@johnsonjn Both surgery and radiation have lower risk of ED with improved treatment methods. This is nerve sparing for surgery and better targeting that misses the penile bulb for radiation. For radiation you want to have the latest equipment with either MRI or CT targeting of the prostate (ie IGRT). One of these will be built into the latest radiation machines. Even though there is mixed data on effectiveness I followed the surgery penile rehab practice of using 5mg generic Cialis daily during and after treatment. It is cheap and also improves urine flow (not as much as Flomax but with better side effects). Strategy is to keep the blood flow and hope to prevent fibrosis scar tissue a primary cause of radiation ED. As far as ED, Brachytherapy probably has the best profile for least loss (is highest for urethra side effects).

Before getting IMRT you want to get a Prostox test. This is newly (2026) commercialized germline genetics test developed at UCLA that predicts if you are in the 12-13% of the population that have a high risk (avg. 75%) risk) of late radiation toxicity. Most common are ED, radiation proctitis or cystitis. These can occur 1-3 years after treatment. If you are not high risk on Prostox there is still a 7% chance of having one of these symptoms. There is a discussion of Prostox with video on this board. There is a separate test for SBRT with about 20% overlap of a person scoring high on both.

Check with your insurance to make sure the treatment you want is covered. Almost no work insurance (including mine) will cover Proton radiation. May not cover SBRT (5 fractions at 7-8 Gys) as a primary treatment. IMRT at 20 fractions of 3.0 Gys is preferred but up to 39 fractions at lower Gys may be approved. Regardless of the protocol get SpaceOar or other gel to minimize rectal side effects.

On ADT testes shrink 25-50% even in 6-months. Recovery tends to be slower but does occur when off the meds. They will also give you ED which I expected. I took Calcium Citrate w/D3 to minimize ADT induced bone loss.