Sexual function and robotic prostatectomy (RARP)

By Benjamin W Lamb, Consultant Urological and Robotic Surgeon.

What is sexual function?

Sexual function is complex and varies between men. It might be defined as the ability of a man to satisfy psychological, emotional, physical and fertility needs through sexual activity. More specifically, healthy sexual function usually relies on sex-drive (libido), genital sensation, erection, the ability to achieve orgasm, ejaculation, and maintenance of bladder and bowel control. This in turn depends on a man’s mood, hormone levels, blood vessels, nerves, and penile tissue.

Sexual function is affected by mood, stress, age, health conditions, medication, among other factors. The prostate is integral to sexual function as it produces much of the fluid in semen and is necessary for normal fertility. It is also surrounded by nerves and blood vessels travelling to the penis. Moreover, the function of the prostate is under the influence of the male sex hormone, testosterone.

How does prostate cancer and its treatment affect sexual function?

The diagnosis of prostate cancer is usually a very stressful period in a man’s life. In addition, diagnostic procedures such as prostate biopsy, as well as the treatment of prostate cancer, whether by hormone treatment, radiotherapy or surgery are likely to affect sexual function.

Different treatments for prostate cancer can affect sexual function in a variety of ways. Some side effects of treatment will occur during treatment, some may improve after, and some may get worse. It is very important that if sexual function is important, the effects of treatments are carefully discussed between patients and their specialists.

How does RARP affect sexual function?

All men undergoing RARP will have some changes to their Sexual function following surgery. Below, I will set out what effects RARP has on the various features of sexual function that have been set out above.

Sex-drive (Libido)

Aside from the distress of being diagnosed with prostate cancer, and stress of undergoing major surgery, RARP does not have a biological affect on sex drive. In contrast to treatments that affect hormone levels, such as hormone injections, RARP does not affect the production of testosterone, the main male sex hormone. Once patients are through the physical challenge of surgery, and have had their cancer treated, there is no reason that they should not have a normal sex drive.

Genital sensation

The nerves that provide sensation to the genitals (penis in general) are not affected by RARP. Sensation following RARP should, therefore, be the same as it was before surgery.

Ability to achieve orgasm.

The ability to achieve climax, or orgasm, relies on sex drive, and sensation as described above. It is therefore achievable after RARP. It may feel different, as there will be no ejaculation (see below), and it can require a different approach if the penis is not erect (see below), but it should be possible and still pleasurable. These challenges, and others arising from a cancer diagnosis and recovery from surgery, can be overcome with the help of material to stimulate the mind, such as erotic material, or porn, and the body, such as vibrators or sex toys. Patients should ensure that they only try what is comfortable but should not feel any shame or stigma.

No ejaculation

RARP involves the removal of the prostate and seminal vesicles, which are the organs that produce the vast majority of the seminal fluid. As a result, following RARP, orgasm is dry, and no ejaculation occurs. This can result in altered sensation, and sub-fertility (see below). Ejaculation is important to many men, and can be part of the male identity, so the effect of RARP on ejaculation should be considered before deciding on treatment.

Sub-fertility

Normal fertility relies on the production of semen, the fluid that contains sperm. As semen is produced by the prostate and seminal vesicles, which are removed during RARP, the ability to conceive through sexual intercourse is lost. The testis still make sperm, however, so these can be retrieved and used in fertility treatments, such as IVF.

Ability to achieve erections.

Loss of spontaneous (natural) erections is perhaps the most profound after effect of RARP. Erectile dysfunction, or loss of normal erections sufficient for penetrative intercourse, is a common side effect of RARP. This occurs for almost all men immediately after surgery, and for many men is a permanent side effect. Some men do recover their erections, but it may take many months, or even years. If can be very frustrating in the time after surgery, especially once the cancer is treated and men want to get back to a normal life. The likelihood of recovering erections after RARP depends on a number of factors. These include:

Age- erections get worse as men get older, and older men have a slightly lower chance of recovery than younger men.

Existing erections- men with good erections are more likely to recover them than men who have existing erection problems.

The type of surgery performed- erections are more likely to recover if nerve sparing surgery is performed. The chance of recovery with non-nerve sparing surgery is low. Full nerve sparing is more effective than partial nerve sparing. There will often be a balance between controlling the cancer and recovery of erections. It is important to discuss this carefully with your surgeon, and to understand what is anticipated to be achievable, and what is likely to be safe.

Urine leak at orgasm (climacturia)

Climacturia is the leak of urine at the point of climax. It occurs in some men, not all, and may improve with time. The amount of urine lost is variable and depends on how full the bladder is and how good the urinary continence is.

Shortening of the penis

It is usual for men to perceive that their penis is shorter after RARP. This appears to occur from a combination of the inward pull on the penis from the join to the bladder, and from changes to the blood supply, which are dependent on the type of surgery. Some studies have found that the length recovers with time, and recovery of erections appears to help.

What can be done to help maintain sexual function after RARP?

I have previously written a blog about outcomes that are important following RARP, which included some aspects of sexual function (What outcomes are important to consider after radical prostatectomy? | Lamb Urology)

Proactivity, positivity and patience– The brain is the most important sex organ in the human body so its important to engage it to be proactive, positive and patient. It can take many months to know whether erections are going to recover or not. If recovery of sexual function is a priority, then it is important not to give up or become despondent.

