By Theresa Waldron

One of the most difficult issues facing men who have undergone treatment for prostate cancer is sexual dysfunction‚ a term used to describe an inability to achieve an erection (“erectile dysfunction”)‚ inability to reach orgasm‚ or other sexual problems.The National Cancer Institute estimates that as many as 70% of men who have had surgery‚ chemotherapy‚ or radiation for prostate cancer have some type of long-term sexual dysfunction.

However‚ sexual dysfunction is almost always treatable‚ experts say‚ and men who have experienced sexual dysfunction following surgery or other treatment for prostate cancer should not lose hope. In some cases‚ sexual dysfunction goes away on its own over time after surgery or radiation; in other cases‚ drugs or other therapies can be used to successfully treat sexual dysfunction.

A number of factors affect sexual function‚ including age‚ sexual and bladder function before surgery‚ the size and location of the tumor‚ and how much tissue was removed during surgery. Patrick C. Walsh‚ MD‚ director‚ James Buchanan Brady Urological Institute at Johns Hopkins Hospital in Baltimore‚ Maryland‚ says sexual dysfunction after prostate removal (“radical prostatectomy”) is often related to damage to neurovascular bundles‚ which are the nerves in and around the prostate.

He has developed a “nerve-sparing” prostatectomy that he says prevents erectile dysfunction in 86% of patients.

However‚ if a man has erectile dysfunction after prostatectomy—whether or not he’s had nerve-sparing surgery—he still has the ability to have normal sexual sensation‚ normal sex drive‚ and achieve orgasm‚ says Dr. Walsh‚ author of Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer.

“Many people don’t understand that if a man cannot have an erection‚ he can still have a normal orgasm‚” he notes. “If a man has a problem with erections‚ there are many ways to restore them after operations. And in doing so‚ you can restore sexual function to normal.”

Dr. Walsh says most men with erectile dysfunction after nerve-sparing prostatectomy can have a sufficient erection to have intercourse with the use of the drug Viagra® (sildenafil citrate).

Viagra does not work if nerves were not spared during surgery‚ says Dr. Walsh‚ but other nondrug methods do work. According to Dr. Walsh‚ 80% of men who have undergone nerve-sparing prostatectomy at Johns Hopkins have reported that use of Viagra led to successful intercourse.

“For patients in whom Viagra doesn’t work‚ there are other options‚” Dr.Walsh says. “All of these can restore sexual function to normal and restore normal penetration and orgasm.”

Viagra may not work well during the year following nerve-sparing prostatectomy because the nerves are “temporarily paralyzed” from the surgery‚ says Dr. Walsh. As the nerves recover over time‚ Viagra works better‚ he adds‚ especially in younger men.

Buford Kemp‚ a 52-year-old Dallas firefighter‚ had a nerve-sparing prostatectomy and radiation for prostate cancer in 1999. Since then‚ he has volunteered with the American Cancer Society‚ where he speaks about his experience with prostate cancer to men’s groups and prostate cancer survivors.

Kemp says his problems with erectile dysfunction after surgery and radiation are “getting better.” He tried Viagra‚ but experienced headaches on the drug. His doctor reduced the dose.

“What happens is that I’m getting an erection‚ but I don’t get it spontaneously‚” Kemp says. “I’ve talked to other men who have had the surgery‚ and they say it took them a year to a year-and-a-half for erectile function to return. I know some guys who say it took three years.”

If Viagra does not work in men with nerve-sparing surgery‚ other methods can be used. These methods also work for men whose nerves were not spared during prostatectomy‚ or for men who have sexual dysfunction from radiation or chemotherapy.

Intraurethral therapy: This method uses an agent that is placed directly into the opening of the penis by the man. The most common agent used is a tiny suppository that contains a drug called prostaglandin E1. However‚ this product may cause pain in the urinary tract‚ especially in men who have undergone prostatectomy. It does seem to work better in men who have undergone radiation therapy‚ according to Dr. Walsh.

Penile injection therapy: Prostaglandin may also be injected into the base of the penis by the man‚ using a fine needle. The drug improves blood flow and produces a normal erection about five minutes after injection. However‚ some men object to injecting themselves‚ and there are side effects‚ such as burning at the injection site.

Vacuum erection devices: An airtight tube is placed around the penis temporarily‚ which causes a vacuum. This method does not always produce a normal erection‚ but it is sufficient for intercourse to occur. Side effects of vacuum erection devices include pain in the penis and trouble with ejaculation.

Penile prostheses (implants): These are prosthetic devices that are bendable‚ inflatable‚ or mechanical. They pump fluid into the penis via a reservoir or inflatable chamber. They are usually implanted into the penis through an incision in the scrotum. Dr. Walsh says the prostheses are usually offered as a “last resort‚” because they involve surgery‚ which increases the risk of complications such as infection or scarring.

“Besides erectile dysfunction‚ another problem with prostatectomy is incontinence‚ or involuntary leakage of urine. However‚ while nerve-sparing surgery helps with incontinence‚ it does not necessarily prevent it‚” says Dr. Walsh.

“The problems with incontinence are more anatomical‚” he says‚ explaining that the sphincter muscle that keeps urine in the bladder either wasn’t strong enough before surgery to hold the urine back‚ or in the process of having the prostate removed‚ the sphincter muscle was damaged.

However‚ in studies at Johns Hopkins of men who have had a prostatectomy‚ 80% were no longer wearing protective pads after six months‚ and 93%-98% reported not having urinary incontinence after 18 months. Exercises to contract and relax the muscles that control urination may be helpful‚ as are injections of collagen into the urethra by a doctor.

Erectile dysfunction can have an enormous psychological impact on prostate cancer survivors‚ says Dr. Walsh.

“There’s a lot of fear of failure‚” he explains. “You have to be proactive. You can’t just wait until you have the perfect erection. It’s very important to have a willing partner‚ and it’s important to have a doctor coach you to recovery. All those things help.”

Psychological factors associated with prostate cancer may include depression‚ anxiety‚ and a fear of dying‚ even if the prognosis is good. Kemp says he depended on his wife Linda‚ and daughter Darragh‚ for emotional support after his surgery.

“We talked about everything after the surgery‚” he says. “They’ve been very supportive of me. My wife has been right there with me all the way.”

Kemp also credits his faith with helping him recover. Dr. Walsh suggests that prostate cancer survivors should not try “going it alone‚” and that they should talk about their feelings with a partner‚ doctor‚ other patients‚ a counselor‚ or member of the clergy.

“You will get your life back‚” says Dr. Walsh.