Surgery is one of a number of options available for the treatment of prostate cancer. Surgery to remove the prostate is called prostatectomy. The decision to undergo surgery is not one to be taken lightly – it should be made only after discussing the risks and benefits of the procedure (and other available treatments) with your doctor.
Issues that need to be taken into account when considering treatment options for prostate cancer include the nature of the cancer, your age, your general health and the risk of side effects.
Common side effects associated with prostate cancer surgery are impotence (erectile dysfunction – the inability to achieve or sustain an erection) and urinary incontinence. Most men experience these side effects to some degree, but they can often be treated and usually improve with time.
Impotence (erectile dysfunction) after prostate surgery
In the past, up to 70 per cent of men who had their whole prostate removed because of cancer had some difficulty achieving an erection afterwards. This is because the prostate lies next to the nerves and blood vessels that are important for erections, and these nerves and vessels can be damaged during the operation. Newer surgical techniques that aim to spare the nerves associated with erectile function have reduced the risk of impotence.
While there is a still a significant risk of erectile dysfunction after prostate surgery, there is often a gradual improvement in erectile function over time. Some men only have short-lived erectile dysfunction and others continue to improve for up to 3 years.
Reducing the risk of erectile dysfunction
To minimise your risk of impotence following the operation, any factors that might predispose you to erection problems should be addressed beforehand. Such risk factors include:
- high cholesterol;
- high blood pressure;
- obesity; and
Your doctor will assess your risk and offer treatment or advice if necessary. They will also make sure that you are not taking any medicines that could contribute to erectile dysfunction.
Recovery of sexual function after surgery
Spontaneous erections may return as early as 6 months after a successful nerve-sparing prostate removal operation. However, some men may not experience the return of spontaneous erections for up to 3 years.
Return to normal sexual functioning can be helped by what is known as penile, or sexual, rehabilitation, which should be started before surgery and continued afterwards. It is thought that the following measures can speed up the return of spontaneous erections.
- Engaging in foreplay.
- Encouraging erections soon after surgery (usually after about a month).
- Regular use of oral medicines to help with erections both before and straight after the surgery.
- Use of a vacuum erection device or injection therapy after the operation.
Erectile dysfunction treatments
There are various impotence treatments available in Australia that can improve the quality of erections.
Many men are helped by phosphodiesterase type 5 (PDE5) inhibitors, which include:
- sildenafil (brand name Viagra, Vasafil, Vedafil);
- vardenafil (brand name Levitra); and
- tadalafil (brand name Cialis).
These medicines help increase blood flow to the penis when you are sexually stimulated. For these medicines to work, the nerves involved in erections must have been spared and be functioning. Sometimes the nerves can be spared but can take a while (up to 3 years) to become functional again.
Side effects of these medicines can include:
- dizziness; and
- blocked nose.
Rarely, sildenafil and vardenafil can cause a distortion of vision or change in colour vision. Tadalafil has been associated with back pain.
PDE5 inhibitors should not be taken by:
- men with certain heart problems;
- men with low blood pressure; or
- men taking nitrates (often used to treat angina) or certain medicines used to treat high blood pressure.
Your doctor will be able to advise you on whether these medicines are an option for you.
Although the thought of penile injection therapy worries most men initially, the majority of men can successfully use this treatment with correct instruction and practice.
Injection therapy involves a medicine called alprostadil (brand name Caverject) being injected into to the penis to produce an erection.
Side effects of penile injections include pain in the penis during injection and bruising at the site of injection. Scar tissue can also sometimes develop in the penis after injection therapy. The most serious side effect of injection therapy is priapism (a persistent erection), which is a medical emergency.
Vacuum erection devices, which draw blood into the penis to help gain an erection, may also be helpful for some men.
For men who are impotent following surgery because they did not have a nerve-sparing procedure or because the nerve-sparing procedure was unsuccessful, a penile prosthesis (implant) is an option if they want to continue to have sex. This involves surgically implanting inflatable tubes or flexible rods that help achieve an erection. It is usually only considered if other treatments have not helped and at least 12 months have passed since having the treatment for prostate cancer.
You may also benefit from visiting a sex therapist or psychologist if erection problems are affecting your sex life or relationship.
Urinary incontinence after prostate cancer surgery
Urinary incontinence (loss of bladder control resulting in leakage of urine) is a common, but usually temporary, problem after prostate cancer surgery. This is because the prostate is located at the base of the bladder and surrounds the urine outflow tube (urethra).
Symptoms and treatment
Urinary incontinence affects most men for several months after prostate cancer surgery. The degree of incontinence varies – some men need to wear incontinence pads while others may just leak a few drops every now and then (often when coughing or straining).
The risk of being permanently incontinent following surgery is quite low these days. Most men find their symptoms have improved within a year of the surgery. In men who have no significant improvement in symptoms after 12 months, surgery may be recommended to help control the flow of urine.
Self-help for urinary incontinence
Pelvic floor muscle exercises for men can help improve symptoms. When started before surgery, pelvic floor muscle exercises can help reduce the risk of ongoing incontinence.
Other self-help measures to improve incontinence include drinking plenty of water and avoiding substances that can irritate your bladder, including alcohol, tea and coffee.
Other side effects
Dry orgasms (where you still have an orgasm but you don’t ejaculate) and infertility are also side effects of prostatectomy. Your doctor will discuss this with you before having the surgery in case you want to take steps to preserve your fertility, such as freezing and storing your sperm. Some men also have a reduced libido, a change in the appearance of the penis or painful orgasms, although these side effects are much less common.
Overall outlook following prostate cancer surgery
Surgery for prostate cancer has been refined over the years, and is now associated with fewer complications and a good long-term success rate. Nonetheless, complications such as incontinence and erectile dysfunction do still occur and can be very distressing.
It is important to ask your surgeon for information about all the things that are important to you before the operation. However, they can only give you statistics and probabilities and will not be able to tell you exactly what will happen to you – every man has a different story to tell.