Penile Rehabilitation
  General Information
Recovery of erections after surgery is a gradual process that takes several months and can continue to improve up to two or more years after surgery. While this process requires patience, one way to maximize (and hopefully quicken) the return of erectile function after radical prostatectomy is “penile rehabilitation.” While many men can regain erectile function after nerve-sparing surgery without medication or other erection aid devices, the following penile rehabilitation program can help to recover erections sooner as well as to improve your chances for ultimate recovery long-term. Many men may choose to use only certain aspects of the programs described below; whereas, other highly motivated men may choose to use multiple methods for rehabilitation. Our goal is to give you the best chance for recovery of erections and a healthy sex life after prostate cancer surgery.

Understanding the Concept
In men without erectile dysfunction before surgery, the penis periodically provides itself with increased blood flow and oxygen when one has erections. This occurs during times of sexual activity but also during regular nocturnal (or night-time) non-sexual erections. This process seems to be necessary for the penis to keep its tissues healthy and functioning optimally. If your surgeon feels that it is appropriate and will not compromise your cancer care, the cavernosal nerves which are located very close to the prostate and help to control erectile function are preserved at the time of surgery. Even when preserved, this results in neuropraxia or temporary nerve dysfunction due to the necessary manipulation of those nerves that occurs during their release from the prostate. Due to neuropraxia, the penis is unable to provide that periodic increased oxygen delivery to itself that occurs normally. This can lead to irreversible changes in the penile tissues such as fibrosis or scarring which can then make it more difficult to regain normal erectile function and also potentially lead to penile shortening. It is thought that by trying to increase blood flow and its accompanying oxygen to the penis on a regular basis after surgery, one can minimize the damage that can occur in the penile tissues and thereby optimize the chance for recovery of erectile function.

While this concept has not been definitively proven at this time, many studies support this theory and it is accepted by most clinical specialists and researchers in the field of erectile dysfunction. There are many different ways to approach a program of penile rehabilitation.  The decision to participate in any of the following treatments will depend on factors such as cost, the invasiveness of the treatment, and the priority that you place on erectile function in your life.   

Penile Physiotherapy
The simplest, safest, and least costly program of penile rehabilitation is attempting to attain an erection on a frequent basis (three or more times per week) once the catheter has been removed. It is important to know that this can be quite frustrating early after surgery as most men will be unable to achieve any significant erectile activity. However, the simple act of improving blood flow to the penis by attempting to get an erection is certainly helpful.

Oral Medications
Studies have now shown that soon after removal of the catheter, attempts to have an erection with sexual stimulation along with the help of prescribed oral medications called phosphodiesterase inhibitors (Viagra®, Cialis®, or Levitra®) can enhance the flow of blood and oxygen to the penile tissue and improve the ability to regain erections after surgery. These medications simply aid the body’s natural mechanism to achieve erection and may improve blood flow to the penis beyond what would occur without the medication.

Optimally, these medications should be taken on a frequent and regular schedule after surgery. Some of these medications are taken two to three times per week while others may be taken daily or every other day. They are usually best taken on an empty stomach to achieve the best results, and generally begin working within one to two hours after taking the pill. It is best to try to get an erection after taking the medication by attempting intercourse or self-stimulation. However, just taking the medication (even without attempting sexual activity) before bedtime can be beneficial due to nocturnal or nighttime erectile responses that occur. Again, it is important to realize that most men will be unable to achieve erections that are adequate for intercourse early after surgery even with the medications. Remember, the goal is only to improve blood flow and oxygen to the penis.

The most common side effects of these medications are headache, flushing, nasal stuffiness, upset stomach, visual disturbances, or sometimes back aches. If these side effects are minimal and tolerable, they are usually not a problem. However, if you experience bothersome side effects, your doctor may recommend trying one of the other available medications or other methods for erectile rehabilitation. Men who take nitrate or nitroglycerin medications for heart disease cannot take phosphodiesterase inhibitor medications as they can drop your blood pressure dangerously low when taken together. In addition, if you develop chest pain you must notify your primary care doctor or emergency room doctor if you have taken Viagra, Levitra, or Cialis in the last couple of days so they do not give you nitrate medications. Serious side effects such as sudden loss of hearing or vision should be reported to your doctor immediately.

Unfortunately, most insurance plans do not cover the cost of erectile medications or cover only a small percentage. However, by checking with your insurance plan, you may find that one particular medication may be less expensive than others. If so, notify your doctor which medication is preferred by your insurance plan. In addition, your doctor may offer coupons or trials that are sometimes available through pharmaceutical companies to help reduce the financial burden when starting certain medications. Your doctor will also be happy to provide a letter of support for you if your insurance plan requires this documentation before covering these medications. We realize all of the available medications are expensive and are not routinely covered by insurance. Therefore, you should take the medications as frequently as possible, but it may be necessary to decrease the frequency of the medication depending on your financial resources. For instance, if you cannot afford to take the medication three times per week, two times or even one time per week is still better than not taking it at all.

Vacuum Erection Device

The vacuum erection device (VED) or penile vacuum pump draws blood into the penis and then maintains an erection by placing a constricting ring at the base of the penis. For rehabilitation, this device is used by “pumping” blood into the penis once or twice per day and then holding it there for five to ten minutes each time. Although no definitive studies have shown that this device improves erectile function after surgery, recent studies have shown that this device may help preserve penile length after surgery. Not all men may choose to utilize this device. It is most appropriate for men who cannot take or cannot tolerate phosphodiesterase medications. Also, it is appropriate for those men who are highly motivated to do everything they can to maximize their chances of regaining/preserving erections and penile length or who wish to participate in sexual intercourse sooner than normal recovery would allow.

If you are interested, your doctor can arrange a meeting with a vacuum erection device clinical specialist here at Alliance Urology Specialists. Free of charge, this representative will offer a consultation explaining how the device works as well as provide information on cost and correct use. This service is provided as a courtesy to our patients who have undergone prostate cancer surgery. Also, there are other similar devices available which may be less expensive (but also are likely less effective) and can be accessed via the internet.    

Injection/Intraurethral Therapy

There are medications that can be applied directly to the penis itself to enhance blood flow to the penis. These medications can be administered by either a pellet that is placed in the urethra (MUSE) or by injecting the medication into the penis. Both of these treatments are advantageous in that they, unlike the oral medications, work irrespective of the body’s natural nerve-induced mechanism of erectile function. That means that even during the period of neuropraxia after surgery, these medications can still result in excellent blood flow to the penis and erections that are adequate for intercourse. The disadvantage is that these treatments are more invasive and have the potential for more serious side effects.

The advantage of MUSE is that it does not require a needle injection. However, it also tends to be less effective than injection therapy. While intracavernosal injection (ICI) therapy is usually more effective and often less costly than MUSE, it does require more instruction on how to administer it and is more invasive. The potential side effects of MUSE or ICI are pain, bleeding, infection, and fibrosis/scarring. There is also a risk for priapism which is a prolonged, painful, non-sexual erection lasting over four hours which requires prompt medical treatment in your urologist’s office or emergency room.

Although none of the above programs guarantee recovery of erections, by playing an active role in your recovery process, you can maximize your chances for the best possible outcome. The decision to participate in any of the above treatment programs is your individual choice and will probably depend on the cost, the invasiveness of the treatment, and how important erectile function is to your quality of life. Remember to have patience as return of erectile function is a gradual process sometimes taking up to two years or longer to see full return of erections after prostate cancer surgery.

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