Erectile Dysfunction (ED) is defined as the consistent or recurring inability of a man to achieve and/or maintain an erection sufficient for satisfactory sexual performance or intercourse.15
The concept of penile rehabilitation is based on the practice of giving men medications to:
- achieve erections
- protect erectile tissue (which is predominately muscle)
- maximize the ability of the patient to recover his pre-operative erectile function (if the patient has had radical prostatectomy)
- if the patient has had radiation therapy, to maximize the chances of him preserving his pretreatment erectile function.
Any treatment for ED is aimed at getting the patient off treatment.16
The longer a man goes without erections after prostate surgery, the more likely he is to suffer permanent erectile tissue damage. The damage is called atrophy, but is actually scarring of the erectile tissue. If the erectile tissue becomes scarred, the patient will never get his erection back without medication and will always struggle to respond even with medication.
Evidence suggests that the incidence of erectile tissue damage, as measured by the presence of a venous leak, is very uncommon before the fourth month after surgery. However, at eight months after surgery, it occurs in approximately 30% of men, and, at one year, 50% of men have permanent erectile tissue damage. It is believed that this damage results from two main factors: erection nerve injury and the absence of blood (and therefore oxygen) getting into the penis. This is the "use it or lose it" phenomenon. The aim of penile rehabilitation is to keep the erectile tissue healthy while waiting for the nerves to recover from the trauma of surgery. 16
A review by the International Journal of Impotence Research about the Cleveland Clinic Penile Rehabilitation Following Radical Prostatectomy experience states:
- Erectile dysfunction is one of the most important quality of life issues following radical prostatectomy.
- The potency rates reported following nerve-sparing technique vary between 40 and 86%.
- The time period for complete recovery of erectile function varies from 6 to 24 months.
- The literature evidence suggests that lack of natural erections during this period of time increases the incidence of venous leak.
- Recently, there is a growing interest among physicians to interrupt these events by preventing cavernosal hypoxia (lack of oxygenated blood flow to the penile tissue) during the period of neuropraxia (trauma invoked to the nerves during surgical dissection of the neurovascular bundles).
- Initial studies using intracavernosal injection show that it appears to be beneficial.17
What is penile rehabilitation
To date, penile rehabilitation has shown promise in helping men who undergo radical prostatectomy (RP) to retain erectile function after surgery. Owing to favorable safety profiles and ease of use, pharmacological therapy is currently the most attractive treatment option for these patients. PDE5 (Phosphodiesterase type 5) inhibitors include Sildenafil (Viagra), Vardenafil (Levitra) and Tadalafil (Cialis). PDE5 C inhibitors have been the main focus of interest, although a combination of PDE5 inhibitors and intracavernosal (injections) or intraurethral (suppositories) alprostadil might be suitable for patients with insufficient responses to treatment with PDE-5 inhibitors alone.18
After a prostate cancer diagnosis, most patients are not thinking so much about the after-effects of prostate cancer treatments. The post-treatment phase is an important time for clinicians to provide this education and support. Many couples receive no help coping with the sexual changes that occur as a result of prostatectomy (or other prostate cancer treatments), in spite of considerable research supporting ED treatments. Kendirci and colleagues (2006) write that in a study of 1,977 men, about 50% reported receiving ED treatment after undergoing a prostatectomy. Although physician surveys indicate that pharmacological erectile rehabilitation is widely practiced with patients undergoing prostatectomy (Teloken, 2007), patient surveys report a different conclusion (Herkommer, Hiespodziany, Gschwend, & Volkmer, 2006;Kendirci et al., 2006). Health care providers are not always effective in providing information, counseling and rehabilitation.19
Recovery of erectile function after prostatectomy normally occurs approximately 18 to 24 months after surgery. There are men who have fully functional erections at six months, but if you look at the general prostatectomy population, the vast majority of men experience erectile function recovery in the second year and many between 18 and 24 months postoperatively. Many patients, if they are not made aware of these realistic expectations, will become significantly depressed by the failure of erections to recover between 6 and 12 months after surgery.16
Medications used in penile rehabilitation after prostate treatment
Phosphodiesterase type 5 inhibitors are medications that increase blood flow to the penis under certain conditions. There is excellent evidence that a man who has good function before surgery, who has nerve-sparing surgery, and who protects his erectile tissue through penile rehabilitation, has an excellent chance of being a PDE5i responder in the second half of the second year after surgery (18 to 24 months). The overwhelming majority of men (85%) do not respond to PDE5 inhibitors in the first six months after surgery irrespective of their nerve sparing status. This is due to temporary cavernous nerve trauma, which leads to the inability to secrete nitric oxide (a chemical that is essential to erectile function).16
Intraurethral Alprostadil (Muse)
Muse is an intraurethral suppository of alprostadil (a prostaglandin) used for the treatment of erectile dysfunction. This suppository looks like a small pellet about the size of a grain of rice. After urination (so the urethra is wet), the Muse applicator is gently slipped into the tip of the penis and goes slightly over an inch down into the urethra. The patient depresses the button on top of the applicator to release the Muse into the urethra for absorption. The penis is rolled between the hands for a minimum of 10 seconds to dissolve the Muse.
