Many authors have reported decreases in penile length and circumference after radical prostatectomy (RP). Raina et al hypothesized that during the period of profound neurapraxia after nerve-sparing RP, when sexual stimulation and nocturnal erections are lost, penile corporal hypoxia is exacerbated and results in increased production of collagen and fibrosis, leading to a subsequent loss of penile length and circumference (Int J Impot Res. 2006;18:77-81). Fraiman et al reported a progressive loss in flaccid length, erectile length, and circumference within the first three to four months after RP (Mol Urol. 1999;3:109-115).
In a prospective study evaluating penile length at three months post-RP, Savoie et al observed significant decreases in the flaccid, stretched, and circumferential measurements of the penis, with nearly 20% of men experiencing a loss of length greater than 15% (J Urol. 2003;169:1462-1464). Furthermore, Gontero et al observed the greatest amount of shrinkage at the time of catheter removal, with shortening occurring for up to one year after surgery (J Urol. 2007;178:602-607).
Vacuum erection device (VED) usage has been advocated to prevent penile shrinkage and preserve penile length. VED assists erections by drawing blood flow into the cavernous sinuses through negative pressure to create engorgement of the penis.
The previously cited report by Raina, which included a prospective study of daily VED use within two months after RP, noted that only 23% of patients using VED reported a decrease in penile length and circumference compared with 60% in the nontreatment group. In a pilot study by Kohler et al on the early use of VED after RP, 28 men were randomized to early intervention (one month after RP) or delayed intervention (six months after RP) (BJU Int. 2007;100:858-862).
Penile length was preserved in the early-intervention group at all sample times. For the delayed-intervention group, stretched penile length was significantly decreased at three and six months after surgery by about 2 cm. Although the exact mechanism for prevention of penile shrinkage by VED is not fully known, both studies suggest a potential early role of VED in the preservation of penile length.
Orgasm is defined as the physical and emotional sensation experienced at the peak of sexual excitement, usually accompanied by ejaculation. Because the ejaculatory apparatus (prostate, seminal vesicles, ejaculatory ducts) is removed during surgery, men who have undergone RP or RALP cannot ejaculate and only experience “dry orgasms.”
Although orgasm itself is poorly understood at the cerebral level, it is associated with well-documented and reproducible anatomic and physiologic events, which include closure of the bladder neck, elevation in BP, tachycardia, and sense of euphoria. The prevalence and nature of orgasmic dysfunction after RP or RALP is not well-known.
Analyzing results from an unvalidated questionnaire on erectile and orgasmic function completed by 239 patients who had undergone RP, Barnas et al reported that 37% reported complete absence of orgasm (anorgasmia), 37% had decreased orgasm intensity, 14% had pain during orgasm (dysorgasmia), and 55% had orgasm-associated pain lasting less than one minute (BJU Int. 2004;94:603-605).
The authors postulated that the physiologic bladder-neck closure that occurs during orgasm can lead to spasm of the vesicourethral anastomosis after RP and subsequent dysorgasmia. Currently, the uroselective alpha-blocker, tamsulosin (Flomax) has been shown to decrease orgasmic pain intensity (Eur Urol. 2005;47:361-365) and may be effective for the treatment of postprostatectomy dysorgasmia.
Orgasm-associated incontinence or climacturia is the inadvertent leakage of urine at orgasm. Such leakage following RP or RALP is a poorly defined entity but has been reported in 20%-45% of men (J Urol. 2006;176[6 Pt 1]:2562-2565). Choi and colleagues reported similar numbers (J Urol. 2007;177:2223-2226) and found no significant difference in prevalence between patients who underwent open versus laparoscopic radical prostatectomy.
The same researchers reported that climacturia was associated with dysorgasmia and penile length loss but not with degree of nerve-sparing, surgical margins, preoperative or postoperative sexual function, or daytime continence. For men complaining of urine leakage at orgasm, the investigators recommend such treatment options as emptying the bladder prior to sexual relations, use of condoms, or use of an ACTIS constriction band around the penis to prevent urine loss during intercourse.
Results from the few reported studies examining postprostatectomy orgasmic dysfunction clearly show that it is more prevalent than previously thought. Further research into the extent and causes of orgasmic changes after RP and RALP are needed to truly understand the underlying mechanisms involved.
Since younger men are being treated for prostate cancer, issues concerning recovery of sexual health are increasingly being addressed prior to surgery. Urologists should be aware of the many aspects of postprostatectomy sexual dysfunction and realize that they are more common than previously thought. Men undergoing radical prostatectomy or RALP should not be discouraged if sexual potency does not return immediately since sexual health may take 10-14 months to improve after surgery.
Penile rehabilitation programs using a combination of oral agents, intraurethral suppositories, intracorporeal injections, and VEDs are designed to promote quicker recovery of sexual function after surgery. Although the optimal penile rehabilitation program is still being developed, sexual health concerns should be addressed prior to or immediately after surgery to facilitate early recovery and restoration of satisfactory sexual activity for both the patient and his partner.
The authors are affiliated with Hackensack University Medical Center in Hackensack, N.J. Dr. Shin is Chief of the Center for Sexual Health and Fertility. Dr. Sawczuk and Dr. Munver are Chairman and Vice Chairman, respectively, of the Department of Urology. In addition, Dr. Sawczuk is Chief of Urologic Oncology and Dr. Munver is Chief of Minimally Invasive and Robotic Surgery.