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Sex after major urologic

surgery
a b c d
Richard D. Amelar & Lawrence Dubin
a
Associate Clin. Professor of Urology , New York
Univ. School of Medicine ,
b
Director Male Fertility Clinic , Bellevue
Hospital , New York, N. Y.
c
Assist. Clinical Professor of Urology , N. Y. Univ.
School of Medicine ,
d
Director Urology Dpt. , Goldwater Memorial
Hospital , New York, N. Y.
Published online: 11 Jan 2010.

To cite this article: Richard D. Amelar & Lawrence Dubin (1968) Sex after
major urologic surgery, The Journal of Sex Research, 4:4, 265-274, DOI:
10.1080/00224496809550582

To link to this article: http://dx.doi.org/10.1080/00224496809550582

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 The Journal of Sex Research Vol. 4, No. 4, pp. 265-274 November, 1968

Sex After Major Urologic Surgery

RICHARD D. AMELAR AND LAWRENCE DUBIN
One of the chief concerns of patients undergoing prostatectomy
is whether sexual potency will be retained after the operation.,
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Unless there are unusual complications, such as severe peripros-

tatic infection, sexual potency is almost universally retained after
prostatectomy for benign prostatic hypertrophy by the suprapubic,
retropubic, and transurethral routes. It is lost in many cases after
conservative perineal prostatectomy for benign disease, and in all
patients in our experience after total prostato-vesiculectomy by ei-
ther the perineal or retropubic routes when this procedure is per-
formed for carcinoma of the prostate.
Some patients exaggerate their sexual power before the operation
and take refuge in the operation as an excuse for deficient powers
thereafter, a loss more frequently attributable to debility or aging.
Although some patients claim improved sexual function after
prostate surgery by the suprapubic, retropubic or transurethral
routes, this must be attributed to improvement in the patient's gen-
eral condition and not to the operation itself.
Figure 1 illustrates the location of the external and internal
urethral sphincters in relation to the prostate gland. This will help
to understand why, even though potency is maintained, an almost
inevitable sequela of all types of prostatectomy is retrograde ejacu-
lation. The ejaculatory ducts and glands of the prostatic cortex open
into the cavity of the prostatic urethra midway between the external
and internal sphincters. Ordinarily, with ejaculation in the normal
male the external sphincter opens or is relaxed, and the internal
sphincter is closed and the seminal fluid is projected through the
urethra. Following prostatectomy, the internal sphincter has either
been completely removed or traumatized, and when ejaculation oc-
curs the seminal fluid flows back into the bladder and is voided
with urine at the next micturition. In some patients the ability to
ejaculate through the anterior urethra returns later, particularly
if the internal sphincter regains part or all of its function.
We have on several occasions successfully retrieved motile sperm
from the bladder in patients who developed retrograde ejaculation
265
 266 RICHARD D. AMELAR AND LAWRENCE DUBIN

URETER

INTERNAL URETHRAL SPHINCTER

AT BLADDER NECK

EJACUtATORY DUCT EMPTYING

-INTO PROSTATIC URETHRA ALONG
WITH PROSTATIC DUCTS
EXTERNAL URETHRAL SPHINCTER
" A T MEMBRANOUS URETHRA
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»COWPER'S GLANDS EMPTYING

INTO BULBOUS URETHRA

-CORPUS SPONGEOSUM

-CORPUS CAVERNOSUM

-URETHRA

TESTICLE -GLANS PENIS

URETHRAL MEATUS
TAIL O F / 'CONVOLUTED
EPIDIOYMIS PORTION OF VAS

Fie. 1. Sketch of male genital organs, illustrating testicle, epididymis, vas deferens,
seminal vesicle, ejaculatory and prostatic ducts, and their relation to the internal and
external urethral sphincters, bladder, prostate and urethra.

