In this blog for a non-medical audience, Alastair Lamb, Senior Fellow in Robotic surgery and Consultant Urologist at Oxford University Hospitals, and Altan Omer, Pelvic GU-Oncology fellow, look at the evidence for use of PDE5 inhibitors (Viagra, Cialis & Levitra) for penile rehabilitation after prostate cancer surgery.
Page last updated 21 February 2022 and last checked 4 April 2023
What is the problem?
Some 6,500 radical prostatectomies are performed every year in the UK (British AssociationA relationship between two characteristics, such that as one changes, the other changes in a predictable way. For example, statistics demonstrate that there is an association between smoking and lung cancer. In a positive association, one quantity increases as the other one increases (as with smoking and lung cancer). In a negative association, an increase in one quantity corresponds to a decrease in the other. Association does not necessarily mean that one thing causes the other. of Urological Surgeons, 2019). While approximately half of these men have pre-existing erectile dysfunction, over 50% of the other half can expect to lose natural erections after prostatectomy surgery, especially if their cancers are locally advanced and require wide clearance to ensure removal of the whole tumour.
Are these erections lost for good?
There’s pretty good evidence to show that men can continue to recover erectile function up to two years after prostatectomy surgery (Montorsi et al., 2014), which we believe is partly because it takes time for the bruising and scar tissue after surgery to settle down. But if spontaneous erections do not recover by this point then it is unlikely that they will do so thereafter. Conversely, there is good evidence that drugs such as Viagra can be used to enhance erections after surgery and that, even if such drugs do not work – for example if the nerves have been removed to maximise cancer clearance – mechanical devices such as vacuum pumps, cavaject injections into the side of the penis or MUSE therapy (small tablets inserted into the end of the urethra) are effective.
Use it or lose it?
The question therefore remains as to whether longer term recovery of spontaneous erections can be assisted by such devices and particularly by the use of PDE5 inhibitors. This is a process generally known as “penile rehabilitation”. The concept is that men need to ‘use’ their penises in order to speed up recovery of the blood vessels and nerves that are essential for erections, indeed that lack of use may inhibit recovery. This Cochrane review pulled together randomised trials testing the effect of PDE5i on erectile function after radical prostatectomy (Philippou et al., 2018). There were eight randomisedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group (the intervention group) will be given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group). trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. including 1699 men and the drugs used were either Viagra (sildenafil), Cialis (tadalafil) or Levitra (vardenafil). The review found no evidence to support penile rehabilitation, defined as an improvement in erectile function, off drug, at the end of the period of follow up (one to two years) compared to a control group who had not received any drug. The authors did note however that the quality of evidenceThe certainty (or quality) of evidence is the extent to which we can be confident that what the research tells us about a particular treatment effect is likely to be accurate. Concerns about factors such as bias can reduce the certainty of the evidence. Evidence may be of high certainty; moderate certainty; low certainty or very-low certainty. Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of evidence. Find out more here: https://training.cochrane.org/grade-approach was poor, mainly because of a lack predefined outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. and inconsistency in reporting standards (varying definitions of potency, different follow-up durations, multiple modes of assessment including both physician and patient-reported outcomes etc).
How important is nerve-sparing?
The short answer is very. All men in these studies had some form of nerve-sparing performed during their surgery so this review was not able to assess the effect of nerve-sparing on subsequent recovery of erections as there was no control group to compare to. Previous studies have convincingly demonstrated the critical nature of nerve-sparing (Patel et al., 2011). The decision to undertake nerve-sparing is made in advance by the surgeon and depends on the extent of cancer. Robotic surgery has allowed more precise and meticulous surgical dissection of the surrounding layers of the prostate. Indeed, 80% of UK prostatectomies are now completed with a da Vinci robot, the remainder split evenly between laparoscopic and open surgery. The outer layers of the prostate are a bit like an onion with several layers. The layer containing the nerves is like the brown skin on the onion and the surgeon can choose to cut inside this layer to leave the brown skin (or nerve layer) in place.
However, when there is a lot of cancer there is a real possibility of leaving some cancer cells behind if this close approach is taken, and so the surgeon instead chooses intentionally to take this outer layer with the prostate – the brown skin stays on the onion. So, while it may increase the riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of prostate tissue being left behind (which incidentally, is one of the reasons why the PSA may remain high post-operatively), sparing the nerves is a critical step for preservation of erectile function, and men who undergo an intentional non-nerve-sparing procedure should always be warned of the inevitability of erectile dysfunction after surgery. Of course, for those men who have already have erectile dysfunction before surgery, no amount of nerve sparing will return natural erections.
Isn’t Viagra very expensive?
