Dear gentle readers: Please note that this post contains details some may consider graphic or extremely personal. I am going to discuss a form of erectile dysfunction treatment. (Hint: It’s not a pill.) Do I need to reveal this part of my personal journey? Probably not. So… If post-radical prostatectomy ED isn’t something you need to know about, you may want to turn away now. If you read on, hang on to your britches.
Pfizer received FDA approval for their little blue pill almost exactly 20 years ago—March 1998. Since then, the treatment of erectile dysfunction (ED) has become a multi-billion dollar a year industry. Given the hyper-sexualized state of our society, you may not have imagined that there were so many flaccid penises. But it’s true. Here’s the problem: these companies are raking in this wad of cash nearly by accident. Most ED pills are vasodilators—formulated to treat pulmonary hypertension. In clinical trials, though, something unexpected happened. The results, um, raised the possibility that sildenafil citrate might have a much firmer market.
The human penis contains three, let’s call them spongy, sets of tissue: the left and right corpora cavernosa (together, the corpus cavernosum), and the corpus spongiosum. Among the many things that happen as a result of male sexual response, the smooth muscle in the arteries of the penis relaxes and lets blood flow into this tissue. By and large, this is the basis for an erection. In some men, the arteries that feed this tissue may not function well. Their nerves tell the smooth muscle to relax. It does. But blood flow into the penis can’t keep ahead of the chemical events that naturally diminish the erection. Drugs like sildenafil and tadalafil help alleviate that condition. In most cases, it’s budda-bing budda-boom, off to the races.
That’s the simple explanation. But, to understand why these drugs won’t alleviate all forms of ED, we have to get a little further out into the weeds. So here we go.
We can think of the particular smooth muscle in the penis as a valve that operates normally closed. Send an electrical signal to the solenoid on that valve, and it opens. When the signal stops, the valve closes again. In this case, the electrical signal is coming from a pair of nerve bundles, the cavernosal nerves. These, though, do not control the smooth muscle directly. Smoth muscle is, by definition, fibrous and involuntary. Rather, they release nitric oxide (NO2). The NO2 starts a reaction the chemical result of which is cyclic guanosine monophosphate (cGMP). It’s the cGMP that relaxes the muscle. Now, contrary to most male thinking, you don’t want a permanent erection. So, your body sees to it that cGMP gets hydrolyzed back into an inactive state by an enzyme called PDE5. So. . . cGMP opens the valves. PDE5 scrubs the cGMP and the valve closes.
If your arteries can’t let enough blood into the penis to maintain an erection, you could do a number of things. You could thin the blood. Systemic—and dangerous. You could increase blood pressure. Even more dangerous. You could increase NO2. But, maintaining higher NO2 levels would be protracted, not short term. Or you could block the PDE5. This is simple, predictable and short term. So that’s what sildenafil citrate does.
This is all well and good if the underlying cause of your ED is vascular. But for a sizable swath of men—and I must shyly raise my hand to be included in this group—the underlying cause is nerve damage. And that’s where Pfizer stumbling onto their little blue pill does no good. Somebody may be writing songs about them. But to me they are just a blind squirrel. Congratulations on finding that nut!
You see, the cavernosal nerves, in that complex cascade of events that lead to sex, can only release NO2 if they respond to whatever is triggering them. Damage them or traumatize them, and they do not respond. In that case, there is nothing for Viagra to do. And this is where ED treatment gets a little rocky. Or, I guess I should say, a little less rocky.
As I mentioned in previous posts, I opted for what I view as the gold standard for prostate cancer treatment: a radical prostatectomy. In my case, it was a robotically-assisted laparoscopic radical prostatectomy using nerve-sparing technology. It was also done at the hands of a competent, extraordinarily experienced urologist.
By definition, a radical prostatectomy removes the entire prostate. If your prostate cancer has not jumped ship, metastasized is the medical term, poof! you are cured. And, with the entire walnut-sized gland out to be sliced and diced, it’s easy to biopsy, easy to tell if the cancer is contained.