after prostatectomy, and pregnancies have resulted from the tech-

nique of artificial insemination using sperm thus retrieved (Amelar
and Dubin, 1968). Of course, if the patient desires further progeny,
a routine bilateral vasectomy should not be performed, as it usu-
ally is done during the prostatic surgery in order to cut down mark-
edly on the incidence of post-prostatectomy epididymitis.
The reason for a high incidence of impotence after perineal pros-
tatectomy is not clear, probably because the physiology of erection
is not well understood. The loss of potency is usually attributed to
damage to the nervi engentes, which control erection; yet impotence
may develop even though these nerves are kept well out of the op-
erative field. Other factors are vascular damage to the penile veins,
and the disturbance of mechanical support to erection by a perineal
incision which may affect the insertions of the corpora cavernosa and
spongiosum.
 SEX AFTER MAJOR UROLOGIC SURGERY 267

There is no satisfactory form of treatment to restore the sexual

potency which is lost after perineal prostatectomy. Impotence is not
only a common sequelae after perineal surgery for resection of the
prostate, but may also occur after simple open perineal biopsy of
the prostate where the prostate has not been removed. This problem
of loss of potency does not occur with the much simpler transrectal
or perineal needle biopsy of the prostate and these methods should
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be used as the routine methods of prostatic biopsy.

When a patient has a carcinoma of the prostate which is not sur-
gically completely resectable, the recommended therapy is usually
castration and estrogens. In performing such a procedure, we ex-
plain to the patient that the portion of his testicles which is pro-
ducing the hormones causing his tumor to grow will be removed;
and when the operation is performed, it is not difficult to excise
the testicles completely and leave the epididymis in place. The epi-
didymis may then be rolled into a ball and sutured into the form of
sphere and this leaves the patient with palpable structures within
the scrotum, even though all testicular tissue has been excised. We
have found that such procedure is psychologically much more ac-
ceptable to the patient and it has been our experience that even after
estrogen therapy has been started the patient for a long time retains
his sexual potency and in many cases of castration for carcinoma of
the prostate, immediate impotence is not a post-operative complica-
tion.
A technique has been reported (Amelar, 1962) for the performance
of a simple subareolar bilateral mastectomy at the time of castra-
tion which subsequently prevents the development of gynecomastia
when the patient is given estrogens. Figure 2 demonstrates what
happened to the breasts of a man with carcinoma of the prostate
with the use of estrogens. He did not have a preliminary subareolar
mastectomy. He complained bitterly of his large breasts and refused
to be seen in public and as his breasts got larger his sexual potency
fell off. A plastic operation on his breasts to remove the enlarged
glandular tissue resulted in a happier patient. However, in many
cases gynecomastia may not be significant or disturbing to the pa-
tient.
The congenital absence of the testicles is, in itself, thought to be
incompatible with good sexual performance. A case in which normal
sexual function was retained has been reported (Amelar, 1956). The
 268 RICHARD D. AMELAR AND LAWRENCE DUBIN
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FIG. 2. 58 year old man with estrogen-controlled prostatic cancer. Estrogen therapy
started in 1953. Disturbing breast enlargement noted in 1954. The patient was receiving
5 mg. Stillbesterol daily.

only other previous case which had been reported was in 1564 when
Cabrol performed an autopsy on a man who had been hanged for
rape and he was unable to find any testicles. Since this fellow was
punished for the deed, we will give him the benefit of the doubt
and assume that he was guilty of the crime. The case which was
reported four centuries later Avas that of a man with normal sexual
potency and desires, and capable of ejaculation, but was born
with a congenital bilateral absence of testicles. In this case, his
psycho-sexual development along masculine lines with normal male
sexual urges and the preserved ability to have ejaculations, was at-
 SEX AFTER MAJOR UROLOGIC SURGERY 269

tributable to the occurrence of extra-testicular Leydig cells found

scattered in islands along the Wolffian duct structures in his inguinal
canals. This patient was made very happy by the insertion of acrilic
testicular prostheses into his scrotum which filled out the scrotum so
that he did not have to be embarrassed in the locker room.
Figure 3 shows the appearance of his penis and scrotum before and
after the insertion of the acrilic prostheses into his scrotum for cos-
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metic effect. These plastic testicles were at that time manufactured

in the hospital dental laboratory. They have since become available
through surgical supply houses, and are now made of a softer sili-
conized material.
A subsequent report by J. Money and D. Alexander (1967) on six
cases of males with congenital bilateral anorchia appeared in this
journal in February of 1967. In four of these cases with satisfactory
followup sexual performance was retained, and in one case the pa-
tient's sexual infidelity led to divorce, many new partners and even-
tual remarriage.
Under normal conditions, reflex erection subsides when the stim-
ulation which called it forth ceases. Long continued persistant en-
gorgement of the erectile tissue or priapism, must therefore be

