BPH

Sex and the Prostate: Overcoming Erectile Dysfunction

According to many studies, erectile dysfunction and prostate health are strongly linked. Lower urinary tract symptoms (LUTS) are very prevalent in men with sexual dysfunction.

However, these men have something in common, too. Most of them are aging males, and we know that benign prostate enlargement is more common in older men.

Moreover, the relationship between the prostate and erectile dysfunction is even stronger. In cases of prostate cancer, certain surgeries and medications may trigger erectile dysfunction. Not all patients experience ED after prostate cancer treatment, but there’s a relevant association.

This article will be about benign prostatic hyperplasia (BPH), prostate cancer, and erectile dysfunction. Is it possible to overcome this problem after prostate treatment?

BPH and erectile function

As noted above, BPH and ED are apparently linked together. We can see a more profound association after reporting the results of various studies.

We can highlight the EDEM study, which was performed in 2476 Spanish men. Their ages ranged from 25 to 70 years old, and the researchers evaluated erectile dysfunction and other health problems.

Among many other health issues, ED’s most decisive risk factor was LUTS. In other words, men with urinary retention and other problems due to BPH had a higher chance of suffering from ED (1). 

Many other studies confirmed this association already. The link is more significant than diabetes and other ailments. Other sexual function problems, such as ejaculatory dysfunction, are also associated with LUTS. Patients with BPH are at a higher risk of having a reduced volume of ejaculate or feeling burning after ejaculation (2).

When we take a closer look, there are different types and causes of lower urinary tract symptoms. However, the association is higher in obstructive LUTS (as in BPH) (3).

Besides affecting the same age range, BPH and erectile dysfunction share other possible mechanisms. This is probably why BPH causes erectile dysfunction (4):

A dysfunction in the nitric oxide chemistry

One of the proposed mechanisms is explained by nitric oxide. This substance is an important vasodilator, which means it increases the blood flow. This substance is produced by an enzyme called nitric oxide synthase.

It is fundamental to relax the corpus cavernosum of the penis and promote erection. But nitric oxide is also found in the prostate tissue and the human bladder. In BPH, there are reduced levels of nitric oxide in the transition zone of the prostate. Consequently, the prostatic tone is increased, the muscle won’t relax easily, and it improves BPH symptoms.

This theory suggests that having insufficient nitric oxide synthase causes proliferation in smooth muscle cells. This proliferation and increase in muscle tone make erection difficult in the penis. And, in the prostate, it contributes with BPH to push the prostate and cause lower urinary tract symptoms.

Autonomic hyperactivity

There are two main branches of the nervous system. One of them is the autonomic nervous system, which controls the heartbeat and other body functions. Studies show that autonomic nerves play a critical role in prostate growth. When this autonomic activity increases in aging rats, BPH and erectile dysfunction start to appear.

But in humans, there is also a significant association. People with a hyperactive autonomic nervous system frequently have LUTS and BPH. Some studies even show that more hyperactivity means a higher BPH Impact Index score.

Sometimes, even an increased prostate volume. Similarly, in the penis, a sympathetic tone is an automatic erection inhibitor. It contracts the muscles in the corpus cavernosum and reduces the blood flow. Thus, they cannot be filled with blood, and the erection does not happen.

A dysfunction in calcium concentration mechanisms

Calcium plays a vital role in muscle contraction. And even though calcium levels are the same, the activity of a calcium-sensing mechanism is apparently disrupted in BPH and ED.

This mechanism is known as the Rho-kinase pathway, and it makes the cell more sensitive to calcium. When activated, this pathway upregulates muscle tone in the prostate. It does the same thing in the human penis. So, an inhibitor of this pathway is required to relax the smooth muscle and promote erection.

The proposed mechanism is that there’s not enough of such an inhibitor. Thus, smooth muscle is susceptible to calcium. The muscle tone increases, and both ED and LUTS get worse.

Atherosclerosis in the pelvis

Another possibility that may link together ED and LUTS is atherosclerosis. This is also more common as we age and may be associated with the development of BPH.

For example, chronic ischemia of the prostate leads to fibrosis. The same happens in the corpus cavernosum if we talk about the penile tissue. This is apparently because it increases the production of a cytokine known as TGF-b1.

Moreover, atherosclerosis in the pelvis may also impair nitric oxide production and the relaxation of the prostate. This problem would increase the muscle tone and reduce the elasticity of the gland.

As you can see, the association between erectile dysfunction and BPH is mostly established by LUTS. However, these are obstructive LUTS, which are commonly associated with BPH.

Post-surgery side effects

Many patients with BPH and selective patients with prostate cancer may require prostate surgery. Radical prostatectomy is sometimes the only way to deal with BPH and prostate cancer.

For many years in the past, prostate surgery caused severe complications. They included:

This erectile dysfunction was common in almost all men who had this procedure done. Thus, in general, many authors and people challenged the use of prostate surgery to manage these conditions.

However, around four decades ago, new anatomical discoveries revealed a new way to do the same surgery. New procedures after this understanding were published reduced the incidence of complications.

