A radical prostatectomy is a surgical procedure to remove the prostate gland, typically performed to treat localized prostate cancer. This surgery often raises concerns about its impact on sexual health, particularly regarding sexual desire (libido) and physical function. While the surgery successfully removes the gland, it can introduce significant changes. This article clarifies how prostate removal relates to sexual drive and how patients can pursue a healthy sexual life after the procedure.
Understanding Libido Versus Erectile Function
It is helpful to distinguish between libido and erectile function when discussing sexual changes after a prostatectomy. Libido refers to sexual desire, or the drive and motivation for sexual activity, primarily influenced by testosterone and psychological factors. In contrast, erectile function is the physical ability to achieve and maintain an erection sufficient for sexual activity, relying on neurological signals and vascular health.
A standard radical prostatectomy removes the prostate but preserves the testicles, generally avoiding a direct, permanent drop in testosterone. Therefore, the hormonal basis for sexual desire often remains intact, and the surgery itself does not typically eliminate libido. However, the procedure frequently affects the physical mechanism of an erection. This physical compromise can indirectly impact desire due to frustration or anxiety.
The Direct Physical Effects of Prostate Removal
The primary reason for a change in sexual function following prostate removal is the close anatomical relationship between the prostate and the neurovascular bundles. These bundles, situated on either side of the prostate, contain the cavernous nerves, which transmit the signals necessary to initiate and maintain an erection. During the radical prostatectomy, these nerves must be delicately separated from the prostate capsule, or they may be removed entirely if cancer is found nearby.
Separating the nerves can cause trauma, stretching, or bruising, leading to a temporary state known as neuropraxia. This stunning of the nerves results in an immediate loss of erectile function for most men, even those who undergo a nerve-sparing procedure. The degree of nerve preservation—bilateral, unilateral, or non-nerve-sparing—is the strongest predictor of long-term functional recovery. Patients who receive a bilateral nerve-sparing procedure typically recover better function.
The small arteries supplying blood to the penis are also interrupted when the prostate is removed. This vascular change, combined with nerve injury, can lead to a lack of oxygenation in the penile tissue, potentially causing fibrosis or scar tissue formation over time. This process is implicated in the small reduction in penile length or girth that some men report. Recovery of nerve function is a slow, regenerative process that can take up to 18 to 24 months to reach its maximum potential.
Non-Physical Influences on Desire Post-Surgery
A man’s sexual desire can still decline due to non-physical influences after surgery, even though libido is often preserved hormonally. The immediate inability to achieve an erection often leads to performance anxiety, causing men to avoid sexual situations and decreasing sexual interest. Psychological stress associated with a cancer diagnosis, surgery, and recovery can contribute to anxiety and depression, both of which reduce libido.
Body image concerns may also arise, particularly related to the loss of ejaculatory fluid, known as dry orgasm, which is a universal consequence of prostate removal. Although the sensation of orgasm is usually preserved, the absence of visible ejaculation can be psychologically significant for some men and their partners. Additionally, fatigue from surgery can deplete energy levels, making the initiation of sexual activity less appealing.
If the prostatectomy is combined with Androgen Deprivation Therapy (ADT), this hormonal treatment directly lowers testosterone, causing a significant drop in libido. For men who undergo a standalone radical prostatectomy, any reduction in desire is usually a secondary effect of physical changes and the emotional impact of the cancer experience. Addressing these psychological and emotional factors is often as important as treating the physical dysfunction to restore sexual health.
Strategies for Restoring Sexual Health
A proactive approach to recovering sexual function, known as penile rehabilitation, is widely recommended and should begin as soon as medically safe, often within a few weeks after catheter removal. The goal of rehabilitation is to encourage blood flow and oxygenation to the penile tissues. This helps prevent scar tissue formation and promotes the recovery of the stunned nerves while awaiting nerve regeneration.
Oral medications, specifically Phosphodiesterase Type 5 (PDE5) inhibitors, are the most common starting point in a rehabilitation program. These medications, which include sildenafil and tadalafil, work by enhancing nitric oxide effects, relaxing smooth muscle tissue, and increasing blood flow to the penis. They are used both on-demand for sexual activity and often at a lower daily dose to encourage tissue health.
Other Treatment Options
If oral medications prove insufficient, other effective options are available. These include the use of a vacuum erection device (VED) or intracavernosal injections. A VED creates a vacuum to draw blood into the penis, while injections deliver a vasoactive drug directly to the penile tissue to induce an erection. For men with severe, long-term dysfunction, a penile implant or prosthesis is a highly reliable surgical option that provides a consistent, mechanically-induced erection. Counseling, either individual or couples therapy, can also be invaluable in addressing the psychological distress and relationship strain that often accompany these physical changes.