Dear Dr G,

I AM emailing in desperation, as a middle-aged man recently diagnosed with prostate cancer.

In view of my age, the specialist persuaded me to undergo the robotic operation.

The surgeon counselled me on the potential complications of the operation.

Since the cancer was stage one, the doctor also mentioned various other options including external beam radiation and active monitoring.

He also mentioned that as the tumour is low grade in nature, I have some time to consider my options.

The most obvious consideration I am taking into account is my erection, as I have a young wife.

Although my wife assured me cancer elimination is a priority, whatever decision I make has to take into account our sexual activities.

I would like to put Dr G on the spot for some opinion.

First of all, why are prostate cancer cases on the rise these days?

Can you tell me what is the correlation between prostate cancer and erectile dysfunction?

What are the impacts of prostate cancer treatment on erectile functions?

What is the best way to preserve erectile functions before interventions?

I also heard about penile rehabilitation. What exactly is that and how do I do it?

Please help.

Yours truly,

Rehabilitate Romeo

The prostate is a gland located just below the bladder, closely surrounded by nerves and blood vessels vital for erectile function. Public awareness of prostate cancer and the utilisation of the Prostate Specific Antigen (PSA) for screening have become more prevalent in the last two decades.

Media coverage of prominent figures affected by prostate cancer, such as the Singapore Prime Minister, has also encouraged men to present younger with early disease that is suitable for radical intervention. Treatments for prostate cancer, though lifesaving, can disrupt these delicate structures.

Radical prostatectomy can potentially cause nerve damage during surgery, which is a major cause of post-operative erectile dysfunction (ED). External beam radiotherapy or brachytherapy can also damage the blood vessels and nerves involved in erection. Lastly, Androgen Deprivation Therapy (ADT), which lowers testosterone, reduces libido and erectile capacity, leading to sexual dysfunction even in the absence of structural nerve damage.

Between 30–80% of men after radical prostatectomy experience ED, depending on surgical technique, patient age, and baseline function. Radiotherapy can also result in up to 50% of men developing ED within 5 years post-treatment. Nearly all men experience reduced libido and erectile function within months of hormonal therapy.

The improvement of medical technology and surgical techniques in recent years has evolved to give clinicians an advantage in identifying and protecting the neurovascular bundle responsible for the erectile and sexual functions of men. Despite the introduction of such “nerve-sparing” radical prostatectomy, the rate of erectile dysfunction can still be at best 14% and in some series as high as 100% in men after the operation.

Of course, the post-operative erectile function recovery is quite variable. Factors that may influence the return of sexual function include age, baseline sexual ability before the operation, and preoperative state of health.

Clearly, men who had problems such as diabetes, smoking, hypertension, and dyslipidemia would expect poorer outcomes in sexual performance after the operation. Although the terminology of “rehabilitating” the penis from “wrongdoing” is somewhat misleading, the notion of penile rehabilitation is essentially to prevent irreversible structural and functional damage.

This is achieved by forcefully enhancing the circulation and hence oxygenation of the tissues to facilitate recovery from the surgical insults. It is generally agreed that the first four weeks following the operation are non-beneficial for rehabilitating the penis. It is also well recognised that the window of responsiveness ranges from one to twenty-four months.

Apart from the recovery of erectile rigidity, some studies have even demonstrated benefits of sensory recovery and penile length that had been compromised after cancer operations. The regime utilised to rehabilitate the penis is very variable. This can range from daily doses of medications such as the blue pills to daily use of penile vacuum pumps and the injections of medications.

Besides, data is also emerging on the use of shock waves aiming to generate new vasculature of the penis to restore functions. Although many trials have demonstrated success, the exact dosage, interval of rehabilitation, and the long-term benefits of penile rehabilitation are generally unknown.

The detection of prostate cancer at early stages often ensures higher chances of oncological outcomes with radical surgery, especially in younger men with aggressive disease.

Undoubtedly, the trauma of surgery itself often leaves men with adversities such as erectile dysfunction and incontinence. Although the concept of penile rehabilitation may be in its early stages of research, it offers potential hope for men to regain functioning manhood after a hard time dealing with surgery.