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Prostatectomy/Prostate Cancer Surgery: What To Expect & What Your Doctor Might Not Tell You

Prostate removal surgery, or prostatectomy, is a very common procedure. It is often performed when someone is diagnosed with prostate cancer that has not spread anywhere else in the body.

Prostatectomies are life-saving surgeries. Because prostatectomy often accompanies a diagnosis of cancer, many men undergoing the procedure are only aware of one of its outcomes—becoming cancer-free! However, there are other definite and potential outcomes of the surgery that every man undergoing the procedure deserves to know and understand.

This article outlines what to expect after surgery, specifically: a change in penis length, dry ejaculate, urinary incontinence, erectile dysfunction, and increased risk of hernia.

If you’d rather watch me discuss these topics than read about them, check out this video from my youtube channel below:

To understand why a prostatectomy could result in the aforementioned outcomes, one must understand the male pelvis. Let’s first begin by breaking down male pelvic anatomy.

Male Pelvic Anatomy

Male pelvic cross section

Above is a drawing of a cross section of a male pelvis. Pay special attention to the green gland located under the bladder labeled as “prostate,” and the orange tube beginning at the base of the bladder, running through the prostate, and exiting at the head of the penis labeled as “urethra.” The prostate gland secretes fluid into male ejaculate. It also helps propel semen into the urethra during ejaculation. The urethra is the tube that carries both urine from the bladder to the head of the penis, and semen from the testes or testicles to the head of the penis.

Below is the same photo, but with a red line indicating the flow of urine. It flows from the bladder, into the urethra, through the prostate, to the head of the penis.

male cross section with flow of urine outlined

Semen or ejaculate, on the other hand, begins in the testicle. Now, pay special attention to the pink “testis” and red “epididymus” connected to the prostate via the red tubing labeled “vas deferens.” Semen begins in the testis or testicle, then travels to the epididymus, where it flows through the vas deferens before emptying into the urethra, and exiting via the head of the penis.

Below is the same photo, but with a red line indicating the flow of semen.

male cross section with flow of semen outlined

When the prostate is removed, the entire green gland, the portion of the urethra that runs through the gland, and the portion of the vas deferens that connects with the urethra in the gland are all removed, too. This makes sense out of some of the surgical outcomes.

Change In Penis Length

Since prostate removal includes removal of part of the urethra, the urethra is sewn together again. It is sewn together at the base of the bladder, and at the base of where the prostate used to be—outlined below in red.

red markers indicating where urethra would be sewn together

The urethra connects to the entire shaft of the penis. You can imagine pulling on the urethra could figuratively change the length of the penis. When the portion of the urethra that lives in the prostate is removed, the remaining urethra is pulled up and sewn to the base of the bladder. This creates a shorter penis length by about 0.5 – 1 inches. This is a completely normal and expected outcome of prostate removal.

A catheter holds open the sewn urethra as it heals! Usually the catheter stays in place between 3-10 days after surgery, depending on the surgeon.

Dry Ejaculation / Dry Orgasm

When the prostate is removed, there is no way to spare the connection between the urethra and the vas deferens—highlighted in red below.

Connection between vas deferens and urethra

In other words, there is no longer a pathway for semen to exit the body. This does NOT mean you will no longer experience an orgasm. You will still orgasm, and your testicles will still create sperm; however, the sperm will not exit through the head of the penis and will instead be reabsorbed in your body. This is a completely normal and harmless outcome following prostatectomy.

Urinary Incontinence / Leaking Urine

Unfortunately, pelvic physical therapy cannot change penis length or dry ejaculate; however, pelvic physical therapy can help a LOT when it comes to leaking urine!

Continence simply means that you have control of your bladder and bowels. Incontinence means that you do not have control. Someone with urinary incontinence, therefore, does not have control over his bladder and leaks urine.

There are two types of urinary incontinence: stress incontinence, and urge incontinence. Stress incontinence means urine leakage with increased intra-abdominal pressure. Think coughing, sneezing, jumping, downhill hiking—essentially movement-induced leakage. Urge incontinence means urine leakage associated with the urge to urinate. Usually, men experience stress incontinence after prostate removal.

Urinary continence is fueled by two things: healthy nerves, and healthy pelvic floor muscles.

You can imagine that the nerves that live near your prostate are affected by prostate removal, and may be injured. These nerves happen to play key roles in urinary continence. Unfortunately, even “nerve-sparing” prostatectomies can result in leaking urine, or urinary incontinence. The literature does not offer an unwavering statistic, instead the chance that you may have urinary incontinence following prostate removal ranges from less than 10% to over 80%, depending on who you read.

