Pelvic surgeries are procedures that seek to solve cancer problems in the bladder, rectum and prostate. These surgeries can damage the nerves in the penis that result in health problems such as erectile dysfunction and urinary incontinence.
In this blog you will learn a little more about pelvic surgeries called: radical cystectomy, abdominoperineal resection and radical prostatectomy. You will also know the possible treatments for the consequences caused by such procedures.
Radical cystectomy is pelvic surgery to remove the entire bladder in cases of cancer. This tumor can compromise the bladder wall in several places, which may require the development of a new organ - or neobladder -, using part of the intestine as raw material.
There is also the possibility of a radical cystoprostatectomy, a surgery necessary in cases where bladder tumors affect the prostate. Then both are removed.
Abdominoperineal resection is indicated when the patient has a tumor of the rectum that threatens the bladder or prostate. This surgery can remove the rectum, bladder, prostate and part of the perineum. As it is the removal of the rectum, a colostomy is performed, where the patient starts to do his physiological needs directly inside two different bags. As it is a pelvic surgery, there are also possibilities of resulting in degrees of erectile dysfunction.
Prostate cancer is the second most common type of disease among men in Brazil. It is a tumor that affects the prostate, a walnut-sized gland located below the bladder, which produces the seminal fluid responsible for transporting sperm and nourishing it.
Radical prostatectomy surgery removes the gland along with the seminal vesicles - both located above the prostate, between the bladder and rectum. It is a surgery that completely removes the tumor and that can have consequences such as Urinary Incontinence and Erectile Dysfunction, both treatable and can be done together in the same surgery.
The nerves responsible for erection are very thin, pass close to the bladder and are located at the back of the penis. These nerves are responsible for relaxing the blood vessels and generating pressure on the cylinder of the penis so that the erection and stiffness necessary for penetration occur. Total removal of the prostate can damage them, partially or completely, and can result in mild, moderate or severe erectile dysfunction.
* It is important to first solve the cancer and then seek treatments for the sequelae it leaves, so that the patient lives happily, without the disease and with good self-esteem.
In addition to the probability of Erectile Dysfunction, such surgeries can also result in Urinary Incontinence, as the urethral sphincter passes very close to the rectum and bladder. Removing these organs can weaken the sphincter that is responsible for closing the urethra so that urine is not lost when performing physical efforts such as lifting weights, coughing or even smiling.
But there is a solution for incontinence! The patient is referred to physical therapy, where the physical therapist will guide him to do the necessary exercises correctly to strengthen this muscle. It's like going to the gym to strengthen your arms, but in this case, the focus is on strengthening the urethra. In some occasions, this “bodybuilding” does not solve the problem completely but improves its effects.
If the sphincter injury is acute, the loss of strength is high and physical therapy does not work, there are other methods such as the sling, which puts pressure on the urethra. It resembles the device used to measure pressure.
It is also possible to perform the treatment with the use of an artificial silicone sphincter that involves the urethra and reduces the damage caused by pelvic surgeries, helping the patient to solve urinary incontinence.
Nocturnal erections, which we are not always awake to observe, are extremely important for the health of the penis, they serve to oxygenate the penile tissues.
The surgeries we talked about earlier can end these erections, as the brain action during sleep does not transmit the necessary command through the nerve for an erection to happen.
All penile tissue that has less oxygenation and less blood flow is likely to develop fibrosis with consequent reduction of the penis, which can also result in thinning and loss of erectile function.
The solution to erectile dysfunction varies depending on the degree it is found. In milder cases, oral drug treatment can solve the problem.
If the nerves have been affected, the pills may not work and treatment with penile injections becomes a possibility. With this treatment, the vasodilating action and penile oxygenation is direct, that is, it does not need brain contact.
However, it is important that all the pros and cons in the option of this treatment are exposed by the urologist who accompanies the patient, because the inappropriate use of intracavernous injection can bring unpleasant results, such as priapism.
Some doctors recommend testosterone replacement for patients with prostate cancer. However, replacing the hormone is only possible if a blood test shows that its level is low. In addition, patients with prostate cancer can only consider using hormone replacement if they have been cured of the disease.
It is worth remembering that the testicles and not the prostate are the ones who produce testosterone, so removing the gland does not affect the production of the hormone.
When dealing with a dysfunction in which none of the previous solutions have been ruled out, it is necessary to opt for a surgical treatment that aims to eradicate the problem directly at the root.
Penile reconstruction surgery aims to solve symptoms such as: thinning, decrease in size, curvature caused by fibrosis and loss of caliber. Along with the reconstruction, the use of a penile prosthesis may be indicated, which will guarantee the necessary firmness for the sexual act.
The reconstruction is done with multiple cuts that allow the expansion of vascular tissues. The direction of these incisions is calculated based on the need for correction of the penis: to correct size, horizontal incisions are made that allow the penis to reach its maximum size respecting the limits of the nerves; to correct the caliber, vertical incisions are made that allow the penis to be expanded. I wrote a blog where I explain better the techniques used for penile reconstruction that you can read by clicking here.
It is important to point out that the nerves responsible for the sensitivity of the glans, called Pudendal nerves, are not affected in prostate surgery. This is because it is located at the top of the penis, opposite the nerves that can cause urinary incontinence, located near the bladder. Penile reconstruction is performed on the tunica albuginea, so it does not damage the nerves responsible for the sensitivity of the penis.
The patient who underwent surgery to remove the prostate continues to have orgasms, but, due to the removal of the seminal vesicles and the organ, this patient loses ejaculation. Therefore, he can have orgasms with a flaccid or “dry” penis, where there is no release of sperm.
The dissociation between orgasms and ejaculations is solved in penile reconstruction surgery using a penile prosthesis. This procedure allows the patient to regain an erection and orgasm through the recovery of the firmness of the penis and its size.
It is essential that you know that prostate surgeries and pelvic surgeries cause dysfunction problems but that there are possible treatments to solve these conditions. If you have had any surgery or have questions about how to solve erectile dysfunction, contact me and my team through WhatsApp and we will help you recover your sexual health and self-esteem.
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MD, PhD, Dedicado no Tratamento da Doença de Peyronie, Pênis Curvo e Implante de Próteses Penianas. Doutor em Urologia pela USP, CRM 67482, RQE 19514. - Vencedor do Debate do Sobrevivente da AUA em 2019.