September Is Prostate Cancer Awareness Month.
In Parts 1 and 2 of this series on Prostate Cancer and how Physical Therapy can help patients post-prostatectomy, we focused mainly on the common symptom of urinary incontinence affecting up to 87% of patients post-prostatectomy. The other most common side effect that affects an equal number of patients (if not more) is sexual dysfunction, more specifically erectile dysfunction (Prota, 2012). Erectile dysfunction affects about 10% of the population at large but affects men post-prostatectomy at a higher rate due to the nerve trauma that can happen during surgery (Frey, 2014). The Cavernous nerves are the nerves that are responsible for erections and they are located very close to the prostate. During a radical prostatectomy, nerve injuries can occur even with nerve sparing techniques used by highly skilled surgeons due to high heat, nerve stretching, local inflammation, and also ischemia (decreased blood flow) during and after the surgery (Dorey, 2004).
The good news is that for some, nerve injuries can heal over time and thus improve sexual performance. While incontinence improves substantially in about 1 year post-prostatectomy, sexual performance takes closer to 2 years to improve. During this slow healing time it is important to do things that will improve your healing and increase your chances of returning to a satisfying level of sexual function.
- Physical Therapy
Physical Therapy is not only effective for Post-Prostatectomy Urinary Incontinence but is also an effective first line treatment for erectile dysfunction (Prota 2012, Gailbraith 2012). Physical Therapist led Pelvic Floor exercises (kegels) have been shown to improve penile rigidity and lead to resuming sexual activity and erectile function faster. Refer to Part 1 of this blog series for more information on kegels such as what position to do them in and how many to do a day. Physical Therapists use biofeedback and different cueing methods making it more effective to see a Physical Therapist in person than read instructions online or in a pamphlet. At Physical Therapy, we perform an in depth evaluation to assess your pelvic floor strength and tone. Some people will actually over train and tighten their pelvic floor muscles too much. A tight muscle is a weak muscle and we will adjust the dosage of your exercises accordingly as well as work on relaxation strategies to allow your pelvic floor muscles to relax using stretching and manual therapy techniques. We will also work together to build out your general exercise program and adjust any lifestyle habits that may be working against your pelvic floor and sexual function.
- Use it or lose it
Just like any other muscle or function in the human body, there is a certain truthfulness to the mantra ‘Use it or lose it’ when it comes to erectile function. There is a period of decreased sexual activity following a prostatectomy while the body recovers where there is little or no erectile function. During this period there is decreased blood flow and nerve signalling to the structures that help with erections. Studies have shown that improving oxygenation to the tissues supporting the penis can improve erectile function in the long-term. This means self-stimulation to encourage blood flow to the penis and surrounding tissues can be helpful during this early healing time, even when there aren’t erections yet. It also means taking your medicine as prescribed by your doctor. The most common medications that are prescribed for erectile function post-prostatectomy are PDE5 inhibitors (Sildenafil/Viagra, Tadalafil/Cialis, Vardenafil/Levitra). I’ve worked with plenty of patients who don’t want to take the medication as prescribed because it can be discouraging when the expected outcome (an erection), doesn’t happen. However, these medications work best when the Cavernous nerves are intact. As I outlined earlier, these nerves can have injuries during surgery and can take time to recover. This means that taking the medicine at 3 months post-op might not work so well, but taking the medicine 6 months or even a year post-operatively may have different results because of the healing of the nerves that has taken place (Segal, 2011). Don’t give up hope. Remember, it’s a slow healing process and can take a full 2 years to progress your sexual function.
- Lifestyle Changes
There are several lifestyle changes that you can make to improve your sexual function. Known factors that help with erectile function are decreasing your alcohol intake, maintaining a healthy amount of physical activity (150 minutes of moderate activity weekly), maintaining a healthy diet, and losing weight if you are overweight. One of the most important lifestyle changes to make is to quit smoking if you are a smoker. Long term smoking is associated with arterial restriction and nicotine is associated with decreased erectile function. This all adds up to the statistic that smokers are 1.5 times more likely to suffer erectile dysfunction than non-smokers. Smoking is also known to delay healing because of its hypoxic effects on tissue. Please try to cut back if you can to recover from your surgery, your cancer, and to regain sexual function (Dorey, 2001).
