Sexual function after RARP: part 2

There are numerous different ways in which men can try to maintain their sexual function following RARP. There are integral components to sexual function, which must be taken into consideration, particularly after robotic-assisted radical prostatectomy (RARP surgery).

In the second article of a two-part series, esteemed consultant urological and robotic surgeon Mr Benjamin Lamb discusses how men can enhance their sexual function following the surgery.

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

Men who wish to maintain sexual function following robotic-assisted radical prostatectomy (RARP) should adhere to the following recommendations.

Proactivity, positivity and patience

The brain is a vital sex organ in the human body, meaning that we must engage it to be proactive, positive and patient. Following robotic-assisted radical prostatectomy (RARP), It can take many months for men to discover whether their erections will recover. If recovery of sexual function is a priority for a man, it is important that he does not give up or become despondent.

Communication

If patients are in a sexual relationship with another person, communication between them and their partners at this challenging time is essential. 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 their man’s emotional state.

It's important to remember that sexual pleasure and orgasm can still be achieved without an erection, and these aspects are largely unaffected by RARP. Effective communication about sexual activities that don't require an erection is essential for maintaining trust, intimacy, and mutual pleasure between partners.

Stimulation

Both mental and physical stimulation is a vital, healthy way to encourage blood flow to the penis, as well as to stimulate the return of regular erections. In some cases, stimulating a soft penis can be challenging, therefore it can be beneficial to use sex toys, such as vibrators. The inability to get an erection can negatively affect a man’s confidence and sex drive. Due to this, some men choose to use erotic material, such as online videos, pictures, books or stories, which can stimulate the sex drive and encourage sexual desire and arousal.

Pelvic floor muscle training

Many men learn pelvic floor exercises prior to RARP. They are encouraged to engage in these exercises before surgery to become acquainted with muscle-tightening techniques and to enhance muscle strength. Although these exercises are primarily designed to enhance urinary control, the improved continence they provide can indirectly contribute to better sexual function, as sexual activity can be challenging without adequate 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).

It is recommended that they begin this on the first day after surgery, however, some urologists may wish for patients to wait for a longer period of time. It is usually taken as a small bedtime dose (5mg) every day, which can stimulate erections. These tablets can cause some side effects, including facial flushing, dizziness, low blood pressure, stomach ache or muscle ache.

Men with allergies to such medicines or who are taking medicines such as nitrates (e.g., angina spray) should avoid such medications.  In our practice, 87% of men who start these medications continue to take them for the recommended time. However, they will not work if a non-nerve-sparing operation has been performed. It is crucial for patients to have a discussion with their surgical team to discover if such medications will be beneficial. 

Vacuum device

Alongside medication, it can be useful for men to use a vacuum erection device (penile pump) on a regular basis: twice daily as an exercise, and/or prior to sexual activity. Penile pumps can maintain penile length, help to prevent negative changes in the penile tissues until natural erections return and improve the quality of erections.

The vacuum device can be employed in conjunction with an elastic constriction band placed around the base of the penis to retain blood and sustain an erection. However, using the vacuum device before full urinary continence has been regained may result in urine leakage. It is advisable to use the device with an empty bladder. It may initially be uncomfortable, requiring some trial and error to use effectively.

It should not cause any pain, and if it does, it should be discontinued. Men who have not undergone nerve-sparing surgery can use the vacuum device, and for those who have undergone such surgery, it can be used in combination with medication (as mentioned above). It is recommended to consult with the surgical team to determine the appropriateness of its use.

Injections/urethral pellets/penile creams

Administration of medications that induce erections directly to the penis is a viable option. These drugs, known as prostaglandins, prompt the dilation of blood vessels within the penis, enhancing blood circulation and resulting in engorgement and the onset of an erection.

In general, the effectiveness of the drug increases as it is applied more directly to the penis: injections yield a greater impact compared to urethral pellets, which, in turn, surpass the efficacy of creams applied to the penis.

Typically, the more localised the application of the drug to the penis, the more pronounced its effects: injections tend to be more effective than urethral pellets, which, in turn, are more potent than creams applied topically to the penis. These drugs can prompt/provoke side effects even in the absence of nerve-sparing, making them a viable choice for individuals undergoing non-nerve-sparing surgery or those whose natural erections do not return.

However, it's important to be aware of potential side effects, such as dizziness or painful prolonged erections (priapism). It is advisable to have the drugs administered in a clinical setting initially, under the supervision of a urology specialist nurse or doctor.

Penile implant surgery

For men who don’t experience the return of erections through the aforementioned methods, there is the option of considering surgical implantation of a device in the penis to facilitate erections. This involves an operation under general anaesthetic accompanied by a brief hospital stay, usually one night. Penile implants are available in fixed sizes and can be adjusted to either an upright or downward position depending on the desired erection. Alternatively, there are implants that can be inflated or deflated to achieve or cease an erection. It is essential to engage in a thorough discussion of both options with an andrologist and to have the procedure performed exclusively at specialised centres. Careful consideration of the benefits and potential risks is crucial, as this surgery can have lasting effects on the penis.

Conclusion

Unfortunately, approximately one out of every three patients do not experience the return of spontaneous (natural) erections, and research indicates that about half of men who were sexually active before RARP cease engaging in sexual intercourse post-surgery. RARP has lasting implications for all men, and regrettably, many find it challenging to recover their previous level of satisfaction in sexual relationships after the procedure. It is of paramount importance to be well-informed about these effects when contemplating treatment options, as this awareness can assist men in avoiding decisions that they may later regret. For those who have undergone RARP, there are interventions available to help them regain and potentially enhance sexual function, even when they have experienced certain unwanted changes to their body.

If you are considering RARP and are concerned about its effects on your sexual function and would like to book a consultation with Mr Lamb, do not hesitate to do so by visiting his Top Doctors profile today.