Erections After Prostate Cancer Surgery: What Is Realistic and What Helps

Few men find this easy to ask about, yet it is one of the most important questions to settle before prostate cancer surgery. The honest answer is that erections are almost always weaker after the operation, many men recover a good part of their function over time, and some need treatment to help. Knowing this in advance makes the recovery far less frightening.

Key points

• Erections are weaker or absent at first in almost every man, even when the nerves are spared.
• Recovery is slow. It is judged over one to two years, not weeks.
• The best predictors are how well you had erections before surgery, your age, and whether the nerves could be spared.
• Treatments exist for those who need them, and partners are part of the plan.
• Orgasm is still possible, but you will no longer produce semen.

Why does surgery affect erections?

Two delicate bundles of nerves run along either side of the prostate. They help bring blood into the penis. During surgery, these nerves can be bruised or stretched even when the surgeon takes great care, and when the cancer lies close to them, one or both may have to be removed to take the cancer out safely.

What does nerve-sparing mean?

In a nerve-sparing operation, the surgeon separates the nerve bundles from the prostate and leaves them in place. Whether this is advisable depends on the cancer, not on preference:

• Your biopsy results and MRI show where the cancer lies and how likely it is to reach the edge of the prostate.
• If the cancer is close to a nerve bundle, that side is often not spared, because removing the cancer completely comes first.
• Some men can have the nerves spared on one side, and some on both.

Sparing the nerves gives them the best chance. It does not guarantee erections.

A realistic timeline

• First weeks to months: the nerves are recovering from the shock of surgery. Erections are usually absent or weak.
• Six to eighteen months: most of the recovery happens. Some men see improvements for up to two years.
• After about two years: function is usually close to what it will be.

Men who were younger, had firm erections before surgery, and had both nerve bundles spared do best. Men who were already having difficulty, or who could not have the nerves spared, are less likely to return to their earlier function without help. Your surgeon can describe what is likely for you, which is more useful than average figures.

What helps recovery

• Tablets (PDE5 inhibitors such as sildenafil or tadalafil): they help many men once the nerves have partly recovered. Whether early, regular use improves the chance of natural recovery is still debated. Your doctor will advise on a plan. They must not be taken with nitrate medicines, and heart conditions need discussion first.
• Vacuum devices: a simple device that draws blood into the penis. It can help keep the tissue healthy and is useful when tablets are not enough.
• Injections into the penis: effective when tablets fail, taught and supervised by your doctor.
• Penile implant: an option for men who do not recover and want a lasting solution.
• Counselling: for you and your partner. Worry and avoidance make recovery harder, and many couples find support useful.

Other changes to expect

• Dry orgasm: the prostate and seminal vesicles are removed, so no semen is produced. Orgasm itself remains possible.
• Fertility: you can no longer father a child naturally. If this matters to you, talk about sperm storage before surgery.
• Leakage with orgasm: some men leak a little urine at climax. It often improves.
• Penile length: some men notice that the penis feels a little shorter. Early recovery of erections may help.

How radiation compares

Radiation does not give a free pass. Erections after radiation usually decline more slowly over a few years, and hormone treatment given with it can also reduce desire and erections. Neither treatment is automatically better for sexual function. The choice should rest on the cancer and on what matters most to you.

Questions to ask your surgeon

• Can the nerves be spared on one side, both sides or neither, based on my MRI and biopsy?
• What are the chances of erections adequate for intercourse at one and two years in someone like me?
• Which medicines or devices do you suggest, and when should I start?
• Is there a physician or counsellor you work with for this?
• Should I store sperm before surgery?

For the full picture of treatment choices, see prostate cancer by stage, or read about robotic prostatectomy versus radiation. You can also request a consultation.

This article is general information. It does not replace advice from your own doctor, who knows your reports and your health.