Penile Rehabilitation

The main treatments for prostate cancer are surgery - in the form of radical prostatectomy (open, laparoscopic, robotic), radiotherapy, or brachytherapy.

Unfortunately, all these treatments can cause sexual dysfunction including erectile dysfunction, loss of ejaculation, shortened penis and the possibility of passing of urine during orgasm.

Loss of libido can also occur when hormone therapy is used to treat prostate cancer.

How well the sexual function recovers after treatment for prostate cancer depends on the age of the patient, the level of sexual function present before treatment and in the case of surgery, the sparing of the nerve bundles (better outcome if both sides are spared).

The other important factor is to keep the penis “healthy” after cancer treatment to maximise the chance of return of erections, the so-called “use it or lose it” approach, or penile rehabilitation.

Surgery tends to result in immediate loss of erections that then hopefully will improve over time, whereas the other treatments such as radiotherapy may result in a delayed loss of erections, up to 6 months or more after treatment.

Penile rehabilitation addresses these sexual dysfunctions, especially erectile dysfunction, that men may experience as a result of treatment for prostate cancer. It is an important part of the care of men with prostate cancer, and should be discussed even before that treatment occurs.

There is evidence that the earlier the erectile dysfunction is treated, the better the chance of a return of erections. This is because the lack of erections for a prolonged period of time causes changes to occur in the structure of the penis, so that it may not be able to respond with a normal erection.

If natural erectile function returns after treatment, the quality of the erections may not be as good as in the past.

Erections may take up to 3 years to recover to their maximum after surgery, but usually a good indication of the outcome is seen at 6 - 12 months, and if nothing in the way of “normal” erection is happening by then, usually nothing will.

Erections can be induced within 2 to 3 weeks of surgery with penile injection therapy using prostaglandin E1 (PGE1) or Trimix. The penis is injected with a small dose of medication, once or twice a week, whether sexual activity occurs or not. The early and regular “exercising” of the penis to erection has been shown to help the return of erections (but only when the nerves have been saved).

Penile injection treatment has been safely used for many years but sometimes its use is painful due to a “chemical” pain. Care must be taken with the amount injected to avoid a prolonged erection and there is a risk of scarring occurring in the penile tissues.

This “exercising” regime allows fresh blood and oxygen to enter the erection tissues thus minimising the risk of deterioration of these tissues due to lack of use, and low oxygen (hypoxia) levels. If there appears to be an improvement in natural erections whilst on PGE1 therapy, then it can be continued in addition to oral therapies as part of penile rehabilitation.

The oral treatments are known as PDE5 inhibitors, there are 3 available in Australia at present (Viagra, Levitra and Cialis). The tablets are swallowed about 1 hour before planned sexual activity when being used on an ‘as required’ basis to improve a man’s erection. However, during the first few months after surgery, these oral tablets may not have the same erection inducing effect that injections have, but some men may prefer tablets to injections at the early stage of recovery.

Men who may not be ready to engage in sexual intercourse in the first few months after surgery may use the tablets which could result in a softer erection not firm enough for penetration, but sexual play is encouraged as part of the “exercise” concept. An orgasm is entirely possible with a soft erection or indeed with no erection when adequate stimulation to the penis occurs.

However there is some evidence that just by taking PDE5 inhibitors, even without an erection occurring, there may be benefit in prevention of deterioration of the erection tissues.

So the concept has developed of use of the oral tablets as a regular dose to optimise the return of erections and to keep the erection tissues healthy during the period of absent erections.

It has been proposed that these tablets be taken at lower doses on a daily or second daily basis. The common side effects include flushing of the face, headache and blocked nose.

PDE5 inhibitors cannot be taken by men who are on cardiac medication known as nitrates.

Other treatment choices are use of a vacuum erection device which is a non-invasive method involving placement of a cylinder over the penis. Suction is applied by a pump that results in engorgement of the penis and the formation of an erection that is held in place by a rubber constriction ring. This may reduce the shortening that occurs after radical prostatectomy.

The surgical insertion of a penile prosthesis should be considered when other treatment has proven ineffective, or when it is apparent that there will be no return of natural erections.

It may be possible to tell this as early as 6 months after the prostate surgery.

This device allows an erection suitable for penetrative intercourse to occur with the simple activation of a pump discreetly placed in the scrotum, and is an excellent way for men to return to normal sexual function after prostate cancer surgery without waiting for years to see if natural improvement occurs.

The best results for penile implant surgery are within the first 12 or so months from radical prostate surgery, before there is too much penile shortening, which cannot be reversed, and before the patients develops too much depression, and loss of self-esteem as a man, because of his ED.