- Educating Yourself and Your Partner
It is important that you understand your diagnosis and also are able to manage your expectations following an impactful diagnosis and surgery. If you have a partner, it can be helpful for them to understand the impacts as well. Some research indicates that your sexual satisfaction is largely dependent on your partner’s satisfaction which means it’s very important to be on the same page. Here are ways you can seek further education and support:
- Join a support group. This website has wonderful links to all kinds of Prostate Cancer specific groups and information about why joining a support group can be a pivotal part of healing: https://www.pcf.org/patient-resources/patient-navigation/support-groups/
- Read up. Knowledge is power and reading about your diagnosis from various sources can be a helpful way to stay informed and feel more in control. My favorite book for Prostate Cancer survivors is “Prostate Recovery Map” by Craig Allingham. It was written by a physical therapist and discusses urinary incontinence and sexual dysfunction post-operatively. https://www.amazon.com/Prostate-Recovery-MAP-3rd-Edition/dp/098707668X/ref=sr_1_1?crid=WQW44ZEBC6B1&dchild=1&keywords=prostate+recovery+map&qid=1599849264&sprefix=MAP+prostate%2Caps%2C241&sr=8-1
- Seek counseling. If you are having a hard time with your current function and are not feeling optimistic about your future, seeing a therapist who specializes in sex therapy and life changing diagnoses can be a helpful way to learn different strategies to improve your mental well-being. Go to aasect.org or psychologytoday.com to find a practitioner near you.
Being cancer free should be a celebration. If you feel that post-surgically your life has been impacted to the point that it is affecting your relationships, your confidence, and your overall state of wellbeing, please connect with a Physical Therapist to address these issues and get help. If you are in the state of Oregon, please call Life’s Work PT at (503)295-2585 or send us a message at firstname.lastname@example.org. For more information on how to find a good physical therapist in your area read our blog ‘How to Find a Good PT’ and visit pelvicrehab.com.
Thank you for reading along and learning about how Physical Therapists can provide support in Prostate Cancer survivors’ return to function. While these posts focused specifically on post-prostatectomy recovery, all the listed tips are also helpful if you are experiencing bowel, bladder, or sexual dysfunction following other common treatments for Prostate Cancer including a TURP (transurethral resection of the prostate), radiation therapy and brachytherapy, a partial prostatectomy, hormone therapy, or watchful waiting. Please reach out if you have questions or are looking for support.
Rudolph E, Boffard C, Raath C. Pelvic floor physical therapy for erectile dysfunction-fact or fallacy? J Sex Med. 2017;14(6):765-766.
Prota C, Gomes CM, Ribeiro LHS, et al. Early postoperative pelvic-floor biofeedback improves erectile function in men undergoing radical prostatectomy: a prospective, randomized, controlled trial. Int J Impot Res. 2012;24:174.
Frey AU, Sønksen J, Fode M. Neglected side effects after radical prostatectomy: a systematic review. J Sex Med. 2014;11(2):374-385.
Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J Gen Pract. 2004;54(508):819-825.
Galbraith ME, Hays L, Tanner T. What men say about surviving prostate cancer: complexities represented in a decade of comments. Clin J Oncol Nurs. 2012;16(1):65-72. doi:10.1188/12.CJON.65-72
Segal R, Burnett AL. Erectile preservation following radical prostatectomy. Ther Adv Urol. 2011;3(1):35-46. doi:10.1177/1756287211400492
Dorey G. Is smoking a cause of erectile dysfunction? A literature review. Br J Nurs. 2001;10(7):455-465. doi:10.12968/bjon.2001.10.7.5331