Penile rehabilitation: use it or lose it?

Penile rehabilitation following radical prostatectomy is a hot topic that has been generating a lot of discussion in the prostate cancer medical community.

During radical prostatectomy, nerves may be removed, damaged, or suffer trauma. Trauma can occur when the surgeon divides these delicate nerves to gain access to the prostate gland to remove it (which is why you want a highly-skilled and well-trained surgeon). These nerves play a role in the health of penile tissue. Erection problems or impotence can also result from damage to arteries (which reduces blood flow to the penis), as well as vein leaks.

Getting the blood circulating

The goal of penile rehabilitation is to stimulate blood flow to the penis soon after radical prostatectomy, to help improve sexual function. Some physicians suggest that if a man’s penis stays soft and limp (or flaccid) for a long period of time after his surgery, it may lead to permanent damage to the sponge-like regions of erectile tissues (called cavernous tissue), which contain most of the blood when a man has an erection. Increasing blood flow to the penis right after surgery is believed to help maintain the penile tissue while the neural pathway regenerates.

How it’s done

Penile rehabilitation involves the regular use of either penile injections, oral erectile dysfunction (ED) medication, urethral pellets, or vacuum pump devices. Some physicians even suggest that men should masturbate to increase blood flow, but this form of penile rehabilitation has not been studied.

Recent clinical data

Penile injections

• Montorsi et al report that men who had penile injections of alprostadil one month after bilateral nerve-sparing radical prostatectomy (which means that both nerve bundles were saved) had a much better recovery rate of natural erections firm enough for intercourse after 6 months, than men who did not use the injections (67% vs 20% in the group that had no treatment). However some question the study methods that were used in this small study of 30 men.
• In a study of 73 men, Gontero et al report that 70% of men who used penile injections within 3 months of undergoing non-nerve-sparing radical prostatectomy were able to achieve natural erections firm enough for intercourse. Only 40% of men who waited 3 months after radical prostatectomy to start using penile injections were able to have erections firm enough for intercourse.

Oral medication

• In a study of 54 men following bilateral nerve-sparing radical prostatectomy, one group of men received 100 mg of sildenafil (Viagra) nightly, while another group received 50 mg nightly, four weeks after surgery. A third group received a sugar pill (called placebo). McCullough et al report that after 48 weeks (all men stopped treatment at 40 weeks), the men who took sildenafil were five times more likely to have return of natural erections firm enough for intercourse, than the men taking placebo.
• Bannowski et al report that in a trial of 43 men following nerve-sparing radical prostatectomy, the men who took sildenafil every night for a year had a much higher rate of natural erections firm enough for penetration (47% vs 28% in the group that had no treatment).
• In a study of 76 men, Padma-Nathan et al report that men who took sildenafil every night for 36 weeks (four weeks after nerve-sparing radical prostatectomy) had higher rates of erections firm enough for intercourse at 48 weeks (27%), compared to 4% of men who received placebo. However, some question the validity of this study because 4% seems like a very low number for men to have erections following radical prostatectomy at 48 weeks.

Combination methods

• In another study of 132 men, Mulhall et al report that men who either used penile injection or took sildenafil three times a week (four weeks after radical prostatectomy) had a higher rate of natural erections (52% vs 19% in the group that had no treatment). After 18 months, more of these men were also able to have erections firm enough for intercourse (64% vs 24% in the group that had no treatment).

Urethral pellets

• Raina et al report that in a study of 91 men who had nerve-sparing radical prostatectomy, regular use of urethral pellets three weeks after surgery (three times a week for six months) helped 50% of men have erections that were firm enough for intercourse. Most of these men were also able to have natural erections that were firm enough for intercourse.

  Vacuum pump devices

• In a study of 109 men, Raina et al report that 17% of men who used a vacuum constriction device within 2 months after radical prostatectomy (nerve-sparing and non-nerve-sparing) had natural erections firm enough for intercourse after 9 months of treatment, vs 11% of men who had no treatment. This study and other studies suggest that using vacuum pump devices may help prevent penile shrinkage following radical prostatectomy.

What does it all mean?

These studies suggest that early use of oral ED medications, penile injections, and urethral pellets for penile rehabilitation may help improve sexual function in men following radical prostatectomy. Even if your man takes an oral ED drug and sees no result, some in the medical community believe there may still be benefits in continuing to take the drug.

However, better studies are needed to determine which penile rehabilitation method can be the most effective. And while these studies report that men had erections “sufficient” for intercourse, they do not indicate whether these men were able to maintain an erection long enough to complete the act of intercourse.

As always, discuss the pros and cons of these penile rehabilitation treatments with your loved one’s doctor.

Updated 1/09

Always discuss everything you read on this web site with a qualified medical professional.

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References:
Bannowski A, Schulze H, van der Horst C, et al. Recovery of erectile function after nerve-sparing radical prostatectomy: improvement with nightly low-dose sildenafil. BJU International. 2008;101(10):1279-1283.

Dall’era JE, Mills JN, Koul HK, Meacham RB. Penile rehabilitation after radical prostatectomy: important therapy or wishful thinking? Reviews in Urology. 2006;8(4):209-215.

Gontero P, Fontana F, Bagnasacco A, et al. Is there an optimal time for intracavernous prostaglandin E1 rehabilitation following non-nerve-sparing radical prostatectomy? Results from a hemodynamic prospective study. Journal of Urology. 2003;169:2166-2169.

Hinh P, Wang R. Overview of contemporary penile rehabilitation therapies. Advances in Urology. 2008. http://www.hindawi.com/GetArticle.aspx?doi=10.1155/2008/481218. Accessed January 25, 2009.

McCullough AR, Levine LA, Padma-Nathan H. Return of nocturnal erections and erectile function after bilateral nerve-sparing radical prostatectomy in men treated nightly with sildenafil citrate: subanalysis of a longitudinal randomized double-blind placebo-controlled trial. The Journal of Sexual Medicine. 2008; 5(2):476-484.

Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve-sparing retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomised trial. Journal of Urology. 1997;158:1408-1410.

Mullhall J, Land S, Parker M, et al. The use of erectogenic pharmacotherapy following radical prostatectomy improves recovery of spontaneous erectile function. Journal of Sexual Medicine. 2005;2:532-540.

Padma-Nathan H, McCullough AR, Giuliano F, et al. Postoperative nightly administration of sildenafil citrate significantly improve the return of normal spontaneous erectile function after bilateral nerve-sparing radical prostatectomy [abstract 1402]. Journal of Urology. 2003;169:375.

Raina R, Agarwal A, Ausmundson S. Early use of vacuum constriction device following radical prostatectomy and the role of postoperative sexual function. The Journal of Urology. 2007;178(2):602-607.

Raina R, Agarwal A, Allimaneni SSR, et al. Sildenafil citrate and vacuum constriction device combination enhances sexual satisfaction in erectile dysfunction after radical prostatectomy. Urology. 2005;65:360-364.