Fie. 3. Use of testicular prosthesis to fill empty scrotum. A. Pre-operative view of

empty scrotum. B. Post-operative view showing testicular prosthesis in place. C. Acrylic
prosthesis which was placed in scrotum for cosmetic effect.
 A-aserans oiooio-an "aofviv ^HX-IY xas

270 RICHARD D. AMELAR AND LAWRENCE DUBIN

regarded as pathologic, although to the impotent male who doesn't

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get erections, priapism must seem like Valhalla.

Priapism is a pathologic erection not associated with sexual de-
sire or ability to have intercourse. It is extremely annoying, dis-
abling, and a sometimes frightening condition, requiring hospitali-
zation for treatment. Most of the cases we see these days are idiopathic
or are associated with some vascular disturbance such as sickle cell
anemia. Most patients give a history of immediately-preceding heavy
sexual activity. When surgical correction by incision or surgical
drainage of the corpora cavernosa is required to reduce the erection,
the patient is usually impotent thereafter. A clever operation to
correct priapism and relieve the pathologic erection was described
by Grayhack and his co-workers (1964), in which the saphenous
vein is anastomosed to the corpora cavernosa to aid in the drainage
of the venous stasis. However, in order for the patient to achieve
erections thereafter, it is necessary for him to compress his saphenous
veins.
Normal erection results from an increased flow of blood into the
corpora cavernosa and a restricted venous return. The principal
factor is the arterial dilation and the venous return is largely passive.
Every disturbance interfering with this mechanism results in dys-
function. Increased inflow of the arterial blood may be caused by
irritation or lesions of certain parts of the central and peripheral
nervous system. Anoxia with the accumulation of carbon dioxide
leading to irritation of the bulbar vaso-dilator system produces erec-
tions which all urologists and surgeons at one time or another have
observed in the course of anesthesia during surgical procedures.
Anoxia by the same mechanism produces priapism in men dying of
suffocation, hanging or carbon dioxide intoxication (Callomon,
1956).
Forensic reports of the finding of strangulation marks on the necks
of young men in California after a sex orgy were related to attempts
at producing repeated erections by causing anoxia, illustrating again
that a good thing can be carried too far.
A presentation on sex after major urologie surgery would not be
complete without a consideration of sexual function after the most
radical type of urologie surgery, namely after complete amputation
of the penis. Drs. Morales, O'Conner and Hotchkiss (1956) from the
 after total loss of the penis in which the reconstruction was per-
formed not only for cosmetic reasons but also to provide the patient
with a sexual organ satisfactory to himself and to his sexual partner.
Two different types of plastic procedures have been utilized, both
with satisfactory results. The first method is by the construction of
a migrating tubed pedicle flap and the other method employs the
construction of a scrotal tubed pedicle.
Figure 4 is a photograph of a fifty-three year old man who under-
went a radical amputation of the penis and perineal urethrostomy
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FIG. 4. The patient was a 53 year old man who underwent radical penile amputa-
tion for cancer. (Top) Tube graft has been formed and transferred to the pubic re-
gion. (Bottom) The newly formed phallus.
 272 RICHARD D. AMELAR AND LAWRENCE DUBIN