Viagra is indeed rather expensive. A box of four 100mg tablets (Viagra, Pfizer) will cost the NHS or you (by private prescription) £23.50 per box. However, since December 2017 in the US, and amazingly since June 2013 in the UK, it has been legal for other drug manufacturers to make generic sildenafil and so, with a private prescription you can now pick up a box of 4 x 100mg sildenafil citratetables for as little as 79p, a thirty-fold price reduction. It’s almost as cheap as paracetamol! The NHS is slowly waking up to this but still official NHS guidance only permits one packet of four tables per month for those who meet strict erectile dysfunction criteria. We hope this will change soon, given that 11 boxes could be purchased for the £8.80 standard NHS prescription charge! Furthermore, Cialis also came off patent in December 2018 in the US and we can therefore expect generic tadalafil, which currently costs £54.99 for a box of 28 x 2.5mg – cialis is generally taken daily due to its longer half-life – to come down to similar prices.
Where does this leave you?
Increasing availability of these previously expensive drugs is a tremendous help for men who have undergone radical prostate surgery. Despite the uncertainty regarding penile rehabilitation, there is no doubt that real-time erections often improve while on Viagra (or Cialis or Levitra etc) and so straightforward access to these drugs is essential for a speedy return to a functioning sex life after cancer, for those who want it.
You can read NHS information about Sildenafil (including Viagra) here.
Join in the conversation on Twitter with @CochraneUK or leave a comment on the blog.
Alastair Lamb and Altan Omer have nothing to disclose.
Altan E. Omer MD FEBU is a Pelvic Uro-Oncology and Robotic Surgery Fellow at the Churchill Hospital, Oxford.
I am exactly five weeks from having a radical prostatectomy. At my four week checkup my urologist said everything is going well. He then told me to wait four more weeks before I can have sex and told me not to try and get an erection until then as well.
Do you agree with this advice. I am anxious to start messing around with my wife. Not necessarily trying to have sex yet but if my erection was hard enough why not? Can I cause some damage to my healing process if I go against my doctor’s wishes?
I had prostate surgery it have been about six weeks no action with my love making .so I tired tadalafil 20 mg did not for me.so I tried 40 mg nothing . Now I am thinking about calling my doctor
Is there other then injections that would work for erection. As viagra 100 mg did not work . my prostate and nerve where taken out due to cancer would love to get answer thank you
For me it will be two years in May for my prostate surgery
removal so I tired the penis pump viagra and no action in the bedroom and my age 52. Help me
I’ve tried All the injections but the erection is only 70%,I’ve also tried viagra 100mg abit better but again only 80%.Is it dangerous to take a double dosage. Gary
I am now 68 and had nerve sparing laparoscopic prostatectomy in 2006 and have managed reasonable erections on sildenafil although not every time and the frequency of success has reduced markedly over the last few months. I had no ED issues before my RP and am a slim, fit, non smoker with lowish blood pressure and not on any medication. Is it just my age or as my wife suggests it may be partly in my mind and if so do you think therapy might help. Thank you.
My husband is 75, and had prostate surgery, due to cancer, in March 2018. He works out of town most of the time, so we have not had
a good chance to try the remedies for ED. He also had open heart surgery several years ago, and his heart doctor has been reluctant to prescribe Viagra, or some similar drug. Is there anything that you might suggest that might help him when he is not home? There is some
response, even at this late date after prostate surgery, when he is home, but he needs something to try in the meantime. Is Viagra safe in
low doses, to help stimulate him? A viberator seems to help some enlargement and maybe some blood flow. Any suggestions would be
I had a radical prostatectomy on October 31st, (for Halloween I was dressed as a hospital patient with nurses, IV’s and real blood),
Sorry,…maybe a bit too graphic 😬
Question; it is now 4 weeks since I had this procedure, so,….
Is it too soon to start with any kind of ED meds to “wake up” the sleeping giant?🤔
Hello Tom, blog author and urologist Alastair Lamb has posted a reply to another comment here (by Susan) which may be helpful to you, as he talks about the timing and purpose of taking ED drugs after prostatectomy.
Sarah Chapman [Editor]
How soon after prostate surgery can I try viagra or other prescribed e.d medicine
My husband (52, fit, healthy, normal sexual function before surgery) has just had a radical nerve preserving surgery and was told to start on viagra straight away. We tried it 3 days after having the catheter, blood drain and stitches out (open surgery) and it failed. I feel it was too soon to try after having all these tubes removed but the surgeon had stressed the importance of getting things moving again straight away. How long should we leave it before trying viagra again? Or might another brand be an option. The GP response has been clueless.
