Sexual Rehabilitation Post Radical Prostatectomy
Email Raji.Kooner@svha.org.au or call 02 8382 6980 for a confidential appointment.
Sexual rehabilitation post radical prostatectomy is a very, very important aspect of the overall management of patients following prostate cancer surgery.
We really emphasise this to patients.
My protocol at the moment, and this is always changing according to literature, but currently what we generally do is when the catheter comes out day six we usually start the patient on an oral phosphodiesterase inhibitor1.
Studies have shown that when patients are placed on this they get a better outcome and return of nerve function at 12 to 18 months than if they do not take this oral medication.2
The downside is that there is significant cost involved.
Obviously if patients are on nitrates, particular heart medications they should not take this medication and if ever they get any chest pain or chest tightness they need to contact their doctor.3
There’s no evidence that there’s any increased cardiovascular or heart risk with these medications.4
They are generally well tolerated5 but it’s important to follow the instructions when taking them.
The second aspect is to discuss with patients the option of a vacuum pump device or penile injection therapy.
Both these are unusually initiated at the six week mark to allow healing to occur.
So a vacuum pump device is relatively easy to use and utilise.
We put a sheath over the penis, the patient pumps this up and creates a negative pressure, it sucks blood into the penis and then you slip a band, a firm band at the base of the penis and this allows the patient to have an erection sufficient for intercourse.
The advantage is that it’s very simple to use, it’s easy to learn, it’s reproducible, there’s a relatively low cost.
The disadvantage is that obviously it’s a planned event, it’s not spontaneous like the natural erection.
It does lead to a slight hinge effect because the erection is from the skin forward and the penile tissue actually goes into the body.6
So you do have slight hinge effect but it’s very effective to use.
The other option is penile injection therapy usually with prostaglandin or in some occasions with a prescription combination medication, three agents mixed together.
This sounds a bit daunting to start off with but it’s very easy to do and once learnt it’s a bit like diabetics giving themselves insulin shots.
It involves drawing a certain medication in a little syringe, you then inject that syringe into the side of the penis, this compound works within five or 10 minutes.
The erection occurs through the whole penile tissue so it occurs on the external part and internal, so it is more natural.7
It lasts 20 minutes to half an hour depending on the dose that you use and usually we advise that it can be used two to three times a week at most.
It’s important to vary the site of the injection so that you don’t get scarring occurring which can occur as a side effect of this treatment.
The other side effect of concern is what we call priapism which is a prolonged erection8.
If this occurs it is a medical emergency, it needs to be treated straight away with medications that you obtain from the accident and emergency department although it is very rare if you’ve been prescribed properly and start off with a low dose.9
They’re the treatment options, patients usually have an oral agent and they either have the vacuum pump or the injection therapy.
Sometimes patients use all three and it’s important with the vacuum pump and the injection therapy to remember that these treatment options are used not only for sexual activity but to keep the penis healthy.10
It’s very, very important.
It can sometimes take one to three years for the nerves to regenerate.10
So these treatments, the rehabilitation allows the patient to have good sexual function during the recovery period and maximises the chance of natural recovery.
References
1. Armaan Dhaliwal; Mohit Gupta - PDE5 Inhibitors - NLM - https://www.ncbi.nlm.nih.gov/books/NBK549843/2. Hyeok Jun Goh, Jeong Min Sung, Kwang Hyun Lee - Efficacy of phosphodiesterase type 5 inhibitors in patients with erectile dysfunction after nerve-sparing radical prostatectomy: a systematic review and meta-analysis - Transl Androl Urol. 2022 Feb; 11(2): 124–138. - doi: 10.21037/tau-21-881
3. Fuminobu Ishikura, Shintaro Beppu, Toshiaki Hamada, et al - Effects of Sildenafil Citrate Combined With Nitrate on the Heart - Circulation Volume 102, Number 20 - https://doi.org/10.1161/01.CIR.102.20.2516
4. Robert A. Kloner - Cardiovascular Effects of the 3 Phosphodiesterase-5 Inhibitors Approved for the Treatment of Erectile Dysfunction - Circulation Volume 110, Number 19 - https://doi.org/10.1161/01.CIR.0000146906.42375.D3
5. Camilla R. Madeira, Fernanda S. Tonin, Mariana M. Fachi, - Efficacy and safety of oral phosphodiesterase 5 inhibitors for erectile dysfunction: a network meta-analysis and multicriteria decision analysis - World J Urol 39, 953–962 (2021). https://doi.org/10.1007/s00345-020-03233-9
6. Vacuum Erection Device (VED) - University of Utah Health - https://healthcare.utah.edu/mens-health/conditions/erectile-dysfunction/vacuum-erection-device
7. Penile injections for impotence - Cambridge University Hospitals - https://www.cuh.nhs.uk/patient-information/penile-injections-for-impotence/
8. Penile Injection Therapy - Memorial Sloan Kettering Cancer Center - https://www.mskcc.org/cancer-care/patient-education/penile-injection-therapy
9. Michael Silberman; Gavin Stormont; Stephen W. Leslie, et al. - Priapism - NLM - https://www.ncbi.nlm.nih.gov/books/NBK459178/
10. Eric Chung and Michael Gillman - Prostate cancer survivorship: a review of erectile dysfunction and penile rehabilitation after prostate cancer therapy - Med J Aust 2014; 200 (10): 582-585. || doi: 10.5694/mja13.11028