What is Penile Rehabilitation?
The Penile Rehabilitation Program
What is Penile Rehabilitation?
Penile rehabilitation is a concept based on the belief that men who develop erectile dysfunction related to prostatectomy, radiation therapy, or other therapies or circumstances are treated soon after the precipitating event to help give them erections, to protect the erectile tissue, and to optimize a man’s ability to regain his pre-treatment erectile function. The ultimate goal is to have men reach a point where they do not need pills, penile injections, or other treatments to achieve an erection.
Given that sexual function is an important factor in the lives of many men, regardless of age, recovering the ability to achieve and maintain an erection through penile rehabilitation is an effort some men may want to consider. Some men can recover some or all of the erectile function they had before prostate cancer treatment, but it can be a slow process that takes years. Other men will never return to their previous level of sexual function. Penile rehabilitation offers men a treatment option that may help them recover erectile function more quickly and completely.
The effectiveness and value of penile rehabilitation after prostatectomy is an area of controversy and debate, primarily because this attempt to minimize the incidence and severity of erectile dysfunction following prostatectomy is, for now, ill-defined and not well studied. One issue is that the studies have involved too few participants to provide valid information; another is that the men studied have all undergone successful nerve-sparing prostatectomy, so researchers do not have any information on how penile rehabilitation can affect men who did not have this procedure. Yet another topic of concern is the fact that the studies thus far have only included men who had normal erectile function before surgery, and so the impact of penile rehabilitation on men who may have experienced erectile dysfunction pre-surgery is unknown as well.
Penile Rehabilitation Program
Generally, men who have undergone treatment for prostate cancer and have developed erectile dysfunction should begin rehabilitative therapy within three months, according to John P. Mulhall, MD, a urologist and micro-surgeon at Sloan-Kettering in New York. Tissue damage to the penis is time dependent, so it is important to not delay taking steps to begin penile rehabilitation. Men who don’t start penile rehabilitation soon after surgery risk developing venous leakage and not regaining erectile function and potency.
The effort to promote penile rehabilitation began when initial trials showed that regular use of intracavernous injections after prostatectomy improved men’s return to spontaneous erectile function. Today the efforts have shifted more to use of the three drugs for erectile dysfunction—Viagra, Cialis, and Levitra–that are on the market, but that does not mean other approaches are not being included as well.
To get an idea of what constitutes a penile rehabilitation program, see the current treatment plan for penile rehabilitation following radical prostatectomy that is used at Memorial Sloan-Kettering Cancer Center. Basically, men may choose to consult with the physician who will monitor their penile rehabilitation before they undergo radical prostatectomy. Some men choose to begin taking one of the three available erectile dysfunction drugs (PDE5 inhibitors) two weeks before surgery; others elect to begin medication when the post-surgery catheter is removed. Treatment can include taking alternating maximum and low-dose PDE5 inhibitors for two to four weeks, after which men are evaluated to monitor their response.
Men who respond well to the medication will continue with whichever of the three drugs has worked for them. They will also be followed-up every four months until two years post-surgery. Men who do not respond well to the initial round of medication will try penile injections two to three times per week along with one of the PDE5 inhibitors 4 to 5 times a week. They can follow this program for several months and then do a rechallenge with the maximum dose of a PDE5 inhibitor every month after the sixth month. When men respond well to the pills alone, penile injections can stop.
Penile Rehabilitation After Cancer Treatment — Sloan-Kettering
Is Penile Rehabilitation Successful?
According to a recent (May 2010) review in Current Opinion in Urology, the intent of penile rehabilitation strategies is to facilitate recovery of erectile function by preserving the cavernous smooth muscle in the penis, but thus far there is no definitive evidence that these attempts are beneficial. (Garcia)
The subjects in a University of Southern California study began their penile rehabilitation four weeks after surgery. In a group of 76 men who had undergone radical prostatectomy, half were given sildenafil (50 or 100 mg) to take every night for 36 weeks while the other half were given placebo. The results, which were published in the International Journal of Impotence Research, showed that return of spontaneous erections occurred in 27 percent of men who were taking sildenafil compared with only 4 percent who took placebo. (Padma-Nathan 2008)
Another recent (October 2010) study evaluated men who had undergone retropubic prostatectomy and who delayed seeking help after failing to respond to phosphodiesterase-5 inhibitors. The 31 men, who had delayed an average of 25.9 months seeking help after failing to respond to ED medication, were offered other forms of penile rehabilitation—a vacuum device (VED), intracavernous injections, and sex therapy. Eleven men declined treatment because they believed their erectile function would return on its own. Twenty men decided to try intracavernous injections, and of these 5 (25%) regained spontaneous erection within 7 to 19 months. Seven (35%) men responded positively to ED medications 3 to 5 months after starting the injections, and three men used vacuum devices. Seven men had sessions with a sex therapist, along with their partner, and reported an improvement in their sex life even if erectile dysfunction was not resolved.
A recent study that apparently included the most participants to date was called the REINVENT (Recovery of Erections: Intervention with Vardenafil Early Nightly Therapy) study. The multicenter, double-blind, placebo-controlled study included 423 men who had undergone radical prostatectomy and were randomly assigned to take either 10 mg vardenafil nightly versus on-demand vardenafil (10-20 mg) versus placebo for 36 weeks. Significantly more men who took on-demand vardenafil achieved erectile function when compared with the other two groups. Among the men who took placebo, however, they did as well when taking on-demand vardenafil one year later. (Montorsi 2008)
Despite the uncertainty surrounding the success of penile rehabilitation, there are indications that it can be effective. The negative impact erectile dysfunction can have on the physical and emotional health of men makes it crucial for patients to receive comprehensive information about how they might recover erectile function after prostatectomy by participating in a penile rehabilitation program.
Cancer Treatments Can Cause Erectile Dysfunction
Other Penile Rehabilitation Strategies
Although penile rehabilitation currently includes the orchestrated use of PDE5 inhibitors such as Viagra and penile injections to achieve an erection, other strategies are being investigated as possible additions to a penile rehabilitation program. Use of a low-dose of the suppository alprostadil (MUSE), for example, could be used in place of the low-dose PDE5 inhibitor. Thus far the research is still preliminary for this use of alprostadil in penile rehabilitation.
Another suggestion is to utilize a vacuum device or VED. No research supports the use of vacuum devices in men who have undergone prostatectomy, but it may help stretch the penis. For now, use of a vacuum device as part of penile rehabilitation could be considered an add-on feature, but not used alone.
See also
Peyronies disease and prostate cancer treatment
References
From Lee J. Penile rehabilitation should not be the norm for patients with post-radical prostatectomy. Can Urol Assoc J 2009 Feb; 3(1): 54-56
Montorsi F et al. Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. Eur Urol 2008; 54:924-31
Padma-Nathan H et al. Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Int J Impot Res 2008; 20:479-86