for squamous cell carcinoma of the penis, following which a bilateral

groin disection was performed in two stages and no tumor was noted
in the specimens removed from the groin. The plastic construction
of a new penis was completed 11 months later and one month after
that, an acrilic rod was implanted into the new penis. This was in-
tended to serve as a splint for the new penis in much the same man-
ner that the rib cartilage transplants have been used for this purpose
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by others.
The patient returned periodically to the outpatient clinic and
reported that he was able to consummate the sexual act, achieve
orgasm and ejaculation.
Urination was performed through the perineal urethrostomy with-
out difficulty. The plastic splint, however, was extruded sponta-
neously from the distal end of the penis two months after the pa-
tient's discharge from the hospital. The absence of the splint did
not impair the patient's sexual ability since the penis apparently
had enough rigidity to permit intromission.
Figure 5 is a photograph of a 34 year old man who underwent
penectomy and perineal urethrostomy for carcinoma of the penis fol-
lowed by radical bilateral groin disections in which no tumor was
found in the inguinal regions. A new penis was constructed from
a scrotal tube three months later and at the same time a plastic
splint was inserted into the penis. The patient was able to enjoy
marital coitus after leaving the hospital. One month later the splint
was spontaneously extruded. The unreinforced penis, however, re-
mained capable of penetration and the patient's sexual ability was
maintained. In addition to these two gentlemen, two other patients
have had reconstruction of the penis after radical penectomy for
carcinoma and all have had a satisfactory sexual life after leaving
the hospital.
Total loss of the penis may precipitate serious mental depression.
This situation obviously does not stem from a loss of reproductive
capacity, but the patient's plight is primarily concerned with the
sexual incapacitation which developed in a man still possessed of
normal desires. The depressive reaction often is jointly shared by
the Avife, who may be incapable of adjusting herself to abstinence.
It is well documented that the genitalia are not the only structures
involved in sexual response. It has long been recognized that there
 SEX AFTER MAJOR UROLOGIC SURGERY 273
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FIG. 5. The patient was a 34 year old man who underwent radical penectomy for
squamous cell carcinoma of the penis. (Top) A tubed pedicle has been raised from the
scrotum. (Bottom) The reconstructed penis 3 months later.

are certain areas of the body which are richly supplied with end or-
gans of touch and which function as erotic zones. Arousal sufficient
to effect orgasms can be achieved when these areas are directly
stimulated. Evidently the rehabilitated penile amputee may receive
erotic satisfaction from the stimulation of other portions of his
body in much the same way that some paraplegics are able to achieve
orgasm in spite of the absence of genital sensations.
It is also known that erotic sensations are derived not only from
tactile stimulation but also from psychological elements. In as much
as the sexuality of these men on the psychic level is usually un-
 approach normal intensity in time. We have learned that the use
of splints is not necessary in these newly constructed phalluses.
In conclusion, it should be stated that sexual function need not
end after most major urological surgery. Satisfactory sexual activity
can continue with occasional assistance from the urologist if the
libido remains intact.
References
AMELAR, R. D. Anorchism without Eunuchism. Journal of Urology, 76: 174-178, 1956.
AMELAR, R. D. Subareolar Mastectomy to Prevent Estrogen-Induced Male Breast En-
largement: A New Procedure for Use in Patients with Carcinoma of the Prostate.
Journal of Urology, S7: 479-484, 1962.
AMELAR, R. D. AND DUBIN, L. Management of the Infertile Male, Current Therapy.
H. F. Conn, Editor, W. B. Saunders Co., Philadelphia 1968.
Downloaded by [Memorial University of Newfoundland] at 06:35 03 August 2014

CALLOMON, F. T. AND WILSON, J. F. The Non-venereal Diseases of the Genitals. Charles

C Thomas, Springfield, Ill., 1956, pp. 334-341.
GRAYHACK, T., MCCULLOUGH, W., O'CONNER, V. J., AND TRIPPEL, O. Venous Bypass To
Control Priapism. Invest. Urology, 1: 509-513, 1964.
MONEY, J. AND ALEXANDER, D. Eroticism and Sexual Function in Developmental
Anorchia and Hyporchia with Pubertal Failure. Journal of Sex Research, 3: 31-47,
1967.
MORALES, P. A., O'CONNER, J. J., AND HOTCHKISS, R. S. Plastic Reconstructive Surgery
after Total Loss of the Penis, American Journal of Surgery, 92: 403-408, 1956.