ED - in my case in particular

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Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25354
   Posted 11/23/2008 9:24 AM (GMT -7)   
Hello one and all,
 
I know I might be getting the cart before the horse, but can't seem to get an answer on my own  As you know, still recovering from my open RP sugery on 11-14, still the dr in the morning to have staples out, and hopefully go over pathlology report.
 
Since it is a fact, that he removed both nerve bundles completely without any effort save some or any of the nerves, where does that leave someone like me in the ED department?
 
Do I assume that there is no way no chance I could ever have a natural errection again?  are my days of coming up at "bat" on my own over with?  Will ED drugs work with someone with no nerve bundles?
 
I don't know what is going on there, so I don't even know what expectations to have with ED, especially since I never experienced it before to compare to.  Or are there methods and treatments available to guys in my boat that I am just not aware of?
 
Looking for blunt honest opinions based on facts and your own life experiences dealing with this subject.  My dr will give me a standard generic answer, but I am looking for reality.
 
Thanks and best wishes to one and all
 
David in SC
Age 56, 56 at DX
 
PSA 2007 5.8
PSA 7-2008 12.3
PSA 9-2008 14.9
 
Biopsy 9-2008 Positive
7 of 7 cores positive, ranging from 40 - 90%
2 tumours noted, Gleason 4+3 and 3+4
Periunual Invasion noted
Additonal High Grade PIN noted
 
Open RP surgery completed on Friday, November 14, 2008 at
St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon,
Nerve bundles not able to be spared, awaiting pathology report, Cath scheduled to be removed on 12-15-2008,


James C.
Veteran Member


Date Joined Aug 2007
Total Posts : 4462
   Posted 11/23/2008 1:37 PM (GMT -7)   
David, here's some generalized answers. A through search using keywords 'non-nerve sparing and ed' will get you some further details.

The short answer, and blunt honest opinion, is the removal of both nerve bundles will not allow for regaining natural erection function in the large majority of cases. That's the basic answer. There's also some qualifiers. Some studies have shown that nerve regrowth can occur, at a slow rate and over a long period of time. The danger is that the penis will atrophy from non-use in the meantime. That's why penile rehab, in the form of pumps, ed drugs, and injections are used to keep the blood flowing and the tissues expanded regularly. Even then, the nerve regeneration may never happen.

If it never happens, then you are left with 3 alternatives with current scientific advances. First, ed drugs such as Viagra and the others will have no effect, as they work on the nerves that have been removed. That said, the use of injections will get the job done, as it affects tissue and valves, and not nerves. So the current 3 type injection drugs, in some form, will likely give you an erection capable of starting and sustaining intercourse. It's no guarantee, but the majority of injection users have adequate response to it. That's a whole different area to study and discuss, which we won't do in this short answer.

Penile pumps are also an option. Successful use of them is high, but they can be problematic, some men can't manage to use them to get and keep a full erection capable of intercourse.

The third option that is available is the penile implant. They are becoming more common now, and there's several guys here who have had them and can better tell you their stories concerning them.

There's also a couple, at least, of guys here who have had non-nerve sparing surgery and can tell you what they experienced, as far as ed is concerned.

As you can find out shortly, when the catheter is removed and things heal a little, is you are capable of an orgasm in a flaccid state. Erections and orgasms aren't tied together. That's why the options of the pump, injections or implant is still available for you. Good manual stimulation with hand, oral or vibrator will give you an orgasm, in the large majority of men. Your sex life, married or not, isn't gone forever, just the circumstances and how you can adapt to it is different, but still doable... Don't dispair, there's several different ways to deal with the situation.

Here's a cut and paste from an article I found while researching and answer for you:

Radical prostatectomy is an operation that completely removes the prostate and the surrounding tissue. Prostate surgery can be:

* Nerve-sparing (keeping intact the nerves which lead to the erection chambers and provide the stimulation for erection)
* Non nerve-sparing (not preserving these nerves)

Even if the majority of the nerves are preserved in the surgery, temporary ED is common.

When the nerve-sparing technique is used, particularly bilateral nerve-sparing, permanent ED is less common than with non-nerve sparing surgery and recovery often occurs within the first year or two following the procedure.

ED from a non-nerve-sparing procedure is common and recovery of erectile function after a non-nerve-sparing technique is unlikely though not impossible.

Erectile function following surgery depends on an individual patient's age, anatomy, extent of cancer and preoperative sexual function.5 Most studies report that 50-80% of men who have a radical prostatectomy have some degree of ED for the first year after surgery even if the surgeon is able to spare all or part of the nerves.6 Even in bilateral nerve-sparing surgery, return of erectile function may take up to 12-24 months. Eventually though, erections adequate for vaginal penetration return in 40-80% of men. Unilateral nerve sparing technique produces results that are intermediate between bilateral and non-nerve sparing surgery. Also, duration of time from the surgery to treatment for ED can play a role in the effectiveness of different therapeutic options.

Other sexual complications following radical prostatectomy include the absence of ejaculation or dry orgasm (orgasm without discharge of semen) in all cases, and loss of penile length in some men.