You can also imagine that your pelvic floor muscles, simplified in red in the image below, are also affected and potentially injured by prostate removal.

simplified pelvic floor

Another simplified depiction of the pelvic floor muscles:

While we cannot change the rate at which nerves heal, we can change the rate at which the pelvic floor heals! Pelvic physical therapy can help to wake up your pelvic floor after surgery, and help you regain control over your bladder, faster.

Urinary Incontinence / Leaking Urine: Getting Your Catheter Removed

I always encourage the men that I work with to bring pads when they get their catheter removed. This is because some men will experience immediate incontinence—or immediate urinary leakage—upon catheter removal.

If you go to the catheter removal appointment prepared, it can save a lot of heart ache! You won’t have to drive home or to a local pharmacy with wet pants looking for pads.

Male pads for urinary leakage are usually referred to as “male guards,” and are available at most local pharmacies. Some common brands include: Depend, Tena, and Prevail.

Go to your appointment prepared, and hopefully you won’t need the pads!

Erectile Dysfunction

Erectile dysfunction is a common outcome following prostate removal. There are important nerves that help initiate and maintain erections that may be injured even in “nerve-sparing” procedures.

We do not have good statistics to represent the chance of erectile dysfunction following prostatectomy. However, we do know that it takes 1-2 years for the injured nerves to recover, and that men continue to regain the ability to initiate and maintain an erection for up to 4 years after surgery.

There is also some budding research investigating the use of Viagra and other erectile dysfunction medications post-operatively to regain erectile function faster. The medical literature does not back up the claim that taking Viagra after prostatectomy can positively influence erectile function; however, some physicians have seen positive clinical outcomes and will prescribe the medication either daily, or as needed. If this is an option that interests you, discuss it with your surgeon!

Finally, both the ability to initiate and maintain less rigid erections and “morning wood” are very positive signs in regaining erectile function!

Increased Risk for Hernia

Following prostatectomy, you are at an increased risk for a hernia—specifically an inguinal hernia. An inguinal hernia occurs in the groin. It is the bulging of soft tissue (usually fat or part of the intestines) through a weak area in the lower abdomen.

inguinal canal and inguinal hernia

The only way to repair an inguinal hernia is with surgery. You don’t need another surgery!

The best thing to do to avoid an inguinal hernia, is to avoid straining. Straining means inhaling, holding your breath, and pushing. This puts a lot of force on your abdominal wall. I often find men are accidentally straining in two places: the bathroom, and the gym.

The Bathroom

If you have to hold your breath and push to have a bowel movement, you’re straining!

The best things to do to avoid straining on the toilet are: managing constipation, and using proper toilet positioning.

If you are taking opioids for pain management after your surgery, you’re at a higher risk for constipation. Work with your physician to make sure your stool is as soft as possible.

Regardless of whether or not you’re taking opioids, sit on the toilet properly when you defecate!

1. Sit with your knees higher than your hips
2. Spread your legs a little bit larger than hip width apart
3. Gently lean forward on your elbows or forearms
4. Let you abdomen relax, “pooch,” and let go
5. Inhale belly big, belly hard and gently bulge your abdomen without holding your breath to initiate defecation
6. Continue to breathe, do not strain

The Gym

The key to exercising without causing a hernia is to exhale while you exert. Imagine weight lifting, or intense body weight exercises. If you cannot breathe through a motion, and instead have to hold your breath and push to accomplish said motion, you’re straining! Decrease the intensity of the exercise until you can breathe through the entire movement.

The same rule applies to other daily activities like lifting heavy groceries, or a small child off of the floor. Exhale while you exert to protect your abdomen!

In Summary

Prostatectomy results in both a change in penis length and dry ejaculate. It may result in urinary incontinence and erectile dysfunction. It also increases your risk of developing an inguinal hernia. You deserve to know and understand these definite and potential outcomes.

Pelvic physical therapy can help restore urinary continence and manage hernia risk. I recommend seeing a pelvic physical therapist at least 6 weeks post-operatively, if not pre-operatively as well. Imagine a total knee replacement surgery. You might strengthen your quadriceps, the muscles that live in the front of your thigh, before surgery. This makes it easier for your quadriceps to “wake up” after surgical trauma. The same can be said for your pelvic floor after prostatectomy!

Getting a prostatectomy? Find a pelvic provider in your area, here!

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