The two most common prostate issues for men are enlarged prostate, also known as benign prostatic hypertrophy (BPH), and prostate cancer. A sign that either might be developing is difficulty urinating. That could mean having sudden urges to urinate, not being able to form a full stream, or even feeling like urine stays trapped in the bladder causing you to strain to get it all out. As a group, these symptoms are called lower urinary tract symptoms (LUTS).
Here, we’ll talk about how both BPH and prostate cancer are related to erectile dysfunction (ED) and what options you have for treatment if this is an issue for you.
How are enlarged prostate and erectile dysfunction related?
Many men wonder if BPH can cause erectile dysfunction. The short answer? Not really. While the prostate is an important organ for male sexual function, BPH is more of a urination issue than a sexual one. The prostate goes through two major growth spurts during a man’s lifetime: one during puberty and another around 50 or 60 years of age. It is estimated that more than half of men will have some form of BPH in their 50’s (and that percentage only increases with age), which is why we see so many older men complaining of LUTS.
Usually, an enlarged prostate isn’t a problem unless symptoms become burdensome and treatment is needed. That’s where concerns about erectile dysfunction come in. To treat BPH, your options are medications to relax the prostate or stop it from getting bigger, and surgery. Flomax and similar medications are part of a class of drugs called alpha-blockers, which cause the blood vessels of the prostate to constrict, relaxing muscles in the prostate so urination can occur more easily. One side effect of these drugs is less blood to flow into the penis during an erection though, and that could be a problem. Another drug, Avodart, is an anti-testosterone drug that stops the prostate from growing. However, lower testosterone levels in the body may cause ED as well. Lastly, surgical procedures can also cause ED due to damage to structures around the penis, which I will go into detail below.
How are prostate cancer and erectile dysfunction related?
If you have issues with your prostate, a general workup can include urine tests, bloodwork, and a physical exam. This exam usually consists of a digital rectal exam (DRE), where a doctor will feel your prostate from inside your anal cavity. If the prostate feels smooth and round, that’s generally a sign that you probably only have BPH. Otherwise, you may need to undergo further testing, and cancer may be a concern. Men who are diagnosed with prostate cancer worry about many areas of their health. I have heard many of these questions over the years: “How bad is it?”, “What options do I have?”, and “What are possible complications of treatment?”
Currently, the mainstays of treatment for prostate cancer are anti-testosterone therapy, surgery, and radiation therapy. Each of these has pros and cons related to treatment success and long-term effects on the body. However, one of the most common complications for all three of these options is erectile dysfunction. We talked about how anti-testosterone therapy can affect erections when we discussed BPH treatments above. Let’s now look at prostate surgery and radiation therapy.
How can prostate surgery and radiation therapy cause ED?
Both prostate surgery and radiation therapy can damage tissue around the prostate and cause ED. In fact, it is estimated that 25% – 75% of men will have ED after the removal of the prostate, called a prostatectomy. Similarly, radiation therapy can also cause damage to the tissue around the prostate. If nerves get damaged, signals from the brain may not be able to reach the penis to initiate an erection. And even when sexual stimulation is present, if blood vessels are damaged, that might mean that blood can’t flow properly to the penis to maintain an erection.
Can I prevent ED after prostate surgery?
These days, many prostatectomies use nerve-sparing techniques to reduce injury to the tissue and prevent ED, though it still can happen. There are also several interventions for men after prostate surgery to help regain erectile function and prevent ED. Research shows that after surgery, 20% – 25% of men regain their erectile function, but it may take several years.
To increase the chances of penile recovery and to prevent ED, several interventions after surgery may be offered. One option is called “penile rehabilitation” which uses medications to help improve blood flow into the penis. This may include the use of drugs like Viagra or Muse taken at night before bedtime. However, current research on the benefits of this intervention is limited. Still, it’s recommended that men be encouraged to proceed with normal sexual habits after healing, as it may help prevent long-term issues, and to use medications to increase blood flow and improve erections.
I have ED after getting prostate surgery. What now?
For treating erectile dysfunction after prostate surgery, Viagra, Cialis, and Levitra are considered first-line therapies. Research has shown that these drugs help improve erectile function by relaxing the blood vessels that supply the penis so more blood can flow through. They might not work right after surgery, though. One reason for that is that blood may not flow easily through blood vessels that are still healing. However, after the blood vessels have healed enough, medication is likely to help with ED. Between 35% and 75% of men with ED after surgery respond to Viagra (though this may take weeks to years).
If Viagra, Cialis, and/or Levitra don’t work, or they’re not an option due to other issues (like a drug interaction), alprostadil may be used instead. Alprostadil comes as an injection (known as Caverject) and as a pill to be inserted into the urethra (known as Muse). Read more about these drugs here.
What if drugs don’t work?
Unfortunately, medications won’t help all men with ED after prostate surgery. If you’ve tried medications and still have ED, you may want to have a close conversation with your doctor about whether or not surgery or mechanical devices (such as vacuum pumps) are good options for you. Remember, though, that it may take several years before you know for sure if drugs won’t work, as tissue around the prostate takes a while to heal.
Also, keep in mind that many things can contribute to ED after prostate surgery, including psychological stress. Seeing a psychologist can be a great help in managing this and other post-surgery issues you might face, like loss of sexual intimacy and urinary incontinence (urine leakage) during sex. Couples counseling should also be considered, as this may help to give a realistic picture of what you can expect and how to overcome potential issues.
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