Since pain is common after prostatectomy, the first dose of Muse should be given during a routine post-prostatectomy office appointment, with blood pressure being assessed before and after administration and with lower dosages initially.20
Raina et al investigated intraurethral alprostadil in 91 healthy, sexually active men, of whom 56 were treated with intraurethral alprostadil and the remaining 35 had erectogenic aids only when needed for sexual intercourse. Treatment was initiated three weeks after RP. This regimen resulted in 74% and 37% of regained erections sufficient for intercourse and a Sexual Health Inventory for Men (SHIM) score of 18.9 and 15.8 for the treatment and control groups, respectively. Although the authors concluded that intraurethral alprostadil seems to shorten the time to recovery of erectile function after RP and is safe and tolerable, one has to be critical in evaluating these results as the drop-out rate in the treatment group was 32%. Most of the men discontinued treatment due to lack of efficacy (50%), reduced sexual interest (27%) and adverse effects around the treatment site such as urethral pain and a burning sensation (23%).21
Patients seeking a treatment option with proven efficacy that provides a fairly natural-feeling erection without a constriction ring may be interested in penile injections. Penile injections use vasoactive medications injected into the side of the base of the penis to dilate the blood vessels causing penile engorgement. Commonly used injectable agents include prostaglandin E1, papaverine and phentolamine.19
Penile injections are one of the most effective treatment options for men after prostatectomy, with success rates reported as high as 85% to 95%. Jeffrey Albaugh's study revealed that among post-prostatectomy men at one month after treatment with penile injections, 80% of study participants reported mild or no erectile dysfunction and 25% reported normal erectile function. At three months, 75% reported mild or no erectile dysfunction, and 35% reported completely normal erectile function. Injections resulted in significant improvement in erectile dysfunction and self-esteem and satisfaction with sexual relationships.19
Montorsi et al first demonstrated that men should be given early injections of intracavernosal alprostadil as soon as the catheter is removed, usually before the end of the first post-operative month. The recommended initial dose was 5 mcg two or three times per week. Similarly, Brock et al demonstrated that long-term, continuous use of intracavernous alprostadil therapy improved penile hemodynamics and restored spontaneous erections after nerve-sparing RP. An added psychological benefit is that successful intracorporal injection therapy soon after radical prostatectomy may allow for the resumption of sexual activity and improved couple satisfaction.22
Postoperative nerve-sparing RP patients who were not enrolled in a pharmacological vasoactive recovery program instituted in the initial year after surgery revealed a progressive increase in venous leakage, varying from 14% at 4 months to 50% at 12 months or longer. When a vasoactive recovery program was promptly instituted, Montorsi et al reported a decrease in venous leakage at 4 months postoperatively. Using intracavernosal alprostadil injections, only 2 of 12 patients developed a venous leak compared with 8 of 15 patients who did not receive intracavernosal injections. These findings support the role of early penile vasoactive rehabilitation after nerve-sparing RP to prevent the development of vasculogenic ED (caused by dysfunction of the blood vessels).23
The Cleveland Clinic study concluded that high compliance can be achieved if good counseling education is performed at the time of the initial dose, and proper dose modifications are made according to the efficacy and side effects profile.
Vacuum erection devices, also known as vacuum constriction devices, have been used for improving erectile function for more than a century. The principle involves the use of negative pressure applied to the penis, specifically the erectile bodies (corpora cavernosa), to restore inflow of blood into the erection chambers and erection ensues. The constriction band is applied to the base of the penile shaft to reduce blood flow draining out of the penis and promote maintenance of erection. The system involves a cylinder, a vacuum pump, and a constriction ring.16
FDA-approved devices have pressure pop-off valves to reduce the likelihood of pressure induced penile injury. The pressure that is permitted is approximately 200 to 250 mm Hg. It takes anywhere from two to 10 minutes to obtain a functional erection, and it takes approximately four attempts at using the vacuum device before patients become proficient with the technique. It is important to place the constriction band as close to the base of the penis as possible. Behind the constriction band, the penis is soft and somewhat unstable, and therefore, if the constriction band is placed on the shaft of the penis, this will result in a hinge effect and the penis will buckle during attempts at penetration. It is estimated that 75% of men achieve adequate rigidity, allowing them to obtain vaginal penetration.16
Probably the most significant disadvantage of the device is that it generates a non-cosmetic erection. Mulhall states, "by this I mean that the penis, particularly in a Caucasian male, does not appear pink or red; in fact, it tends to be blue or grey.16
Penile Prosthesis (Penile Implant)
Penile implants, or prostheses, are available in several varieties; the older versions are simpler and bendable, and the newer more complicated ones are inflatable or mechanical. Over the past thirty years, implants have improved tremendously. The latest models are sleek, sophisticated and user-friendly. They are more reliable, easier for surgeons to implant, and designed to look more natural in the nonerect phase—even the bendable prostheses, which are more malleable than before. They can restore sexual function entirely to normal.24
Now, most prostheses are implanted into the penis through an incision in the scrotum. Some of the more complicated devices involve a pump and a reservoir for fluid housed in the abdomen or scrotum and inflatable chambers, which are placed in the corpora cavernosa. Fluid is pumped into the penis to create an erection and is held there by a valve. Afterward, the valve is released and the fluid returns to the reservoir.24
A penile prosthesis used to be offered routinely to most impotent men. Now, with other good treatments available, many urologists have come to regard penile prostheses as a last resort because they involve surgery and carry the risk of complications. Complications can include infection, scarring, damage within the corpora cavernosa, or a problem with any part of the prosthesis such as leakage of the reservoir. However, these side effects are relatively rare. Most men who have penile prosthesis are satisfied with the result and have a normal sex life.24
- SUNA 2010 Clinical Practice Guideline Prevention and Control of Catheter Associated urinary Tract Infection. Available at: http://www.suna.org. Accessed Feb.2, 2010.
