This page was reviewed under our medical and editorial policy by
Maurie Markman, MD, President, Medicine & Science
This page was reviewed on September 12, 2022.
A radical prostatectomy is a type of prostate surgery that removes the prostate gland to treat prostate cancer. This procedure may often causes a variety of side effects. One of the most challenging is erectile dysfunction (ED), which makes it difficult to maintain an erection.
Nerves around the prostate may be affected during surgery and lead to erectile dysfunction. The prostate is a small gland in the pelvis about the size of a walnut that sits between the bladder and rectum at the base of the penis. During a radical prostatectomy, the primary surgery for prostate cancer, the whole prostate gland and some of the surrounding tissue are removed.
On either side of the prostate are bundles of nerves necessary for an erection. These nerves pass close to the prostate gland, and if one or both are removed or damaged during the surgery, it can lead to erectile dysfunction. If possible, doctors will perform a nerve-sparing surgery to preserve the penis’ erectile function. However, the nerves may need to be removed if the surgeon finds cancer nearby.
If the surgeon leaves one or both nerves in place and undamaged, spontaneous erections remain possible depending on other factors, including age, general health and whether the patient experienced erectile dysfunction before the surgery.
The patient may experience short-term dysfunction if the nerves and blood vessels were damaged during surgery. As swelling recedes and the area heals, spontaneous erections may return on their own.
If loss of function lasts longer than two years, it's likely long-term erectile dysfunction. ED lasting multiple years is likely permanent and may result from the surgeon removing one or both nerve bundles during surgery.
Erectile dysfunction affects almost all men within the first months of a prostatectomy. Most, though, will experience significant improvement within a year or so. However, for some men, it may take up to two years to fully recover and have regular erections.
The risk of ED after a prostatectomy increases with age. Men younger than 50 are most likely to avoid ED or recover more quickly.
When possible, the surgeon will perform a nerve-sparing prostatectomy to spare the nerves that pass close to the prostate. Men who receive nerve-sparing surgery may still experience ED after surgery, but they’re more likely to recover erectile function within two years.
Penile rehabilitation is designed to preserve penile blood vessels and tissues so that they remain healthy and active. The therapy has the patient purposefully maintain an erection two to three times each week, often starting within a few weeks after surgery. Your surgeon may also prescribe a low-dose ED medication, designed to increase blood flow to the penis by relaxing the blood vessels.
The ED medication may take a while to work as the nerves recover, even in men who have undergone nerve-sparing surgery. Men with more severe nerve damage may not respond to the medication, while those with heart problems or who take alpha-blockers do not typically qualify for the medication.
If ED medications don’t work, other options may help, including:
Penile injections: These medications, injected into the shaft of the penis using a thin needle, are considered the most reliable treatment for ED, according to the American Cancer Society. Your doctor will show you how to give yourself these injections when you want to have an erection.
Urethral pellets: One pellet is placed into the opening of the penis, where it melts, leading to an erection. However, this approach is less reliable than injections.
A vacuum erection device: This is a plastic cylinder placed over the penis and attached to a suction pump. The pump creates a vacuum that forces blood into the penis to create an erection. Once the penis is erect, a special elastic band is placed around the base of the penis to hold in the blood and maintain the erection. The band can be left in place for up to 30 minutes.
If other treatments have not helped, three surgical implant procedures are available. There are two inflatable options and one semi-rigid option:
Inflatable implants are the most common choice of penile implant. The advantage of an inflatable implant is that the penis is flaccid (soft) when not needed for sexual activity. A semi-rigid implant means the penis is slightly rigid at all times, so it can be concealed by bending it toward your body or be used for sexual intercourse by bending it away from your body.
At City of Hope, Boston Scientific technology is used for surgical penile implants.
For the surgery:
With a penile implant, you can maintain an erection as long as you wish—you control the implant and can activate and deactivate it as you want.
Your doctor will usually suggest waiting to have sex until four to six weeks after surgery.
Pain and soreness are common side effects as you heal. Surgical implants may also have risks, including:
Fear over ED can be enough to actually cause it, even when there’s enough nerve and blood supply to the penis. This is called psychological ED. Men who have physical ED may have psychological impacts, such as anxiety and depression, from the effects of ED on their sex life and self-esteem.
Psychosocial counseling with a mental health provider may be helpful, regardless of what’s causing the ED. Counseling can also help you cope with sexual relationship challenges you may be experiencing.