Do men respond to PDE5 inhibitors after having prostate surgery?

The first line of treatment for ED following prostate surgery is oral medications, such as phosphodiesterase-5 inhibitors (PDE5i) - sildenafil (Viagra®), vardenafil (Levitra®) and tadalafil (Cialis®). about 70% of men respond in some fashion to oral drug therapy in the post-operative setting.

Since these drugs are designed to increase blood flow to the penis upon sexual stimulation, they require intact nerves and arteries. Men receiving the nerve-sparing prostatectomy generally have a better response.

Does self-injection therapy used after prostate surgery help erectile function?

Penile self-injections provide very effective treatment of ED after prostate cancer surgery. Some studies report that penile self-injections can achieve a 95% success rate. Self-injection therapy is usually used after trying oral medications because of the convenience of oral therapy.

The role of oral, self-injection, intraurethral and vacuum therapies after treatment for prostate cancer:

For men who have had surgical or radiation treatment for prostate cancer, evidence suggests that oral, self-injection treatments started soon after treatment may improve the chances for later recovery of natural spontaneous erections. Oral therapy can be used with any of the three PDE5 inhibitor drugs. There are three vasodilator drugs used for self-injection therapy:

* papaverine,
* phentolamine and
* Alprostadil, a type of prostaglandin E 1.

Injection of Alprostadil may cause penile pain. If this occurs, lowering the dose of Alprostadil and/or mixing Alprostadil with papaverine and phentolamine may reduce or eliminate the pain. The prescription drug called MUSE is used in intraurethral therapy.

Penile implants are a third line therapy, with a success rate of about 80-90%. They are the single most reliable form of treatment for erectile dysfunction, and they provide an excellent solution to the problem of erectile dysfunction.
James C.
Co-Moderator- Prostate Cancer Forum
Age 61
4/19/07 PSA 7.6, referred to Urologist, recheck 6.7
7/11/07 Biopsy- 16 core samples, size of gland around 76 cc. Staging pT2c
7/17/07 Path report: 3 of 16 PCa, 5% involved, left lobe , GS 3/3:6.
9/24/07 (open) Retropubic Radical Prostatectomy performed
9/26/07 Post-op Path Report: GS 3+3=6 Staging pT2c, 110gms, margins clear
Present- 1 year: ED- Viagra, pump continues, no response- Trimix .10ml x 2 weekly continues
Post Surgery PSA's: 3 mts-.04, 6 mts.-.04, 9 mts.-.04, 1 Year-.02.


Piano
Veteran Member


Date Joined Apr 2008
Total Posts : 847
   Posted 11/23/2008 2:48 PM (GMT -7)   

I agree with James -- it is unlikely that you will recover natural function. But a couple of guys who post here have recovered, so nerves can grow back even if completely severed. Based on my reading, I put the chances at about 5%, and don't expect anything before 18 months.

If you were getting good erections before surgery, chances are very good that injections will work well for you. But there is a learning curve while you master the techniques, and find the best dose -- so expect to have some early failures. 

Likewise the pump will probably work for you too, but again you will need to experiment, with constriction rings in particular. In my view, the pump is not as good as injections, as you have a "hinge effect" -- but still a lot better than nothing at all.
 
I haven't tried Viagra and the like, as I believe they need at least some nerves.
 
It's not all doom and gloom. I am now 8 months from non-nerve-sparing surgery. Still no real sign of natural erections -- just a few little hints. But I find injections to be now 100% reliable, and sex is every bit as good as before, if not better -- two-hour erections and no premature ejaculation!
Age 63. Other than cancer, in good health; BMI 20
Pre-op: No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4 of 12 cores
7 March 2008, RRP, non nerve sparing
Two nights in hospital; catheter and staples out after 7 days
Continent, no pads needed from the get-go
Post Op: Stage pT2 M- N-; clear margins and lymph nodes; Gleason 4+4=8; prostate weight: 37gm
6-week and 7-month PSAs: 0
Bimix injections working well 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25354
   Posted 11/23/2008 4:15 PM (GMT -7)   
Thanks Piano and James, that's the kind of general info I am/was looking for, I am hoping at some future point that my doctor will spend some quality time with me on the ED subject. I kind of figured it would be more along the lines that you both discussed here. Being my 4th bout of cancer, I am still more interested in this PC being killed off or so slowed down that it won't "get" me in this lifetime. On the sexual side, I would say I am disapointed, but not angry or hurt, being in a good ltr with my wife will really help with this subject Next April will make 35 years Thanks for info and advice.

David in SC
Age 56, 56 at DX
 
PSA 2007 5.8
PSA 7-2008 12.3
PSA 9-2008 14.9
 
Biopsy 9-2008 Positive
7 of 7 cores positive, ranging from 40 - 90%
2 tumours noted, Gleason 4+3 and 3+4
Periunual Invasion noted
Additonal High Grade PIN noted
 
Open RP surgery completed on Friday, November 14, 2008 at
St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon,
Nerve bundles not able to be spared, awaiting pathology report, Cath scheduled to be removed on 12-15-2008,

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