The prostate is a small, walnut-shaped gland located deep in the pelvis, situated below the bladder and in front of the rectum. It produces fluid that makes up a significant portion of semen, which helps nourish and transport sperm. A radical prostatectomy is the surgical procedure involving the complete removal of this gland, along with the attached seminal vesicles, and is a standard treatment for localized prostate cancer. Living without the prostate introduces predictable long-term changes that affect both urinary control and sexual function. Understanding these changes is necessary for managing expectations and seeking appropriate post-operative care.
Changes to Urinary Function
The most common side effect following a radical prostatectomy is a temporary or persistent issue with urinary control. This results from the removal of the prostate and the internal urethral sphincter, which is located at the bladder neck. With the internal sphincter gone, continence relies completely on the external urethral sphincter and the surrounding pelvic floor muscles.
Almost all patients experience some degree of stress urinary incontinence (SUI) immediately after the urinary catheter is removed. SUI is the most prevalent form of incontinence, involving involuntary leakage of urine when pressure is placed on the bladder (e.g., during coughing, sneezing, or lifting). Urgency incontinence, which involves a sudden, intense need to urinate, is typically related to temporary changes in bladder function. For the majority of men, urinary control gradually improves over the first year as the remaining external sphincter and pelvic floor muscles strengthen and compensate for the loss of the internal sphincter.
Alterations in Sexual Health
The removal of the prostate can significantly alter sexual health, primarily through its impact on erectile function and ejaculation. The nerves responsible for achieving an erection, known as the neurovascular bundles (NVBs), are delicate structures that run along the back and sides of the prostate. Damage to these cavernous nerves during the surgical dissection is the main cause of post-operative erectile dysfunction (ED).
Surgeons use nerve-sparing techniques to preserve these bundles, which significantly increases the chances of recovering spontaneous erections. However, if the cancer is close to or involves these bundles, they must be removed to ensure complete cancer removal, leading to a higher likelihood of long-term ED. Erectile function recovery is a gradual process, often taking up to 18 to 24 months, as the nerves must regenerate or heal.
A dry orgasm, or anejaculation, is a permanent consequence of radical prostatectomy. This occurs because the prostate and seminal vesicles, which produce nearly all the fluid that makes up semen, are removed during the procedure. While the sensation of orgasm can still be achieved, it occurs without any fluid exiting the body.
Changes in the sensation of orgasm are also commonly reported, with some men describing a decrease in intensity, a quicker climax, or a change in the physical feeling. Some patients also report climacturia, which is the leakage of urine during sexual arousal or orgasm, though this often improves as urinary control returns. The ability to achieve orgasm is independent of the ability to maintain an erection or ejaculate fluid.
Impact on Fertility
The complete removal of the prostate and seminal vesicles results in sterility. This is because the seminal fluid, which transports the sperm, is no longer produced. The procedure also involves severing the vas deferens, the tubes that carry sperm from the testicles.
Although the testicles continue to produce sperm, these cells have no pathway to exit the body, resulting in azoospermia. For individuals who wish to maintain the option of having biological children, sperm banking is the recommended procedure and must be completed before the prostatectomy.
Management of Post-Surgical Symptoms
Effective strategies exist for managing post-surgical symptoms affecting urinary and sexual function. For improving urinary control, pelvic floor muscle training (Kegel exercises) is the first-line treatment. These exercises strengthen the remaining external urethral sphincter and the muscles that support the bladder.
Formalized pelvic floor rehabilitation, often guided by a physical therapist, can incorporate biofeedback to help patients isolate and effectively contract the correct muscles. For patients with persistent or severe stress incontinence that does not resolve within the first year, surgical options are available. These procedures include the placement of a male sling for mild to moderate leakage, or the implantation of an artificial urinary sphincter for more significant continence issues.
To address erectile dysfunction, treatment commonly involves the use of phosphodiesterase type 5 inhibitors (PDE5-Is), such as sildenafil or tadalafil, which increase blood flow to the penis. These medications help to maintain tissue oxygenation, which can prevent the long-term changes of tissue fibrosis while the nerves heal. Other non-surgical options include vacuum erection devices, which draw blood into the penis to create an erection. For those who do not respond to these therapies, a penile implant is a permanent surgical option for restoring functional erections.