Treating erectile dysfunction after prostate surgery can involve an approach called penile rehabilitation. The concept of penile rehabilitation is 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, protect the erectile tissue, and optimize a man’s ability to regain his pre-treatment erectile function. The ultimate goal is to have men not need pills, penile injections, or other treatments to achieve an erection.
Sexual function is an important factor in the lives of many men, therefore penile rehabilitation is an effort some men may want to consider. Some men can recover part or all of the erectile function they had before prostate cancer treatment, but it can take years. Other men will never return to their previous level of sexual function. Penile rehabilitation offers men a way for treating erectile dysfunction after prostate surgery that may provide faster, more complete results.
The effectiveness and value of treating erectile dysfunction after prostate surgery with penile rehabilitation is an area of controversy and debate, primarily because it 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 know how penile rehabilitation can affect men who did not have this procedure. In addition, the studies thus far have only included men who had normal erectile function before surgery. Thus the impact of penile rehabilitation on men who had erectile dysfunction pre-surgery is unknown as well.
Generally, treating erectile dysfunction after prostate surgery using rehabilitative therapy should begin within three months postsurgery, 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 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 as a way of treating erectile dysfunction after prostate surgery 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 drugs for erectile dysfunction—Viagra, Cialis, Staxyn, Stendra, and Levitra–but other approaches are 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 an erectile dysfunction drug (PDE5 inhibitors) two weeks before surgery; others elect to begin treating erectile dysfunction after prostate surgery and 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 the drugs and will 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 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
According to a 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 treating erectile dysfunction after prostate surgery with penile rehabilitation. 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 beginning 4 weeks postsurgery. The results showed that return of spontaneous erections occurred in 27% of men who were taking sildenafil compared with only 4% who took placebo. (Padma-Nathan 2008)
Another study evaluated men who had undergone retropubic prostatectomy and who delayed seeking help after failing to respond to PDE5 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. Twenty men tried 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 study that apparently included the most participants to date was 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 treating erectile dysfunction after prostate surgery with penile rehabilitation, there are indications that it can be effective. The negative physical and emotional impact erectile dysfunction can have on men makes it crucial for patients to receive comprehensive information about the potential benefits of a penile rehabilitation program.
Cancer Treatments Can Cause Erectile Dysfunction
Although penile rehabilitation currently includes the orchestrated use of PDE5 inhibitors and penile injections to achieve an erection, other additional strategies are being investigated. 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 VEDs 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.
References for Treating Erectile Dysfunction after Prostate Surgery
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