Erectile dysfunction (ED) is one of the main side effects that can happen because of prostate cancer treatment. For men that are sexually active, this is the most feared side effect. Most men will experience some loss of sexual function. However, there are treatment options for this depending on the severity of the lack of function. For mild to moderate ED, there are oral and injectable medications that can cause an erection. But what if you do not respond to medications or do not like or want to use them? What are your options? You may need a penile implant or prosthesis. This is a medical device that helps you get an erection.
What Does a Penile Prosthesis Do?
All penile prostheses have two cylinders that sit side by side in the corpora cavernosa or erectile chambers within the penis. The goal of a prosthesis is to help make the shaft of the penis hard. Due to the anatomy of the penis, the prosthesis does not cause engorgement or swelling to the glans (the tip) of the penis.
If you have had ED for a long time, then you will have penile shortening, meaning the penis shrinks. This device will NOT make the penis larger or return it to its original length but it will restore sexual function. It will not change anything with urination or orgasm. These devices are completely hidden within the body and cannot be seen. They also give spontaneity back to the patient by allowing quickly achieved erections, unlike pills and injections that need to be timed to work.
You cannot “try an implant” because once it is placed it changes the architecture of the erectile tissue (how the penis is structured inside). It is a permanent change — this means that you will need the device for the rest of your life to have erections.
Types of Penile Prostheses
There are two main types of penile implants—semirigid or inflatable.
Semirigid Penile Prosthesis
As the name implies, this device is always “semirigid,” and made of malleable material that can be bent. This is the simplest implant that consists of two cylinders that are placed in the erectile chambers. The size of the cylinders depends on penile size. When an erection is desired, you simply straighten the device upward to allow penetration. When it needs to be concealed or hidden, you bend it downward.
This device is less like a “normal” penis that goes from soft to erect. It is a good choice for patients that do not want to have to pump up an implant or are unable to due to poor dexterity (meaning you can’t move your hands well, maybe because of a stroke or Parkinson’s disease, etc.).
Inflatable Penile Prosthesis
There are two types of inflatable penile prostheses—a two-piece and a three-piece. These devices are filled with saline fluid that allows them to be inflated and deflated, which helps to make them more “normal.” The two-piece prosthesis consists of two cylinders and a pump. The pump is about the size of a large acorn and sits inside the scrotum next to the testicles. When an erection is desired, the pump is squeezed, and the fluid moves from the pump to the cylinders. When the erection is no longer needed, the penis is gently bent to push the fluid back to the pump. The degree of softness that can be achieved depends on the size of the cylinders/penile size. Larger cylinders will have more fluid left in them because the size of the pump is the same for all these implants.
This device is good for patients who want to hide their device better than the semirigid implant but who also may have had several abdominal surgeries that make it difficult to put in a reservoir for a three-piece prosthesis.
The three-piece prosthesis has two cylinders, a pump, and a reservoir (a small tank that holds fluid). The cylinders and pump are a lot like the two-piece prosthesis. The difference is the pump has a deflate button that allows all the fluid from the cylinders to go into the reservoir in the abdomen. This implant works the most like a “normal” penis — pump up to get an erection and deflate to regain softness. Most patients choose this device.
Conclusions
Restoring your sexual function is one way to improve your quality of life as a prostate cancer patient and survivor. When medications are no longer working, then the penile prosthesis is an excellent option to quickly get lasting and reliable erections. With all the good that comes with these implants, if you are considering having one placed, you must have realistic expectations of what it can and cannot do. Also, be sure that your urologist is comfortable performing this procedure or seek an opinion from a urologist who is an expert in sexual medicine.
If your doctor diagnoses you with erectile dysfunction, it is important to understand your treatment options. This article will explain several non-surgical and surgical treatment options for men who have erectile dysfunction (ED) after prostate cancer therapy.
Non-Surgical Treatment Options
There are many treatment options for erectile dysfunction depending on how severe it is. For mild to moderate erectile dysfunction, there are several non-surgical treatments. These include oral and injectable medications, urethral suppositories, and vacuum erection devices that can create and help you keep an erection.
Oral medications
The first line of treatment for erectile dysfunction is oral medications (medicine that you take by mouth). These include sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra or Staxyn), and avanafil (Stendra). They work by causing more blood to flow into the arteries (blood vessels) of the penis. They work best for patients with inflow disease. These medications need to be taken before having sex—15 minutes (for avanafil) to one hour (for all others). They also need stimulation to work, which means either you or your partner touching you. Oral medications are easier to get since they have become generic and are a cost-effective treatment option. The most common side effects are headache, nasal congestion (stuffy nose), flushing (face turning red), and upset stomach.
Intracavernosal (Penile) Injections (ICI)
Often, an ICI is the next step if oral medications are not strong enough to get an erection. Instead of taking a medication by mouth, you inject an ICI directly into the penis with a small needle. This helps the medication to work faster because it is acting directly on the penis instead of first having to go through the whole body. It usually works within 5 to 10 minutes after it is injected, so it allows you to have a freer, “in the moment,” experience than oral medications.
