Prostate Cancer: Erectile Dysfunction

Last Editorial Review: 12/1/2006
The Cleveland Clinic

Erectile dysfunction, also called impotence, is the inability to develop or sustain an erection satisfactory for sexual intercourse.

Though prostate cancer is not a cause of erectile dysfunction, treatments for the disease can cause the problem. These include:

  • Surgery to remove the entire prostate gland

  • Radiation therapy, whether by external beam or radioactive seed implants

  • Cryosurgery (freezing cancerous tissue)

  • Hormone therapy

All current treatments for prostate cancer can cause erectile dysfunction, though some treatments can lead to impotence sooner than others.

When Can Erectile Dysfunction Occur After Treatment?

  • Surgery. Some degree of erectile dysfunction occurs right after surgery to remove the prostate, regardless of whether the technique that tries to spare the nerve that controls erections is performed.

The severity of the erectile dysfunction depends on the type of surgery, stage of cancer, and skill of the surgeon.

If the nerve-sparing technique is used, recovery from erectile dysfunction may occur within the first year following the procedure. Recovery of erectile function after a non-nerve-sparing surgery is unlikely, but possible.

One study shows erectile dysfunction rates of 66% for nerve-sparing prostatectomy versus 75% for non-nerve sparing surgery at one year after the surgery. The use of vacuum devices or drugs such as Viagra after surgery once the body has healed may improve the quality of erections and speed the return of normal sexual function (see below).

If an erection can be achieved after surgery one does not lose the ability to have an orgasm but they are "dry" orgasms in which little (if any) ejaculation comes out. This results in infertility for most men. Although this is often not a concern, since most men are older at the time of diagnosis, if desired you could talk to your doctor about "banking" sperm before the procedure.

  • Radiation therapy. The onset of erectile dysfunction following radiation therapy is gradual and usually begins about six months following the treatment.

Loss of erectile function is the most common long-term complication of radiation therapy. But its occurrence decreases when more sophisticated treatments, like radioactive seed implants (brachytherapy), intensity-modulated radiotherapy (IMRT), and 3-D conformal radiotherapy, are used.

  • Hormone therapy. When hormone therapy is used, erectile dysfunction may occur approximately two to four weeks after the start of therapy. A decreased desire for sex also occurs.

How Is Erectile Dysfunction Treated?

Current treatment options for erectile dysfunction for men who have received treatment for prostate cancer include:

  • Oral medications, such as Viagra, Cialis or Levitra

  • Injections of medicine into the penis before intercourse (called intracavernous injection therapy)

  • Use of a vacuum constriction device to draw blood into the penis to cause an erection

  • Medicine taken as a suppository placed in the penis prior to intercourse

  • Penile implants

How Effective Are Oral Erectile Dysfunction Drugs?

  • Following surgery The Cleveland Clinic's own experiences suggest that as many as 60% to 70% of men who have had nerves spared on both sides of the prostate will regain erections. Results are less favorable for men who have had a single nerve spared or no nerves spared.

  • Following radiation therapy Overall, 50% to 60% of men regain erections with Viagra following radiation for prostate cancer. However, current data are rather limited, especially for patients treated with radioactive seed implants.

  • Hormone therapy Specialists at The Cleveland Clinic find that men treated with hormone therapy do not respond well to any erectile dysfunction treatments, including Viagra, but data are limited.

How Effective Is Injection Therapy with Each Type of Treatment?

If Viagra and other oral drugs fail, injections into the penis can be an effective form of treatment for men who have undergone surgery or who have received radiation therapy (whether by external beam or seed implants) for prostate cancer.

Overall, 60% to 80% of men will regain erections with the use of injection treatments. Side effects include occasional pain due to one of the medicines used for injection therapy, and the development of scar tissue.

What About Other Treatments?

If Viagra and injections fail (or if you are unwilling or unable to use either therapy), other treatments may be appropriate.

  • Vacuum Constriction Device A cylinder is placed over the penis. The air is pumped out of the cylinder, which draws blood into the penis and causes an erection. The erection is maintained by slipping a band off the base of the cylinder and onto the base of the penis. The band can stay in place for up to 30 minutes. Although these devices can be effective, they generally have been less desirable for patients who have been treated with surgery. Many patients dislike having to use the band at the base of the penis and find it uncomfortable.

  • Penile Suppositories For this treatment, the patient places a suppository into the urinary tube (urethra) using a plastic applicator. The suppository contains the drug alprostadil, which travels to the erection chambers. Alprostadil relaxes the muscle in the erection chamber, allowing blood to flow into the penis. This treatment works in only about 30% of men.

  • Penile Implants This option may be considered if the patient has had erectile dysfunction for about one year following cancer treatment and nonsurgical therapy has either failed or is unacceptable. An implant, or prosthesis, is an effective form of therapy in many men, but it does require an operation to place the implant into the penis. Surgery can cause problems, such as mechanical failure or infection, which may require removal of the prosthesis and re-operation. However, most men and their partners are very satisfied with these devices. The success rate is as high as 95%.

Reviewed by the doctors at The Cleveland Clinic Urological Institute.

WebMD Medical Reference provided in collaboration with the Cleveland Clinic


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SOURCES: American Cancer Society. Muse (alprostadil) package insert. American Urological Association.

Edited by Paul O'Neill, MD on December 01, 2006

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