What the surgery does
The nerves that trigger an erection — the cavernous nerves — run in two bundles along the back and sides of the prostate, close enough that they are effectively wrapped around the organ being removed. There is no route to the prostate that does not come near them.
A nerve-sparing prostatectomy separates those bundles from the prostate rather than cutting them. But separating them still means handling, stretching and heating tissue that does not tolerate any of those things well. The result is neurapraxia — a bruised nerve that has stopped conducting but has not been severed.
That distinction is the whole story of recovery. A cut nerve does not come back. A bruised one does, slowly, and on a timescale set by biology rather than by how motivated you are.
The timeline nobody quite tells you
In the first weeks after surgery, most men have no spontaneous erections at all. This is the expected finding, not a complication.
Function then returns gradually over twelve to twenty-four months, and in some men it continues improving beyond two years. The curve is slow and uneven — a good night followed by three poor ones is the normal pattern, not a relapse.
Three things predict where you land: how good your erections were before surgery, your age, and whether one, both or neither nerve bundle was spared. A man of 55 with normal pre-operative function and bilateral nerve sparing has a substantially different outlook from a man of 70 with pre-existing vascular disease and a non-nerve-sparing operation, and the two should not be given the same expectations.
Why the pills may do nothing at first
Sildenafil and tadalafil do not create an erection. They amplify a nitric oxide signal that the nerves have to deliver in the first place — which is precisely the thing that is not working after surgery.
So a man who takes a full dose in month two and gets nothing has not learned that pills will never work for him. He has learned that the nerve is still quiet. The same dose at month twelve frequently produces a completely different result, and this is one of the few situations in ED treatment where retrying something that previously failed is actively worth doing.
Penile rehabilitation, honestly assessed
Many surgeons start men on a low daily dose of tadalafil, or on injections, soon after surgery. The theory is that regularly oxygenating the tissue prevents the erectile tissue from becoming fibrotic and losing elasticity while the nerves are out of action.
The theory is biologically sound. The evidence that it improves the final outcome is genuinely mixed — some trials support it, others show no difference against treating on demand. You will meet urologists with firm views in both directions.
What can be said fairly: it is low-risk, it gets you using the treatment ladder early rather than waiting passively, and it tends to produce results sooner even if the two-year endpoint turns out the same. If your surgeon offers it, there is little reason to decline. If they do not, it is a reasonable thing to ask about.
What works while you wait
Injections bypass the problem entirely. Alprostadil injected into the erectile tissue opens the arteries directly, without needing any nerve signal to arrive. That makes it the most reliable option in the first post-operative year, and it is offered far less often than it should be. How injections work.
Vacuum devices work by mechanics alone, so nerve status is largely irrelevant to whether they produce an erection. They are also used in rehabilitation protocols for the same tissue-oxygenation reason. Vacuum devices explained.
Implants are the endpoint, not the failure. For men who reach two years with no useful recovery, an implant has the highest satisfaction rate of any ED treatment. Nobody should be rushed there, but nobody should be left to believe that a poor two-year result is the end of the road either. What implant surgery involves.
The things men are not warned about
Two changes surprise men because they are frequently left out of the pre-operative conversation, and both are worth knowing in advance rather than discovering.
- Orgasm without ejaculation. The prostate and seminal vesicles produce most of the fluid, and both are gone. Orgasm still happens and still feels like orgasm; nothing comes out. This is permanent and expected.
- Leakage of urine at orgasm — climacturia — affects a meaningful minority, usually improving as continence returns overall.
- Some loss of length is commonly reported in the first year, and is one of the arguments made for early rehabilitation.
- Sensation is usually preserved. The nerves carrying sensation are different from the ones carrying the erection signal, which is why men who cannot get an erection can still feel everything normally.
Radiation is a different curve
Where surgery causes immediate loss followed by gradual recovery, radiation typically does the opposite: function is reasonably preserved at first and then declines over the following two to five years, as vascular damage accumulates.
That matters when comparing treatment options, because the short-term comparison flatters radiation and the long-term one is closer than men expect. It also means a man doing well eighteen months after radiation should not assume he is out of the woods.