But let’s go back to that nerve-sparing part. Your prostate is packed into your pelvis like an iPhone chip. Basically, when it comes out, some stuff is coming with it. The surgeon’s goal is not to cut or cauterize anything that can’t eventually return to normal. So, with nerve-sparing technology, the surgeon uses some electrical impulses to map key nerves and the robot ‘learns’ those locations so these can be avoided. Of course this includes the cavernosal nerves. The problem is that, as the cavernosal nerves branch off of the pelvic plexus on their way to the corpus cavernosum they attach tendrils to the prostate gland.
More specifically these tendrils are attached to a sheath on the surface of the prostate. So easy-peasy then, right? Just peel up that sheath and the cavernosal nerves stay intact. Well, yeah, except that peeling that sheath without tearing it is likened to peeling wet tissue paper from your kitchen counter without tearing it. We have to take the term ‘nerve-sparing technology’ with a grain of salt here. The reality is that there is going to be trauma to the cavernosal nerves. That means there is going to be some ED. How bad will it be? And for how long? Well, it’s a bit like the urinary incontinence that comes with a radical prostatectomy: it depends.
Diaper jokes aside, it depends because it’s an individual thing. This starts before surgery. A lab manager that once worked for me always said: “Good. Cheap. Fast. Pick two.” In the case of prostate cancer your choices are longevity, continence, and sexual function. Yep, it’s the age-old live/fuck conundrum.
I was only 60 when I had my surgery. And I have to admit that fucking still ranked pretty high on my to-do list. But, at 60, untreated prostate cancer probably wasn’t going to let me get to 80. My cells simply haven’t slowed that much. And other treatments were going to have to be aggressive enough to also cause ED. So out comes the walnut-sized gland. In pre-operative discussions with the urologist, my wife and I picked longevity and continence over erectile function. (She picked longevity; I picked continence.) We weren’t worried. I’ve hiked to the Old Baldy summit plenty of times. But I don’t always take the Old Baldy Trail. Sometimes I take the Super Trail. Or the Florida Canyon Trail. Or the Gardener Canyon Trail. There are lots of ways to peak. Some just take a little more patience.
So I accepted ED as at least a temporary result of the surgery. In part this was because all data suggested that ED resulting from a robotically-assisted laparoscopic radical prostatectomy using nerve-sparing technology at the hands of a competent, extraordinarily experienced urologist would be temporary at best.
How temporary? Well, that depends on the other individual thing: the exact location of those nerve bundles. Essentially, I had given the surgeon permission to cut them if need be to meet my first two goals. Some obviously needed to be cut. How many God only knows. Now we can only wait and see.
The point is that I’ll probably be able to screw, bang, fuck, bump uglies, knock boots, churn butter, or slam like a dunny door in a gale again someday. Just not today. Meanwhile, there is one slight problem. The spongy tissue in the penis can, without use, become less spongy. The tissue atrophies. I can put up with a year or two of impotence. But total loss of my erectile tissue is not an option. Unfortunately, most of the therapies for getting blood into that tissue are just plain bad. Some require injections. Some require surgery. Some require implants. No. No. And no thank you.
And then there is the vacuum pump. I know. There was that day you were a little curious. So you went to that web site. And in the game of whack-a-mole that started with the pop-up ads, you swear you saw claims that your masculinity could be, um, enhanced with a vacuum pump. It probably can’t. But, as it turns out, getting blood into the penis using a vacuum is an age-old remedy.
Rather than trying to find those old pop-up ads again, I talked to my urologist. His practice works with a company called University Compounding Pharmacy. They have reps who sell the Pos T Vac pump. Long story short, the UCP rep did a good job of making it seem a lot less weird. My wife did a good job of making it seem a lot less weird. So off we went.
If you are still reading, you have one more chance to turn back.
No matter what I say next, I recommend you consider a vacuum device if you end up with ED resulting from a radical prostatectomy. As it turns out, those nocturnal erections you get are important. It’s a bit of biological housekeeping. Maintaining a healthy corpus cavernosum depends on having blood flow into it on a regular basis. The penis vacuum makes it easy to emulate exactly that.
