One of the most serious problems related to the treatment of some types of male reproductive cancers is the inability to have an erection after treatment. However, in the last 20 years, important advances have been made in treating these problems. It is still possible to enjoy a satisfying sex life after prostate cancer treatment. Most men can find solutions, either through methods that help with impotence or by discovering new ways to achieve intimacy with their partner.

There are several options available to men who are impotent and many strategies for approaching sex that can help, even before beginning cancer treatment. Before treatment begins, it is important that the patient be honest about pretreatment sexual functioning. The doctor may ask questions about frequency of sexual activity, detailed information about erections (including firmness and frequency), and current problems related to erections. A clear discussion of sexual functioning before treatment can help in identifying any problems that occur after treatment.

Before a patient makes any treatment choices to restore potency, it is important that he learn about all the treatment options first and involve the partner in decisions. Counseling may help when talking about sexuality is uncomfortable.

Treatment for sexual problems is not required; the patient and his partner may decide not to treat the problem after exploring all the issues. There is no reason that patients cannot enjoy a satisfying sex life in other ways than having intercourse. For many men and their partners, this is the best choice.

Counseling

Counseling may help the patient and his partner talk about sexual issues. Counseling can help reduce a man’s anxiety about sexual functioning and body image issues and help him deal with depression or sadness that results from a cancer diagnosis. Many people seek guidance from a mental health professional when cancer strikes.

When dealing with impotence, starting with the least invasive treatment method first and proceeding from there can make sense. For example, a man may wish first to try sildenafil (Viagra) and then the vacuum device, followed by injection therapy or implant if other methods prove unsatisfactory. Men also need to remember that even if a treatment restores potency, erections will probably not feel as they did before. A realistic goal is to achieve erections that are firm enough to allow penetration.

Medication

Three drugs can treat impotence successfully for many patients: sildenafil (viagra); tadalafil (Cialis); and vardenafil (Levitra).

Vacuum

Alternatively, vacuum erection devices (or vacuum pumps) are a noninvasive option that can be used immediately after a man recovers from radical prostate surgery. In this method, the man inserts the penis into a cylinder and activates a pump (by hand or by battery), which causes a vacuum that draws blood into the penis. After the penis becomes swollen and erect, an elastic ring is placed at the base of the penis to retain the blood. This is done each time an erection is desired, and each erection can last 20 to 30 minutes. (The elastic ring must be removed within 30 to 40 minutes to restore the normal flow of blood.)

This method tends to work best for men who still achieve some swelling in the penis with sexual stimulation. However, these devices may cost $75 to more than $200. Fortunately the cost is often covered at least partially by insurance and Medicare.

Some men find the elastic ring uncomfortable or have difficulty coordinating the process. Using the device can be built into the sexual experience, although some partners report discomfort caused by the disruption.

Injections

Injections of medication directly into the penis also can stimulate or help maintain erections. Most men actually report little discomfort from the procedure. The medication most often used is prostaglandin E1 (Caverject) or a combination of papaverine and phentolamine (Regitine). Combinations of all three drugs may be the best option for long-term use and decreased risk of side effects.

The erections last between 40 and 60 minutes and most men report no adverse side effects. A few men develop scar tissue at the site of the injection. Injections can be expensive, and are often not covered by insurance.

Penile implant

Also called a penile prosthesis, the implant can be surgically implanted into the penis to provide an erection rigid enough for sexual intercourse. Because an implant destroys the natural erection reflex, it is important to use this option only when erections are unlikely to improve. Complications of the procedure include mechanical failure of the device and infection (about 10 percent of men have complications).

The cost is usually between $15,000 and $20,000; insurance usually covers it when a medical problem has been documented.

Available devices include simple semirigid or malleable models that are inserted surgically, making the penis permanently semierect. The rod can be bent up into an erection or down into a relaxed position. The implant procedure is simple, and there is little risk of infection or other complications. Inflatable implants include a small reservoir, two cylinders on each side of the penis, and a pump that squirts fluid into the cylinders to create an erection. After sex, a valve releases the liquid back into the reservoir. There are several models of inflatable implants, which range from simple to more complex.

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