Achieving orgasm after radical prostatectomy

By Peter Wehrwein

Men worry about erectile dysfunction after radical prostatectomy, the operation that involves removing the prostate gland as a way to treat prostate cancer. It’s a legitimate concern. Men, their spouses and partners, and their surgeons should talk about erectile dysfunction before and after the surgery. Almost all men will experience erectile dysfunction for several months to a year after a radical prostatectomy, although today’s nerve-sparing operation has decreased the number of cases when it’s permanent.

But orgasm after radical prostatectomy? It’s often even not on the radar screen. Dr. Ravi Kacker thinks that should change.

“Sometimes orgasm gets forgotten because everyone is so focused on erectile dysfunction,” says Dr. Kacker, a urologist and fellow in male sexual medicine at Harvard-affiliated BethIsraelDeaconessMedical Center. “But for some—maybe most—men and their partners, achieving orgasm can be as important as erections—or even more so —for having a healthy sex life.”

And, says Dr. Kacker, there’s good news. “Orgasms after radical prostatectomy may feel qualitatively different for most men, but they don’t need to be any less pleasurable or satisfying.”

The three parts of male orgasm

Kacker starts by pointing out a common misconception that erections are necessary for male orgasm. They aren’t. Men can have experience orgasm without an erection. The converse is also true, of course: men can have an erection without having an orgasm.

When discussing orgasm and radical prostatectomy, it’s useful to think of the male orgasm as having three separate parts, says Dr. Kacker.

First, secretions from the testicles, the prostate, and the seminal vesicles—small, slender glands near the prostate—flow into the urethra, the tube-like structure that carries semen through the penis and out the body. The emission of those fluids creates a feeling of fullness and a sensation of inevitability.

Second, there’s ejaculation, which is accompanied by contractions of the pelvic floor muscles, the group of muscles used to hold in intestinal gas and urine.

And third is the mental component—all of the processing the brain does of incoming sensory signals from penis and pelvis that contribute to the mental experience of “build up and release.”

How radical prostatectomy affects orgasm

The first two parts of orgasm are affected by radical prostatectomy, explains Dr. Kacker. Removal of the seminal vesicles and prostate gland during the operation means no fluid can come in from the testicles or the prostate. With the gland or the vesicles gone, there’s no fluid buildup in the urethra and the sense of fullness and inevitability, which may have been a familiar part of your orgasm prior to surgery, is now missing.

And there’s no ejaculate after radical prostatectomy. Some men also report that the operation affects their pelvic floor and its contractions.

But the third part of orgasm occurs in the brain and can be just as intense as before surgery.

Steps men can take to improve or recover orgasms

This doesn’t mean that some men don’t have difficulty experiencing orgasm after radical prostatectomy. The missing sensation of fullness and the lack of ejaculate are big changes. But there are some things you can do to correct the problem, according to Dr. Kacker.

Men can achieve an orgasm on their own with manual stimulation or with a partner through manual or oral stimulation. Just remember that an erection is not needed. Using a vibrator on the head of penis is often helpful. Vibration can stimulate the nerves in the penis and increase the signals being sent to the brain.

Hormone adjustments can help with orgasm

Sometimes hormone levels contribute to orgasmic problem. Many men with low testosterone have problems with orgasm, but treating prostate cancer patients with testosterone is still very controversial. Other hormones can also play a role. For example, a low thyroid hormone level or a high prolactin level can make it more difficult to reach orgasm. Even if you have a normal hormone levels, there are a few hormonal medications that may be able to help.

Another hormone that plays a role in orgasm is oxytocin. (Don’t confuse it with OxyContin, the narcotic pain reliever.) The level of oxytocin increases in both men and women during sexual arousal. Taking an under-the-tongue (sublingual) formulation of oxytocin five to 10 minutes before sexual activity can help some men achieve orgasm. It’s safe and no side effects have been reported, says Dr. Kacker. You need a prescription for oxytocin, and it’s available only through special compounding pharmacies, not through retail pharmacies.

Cabergoline is another medication that can help with orgasm problems. It blocks the release of prolactin, a hormone that appears to play an important role in the refractory period after orgasm when men can’t have another orgasm for a while.

Cut back or change antidepressants

Another thing to think about is any other medications you’re taking, notes Dr. Kacker. Many men are, unknowingly, taking medications that suppress orgasm. By far the number one offender is the SSRI class of antidepressants, which include fluoxetine (Prozac) and Paxil (paroxetine). By reducing the dose of these drugs or eliminating them entirely, or switching to a non-SSRI like bupropion (Wellbutrin), many men see an improvement in their ability to orgasm.

Talking about orgasm problems is important

Men and their partners have become much more open about talking erectile dysfunction, in general and as a consequence of prostate cancer treatment, notes Dr. Kacker.

Whatever you think about all those ads for Viagra and Cialis, they have made it easier to talk about ED and helped remove some of the stigma around the condition.

“We should be having the same frank, open discussions about orgasm,” says Dr. Kacker. “Orgasms can bring a couple together and allow them to maintain sexual intimacy in the difficult period around diagnosis and treatment of prostate cancer.”