Andrew Siegel MD 12/27/14
Having your prostate removed is a highly effective means of curing prostate cancer. Unfortunately, because of the prostate’s “precarious” location—smack in a busy area at the crossroads of the urinary and genital tracts, connected to the bladder on one end, the urethra on the other end, touching on the rectum, and nestled behind the pubic bone in a well-protected nook of the body—it’s removal has the potential for causing some unwanted and undesirable side effects.
Trauma to nerves, blood vessels, and muscular tissue during surgery can potentially compromise sexual function and urinary control. Generally, patients are informed about ED, urinary incontinence, the possibility of the surgery failing to cure the cancer and the risk of rectal injury. However, there are other possible complications that may affect your sexual quality of life that are often glossed over, perhaps because they are not considered that important in the grand scheme of cancer care.
Note that there are many men who undergo radical prostatectomy and experience absolutely no complications whatsoever, achieving “trifecta” status: a PSA (Prostate Specific Antigen) that is undetectable, full urinary control and intact erectile function. A small percentage of men experience significant urinary incontinence whereas many men will experience mild urinary incontinence. Many men note a decline in their ability to obtain and maintain an erection after the radical prostatectomy. What about the side effects that often go less mentioned?
Additional sexually related side effects that may occur including the following:
- Ejaculation of urine at the time of sexual climax
- Urinary leakage with sexual stimulation
- Altered sensation of climax
- Pain with climax
- Penile shortening and deformity
Ejaculation of Urine at Sexual Climax
After radical prostatectomy, ejaculations are typically “dry” because of the removal of the structures that supply the contents of the ejaculate: prostate gland, seminal vesicles and the clipping of the sperm ducts. However, some men after radical prostatectomy may ejaculate urine at the time of sexual climax. This can be a nuisance and embarrassment to both the patient and his partner. This problem is most prevalent during the first year after prostatectomy and tends to improve with time.
Coping strategies are urinating before sex and/or using a condom or constrictive penile loop that pinches the urethra closed. Pelvic floor muscle training can strengthen the levator ani muscle, which contributes strongly to the voluntary urinary sphincter.
Urinary Incontinence at the Time of Sexual Stimulation
Urinary leakage is not always restricted to the moment of ejaculation as some patients can have it with foreplay. Once again, this is a potential bother and embarrassment to both patient and partner. Like ejaculation of urine, this issue is most commonly experienced during the first year after radical surgery and thereafter tends to improve.
Altered Sensation of Climax
Most men after radical prostatectomy will experience an altered perception of climax. Some will experience diminished pleasure, often with a feeling of diminished intensity of orgasm. Some are bothered by the dry climax. On occasion, one loses the ability to climax. In rare instances, a patient after radical prostatectomy will notice an increase in orgasm intensity.
Pain With Climax
Up to 20% of men after radical prostatectomy will experience discomfort or pain with climax, which is often perceived in the penis, testes or the rectum. With time both the intensity and frequency of pain usually decrease, although a small percentage of men will have persistent pain that persists beyond several years following the surgery.
Penile Shortening and Deformity
After radical prostatectomy, it is common to experience an alteration in penile size with a decrease in flaccid length, erectile length and erectile girth. The loss in penile length occurs during the first several months after the radical prostatectomy and whether the situation is reversible seems unlikely.
The shortening is likely based on factors including loss of urethral length, nerve and blood vessel damage and the presence of erectile dysfunction with its associated “disuse atrophy.” Lack of regular erections results in less oxygen delivered to the penile smooth muscle and elastic fibers with subsequent scarring and hence shortening.
The solution is to resume sexual activity as promptly as conceivable after surgery, pursuing “penile rehabilitation” to help avoid disuse atrophy. Pelvic floor exercises, oral medications of the Viagra class, the vacuum suction device, and penile injection therapy have proven to be helpful.
Up to 15% of men after radical prostatectomy will experience a penile deformity resulting in what appears to be a “waistband” or alternatively a penile curvature with erections.
Bottom Line: The potential sexual side effects from radical prostatectomy aside from ED may be bothersome and adversely affect one’s quality of life.
Reference: Frey AU, Sonksen J, Eode M: Neglected Side Effects After Radical Prostatectomy: A Systematic Review. J Sex Med 2014; 11:374-385
Wishing you the best of health and a peaceful upcoming 2015,
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Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Kindle, iBooks, Nook, Kobo) and paperback: http://www.MalePelvicFitness.com
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