvic surgeries (prostate or uterus removal) attempt to maintain the health of function of these large bundles, because the larger bundles contain the nerves which control blood flow to the clitoris and therefore erection.
Where did Peter go?
During the process of removal of the prostate (or uterus), every attempt is made not to cut these nerve bundles, as long as the goal of tumor removal is maintained. There are circumstances where a surgeon might attempt to avoid nerve bundles, but an invasion of tumor cells prevents her from leaving the nerves intact. In this case, the surgery would be termed a “non-nerve sparing” surgery (seen info below).
Even if nerve sparing is accomplished, the real estate in the lower pelvis is crowded. Some of the smaller nerves are cut during organ removal, while others, although not cut, are stretched and/or pressed on. This stretch and compression of the nerves cause an immediate slow down or work stoppage of communication along the nerves (technically this process is referred to as “immediate neurapraxia” or “grade 1 neuropathy”). This is a reversible process, but it will take time for function to return. Depending upon which nerve is involved, you might notice an immediate post-surgical change in genital sensation (numbness, tingling or muscle weakness) and/or function (no erection/engorgement/genital swelling). All forms of spontaneous erection/arousal will stop directly after surgery (includes nocturnal, morning and arousal erections), although some people maintain the ability to directly stimulate their genitals to erection/arousal .
Eventually, if the nerves were functioning prior to surgery, function will return as long as they were not completely damaged during surgery . As the temporary nerve dysfunction resolves, the clitoris becomes more responsive to direct and cognitive sexual stimulation, and nocturnal erection/arousal activity heralds the return to spontaneous daytime erectile function .
So I should just wait?
No, there is more to think about. In men, normal function dictates that the clitoris lightly swells about 4 times per 24 hours, and this accounts for nocturnal and morning erections. It’s the body’s way to make sure that oxygen/blood flow makes it into the clitoris routinely for maintenance blood flow. Our nitrergic nerves produce nitric oxide that diffuses into the little blood vessels of the clitoris, and a bit of blood puffs in to the clitoral caverns. (In women, we are much less aware of erection/swelling of the clitoris, so this effect happens but it is less obvious.)
But what if this doesn’t happen? At the time of surgery, the stretched nerves of the pelvic plexus go on strike, and this maintenance blood flow stops. The absence of clitoral blood flow causes a cascade of things to begin:
- lack of oxygen (hypoxia) causes the death of the smooth muscles which line the helicine (pigtail) arteries of the clitoris .
- stagnation of hypoxic blood allows inflammation (usually a chemical reaction between nitric oxide and free radicals) to occur, enhanced by reduced blood flow .
- shrinkage of the clitoris as the body’s healing processes increases the scarring/collagen process inside of the clitoris, reducing potential flexibility and shortening both the length and girth of the clitoral body .
If allowed to continue for full effect, this inflammatory/hypoxic process will prevent the clitoris from responding to arousal stimulation even when the nitrergic nerves return to function. The bottom line is that unless mechanical blood flow replaces the blood in the clitoris during early nerve dysfunction, the clitoris won’t be able to respond even when the nerves do.
Is there anything that can be done?
Medicine knows much more about penile function, so this next section will focus mostly on male rehabilitation techniques. First of all, nerve/erectile function rebounds better when pre-operative erectile function was good. If your system was healthy before surgery, a healthy pre-op predicts healthy post-op. For example, 76% of men under the age of 65 with good pre-operative erectile function who had good nerve-sparing surgical outcome, had recovered effective function after 3 years . This is good news, indeed. On the other hand, if medication (sildenafil/Viagra), was required for successful erection prior to surgery—suggesting pre-surgical erectile dysfunction—successful erection was lower post-surgery .
Secondly, penile rehabilitation has much more clinical research and support . (If you laugh at the term penile rehabilitation, it hasn’t happened to you, yet.) The gist of this process is to mechanically induce blood flow, thereby reducing the fibrosis and scarring of the inside of the penis. This allows the maintenance of length and girth by preserving the flexibility and function of the clitoral structure.
The three main ways may be used separately, or in concert, depending on the effect and acceptability.
- Vacuum pumps with or without constriction devices ,
- Phosphodiesterase 5 (PDE5) Inhibitors (sildenafil/Viagra)
- (a combination approach with Vacuum pumps and PDE5 Inhibitors )
- Lipid soluble anti-inflammatory drugs with a positive effect on nitric oxide (statins , lipid soluble ACE inhibitors , , , )
From 4 weeks post surgery, routine mechanical vacuum perfusion of the clitoris is important to minimize hypoxia-related scarring and cell death of the lining of the blood vessels. Vacuum pumping once or twice a day to low pressures mechanically holds the outer walls of the clitoris open so that blood can more easily fill the caverns. Vacuum pumping is so successful that between 52-60% of men with completely severed pelvic plexus nerves can achieve successful erections with the use of a vacuum pump and constriction ring (cock ring) . Until you know for sure whether nerve function is going to return, maintaining routine vacuum blood flow will work in your favor.