In this type of conservative surgery, physical capacity is much better, urinary continence returns to normal in 95% of patients, and the erectile function can be recovered in 2 years or less.

Still, patients usually feel their erectile function recovery is lagging behind other types of recovery. Most of them are very concerned about this issue. Sometimes they even become skeptical that they will return to normal potency. In many cases, when they do recover erections, these may not be as potent as they used to be.

But why is it that erectile dysfunction follows radical prostatectomy? It is because, in previous non-conservative surgeries, the cavernous nerves were severed. These are important nerves of the autonomic nervous system. They run along the lateral borders of the prostate and the rectum and then reach the penis. New surgery is always aimed at leaving these nerves intact. Still, there are conditions where they cannot be spared, as local cancer cases spread.

After nerve-sparing radical prostatectomy, the erectile function can now be recovered by up to 85% of patients. However, these numbers belong to certain institutions and may differ according to gender, relationship status, comorbidities, and other demographic differences.

But in some cases, even a nerve-sparing radical prostatectomy with immaculate technique may cause complications. When this is the case, they are usually erectile dysfunction and urinary incontinence. But why is erectile dysfunction still happening after sparing those nerves? This is probably a result of a nerve inflammation or stretching during surgery, which is required to retract the prostate.

Another possibility is thermal damage to the nerve when cauterization is used. Or maybe there was a surgical bleeding and an ischemic injury to the nerve tissue.

With the recent addition of laparoscopy and robotic surgery, the chance of complications is further reduced. There are more success stories than bad experiences, and prostate surgery is still an accepted and appropriate treatment for some cases of prostate cancer and BPH (5).

Medication side effects

Other treatments for prostate cancer may cause similar effects on the prostate gland. For example, we can describe the following:

Radiotherapy and brachytherapy: Besides radical prostatectomy, radiotherapy and brachytherapy are both alternative treatments for prostate cancer. They both use radioactive beams, but the former is performed from the outside, and the latter is an internal type of radiotherapy.

In these cases, erectile dysfunction is also possible, but this time it is due to vascular changes in the penile structures. According to studies, even in patients with apparently normal erections after radiotherapy, Doppler evaluations are abnormal. In other words, their blood flow is compromised. Other causes are also possible, including impairment in the nitric oxide synthase system.

In some cases, patients retain their erectile function. But they still have other sexual dysfunctions, such as lack of ejaculation, decreased libido, or decreased orgasm. Indeed, the number of patients with erectile dysfunction in this group is lower than those undergoing surgery (6).

Androgen deprivation therapy: Testosterone and DHT are both androgens associated with prostate cancer. Sometimes they need to be targeted as a part of prostate cancer treatment. Naturally, by countering testosterone action, this type of therapy results in sexual side effects. These are similar to having low testosterone levels. They include erectile dysfunction, but also loss of libido and hot flashes (7).

Chemotherapy: It is sometimes used in combination with androgen deprivation therapy. Similar to chemotherapy in other types of cancer, these substances cause a wide array of side effects. One of them is certainly erectile dysfunction.

Cryotherapy: This is another treatment option for prostate cancer. It consists of killing localized cancer by freezing the area. The incidence of erectile dysfunction after cryotherapy is not very high. There’s still a possibility of having erectile problems, though. But with the development of new cryotherapy methods and technologies, the incidence of ED is reducing (8).

Similarly, other treatments for prostate health may also impair sexual function. For example, some BPH medications may compromise the duration of an erection.

Others cause decreased ejaculation. For example, alpha-blockers like tamsulosin, doxazosin, and terazosin have a risk of sexual side effects. However, they are very mild compared to finasteride, which is an anti-testosterone treatment (9).

ED treatments and BPH

There’s another interesting fact about BPH and erectile function, but this time it is not bad news. Quite the opposite, because there’s one type of treatment that may tackle both conditions simultaneously.

The so-popular Viagra medication for ED can be useful for BPH, as well. The chemical name is sildenafil, and other drugs of the same family have a similar effect. For example, tadalafil, sold as Cialis, and vardenafil, sold as Levitra. According to scientific evidence, they are likely useful for an enlarged prostate, too.

These drugs are not to be used for BPH, though. They are not a part of the current treatment, but studies show promising results. If this continues to be so, it may shortly be included as a part of BPH treatment, too.

What does Viagra do in favor of the prostate? If you read the above, you should already know that relaxing the prostate’s smooth muscle and the penis is a good thing.

By achieving this relaxation, passing urine becomes easier, and we can restore the erectile function. By boosting cGMP, Viagra achieves this relaxation, not only in the penis but also in the prostate. So, Viagra won’t reduce the prostate volume. But it can surely reduce enlarged prostate symptoms (10).

Treating ED

It is possible to treat or manage erectile dysfunction, even after transurethral resection or prostate cancer treatment. This is actually a problem with major importance for patients, especially those with a sexually active life before surgery. There are two types of options to treat erectile dysfunction: pharmacological and non-pharmacological.

