PENILE REHABILITATION FOR ERECTILE DYSFUNCTION (IMPOTENCE) FOLLOWING ROBOTIC RADICAL PROSTATECTOMY.
This article is designed to give you as much information as possible regarding penile rehabilitation following your robotic radical prostatectomy.
Please do not start any of the treatments mentioned in this leaflet without discussing it with the urologist. Make sure to inform him about any medication you take.
Following a Robotic Radical Prostatectomy, erectile dysfunction is a common consequence and erectile function may take 6-24 months to return, even if bilateral nerve sparing technique has been used. Sexual dysfunction is a common quality of life issue following prostate surgery.
Neuropraxia of the cavernosal (erectile tissue) nerve leads to hypoxia and fibrosis of the tissue of the penis. Neuropraxia is usually a result of trauma sustained by the cavernosal nerves during surgery and is almost impossible to avoid. Even minor trauma will lead to short term erection problems. Cavernosal smooth muscle is dependent on oxygenation of the tissue for normal function. If there is lack of sufficient oxygenation due to neurological and arterial trauma this leads to fibrosis and collagen formation, making the recovery of erections more difficult, as well as the possible resultant reduction in penile length and circumference.
The aim of penile rehabilitation is to prevent fibrosis from occurring and to maximise the recovery of erectile function. There is some evidence to suggest that the longer a man goes without erections, the more tissue damage may take place leading to more difficulty in restoring the erections. The outcome of successful penile rehabilitation is measured by the ability to achieve a spontaneous erection that is rigid enough form successful penetrative intercourse.
Penile rehabilitation should ideally be started at around 6 weeks post-surgery, however this will depend on the recovery of each individual and whether you feel ready. The rehabilitation program does require time and dedication in order to achieve the best possible results. Research suggests that the sooner rehabilitation is started the better the outcome is likely to be.
There are 5 medical treatments available for erectile dysfunction and each of these has a place in the rehabilitation programme.
PELVIC FLOOR EXERCISES
Pelvic floor exercises are traditionally taught to aid in the recovery of continence following surgery. There is evidence to suggest that they are also an important part of penile rehabilitation. Performing pelvic floor exercises promotes the delivery of oxygenated blood to the injured nerves as well as helping to remove deoxygenated blood, which together improves healing. With regular exercise the pelvic floor muscles remain toned and this can help you achieve a better quality of erection and assist in sustaining your erection.
You will be taught pelvic floor exercises as part of your preparation for surgery and should begin to practise these as soon as it is comfortable to do so (usually after the catheter is removed). It is important that you perform at least two to three sets of exercise per day in order to benefit from them and that you continue to do them for the rest of your life. Quality is more important than quantity however.
VACUUM CONSTRICTION DEVICE (VCD)
The British Society for Sexual Medicine Guidelines of 2007 recommends a VCD as a first line treatment option for erectile dysfunction following prostatectomy. VCDs are very effective in inducing erections no matter what the cause of the erectile dysfunction is; therefore they can be used in penile rehabilitation while the nerves are healing. The recommendation is to use the VCD at least 3 times a week as an exercise tool to encourage blood supply to the penis. This can also be done on a daily basis if it is practical.
According to research done using a VCD early in the rehabilitation programme (usually recommended to start at around 6-8 weeks post operation) include:
- Facilitating early sexual intercourse
- Early patient/partner sexual satisfaction
- Maintenance of penile length
- Earlier return of natural erections
Using the VCD in conjunction with a PDE-5 inhibitor has been shown to increase efficacy and satisfaction.
It is important to note that it will usually take about 2 weeks of regular use to become familiar with and comfortable with the use of the VCD.
There are 3 PDE-5 inhibitors available on the market, all in tablet form. They are safe to use if they are obtained on prescription and taken as prescribed. There are certain medical conditions and medications you may take which may preclude you from using these but this will be discussed with your urologist. The oral tablets are:
- Cialis (Tadalafil)
- Viagra (Sildenafil)
- Levitra (Verdenafil)
There are studies which show that using PDE-5 inhibitors in penile rehabilitation promotes improved blood flow to the penis and this may enhance the return of spontaneous erections following prostatectomy. Emerging research continues to support the early use of these agents for penile rehabilitation. Studies have shown that in order to obtain maximum effectiveness the drug of choice should be taken on a regular basis for a minimum of 3 months, but possibly for longer.
Cialis has the longest lasting effects (36 – 48 hours) and therefore taking a tablet once every 2 – 3 days (ie 3 times a week) is sufficient to produce the required effect. Usually the largest dose of 20mg is recommended.
Viagra may be taken as a small dose (25 – 50mg) on a daily basis. The effects of Viagra usually last for around 6 hours.
Levitra may be taken as a 3 tablets a week dose although the effects do not tend to last for more than 24 hours. The dosage is usually 20mg although in some cases you may be advised to take 5mg or 10mg daily.
It is very important to remember that you will be using the tablets as part of the rehabilitation programme and it is extremely unlikely in the first few months that they will actually work to get you an erection suitable for penetrative intercourse on their own.
INTRAURETHRAL ALPROSTADIL (MUSE)
MUSE is a small “pellet” which is inserted into the urethra (water pipe) where it dissolves, allowing the medication to be absorbed locally into the penile tissue. There is some evidence that suggests it may be useful as part of penile rehabilitation. It has the added benefit that it may produce an erection sufficient for penetrative intercourse. When trying MUSE it is important to consider that even if you are unable to achieve an erection suitable for penetrative intercourse, the act of using the MUSE is likely to have a positive impact on the rehabilitation programme and long term outcome. MUSE is available as 250, 500 and 1,000 micrograms. In the first year following prostatectomy men are more likely to experience some pain following administration of MUSE at the higher doses, therefore you will usually be started on a 500 microgram dose initially.
INTRACAVERNOSAL PENILE INJECTION
There are various medications available, which, when injected into the side of the base of the penis causes the blood vessels of the penis to dilate, leading to penile engorgement.
The benefit of using injection therapy is that it has a very high and proven rate of producing an erection sufficient for penetrative intercourse. For most men the idea of injecting into the penis stops them from trying injection therapy, however the process of injecting is in itself not painful. You will need to attend a supervised session with a urology nurse to be taught how to inject safely.
Although penile implants are not strictly part of the rehabilitation programme they have their place in the process of regaining erections following prostate surgery and are the treatment of choice for some men. Most urologists who specialise in this however would not consider placing an implant within the first year following the prostate surgery and certainly not prior to other forms of treatment being attempted first. It should be remembered that implants cause permanent damage to the erectile tissue of the penis and therefore if they fail or are unsuitable it will be impossible to regain normal erections if they are removed.
There are two types of implant available:
Malleable implants consist of two “rods” which are inserted into each corpora cavernosa forming a “permanent” erection. The penis can be bent away when not in use and bent forward in order to have sexual relations.
Inflatable implants consist of two “rods” which are inserted into each corpora cavernosa and a reservoir and pump which is placed within the scrotum. The rods are inflated using the pump and the fluid is drained out again by a release mechanism. The implants work extremely well but men do require full counselling before going ahead with this type of surgery.
The information in this article has been obtained from various sources. Further information can be accessed at: