Sexual function after RARP: part 1

Prostate cancer creates a huge amount of stress for men, and many are concerned about the effects of robotic-assisted radical prostatectomy (RARP) on their sexual function. In the first article of a two-part series, we speak to experienced consultant urological and robotic surgeon Mr Benjamin Lamb who clears up any concerns you may have.

What is sexual function?

Sexual function is very complex and can vary greatly between men. It can be defined as a man’s capacity to satisfy psychological, emotional, physical and fertility needs through sexual activity.

To elaborate further, optimal sexual function usually relies on factors such as libido (sexual drive), genital sensation, the attainment of erections, the ability to achieve orgasm, ejaculation, and the maintenance of urinary and bowel control. These aspects are closely intertwined with a man's emotional state, hormonal balance, vascular health, nervous system function, and penile tissue.

Sexual function is affected by mood, stress, age, health conditions and medication, among other factors. The prostate is integral to sexual function as it produces much of the fluid in semen and is necessary for normal fertility. It is also surrounded by nerves and blood vessels travelling to the penis. Moreover, the function of the prostate is under the influence of the male sex hormone, testosterone.

How does prostate cancer and its treatment affect sexual function?

Being diagnosed with prostate cancer can cause a significant amount of stress. Not only does this stress affect sexual function, but it can be impacted by treatment, whether it is hormone treatment, radiotherapy or surgery.

Each treatment option has various effects on sexual function. Certain side effects will occur during treatment and some may improve after, while some may worsen as the treatment finishes. If sexual function is an integral part of a man’s life, he should discuss his treatment options and each of their effects thoroughly with a consultant before undergoing treatment.

How does RARP affect sexual function?

All men undergoing robotic-assisted radical prostatectomy (RARP) will have experience some changes to their sexual function after undergoing surgery. The following aspects will be impacted by the surgery:

Sex-drive (libido)

Aside from the distress of being diagnosed with prostate cancer and the anxiety associated with undergoing significant surgery, it is important to note that RARP does not exert any biological influence on a man’s sex drive. In contrast to treatments that impact hormone levels, such as hormone injections, RARP does not interfere with the production of testosterone, the primary male sex hormone. Once patients have overcome the physical challenge of surgery and their cancer has been successfully treated, there is no reason to expect that their sex drive will be negatively impacted.   

Genital sensation

The nerves that provide sensation to the genitals (penis in general) are not affected by RARP. Sensation following RARP should, therefore, be the same as it was before surgery.

Ability to achieve orgasm

The ability to achieve climax or orgasm relies on sex drive and sensation, meaning that it remains achievable after undergoing RARP. However, it may feel different because the man cannot experience ejaculation and therefore may require a different approach if the penis is not erect, but it should be possible and pleasurable. Such obstacles, along with others which are caused by cancer diagnosis, can be overcome with material which can be used to stimulate the mind, such as erotic material or porn. Additionally, they can use other materials to stimulate the body like vibrators or sex toys; whatever works for the patient and whatever they feel comfortable with.

No ejaculation

RARP involves the removal of the prostate and seminal vesicles, the organs that produce the vast majority of the seminal fluid. Due to this, after undergoing RARP, the orgasm is dry and ejaculation does not occur. This can cause altered sensation and sub-fertility. Ejaculation is extremely important to many men, and can be part of the male identity, therefore the effect of RARP on ejaculation should be considered before deciding on treatment.

Sub-fertility

Normal fertility relies on the production of semen, the fluid that contains sperm. Semen is produced by the prostate and seminal vesicles, which are removed during RARP. This ultimately means that the ability to conceive through sexual intercourse is lost. However, it is important to note that the testis can still produce sperm, which can be retrieved and used in fertility treatments, such as IVF.

Ability to achieve erections

Loss of spontaneous (natural) erections is perhaps the most profound after-effect of RARP. Erectile dysfunction or loss of normal erections sufficient for penetrative intercourse, is a common side effect of RARP. This occurs for almost all men immediately after surgery, and for many men is a permanent side effect. Some men do recover their erections, but it may take many months or in some cases, years.

This can be extremely frustrating for men after their surgery, especially when cancer has been treated and they wish to get back to their normal lives. The likelihood of recovering erections after RARP depends on a number of factors, such as:

Age: As men grow older, their erections tend to deteriorate and older individuals generally have a slightly lower chance of recovering erectile function compared to younger men.

Pre-existing erections: Men with good pre-surgery erectile function are more likely to regain it compared to those who already have erection problems.

Surgical approach: The probability of erectile recovery is higher with nerve-sparing surgery, while the chance of recovery with non-nerve-sparing surgery is relatively low. Full nerve sparing is more effective than partial nerve sparing. There must be a balance between cancer control and preserving erectile function. It is crucial to have a thorough discussion with your surgeon to understand what can realistically be achieved and what is safe.

Urine leak at orgasm (climacturia)

In addition to erectile dysfunction, some men may experience climacturia, the leak of urine during climax. This issue affects some men, but not all and may improve over time. The amount of urine leaked varies based on bladder fullness and urinary continence.

Shortening of the penis

It is usual for men to perceive that their penis is shorter after RARP. This appears to occur from a combination of the inward pull on the penis from the join to the bladder, and from changes to the blood supply, which are dependent on the type of surgery.

Some studies suggest that penis length may gradually recover over time, with the recovery of erections playing a potential role in this process.

If you are considering RARP and are concerned about its effects on your sexual function and would like to book a consultation with Mr Lamb, do not hesitate to do so by visiting his Top Doctors profile today.