Table of Contents

Chapter 3: Maximizing Quality of Life After Initial Treatment

c. Erectile Dysfunction

In various studies reported in the medical literature, you will find an extraordinarily wide range of erectile dysfunction rates—ranging from a low of 2% to a high of 98%. But if you look more carefully at what these studies measured, a few things stand out.

The first issue to consider is the procedure being studied. For example, when looking at men undergoing prostatectomy, you need to distinguish between those who underwent nerve-sparing procedures and those who didn’t. If the nerves are cut or otherwise damaged during surgery, it is highly unlikely that any spontaneous erections will occur. Remember, too, that the nerve-sparing procedure became more widely used relatively recently. So unless they were treated at a major cancer center with a rigorous prostate cancer program, men who underwent prostatectomy 10 or more years ago are unlikely to have had a nerve-sparing procedure. Be sure to keep that in mind when discussing treatment options and side effect profiles with other men with prostate cancer. The same is true with radiation therapy. Brachytherapy and IMRT deliver much more focused radiation to the prostate tissue and therefore cause less damage to the surrounding tissue. The side effect profile for these procedures can vary compared with the side effects seen with standard external beam radiotherapy.

The second consideration is how one actually defines erectile dysfunction. Is it referring strictly to spontaneous erections? What if medication or mechanical devices are used? The technical definition of a "normal" erection is one that stays rigid sufficient for sexual intercourse. But it’s often difficult to distinguish between technical erectile function and subjective sexual function,which will obviously vary much more widely from person to person.

Finally, the third consideration is the time factor. Erectile function rates tend to improve over time following prostatectomy, but tend to remain stable following radiation therapy or decline over time. Therefore, identifying how long it’s been since treatment is an important part of understanding how erectile dysfunction might affect your life.

Given these three caveats, let’s look at the numbers.

Regardless of whether the nerves were spared during surgery or whether the most precise dose planning was used during radiation therapy, nearly all men will experience some erectile dysfunction for the first few months after treatment. The reason for this is simple: the nerves and blood vessels that control the physical aspect of an erection are incredibly delicate, and any trauma to the area will result in changes to the natural order. However, within one year after treatment, nearly all men with intact nerves will see a substantial improvement. By this point, about 50% of men who undergo nervesparing prostatectomy will have returned to their pre-treatment function; after two years, about 75% will have returned to pre-treatment function. (Remember, you can only get back to where you started.) For those who underwent radiation therapy, the numbers are better, but tend not to improve too much over time. About 25% of men who undergo brachytherapy will experience erectile dysfunction vs nearly 50% men who have standard external beam radiation; after two years, few men will see much of an improvement.

Of course, the challenge lies in trying to figure out how you will fare compared with the averages. The two most important factors in anticipating whether a man will regain erectile function following treatment are the type of procedure (coupled with practitioner skill) and prior sexual function. Men who undergo procedures that are not designed to minimize side effects and/or those whose treatments are administered by physicians who are not proficient in the procedures will fare worse. If restoring erectile function after initial therapy is important to you, be sure to fully investigate the exact type of procedure and the success rates of the individual surgeon before you begin treatment.

But it is equally important to be realistic about what to expect after treatment. If you have other diseases and/or disorders that have impaired your ability to maintain an erection, you’ll have a more difficult time returning to pre-treatment function. Diabetes, vascular problems, smoking, and even certain drugs are known to cause sexual side effects—add in the possible trauma to the genital region during treatment and it’s not too surprising that it can take a while, even a few years, for things to get back on track.