But let’s face it. Once you have one, you are going to want to use that erection to have sex. It’s not necessary. To be clear, it is absolutely possible to have an orgasm without an erection. And as for your partner, well, like I said there are lots of ways to the summit. But you will still want to. I get it. If you are old enough to have prostate cancer, that hard-on probably has some sentimental value.
So, since you are heading down that road anyway, I’ll tell you now that a vacuum induced erection takes some getting used to. Unless you are Christian Gray, sex and mechanical devices just don’t seem to go together. And of course, the erection you get from the device doesn’t hang around on its own. You have to keep the blood in your penis with a support ring—essentially pinching off the dorsal vein. To grasp how this affects the look, feel and texture of your penis, wrap a rubber band around one finger about halfway toward the tip. After a minute notice the difference between the skin before and after the band. So… it feels different. And, of course, the support ring can’t keep your dorsal vein completely pinched off. So you can dally a bit on the preliminaries. But not too long. In fact, no matter how well the dorsal is clamped, you have no more than 30 minutes to get to the point. Otherwise you risk doing the very type of damage you bought the pump to avoid.
The other thing—and this is hard to describe—is that it seems like the support ring interferes with the suspensory ligament. This makes the penis seem less like a beam attached to a column and more like universal joint attached to nothing. And, and this is probably starting to sound negative, you’ll probably have some loss of sensation. These two things combine to make it tough to know the angle of your dangle. Like a mortar team needs a spotter, your partner is going to have to let you know when you have things landing where they should.
Oh, one more thing. Don’t think you can show up for the big dance the first time you use your device. This is not a big deal. One reason you want the device is to maintain the health of your corpus cavernosum. You’ll be using it more often than you have sex. So use it a few times before you put a ring on it. That will give you a chance to get the hang of it. And to figure out how to fit a mechanical device into your lovemaking.
If there is an upside—as if having sex using your very own penis isn’t enough—those old-time pop up ads are partly correct. While there is no evidence that the effects are permanent, the vacuum can allow your corpus cavernosum to fill beyond its usual, um, capacity. (Or maybe it’s just my age becoming more evident.) If that proves true for you too, enjoy!
That said, great device. No drugs. No implants. No surgery. No side affects. You can use it at will. And, once those cavernous nerves start to heal, you could use it in conjunction with sildenafil, tadalafil, vardenafil, udenafil, avanafil or the vasodilator of your choice until they heal completely.
Thanks for sticking with me. I know that’s a pretty deep dive into the chemistry of sex. And we only touched on what happens in the pudendum. When you get into the brain, serotonin, dopamine and testosterone produce a whole other sexual chemistry. And ED has an impact on those. In fact, ED can trigger a bit of a chemical downward spiral.
That’s why I give Pfizer no props. It’s bad enough that they think the little woman wants to cuddle with me after the Sunday game. She doesn’t. She wants to discuss why the Steelers didn’t create a penalty so that Boswell could get a better angle on that last second field goal. But its even worse that their constant advertisement of the little blue pill has reshaped the sexual landscape as much or more as The Pill. In this post, I use the term erectile dysfunction. But outside the medical field that term didn’t exist two decades ago. You were impotent. Well, now you can’t be impotent in America. And that’s a problem. Because some of us are. But we live in a world where the problem is solved. All couples now saunter, in gorgeous high-key lighting, toward beautifully paired clawfoot tubs. There is nothing more to discuss. Except that outside the realm of PDE5 inhibitors, impotence is still a lonely, depressing place. And there is no pill for that.
(Hopefully, any other posts about that walnut-sized gland will be shorter and less revelatory. I’m going to dabble with nitric oxide supplements—more specifically L-arginine. I might also delve into the relationship between testosterone, serotonin and dopamine. If anything turns up as a result of it, I’ll let you know. Meanwhile, if you would like a super-deep dive into the vascular and innervation functions of the penis, click here.)