Pharmacological therapy for erectile dysfunction is mainly based on PDE5 inhibitors. The main player in this group is sildenafil or Viagra, and similar options numbered above. It is also possible to use suppositories of alprostadil administered into the urethra. Or intracavernous injections of the same drug applied just before sexual intercourse. These ED medications tend to be very useful in most cases.

Non-pharmacological therapies include penile prostheses (implants) and vacuum devices. Implants are surgically inserted in the penile tissue. They can be inflated at will before starting sexual activity. Vacuum devices create a negative pressure in the penis, which favors erection.

Which treatment is the most appropriate for you? It depends on various factors, and there’s a stepwise algorithm to answer this question. Cost, ease of administration, and minimal invasiveness should be taken into consideration. So, the first-line treatment is always PDE 5 Inhibitors (with the efficacy of 70-80% after radical prostatectomy).

The second-line treatment includes suppositories (20-40% of effectiveness), injections (85-90% of effectiveness), and vacuum devices (90-100% of efficacy after radical prostatectomy). And penile implants are only considered a third-line treatment (95-100% of efficacy after radical prostatectomy) (5).

After nerve-sparing surgery, doctors will always look for the recovery of the natural erectile function. That’s why penile implants are only considered if the patient does not recover erectile function after 2 years. Only then it is evident that such natural recovery is not likely. Non-nerve-sparing surgery does not require such a long waiting period before exploring new options.

Another critical therapeutic step is erection rehabilitation. It consists of inducing sexual stimulation as soon as possible after surgery. By doing this, and regardless of the results, we can facilitate the recovery of natural erections.

So, the advice is not quitting and not giving up. Remember that erectile dysfunction after prostate surgery is rarely permanent. Recovery sometimes takes longer than expected, but it should not take longer than 2 years (5).

Conclusion

The prostate gland is very close to the penis, and prostate problems are linked to erectile dysfunction. Treatment to recover prostate health may also lead to erectile dysfunction.

For example, we use alpha-blockers for BPH, and they sometimes affect erection maintenance.

For prostate cancer, we can use androgen deprivation therapy. But this type of treatment leads to potential sexual problems. For severe BPH and prostate cancer, surgical resection of the prostate is another therapeutic option.

There’s a nerve-sparing technique that reduces the incidence of erectile problems after surgery. However, slow rehabilitation is needed before the patient recovers his normal erections.

Erections are recovered in up to 85% of patients within 2 years. Such a slow recovery may result from stretching of the nerve, inflammation, and other causes. But patients should be reassured. They are very likely to recover their erections after some time and with appropriate measures.

Sources

  1. Martin-Morales, A., Sanchez-Cruz, J. J., Saenz de Tejada, I., Rodriguez-Vela, L., Fernando Jimenez-Cruz, J., & Burgos-Rodriguez, R. (2001). Prevalence and independent risk factors for erectile dysfunction in Spain: results of the Epidemiologia de la Disfuncion Erectil Masculina Study. The Journal of urology, 166(2), 569-575.
  2. Rosen, R., Altwein, J., Boyle, P., Kirby, R. S., Lukacs, B., Meuleman, E., … & Giuliano, F. (2003). Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male (MSAM-7). European urology, 44(6), 637-649.
  3. Elliott, S. P., Gulati, M., Pasta, D. J., Spitalny, G. M., Kane, C. J., Yee, R., & Lue, T. F. (2004). Obstructive lower urinary tract symptoms correlate with erectile dysfunction. Urology, 63(6), 1148-1152.
  4. McVARY, K. E. V. I. N. (2006). Lower urinary tract symptoms and sexual dysfunction: epidemiology and pathophysiology. BJU international, 97, 23-28.
  5. Burnett, A. L. (2005). Erectile dysfunction following radical prostatectomy. Jama, 293(21), 2648-2653.
  6. Akbal, C., Tinay, I., Şimşek, F., & Turkeri, L. N. (2008). Erectile dysfunction following radiotherapy and brachytherapy for prostate cancer: pathophysiology, prevention and treatment. International urology and nephrology, 40(2), 355-363.
  7. Higano, C. S. (2003). Side effects of androgen deprivation therapy: monitoring and minimizing toxicity. Urology, 61(2), 32-38.
  8. Zhou, J. T., Fang, D. M., Xia, S., Li, T., & Liu, R. L. (2019). The incidence proportion of erectile dysfunction in patients treated with cryotherapy for prostate cancer: a meta-analysis. Clinical and Translational Oncology, 21(9), 1152-1158.
  9. Traish, A. M., Haider, K. S., Doros, G., & Haider, A. (2015). Finasteride, not tamsulosin, increases severity of erectile dysfunction and decreases testosterone levels in men with benign prostatic hyperplasia. Hormone molecular biology and clinical investigation, 23(3), 85-96.
  10. Ko, W. J., Han, H. H., Ham, W. S., & Lee, H. W. (2017). Daily use of sildenafil 50mg at night effectively ameliorates nocturia in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia: an exploratory multicenter, double-blind, randomized, placebo-controlled study. The Aging Male, 20(2), 81-88.

 

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