Thank you for your comment Susan. I’m really glad that your husband has got through his surgery well. As you say, it can seem quite early to start taking viagra so soon after a major operation. However, there is a bit of evidence emerging (not strong as yet) that starting viagra early, or even before surgery, can help. The message is a little mixed as, from the Cochrane Review we commented on above, the concept of “penile rehabilitation” has essentially been debunked. However, it may be that starting the drug very early catches the vessel and nerve changes at just the right time. It should be emphasised that the purpose of taking viagra this early is not to give immediate erections, but rather to improve future erections in the weeks and months to follow. Tadalafil is probably the best PDE5 inhibitor to take for this purpose because of it’s longer half-life, but it is still rather expensive and so, as outlined above, I tend to give my patients a quarter dose (25mg) of sildenafil (viagra) daily which, when prescribed “privately”, can be paid for over the pharmacy counter and is almost as cheap as paracetamol.
I hope this helps.
I have not been part of any survey and had my prostate removed one year ago using the Da Vinci robot. I was stage 3b and had no nerve sparing. I am still clear with no follow up radiation or hormone treatment.
After not getting on with muse or the cream variant of the same drug I took it upon myself to buy some Viagra over the counter as I had seen some evidence of activity. To cut a long story short the Viagra helped but I didn’t get a full erection. I told my post surgical team and they are now trying me on Cialis. At first 5mg a day which brought some results. Most recently I have tried the 20mg dose less frequently and results within a few hours seem further improved. Although unusual I do not think my case is unique.
Mr Lamb, it’s very impressive that you’ve attended Mani Menon’s recent presentation at AUA19 on 5 May of the Menon Precision Prostatectomy technique, aimed at reducing ED. Plainly, one should not just MRI the area of the PZ to be left in situ, but also biopsy it too. Yes, there is a risk that the sliver of PZ which is left in situ may generate CaP. But in any event, even if you did a full RARP, traditional or Retzius-sparing, my understanding is that the patient will still be taking some risk of biochemical reoccurrence in some circumstances, even if there are “clear” margins at the finish of the operation. It seems to me that it is for the patient to choose what level of risk he’d prefer – and whether he’s willing to take some CaP risk to have a better chance of continued normal erectile function, given that he is, as I understand it, already taking at least some risk of biochemical reoccurrence anyway. So it seems to me that surgeons, in principle, ought to be prepared to have the technical capacity to “do it the patient’s way” provided that the patient understands and signs up to any extra risk, rather than the surgeon saying ab initio that no sliver at all of PZ can be left and imposing a decision on the patient of greater ED risk when the patient might prefer a better chance of erectile function and be willing to tradeoff some CaP risk, at least if it is found that there is negative MRI report AND a negative biopsy in the area. Any views you have are of great interest. Someone needs spend a little time with Menon in the USA and bring the learning over the Atlantic because there are lots of men who’d prefer to have this chance if MPPs can be done in a way that makes sense.
yes it does work, viagra should be first consulted by the doctor in this case before consumption.
What do you think of the Menon precision prostatectomy technique described by Dr Mani Menon in the link below: early results on the first 50 patients are said to yield a much higher recovery of erectile function (said to be about 95%) compared to the usual robot assisted radical prostatectomy, whether retzius sparing or traditional? Of course, one could not apply the MPP technique to every case (eg where cancer has invaded the cap of the prostate); but one would think that there must be a significant subset of patients for whom Dr Menon’s suggested technique may reasonably be considered. Early days yet in relation to proof of this new technique, of course, but looks promising.
Thank you for your comment Ian. Mani Menon is a legend in our field and I want to learn everything I can from him! However, I do have reservations about his proposed technique, just as I have reservations about any focal therapy in prostate cancer. We know that approx 70% of prostate cancer occurs in the “peripheral zone” of the prostate – the “cap” you refer to in your comment. And this is precisely the zone that Dr Menon chooses to leave behind. We also know that up to 30% of negative MRI scans/prostate biopsies actually harbour clinically significant prostate cancer. I am concerned about doing an operation which, by it’s nature, precludes further radical surgery, but which involves the very real possibility of leaving behind prostate tissue harbouring lethal prostate cancer. Until we can precisely determine the presence or absence of small quantities of lethal prostate cancer cells at diagnosis I will not be offering these treatments to my patients. Instead I think we should put our efforts and fundraising into basic scientific endeavour to identify such “lethal clones” in the prostate (http://www.nds.ox.ac.uk/team/alastair-lamb). I am also very encouraged by the potential of “retzius-sparing” prostatectomy techniques, using both posterior and anterior approaches, early results of which seem to offer very promising erectile function and continence results without compromising radical treatment (several abstracts to be presented this year at EAU19 and AUA19 https://eaucongress.uroweb.org/scientific-programme/.
Tadalafil isn’t always taken once daily. It’s also available as PRN does of 10mg and 20mg as well as daily doses of 2.5mg and 5mg.
The long half-life isn’t the reason it’s given daily!