Success with Viagra – 2 years after radical prostatectomy

13 December 2021 – While adapting to and celebrating the joys of softer sexuality, I also admit to pining for the return of hard erections.  Drugs like Viagra and Cialis can help but it is complicated. Today I tried again with the famous little blue pill and it worked! What a lot of fun we had.

I know it is obvious, but there are things some people like to do sexually with an erection. And without the hardness it’s just not the same.

Reflecting on my learning about penile rehabilitation, I now realise there are two quite different potential uses for PDE5i drugs. PDE5i is the name for the category of drugs commonly known by brands like Viagra, Cialis and Levitra. They were originally designed for men to use on demand to support erections in a sexual situation. More recently, a whole new market was opened up: prescribing these drugs as a routine daily medication for non-sexual penile rehabilitation after prostate cancer.

In this post I’ll share my experiences and review the rather inconclusive research. This might help draw some distinctions that have perhaps been blurred in the interests of selling more of these drugs.

Prescribed daily Cialis or Viagra after prostate cancer treatment

It’s not sexy at all (see breakfasts with Cialis) and yet millions of prostate cancer survivors do it worldwide every day. We do it at great expense in the hope that the drug will work some magic with our sexy bits, enabling a return to better sexual function in the months or years to come.

As soon as I reported erectile dysfunction after my radical prostatectomy, my urologist prescribed 5 mg daily doses of Cialis to assist with penile rehabilitation. You take the pills every day at breakfast time for months on end. That’s regardless of whether or not you are sexually active. I did some reading and questioned what seemed to be the shaky scientific basis for this. My urologist acknowledged this and said more or less “it probably helps increase blood flow to the area, even though you might not notice any changes to erectile dysfunction for months. And it probably won’t do any harm.”

Prescribing routine daily doses of Viagra, Cialis, Levitra has become the go-to remedy for most urologists worldwide. I wonder how much these daily prescribed doses of drugs that were previously only used on-demand have added to Pfizer’s Viagra profits. Nowadays as patents run out, many have switched to generic alternatives named sildenafil, tadalafil and vardenafil respectively. That slightly reduces the high cost of taking these every day for months on end. But do they really work as routine non-sexual medication for penile rehabilitation?

Side effects of PDE5i drugs like Viagra and Cialis

Most men report adverse side effects from these medications. Headaches, nasal congestion, nausea, dizziness and indigestion are the most common. For me it felt as if my head was just a bit swollen, thicker than usual, a bit “off.” And I didn’t sleep as well as I usually do.

Of course I persisted in spite of the side effects because sexual function is so important to me. Many other users I have talked with report similar experiences. The common denominator seems to be “I will put up with headaches if I can have my erections back.” However for me, there was no discernable impact on my erections. It’s really an act of faith to keep taking the drugs when there is no obvious penile expansion as a result.

I was overjoyed to find an alternative to Cialis for penile rehabilitation: using a Vacuum Erectile Device (VED) to keep the erectile tissues of my penis healthy. I could immediately see and feel the positive impact. So I happily ditched the Cialis around Month 6. I did carry out an experiment, stopping Cialis for a month and then restarting. Again, there was no discernable difference in erectile function. So I have been getting on fine without the drugs, sleeping better and no headaches. And saving a lot of money on the daily dose of Tadalafil I am no longer buying.

Using Viagra to support natural erections

Now, in Month 22, I just tried again with another PDE5i drug, sildenafil (the generic version of Viagra) and wow, was it a good experience!

There were three big differences: Firstly it was in a sexy situation. Secondly I took the drug that wears off the fastest to minimise side effects. And thirdly my body has had time to recover some (limited) natural erectile function.

In a groundbreaking interview earlier this year, Melissa Hadley Barrett advocated trying every month or two what she calls a “challenge dose.” What she meant was, take one of these drugs when you are sexually active, and see if it supports erectile function in a conducive environment. I had delayed taking her advice because I didn’t want the headaches.

The “Aha” moment for me was to realise that the very thing some men criticise about Viagra could work in my favour. Some people don’t like the fact that Viagra’s effects wear off in about four hours. But neither I nor my partner wanted to go at it for more than four hours (except in my wilder dreams). And we are learning that time often needs to be scheduled for things that are important for us – even sex.

On the other hand limiting headaches to a maximum of four hours sounded very good to me, compared to the 24-hour lifespan of Cialis which left my head permanently “off.”

It worked! I took just 25 mg (half of one of the pills I had been prescribed) on an empty stomach at 7 am. Within half an hour my body was able to respond to arousal just like the good old days. It felt wonderful! We were able to have wonderful, leisurely, mutually orgasmic penetrative sex on a weekend morning. Heavenly! And by 11 am the effects were all gone – both the headache and the easy erections (I checked!).

Inconclusive results from scientific research

There is plenty of evidence that these drugs can support stronger erections in sexy situations for people who have partial natural erectile function. But the scientific case for the daily non-sexual dose for penile rehab is not nearly so strong.

Sex is so infinitely variable that it is difficult to do reliable randomised controlled scientific trials (RCT). The main RCTs on using these drugs daily for penile rehab which I’ve found were done between 2008 and 2015. They were largely inconclusive. The following two studies, published side by side five years ago, show how researchers were able to look at the same data and come to opposite conclusions: yes and no to the efficacy of using PDE-5 inhibitors post radical prostatectomy as erection function rehabilitation.  A study last year concludes that starting the drug therapy immediately after surgery has additional benefits.

There have been a number of systematic reviews of the aggregated studies published recently, such as this particularly wide ranging review in Frontiers in Surgery which includes drugs and alternative rehabilitation methods. It concludes that “clear guidelines for penile rehabilitation after treatment for localized PCa are not easily provided based on current RCT available in literature.”

In other words, nobody really knows whether taking Cialis (or similar) every day actually helps long term recovery of erectile function after prostate cancer treatment.

What the research says (and what it doesn’t say)

Essentially, scientific research doesn’t conclusively prove the best way forward in penile rehabilitation. The researchers I found most convincing advocate trying one or two options in conjunction. The large number of articles advocating daily use of PDE5i drugs may be as much due to the influence of drug manufacturers as coming from hard science.

You can read a dispassionate summary of the situation in plain English here.

Taking the drugs daily in those limp months directly after surgery is something you and your doctor will have to decide on some mixture of faith, economics and science. And my experience says that regular use of a VED like Vacurect can achieve the same health benefits during the limp months at lower cost and with fewer negative side effects.

What the research does say is that the PDE5i drugs like Viagra and Cialis do support erectile function during sexual activity if your body can generate some natural swelling. My own experience this weekend confirms this. In this case, it’s not about rehab. It’s about recovering some of the joy of intimate connection, with the added benefit that you and your partner get to play with a real live erection. Not essential or medical, but nice for those that like it.

How it might be relevant to you

• I suggest a bit of caution before accepting the “daily dose” prescription of PDE5i drugs uncritically.
• The process of recovering erectile function is unfathomably complex. You could try Melissa’s “challenge dose” of one or other PDE5i drug every month or two. It might help get a rise out of your tired member just when you were about to give up.
• Look out for new research opportunities to make more sense of this complex field.

Update February 2024: you might also like to explore mechanical support for erections, either as alternatives or in conjunction with the drugs discussed above. I have recently discovered a remarkably subtle, comfortable and effective soft wearable erection support system – effectively a cleverly redesigned cock ring. The manufacturer says it works exceptionally well in tandem with a PDE5i drug.