Communication- If patients are in a sexual relationship with another person, the communication between partners at this challenging time is very important. Many men are used to having an erection as a sign of their own arousal, interest in or love for a partner. Similarly, partners are used to using the erection as a barometer of how their man is feeling. Without the ability to get an erection, other forms of communication are required. Remember that sexual pleasure and orgasm are possible without an erection and are largely unaffected by RARP. Communication about sexual activity other than that requiring an erection is needed to maintain trust and intimacy, as well as pleasure for both partners.

Stimulation– stimulation- both mental and physical- is a healthy way to encourage blood flow to the penis and stimulate return of normal erections. It can be difficult to stimulate a soft penis, so sex toys, such as vibrators, can be useful. In addition, failure to get an erection can be very demotivating and erode a man’s confidence and sex drive. Erotic material, whether online videos, pictures, books or stories, can help to stimulate the sex drive and help to produce sexual desire and arousal.

Pelvic floor muscle training – Pelvic floor exercises are learned by many men prior to RARP. Men are encouraged to practice them before surgery in order to become familiar with the action of tightening the muscles, and to build strength in the muscles. Whilst these exercises are intended to improve urinary control, improved continence can have indirect benefits for sexual function as sexual activity is difficult without urinary control.

Medication– In order to improve recovery of erections after RARP, patients can start a medication to help improve the penile blood supply (tadalafil, or Cialis). I usually recommend that this is started on the first day after surgery, whilst other urologists may want patients to wait a little longer. This medication is usually taken as a small bedtime dose (5mg) every day. This appears to accelerate recovery of erections. These tablets can cause some side effects, such as facial flushing, dizziness, low blood pressure, stomachache or muscle ache. They should not be taken by men with an allergy to these medicines, or by men taking other medicines containing nitrates (e.g., angina spray). In our practice, 87% of men who start these medications continue to take them for the recommended time. They do not work if a non-nerve sparing operation has been performed. Patients should have a discussion with their surgical team about whether or not they may be beneficial.

Vacuum device– In addition to medication, I recommend use of a vacuum erection device (penile pump) on a regular basis: twice daily as an exercise, and/or prior to sexual activity. Using a penile pump maintains penile length, helps to prevent negative changes in the penile tissues until natural erections return, and can improve the quality of erections. The vacuum device can be used with an elastic constriction band around the base of the penis to keep the blood inside in order to maintain an erection. Using the vacuum device when the urinary continence has not properly returned can lead to leakage of urine. It is advisable to use it with an empty bladder. The vacuum device can be awkward and uncomfortable, so trial and error are needed to get it working properly. It should not be painful, and if it is it should not be used. It can be used for men who have not had nerve sparing surgery, and for men who have had nerve sparing it can be used in conjunction with medication (see above). Discuss with the surgical team whether it is appropriate to use.

Injections/urethral pellets/penile creams- It is possible to apply drugs that cause erections directly to the penis. These drugs (prostaglandins) cause dilatation of the blood vessels in the penis and improve blood flow causing engorgement and erection. Generally, the more directly the drug is applied to the penis, the greater its effect: injections are more effective than urethral pellets, which are in turn more effective than creams applied to the penis. These drugs work even without nerve sparing, so can be a good option for men having non-nerve sparing surgery, or whose erections do not return naturally. The drugs can have side effects such as dizziness or painful prolonged erection (priapism). The first time they are used they should be tried in the clinic and supervised by a urology specialist nurse, or doctor.

Penile implant surgery- The option for men who do not get return of erections with the above methods could consider surgery to implant a device into the penis to give erections. This involves an operation under general anaesthetic, usually with a stay in hospital for one night or so. Penile implants can be of a set size and can be bent up or down depending on whether an erection is desired. The alternative is an implant that can be inflated or deflated to get or lose an erection. Both options should be discussed with a urologist who specialises in this type of operation (andrologists) and performed only in one of a few specialist centres. The benefits and risks should be carefully discussed as it can have permanent effects on the penis.

Conclusion

Unfortunately, spontaneous (natural) erections do not return for about 1 in 3 patients, and research suggests that about half of men who engaged in sexual intercourse prior to RARP stop doing so after surgery. RARP has a permanent effect on all men, and sadly, many men are unable to enjoy sexual relations after RARP in the way they had before. Being aware of these effects when considering treatment is very important and can help men to avoid making a decision that they later regret. For men who do have RARP there are things that can be done to help them to enjoy and hopefully restore sexual function, even when there are some undesirable changes to their body.

Further reading

Prostate Cancer UK information on sex and relationships https://prostatecanceruk.org/prostate-information/living-with-prostate-cancer/sex-and-relationships

NHS information about sexual rehabilitation after cancer https://www.networks.nhs.uk/nhs-networks/sexual-rehabilitation-after-cancer/resources-1/patient-information-leaflets/patient-information-prostate-cancer/sex%20and%20prostate%20cancer.pdf

Relate charity for relationship advice https://www.relate.org.uk/

British Association of Urological Surgeons information sheet about vacuum device VEDs.pdf (baus.org.uk)