Penile rehabilitation
What is it and how can it help?

The goal of penile rehabilitation is to stimulate blood flow to the penis right after radical prostatectomy to help improve sexual function.  

During radical prostatectomy, delicate nerves that play an important role in the health of penile tissue may be:

  • Removed
  • Damaged
  • Suffer trauma

Damage or trauma can occur when the surgeon divides the nerves to gain access to the prostate gland to remove it.  This is why you want a highly skilled and well-trained surgeon!


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Erection problems or impotence can also result from:

  • Damage to arteries, which reduces blood flow to the penis
  • Vein leaks

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).  These tissues 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 is penile rehabilitation done?

Penile rehabilitation involves the regular use of either:

Some physicians suggest that men should masturbate to increase blood flow, but this form of penile rehabilitation has not been studied.

What do clinical studies report about penile rehabilitation?

Penile injections:

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)
  • But some question the study methods Montorsi et al used in this small study of 30 men

In another study of 73 men (Gontero et al):

  • 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 medications:

In a study of 54 men following bilateral nerve-sparing radical prostatectomy (McCullough et al):

  • One group of men received 100 mg of sildenafil (Viagra) nightly
  • Another group received 50 mg nightly, four weeks after surgery
  • A third group received a sugar pill (called placebo)

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.

In a trial of 43 men following nerve-sparing radical prostatectomy (Bannowski et al):

  • 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 men who had no treatment)

In a study of 76 men (Padma-Nathan et al):

  • 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% vs 4% of men who received placebo)
  • Some question this study because 4% seems like a very low number for men to have erections following radical prostatectomy at 48 weeks

Combination methods:

In the first large, randomized, prospective study (McCullough et al) of 139 men comparing nightly intraurethral alprostadil (urethral pellets) to oral sildenafil citrate:

  • There were no statistically significant differences in International Index of Erectile Function erectile function domain and intercourse success rate
  • This means the efficacy of the two treatments were comparable to one another

In another study of 132 men (Mulhall et al):

  • 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 men who had no treatment)
  • After 18 months, more of these men were also able to have erections firm enough for intercourse (64% vs 24% in men who had no treatment)

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Urethral pellets:

In a study of 91 men who had nerve-sparing radical prostatectomy (Raina et al):

  • Regular use of urethral pellets (three times a week for six months) three weeks after surgery 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 that followed 141 sexually active men who had radical prostatectomy (Raina et al):

  • At 5 years, 62% of the men remained sexually active and 71% had natural erections sufficient for intercourse without assistance
  • 8.5% of men were still using sildenafil and 10% were using combined therapy (sildenafil plus a vacuum erection device)
  • The natural rate of erections for sufficient intercourse without an erection aid were preserved and maintained in the early-prophylaxis group (the group of men who started using an erection aid soon after surgery) and almost 60% of these men had used a vacuum erection device early after surgery

In an earlier study of 109 men (Raina et al):

  • 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 do the clinical study results mean?

These studies suggest that early use of oral ED medications, penile injections, urethral pellets, and a vacuum erection device for penile rehabilitation may all help improve sexual function in men following radical prostatectomy.

Even if your man takes an ED medication and sees no result, some in the medical community believe there may still be benefits in continuing to use an ED drug for penile rehabilitation.

While these studies report that men had erections "sufficient" for intercourse, unfortunately they do not reveal whether these men were able to maintain an erection long enough to complete the act of intercourse.

The promise of gene therapy 

Advances in molecular biology have allowed the transfer of genetic material to humans and animals and this technology is being researched to see how it can affect ED.

Gene therapy has shown some promise in animal studies and human trials are currently underway.

Updated 4/13

Back to sex after prostate cancer
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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. 

McCullough AR, Hellstrom WG, Wang R, Lepor H, Wagner KR, Engel JD. Recovery of erectile function after nerve sparing radical prostatectomy and penile rehabilitation with nightly intraurethral alprostadil versus sildenafil citrate. J Urol. 2010. 183(6):2451-6. Epub 2010 Apr 18.

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, Pahlajani G, Agarwal A, Jones S, Zippe C. Long-term potency after early use of a vacuum erection device following radical prostatectomy. BJU Int. 2010;106(11):1719-22.

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. 

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