I had nerve Sparing RARP at Mayo Rochester in late October 2025. I am 64 years old. Gleason (3+4) 7. Post-surgery pathology showed multifocal 2mm margins, including 4's, and the prostate biopsy showed some cribriform. For now, six months out, my PSA (previously 11) remains undetectable, so I won't worry too much about that until I hear otherwise.

Sexually, everything worked fine before surgery. I hate to be the bearer of bad news, but post-surgery has been an ongoing project in that area. I immediately started taking 5 mg Cialis daily post-surgery, and an additional 15 mg as needed, doing Kegels, and using a pump and encouraging erections (Use it or lose it). I was able to get an erection right away after catheter removed. But.... it was not what it was prior, and it has not returned to that.

My first orgasm masturbating, I was expecting the dry orgasm, but much to my surprise I shot gushing spouts of urine all over the bedroom ceiling and walls. It was shocking!! That is called climacturia. I ejaculate urine when I have an orgasm. It turns out that is common post RARP, but I hadn't read the fine print.

I otherwise regained continence after a couple of months except... in addition to climacturia, I have "arousal incontinence" If I start making out or getting aroused, I leak unexpectedly without warning.

I am now six-months post-surgery. I can get an erection sufficient for penetrative sex, but it takes some work. The problem now is that I cannot maintain it until orgasm when I am having intercourse. I can have an orgasm masturbating, but it takes longer, and I have to clamp the base of my penis to keep it hard when I get close to orgasm. I try to empty my bladder as much as possible before any sexual activity, but I still get some level of climacturia.

My partner is very patient and understanding. Fortunately, my boners do last long enough to satisfy her, so that is a relief. She says it is no problem if I pee on her or in her, so that should be reassuring. Despite that, I have had only one orgasm with her in the last six-months. I use Viagra and/or Cialis, but it is still not enough to keep me hard to orgasm. Erections overall are maybe at 75% of baseline when I start, but they fade.

People and AI recommend using a condom or cock-ring for the climacturia. Neither is very helpful. Theoretically a condom would contain the urine, but it is not an issue because I am unable to orgasm while wearing one. The cock-ring made no difference in stopping the pee.

I recently went back to Mayo Men's Health Clinic and got a prescription for Trimix. It is supposed to be like Viagra x 10. Trimix is injected into the penis with a needle. I did not like the practice run in front of the nurse very much, but C'est la vie. I am optimistically awaiting its arrival.

Mayo Men's Health said that, as a practical matter, I was at max improvement. That is despite the literature that says function can improve for 18 to 24 months before reaching the new baseline. The Mayo provider said that, while there may be further improvement (consistent with the literature) that for me it would be very incremental and insignificant from my present situation. Mayo said I was eligible for the implanted pump surgery and we discussed that option. If necessary, that sounds very viable. I will give Trimix a chance first.

It has taken a toll psychologically. I think that aspect is under appreciated by the Urology clinics. At least that is my experience with Mayo. I am practical. It is what it is. I had cancer and the ED is collateral consequence. I will deal with it. But, despite a very understanding and generous partner, it has had a significant impact on my sex life and self-confidence. Perhaps my self-identity is too intertwined with my sexuality. Not much to do about that now except to work on accepting the new reality.

I don't want to steal the thread, but does anyone else want to share comments about the psychological and emotional challenges of ED post RARP?
Jim