- Eastham et.al. Risk Factors for urinary incontinence after radical prostatectomy. J urol 1996;156L1707.
- U.S. Dept of Health and Human Services,1996, Clinical Practice Guideline number 2 (Update). Rockville, MD Agency for health Care Policy and Research.Publication No. 96-0682.
- Ellsworth et al. 100 Q & A about Prostate Cancer, 2007, 184,185,187,189.
- Hulme Janet a. Beyond Kegels s 2nd Edition Phoenix Publishing Co. 2002; 124,11,120,72,73.
- Sandhu J.S. Nat Rev Urol.7, 222-228 (2010);doi1038/Nrurol.2010.26.
- Newman D, Wein A. Managing and Treating Urinary Incontinence, Second Edition, Health Professionals Press-Baltimore, MD. 2009, 234,235,371,459.
- Mayo Clinic. Kegel exercises for men: Understand the benefits. Available at: http://www.mayoclinic.com/health/kegel-exercises-for-men/MY01402. Accessed on June 9. 2011.
- Bernier F, Sims TW. Management of clients with urinary disorders. Medical-surgical nursing: Clinical management for positive outcomes (8th ed. P 727-778). St Louis, MO. Elsevier Saunders; 2009.
- Ribeiro LH. Gomes CM et al. Prostate Cancer. Journal of Urology 184: 1034-9,2010.
- Bauer et al. Contemporary Management of post prostatectomy incontinence. European Urology (volumes 59 issue 6 page(s) 985-996 EOI: 10.1016/j.eururo.2011.03.020) European Urology 2011/03/18. Available at: http://www.ncbi.nlm.nih.gov./pubmed/20518761. Accessed on June 9, 2011.
- Bioderm. Liberty 3.0. Available at: http://www.bioderm.us/index.php?option=com_content&view=article&id=52&Itemid=168. Accessed June 9, 2011.
- SeekWellness. Afex for managing male incontinence. Available at: www.seekwellness.com/male_incontinence/afex.htm. Accessed June 9, 2011.
- Omni. URINCare. Available at: www.urinCare.com. Accessed on June 9, 2011.
- NIH consensus conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993: 270 (1): 83-90.
- Mulhall. Saving Your Sex life. Munster, IN: Hilton Publishing Company. 2008.
- International Journal of Impotence Research. 2008:20, 121-126.
- Nature Reviews. Urology. Volume 6, August 2009. p.424.
- Urologic Nursing. December 2007:27:6-563.
- Albaugh. Urologic Nursing. May-June 2010;30-3.
- Raina R, PahlajaniG, Agarwai, Zippe C. The early use of transurethral alprostadil after radical prostatectomy. BJU Int. 1998;100;1317.
- Burnett AL. Erectile dysfunction following radical prostatectomy. JAMA 2005;293(21).
- J Urol 1997; 158 (4): 1408-1410.
- Walsh PC, Worthington JF. Dr. Patrick Walsh's Guide to Surviving Prostate Cancer, Second Edition. New York: Wellness Central; 2007:435-441.
- Moyad M. Promoting Wellness for prostate Cancer patients, 3rd edition, Ann Arbor: Ann Arbor Editions, 2010:93-104.
- Radiation Oncology, Division of Nursing, James Cancer Hospital and Solove Research Institute, Patient Education Handout, The Ohio State University Medical Center.
- Bostwicket al. Complete Guide to Prostate Cancer. Atlanta: American Cancer Society; 2005:306-308.
This article has been reviewed by a member of the Wellness Partners Editorial Board.
Posted June 2011