After a prostatectomy: when should a penile prosthesis be considered?

Following surgery for prostate cancer, erectile difficulties can take their toll on self-confidence, intimacy and relationships. A penile prosthesis is an option when other solutions do not adequately meet the patient’s needs. The CHUV specifically cites damage to the erectile nerves following a prostatectomy as one of the indications for this procedure. [Source 2]

However, the question is not simply ‘how long should one wait?’. It is also necessary to consider the prospects for recovery, treatments already tried and personal expectations.

Which type of prostatectomy are we talking about?

This article mainly concerns radical prostatectomy, which involves removing the prostate to treat cancer. The sexual consequences of this procedure should not be confused with those of operations carried out for a benign enlargement of the prostate.

Even when the nerves can be preserved, recovery of erectile function can be slow. The urology department at UCLH states that it can take up to two years. Nerve preservation and erectile function prior to the operation are factors in the individual prognosis. This timeframe is neither a guarantee of recovery nor a deadline applicable to everyone. [Source 3]

Can we discuss this early on, without having to decide straight away?

Yes. European guidelines encourage early management of erectile dysfunction following prostatectomy. However, they do not specify a universal timeframe in months before the insertion of a prosthesis.

The discussion becomes particularly useful when the proposed solutions remain inadequate, are poorly tolerated or are unsuitable for the patient. The patient’s choice, after being informed of the benefits and risks, forms part of the decision. [Source 1]

During the consultation, one question helps to clarify the situation: ‘What are my chances of recovery, and what might influence your recommendation?’ This helps to understand the rationale behind a period of observation or, conversely, the need for a discussion about surgery.

Which treatments should be considered before an implant?

Depending on the situation, management may include oral medication, injections into the corpora cavernosa or a vacuum pump. Before concluding that treatment has failed, the doctor checks, in particular, how the treatment has been used.

It is also important to distinguish between an erection achieved through treatment and one resulting from spontaneous recovery. European guidelines state that the available data do not support recommending a single protocol for penile rehabilitation. Medicines in the PDE5 inhibitor class have not been shown to increase the chances of spontaneous recovery following prostatectomy. [Source 1]

Psychosexual counselling may also be discussed. The patient may ask to involve their partner in the discussions, if they wish.

What does a penile prosthesis do?

A prosthesis provides mechanical rigidity, enabling sexual intercourse. There are inflatable and semi-rigid models. The choice requires an explanation of how they work and their limitations. [Source 1]

With an inflatable model, a pump placed in the scrotum is used to fill the cylinders implanted in the penis and then deflate them. Training is provided by the healthcare team. The implant is not designed to increase the length or girth of the penis. [Source 4]

Ask to see a demonstration of the device being considered. This is an opportunity to check that you find its operation straightforward and suitable for your daily life.

What about orgasm and ejaculation?

Following a radical prostatectomy, ejaculation of semen usually ceases as a result of the operation. A penile prosthesis does not restore ejaculation or natural fertility. [Source 3]

Orgasms may still be possible after prostate removal, even without an erection, but the sensations may change. It is helpful to discuss rigidity, pleasure, desire and any pain separately: these aspects are not limited to how the implant functions. [Source 5]

What risks should you be aware of?

Fitting the implant requires surgery. Possible complications include, in particular, infection, haematoma, tissue erosion and problems with the device’s functioning. A further operation may be necessary.

The decision is a long-term commitment: removal of an implant does not guarantee a return to the previous erectile function. This irreversible nature must be explained before consent is given. [Source 4]

Ask the surgeon which risks apply to your specific case, how they can be minimised, and how any complications would be managed.

How should you prepare for the consultation?

Bring your surgical report, details of your cancer treatment, your list of medications and a summary of the treatments you have already tried for erectile dysfunction.

Also prepare your questions:

- Is recovery still a possibility in my case? - Were the treatments I’ve tried used correctly? - What benefits can I expect from the implant, and what are its limitations? - Which model would be suitable for me and why? - How will training, check-ups and the management of any problems be organised? - If I have the operation far from home, who will provide follow-up care when I return?

When can I resume sexual activity after the implant has been fitted?

Resuming sexual activity depends on how well the wound has healed and on the surgeon’s approval. As a guide, Memorial Sloan Kettering recommends six weeks without sexual activity following implantation, with a follow-up consultation at that point. This timetable must be confirmed by the team performing the procedure. [Source 4]

A personal decision, with support

You can request information about the prosthesis without committing to having the operation. The aim of the consultation is to compare your options based on your individual situation and priorities, and then to make a decision with a clear understanding of the benefits, limitations and follow-up care.

This content provides general information and is not a substitute for a medical consultation.

Medical sources

1. European Association of Urology — Management of Erectile Dysfunction, online guidelines: https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/management-of-erectile-dysfunction 2. CHUV — Penile prosthesis: https://www.chuv.ch/fr/urologie/uro-home/patients-et-familles/andrologie-et-infertilite/prothese-penienne 3. University College London Hospitals — Robotic prostatectomy: https://www.uclh.nhs.uk/patients-and-visitors/patient-information-pages/robotic-prostatectomy 4. Memorial Sloan Kettering — About Penile Implants, updated 24 August 2023: https://www.mskcc.org/cancer-care/patient-education/penile-implants 5. Macmillan Cancer Support — Prostatectomy for prostate cancer: https://www.macmillan.org.uk/cancer-information-and-support/treatments-and-drugs/prostatectomy-for-prostate-cancer