It is important to note that high vacuum pressures are not important: in the early therapy exchanging the blood is important, not creating a complete erection. Vacuum pumps are very well tolerated, non-pharmacological tools, and risk occurs at high or prolonged vacuum pressures . If you use a constriction/cock ring, only wear it for 30 minutes, then take it off. You can re-pump new blood in there in a bit.
What about my orgasms?
A decade ago, when surgeons knew less about neurologic control of erection and so unknowingly cut through more of the pelvic plexus, 25% of men had normal post-operative orgasm, while 50% reported a decrease in orgasmic sensation . With today’s current surgical awareness, nerve-sparing surgery is much more actively pursued, with an astonishing 92% normal post-op orgasm reported . This underlines the fact that orgasm is not dependent upon erection, and men with incomplete erections are able to happily stimulate themselves to orgasm routinely after prostate surgery. Many men, unaware of this fact, become depressed at the slowness of return of erection, and don’t even try to stimulate themselves to orgasm.
The bottom line: none of us knows how well preserved your nerves were during the surgery. We do know that successful penile rehabilitation—including the use of vacuum pumps, and sometimes medications—can help to preserve normal clitoral function. Taking a rehabilitative stance and mechanically reestablishing blood flow preserves function, while experimentation into methods of stimulation to reestablish your orgasmic pathway can help maintain this important neurologic function.
Good luck, and take care,
Dr. Myrtle
References 1. McCullough AR, Sexual dysfunction after radical prostatectomy. Rev Urol. 2005 7S2:S3-10.2. Martinez-Salamanca et al, Orgasm and its impact on quality of life after radical prostatectomy. Actas Urol Esp. 2004 28(10):756. 3.McCullough AR, Sexual dysfunction after radical prostatectomy. Rev Urol. 2005 7S2:S3-10. 4.Dall’Era et al, Penile rehabilitation after radical prostatectomy: important therapy or wishful thinking? Rev Urol 2006 8(4):209. 5.Hong et al, Effect of statin therapy on early return of potency after nerve sparing radical retropubic prostatectomy. J Urol 2007 178(2):613. 6. Albersen et al, Preclinical evidence for the benefits of penile rehabilitation therapy following nerve-sparing radical prostatectomy. Advances in Urology. 2008. pg 1.7.Ciancio and Kim, Penile fibrotic changes after radical retropubic prostatectomy. BJU Int. 2000 Jan;85(1):101. 8. Munding et al, Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy. Urology 2001 58(4):567. 9. Gontero et al, A prospective evaluation of efficacy and compliance with a multistep treatment approach for erectile dysfunction in patients after non-nerve sparing radical prostatectomy. BJU Int 2005 95(3):359. 10. Rabbani et al, Factors predicting recovery of erections after radical prostatectomy. J Urol 2000 164(4):1929. 11.McCullough AR, Sexual dysfunction after radical prostatectomy. Rev Urol. 2005 7S2:S3-10. 12.Albersen et al, Preclinical evidence for the benefits of penile rehabilitation therapy following nerve-sparing radical prostatectomy. Advances in Urology. 2008. pg 1. 13.(pre sildenafil: Cookson & Nadig, Long-term results with vacuum constriction device. J Urol1993; 149(2):290); post sildenafil: Raina et al, Early use of vacuum contriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function Int J Impot Res 2006 18(1):77, Kohler et al, A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. BJU Int 2007 100(4):858. 14.Lowentritt et al, Sildenafil citrate after radical retropubic prostatectomy. J Urol 1999 162(5):1614. 15. Mullhall JP, Morgentaler A, Penile rehabilitation should become the norm for radical prostatectomy patients. J Sex Med 2007 4(3):538, Zippe CD, Pahlajani G. Penile rehabilitation following radical prostatectomy: role of early intervention and chronic therapy. Urol Clin North Am. 2007 34(4):601. 16. Hong et al, Effect of statin therapy on early return of potency after nerve sparing radical retropubic prostatectomy. J Urol 2007 178(2):613. 17. Shiri et al, Cardiovascular drug use and the incidence of erectile dysfunction. Int J Impot Res. 2007 19(2):208. 18. Becker et al, Plasma levels of angiotensin II during different penile conditions in the cavernous and systemic blood of healthy men and patients with erectile dysfunction. Urology 2001, 58(5):805. 19. Dorrance et al, 2002
20. Speel et al, Long-term effect of inhibition of the angiotensin-converting enzyme (ACT) on cavernosal perfusion in men with atherosclerotic erectile dysfunction: a pilot study. J Sex Med 2005 2(2):207, no significant difference from placebo. 21. Gontero et al, A prospective evaluation of efficacy and compliance with a multistep treatment approach for erectile dysfunction in patients after non-nerve sparing radical prostatectomy. BJU Int 2005 95(3):359. 22. Ganem et al, Unusual complications of the vacuum erection device. Urology 1998;51(4):627. 23. Koeman et al, Orgasm after radical prostatectomy. Br J Urol 1996 77(6):861. 24. Martinez-Salamanca et al, Orgasm and its impact on quality of life after radical prostatectomy. Actas Urol Esp. 2004 28(10):756.
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