The two main types of ICI are single-agent medications (alprostadil) which are FDA-approved and compounded medications (Bimix, Trimix, etc.). They do not have the same kinds of side effects as oral medications. But they can cause priapism — an erection that lasts longer than four hours — which can be an alarming side effect. For this reason, it is important that ICIs are prescribed by a urologist who understands the dosing of injectable medications. Most urologists will have you try injections in the office to make sure you get the correct dose. Other side effects include pain and scar tissue at the injection site if you don’t do the injection properly.
Urethral Suppositories
Urethral suppositories are alprostadil pellets (another type of ED drug) that are placed into the urethra to help erections. Like the other medications, they work by increasing blood flow to the penis. Like the injections, they work fast (within 5 to 10 minutes). The most common side effect of this medication is penile and urethral pain/burning. For this reason, they are not a first-line treatment for erectile dysfunction.
Vacuum Erection Devices (VED)
VED is a device that is placed on the outside of the penis that uses suction to pull blood into the penis. These can be mechanical (hand pump) or electric. They also come with a constriction band to place at the base of the penis after the erection is achieved. The constriction band squeezes the base tight to help keep the blood inside the penis. Most patients find VEDs very awkward to use. Some patients will complain of numbness and coldness of the penis because of the constriction band. Many urologists will recommend using them (without the band) to help the penis recover after prostate cancer treatment. This is done to boost blood flow into the penis to keep the tissues healthy with or without low-dose oral medication.
Constriction Rings or Bands
These devices are placed at the base of the penis to help keep the blood in the penis after an erection is achieved. They can be used alone or with a VED. They should be made of soft materials that can be easily removed to prevent injury. You must remove them once you are done having sex. A long period of time with a lack of blood flow (and not enough oxygen) can harm the penis.
Surgical Treatment Options
When the above treatments do work to get an erection, or if you do not like them or their side effects, the next treatment option is a penile prosthesis or implant. All penile prostheses have two cylinders that sit side by side in the corpora cavernosa (erectile chambers) within the penis. The goal of a prosthesis is to make the shaft of the penis hard. It does not make the penis larger.
The best feature of penile implants is they give some freedom back to the patient. There are two main types of penile implants—semirigid or inflatable. The side effects include:
- The implant might not work properly
- An infection could be possible
- You might feel unhappy if you have unrealistic expectations about the device
For more information about a penile prosthesis, please see What is a Penile Prosthesis?”.
Conclusion
As a prostate cancer survivor, you should know that you are not alone if you suffer from erectile dysfunction. There are treatment options available for you. But there are people who will sell “snake oil” or experimental treatments to men desperate to restore their erectile function. Because of this, it is very important that you find a urology specialist to help guide you through these treatments. There are no miracle treatments. But with the treatments outlined in this article, you can perform in the bedroom again.
One of the main side effects of prostate cancer treatment is erectile dysfunction (ED). This can happen if the nerves and blood vessels that control erections are injured by surgery or radiation. The erectile tissue inside the penis can also be injured by radiation. Plus, hormone therapy (called androgen deprivation therapy, or ADT) may also cause erectile dysfunction. For men that are sexually active, this is the most feared side effect. It’s true that most men will experience some decline in their function. However, there are many treatment options depending on how severe the ED is.
How Do Erections Work?
To understand erectile dysfunction and its treatments, it is important to understand how erections work. There are two “phases” of an erection — the filling and trapping phases.
The “filling phase” occurs when excitement causes blood flow to increase into arteries (blood vessels) in the penis. Once this begins, the blood fills the erectile tissue, which causes it to expand. This leads to fullness of the penis.
The “trapping phase” begins once erectile tissue expands enough to collapse (close off) veins that drain blood from the penis. When these two things happen, the penis can get and keep a full, hard erection.
What is Erectile Dysfunction?
Erectile dysfunction means not being able to get or keep an erection hard enough for sex. This may mean not being able to get an erection at all, not being able to get an erection hard enough for intercourse every time, or not being able to keep an erection long enough for penetration.
Erectile dysfunction can be a problem in the filling or trapping phases that occur during an erection. When there is a problem with filling, you usually notice you can’t get an erection at all or it takes a long time to get an erection.
However, if it is an issue with trapping the blood in the penis, then you will lose the erection before climaxing. This is called a venous leak. It is like having a nail in your tire — this means that no matter how much blood comes into the penis, it will leak out. If erectile dysfunction goes on for a long time, you may have penile shortening (the penis gets shorter).
Work Up for Erectile Dysfunction
When you see a urologist about your ED, he/she will need to completely understand your history of erectile dysfunction, including:
- When it started (Was it before or after your treatment?)
- The quality of your erections (How hard are they and how long do they last?)
- What treatment options have you tried?
Your doctor also will give you a physical exam. Depending on your erectile function, they may order a penile doppler or ultrasound to diagnose which type of erectile dysfunction you have. Arterial insufficiency is the decrease of blood flow into the penis. A venous leak means the penis can’t store enough blood to keep an erection. Knowing which type you have will help decide which treatment options are best for you.
Conclusions
Erectile dysfunction after prostate cancer treatment, whether it is surgery, radiation and/or hormone therapy, is common. ED is also debilitating, and patients and doctors often don’t talk about it. Understanding how normal erections work is important to understand how erectile dysfunction happens after prostate cancer treatment. Remember, be sure to seek out a urology specialist who is well-versed in explaining, working up, and treating erectile dysfunction. This will help to make sure that you get the best care in restoring your sexual health.