Originally published 11/29/2018
Since we posted the blog below, more articles support its message. Yes, penile rehab (PR) after radical prostatectomy (RP) using PDE5 inhibitors like Viagra, with or without pumps, injections, etc. appears to facilitate return of erections sooner than no PR. Now, two other recent articles clarify the patient’s role:
- Albaugh et al. (2019) reported that 79% of their post-RP patients who reported “normal” erections before surgery were already using PDE5 medications, and “…only 23.1 and 28.6% regained baseline function at 1 and 2?years, respectively.”[i] In their cohort, adherence to penile rehab was low “… with only 55.8% of men remaining at 12?months and 45% of men completing 24?months. The most common barriers to PR adherence were cost, inconvenience and perceived ineffectiveness.” In other words, it may be a hard protocol to stick with, but if you don’t, you can’t expect good results.
- Vanderhaeghe et al. (2021) take PR an important step further. They point out that ED after surgery is not simply physical. Both in terms of personal psychology and the stress of initial post-treatment impotence, sexual rehabilitation may also be needed. “The important strategies described to rehabilitate sexual function include pelvic floor muscle therapy, couple therapy, appropriate preoperative counseling, and focusing on non-penetrative alternatives. A multidisciplinary approach and including the partner is important. Erectile function alone is not sufficient for satisfactory sexual experience and may not be used as a proxy for sexual quality of life.”[ii] Thus, the commitment and good will—not to mention openness to experimentation—of both partners is needed to reclaim satisfying sex after surgery.
As we concluded in the blog below, for qualified patients Focal Laser Ablation is an alternative to RP that has a very high probability of maintaining sexual function. This can avoid an entire program of penile rehab while offering comparable cancer control for appropriately matched prostate cancer level.
Anyone who has been through physical therapy (PT) after an injury severe enough to impair daily function can attest to positive progress, even if painstakingly small and slow. Often, returning to normal function requires patience and practice as you implement the recommended protocol on the days between PT appointments, as you hope for restored abilities.
Radical prostatectomy and impaired nerve function
A man diagnosed with prostate cancer (PCa) may suddenly spend a good deal of time worrying about a very small part of his anatomy called the neurovascular bundle (NVB). This network of nerve fibers and blood vessels is nature’s essential contribution to erection. It’s been said that the most important sex organ is the brain, and this is true. Sexual arousal starts in the brain, which transmits impulses to these local nerves. In turn, the spongy penile tissues begin to relax. Assuming there are no cardiovascular or circulation issues, blood flows in and fills the open spaces, creating an erection. No matter how much desire the brain registers, no local nerve function means no natural erection.
Radical prostatectomy (RP), or surgical removal of the complete prostate gland, is considered the gold standard of PCa treatment. However, it puts sexual function at risk. It is not possible to avoid some disruption of the two NVBs that literally hug each side of the gland. Until Dr. Patrick Walsh developed a nerve-sparing open prostatectomy technique, RP had a very high rate of post-surgery impotence. Then, with the advent of robotic-assisted RP (RARP) which uses very small instruments under extreme magnification, it became easier to visually avoid butchering the NVBs. Still, during RARP the nerves are undergo a certain amount of tugging and stretching—not something they take kindly to—even when the surgeon is experienced and skilled. In most cases, this will impair nerve function (at least temporarily) while the nerves recover. If you are not faint-hearted, you may want to watch a 9-minute video of a nerve-sparing robotic prostatectomy so you can see what I’m talking about.
Some facts about nerve-sparing RARP
First of all, not every patient who undergoes RP is a candidate for a nerve-sparing approach. The location, extent and aggression of an individual’s PCa may mean that it’s not safe to spare the nerves, since PCa that manages to penetrate the NVB has a “superhighway” to other sites in the body.
It’s also worth noting that potency does not require both NVBs in order to happen. There’s a difference between bilateral nerve-sparing RARP (the surgeon attempts to spare both NVBs) vs. unilateral NVB, in which cancer on one side of the gland requires removal of the NVB on that side, but the surgeon feels it’s safe to spare the other NVB.
So let’s say a patient is an ideal candidate for nerve-sparing RP. Here are some facts:
- Immediate erectile dysfunction (ED) after RP is virtually 100%
- Recovery may take 18-24 months
- Reports vary, but anywhere from 20-80% of patients never regain normal erectile function
- Permanent partial ED is reported to range from 16-48%
- Post-RP potency is increasingly defined as erection with the aid of PDE5-inhibitors (PDE5-Is), e.g. Viagra, Cialis, Levitra.[iii]
That last point about redefining potency as erection with the aid of oral medication (PDE5-Is) brings me to the topic indicated in the title: post-RP penile rehabilitation. Think of it as physical therapy for the penis, only you need to pop a pill before you do the exercise. However, keep in mind that taking Viagra, Cialis or Levitra does not cause an erection. Stimulation and desire cause an erection, so sexual activity (or even watching sexual activity on a video) is needed to activate the brain. However, the medication helps compensate for lack of nerve function—and there’s even clinical evidence that over time, it may actually encourage nerve recovery, even if taken in the absence of sexual stimulation or desire.
Therefore, a new trend began in helping patients regain sexual function after RP. It is called penile rehabilitation. Inevitably, debate arose as to whether rehabilitation with PDE5-Is should be used “on demand” or prescribed on a regularly scheduled basis.
As it turns out, a 2018 article out of Oxford University may put the debate to rest. The authors open with the statement, “Despite efforts to preserve the neurovascular bundles with nerve-sparing surgery, erectile dysfunction remains common following radical prostatectomy. Postoperative penile rehabilitation seeks to restore erectile function but results have been conflicting.” After comparing numerous research studies involving on-demand and scheduled penile rehab, the authors report that “…penile rehabilitation strategies consisting of scheduled PDE5I use following radical prostatectomy may not promote self-reported potency and erectile function any more than on demand use.”[iv]
At the Sperling Prostate Center, we pioneered and are the leading authorities in Focal Laser Ablation (FLA) for prostate cancer tumors. We have performed the largest number of FLA procedures in the world, and our patients have minimal-to-no risk of ED. This makes the typical post-RP penile rehabilitation protocol simply not necessary. I am grateful that we are able to offer this outpatient procedure, thanks to multiparametric MRI visual guidance and the precision of laser energy.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Albaugh J, Adamic B, Chang C, Kirwen N, Aizen J. Adherence and barriers to penile rehabilitation over 2?years following radical prostatectomy. BMC Urol. 2019; 19: 89.
[ii] Vanderhaeghe D, Albersen M, Weyne E. Focusing on sexual rehabilitation besides penile rehabilitation following radical prostatectomy is important. Int J Impot Res. 2021 May;33(4):448-456.
[iii] Kaulback K, Argaez C. Phosphodiasterase type 5 inhibitors for penile rehabilitation post radical prostatectomy: a review of clinical effectiveness and guidelines. CADTH Rapid Response Reports. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Aug.
[iv] Phillippou YA, Jung JH, Steggal MJ, O’Driscoll ST et al. Penile rehabilitation for postprostatectomy erectile dysfunction. Cochrane Database Syst Rev. 2018 Oct 23;10:CD012414.