Prostate cancer can be treated with radiation therapy, hormone therapy, and chemotherapy. The symptoms of the disease can be controlled with alpha-blockers.
Sometimes active surveillance is enough to avoid the side effects of prostate cancer treatment. However, radical prostatectomy stands as the surgical treatment of choice for most patients. It is particularly useful in localized prostate cancer.
Recent advances in radical prostatectomy have developed new techniques. They are known as nerve-sparing radical prostatectomies. These techniques are different because they leave the nerves behind the prostate intact. Many cases are transient, and patients recover their erectile function after a while. Some patients may still experience erectile dysfunction. Others can be particularly difficult to treat.
Some urologists may enroll their patients in penile rehabilitation. What is it, and how does it work? Do you need penile rehab? What can you expect? In this article, you will find these and other answers to frequently asked questions.
What is penile rehabilitation?
Penile rehabilitation is a strategy aimed to recover healthy erections. It is usually recommended after prostate cancer surgery. The technique was named in the ’90s and included various approaches to manage or treat erectile dysfunction (1). Most of us know some of these approaches, especially Viagra. However, more treatments and different combinations are proposed in new studies.
These management approaches include (2):
- Viagra and other phosphodiesterase type 5 inhibitors (PDE5 inhibitors)
- Intra-cavernous injection therapy
- Vacuum erection device
- Other management options under research (penile vibratory nerve stimulation, tacrolimus, low-intensity extracorporeal shockwave lithotripsy, hyperbaric oxygen therapy, aerobic training, and pelvic floor therapy).
These methods are often used in combination. Penile rehabilitation may also include psychotherapy and sexual counseling.
Not all urologists use penile rehabilitation methods, and this management is not yet standardized. However, recent studies suggest that the majority of them use these techniques after surgery. Members of the American Urological Association use penile rehabilitation in 89% of patients after surgery. Their preferred option is PDE5 inhibitors, followed by vacuum erection devices (3).
Who might need penile rehabilitation?
There is currently no standardized recommendation of penile rehabilitation. It is not a formal part of the protocol. However, urologists still decide to use these methods to prevent side effects after surgery. How do they choose which patients need penile rehabilitation? Is there a way to predict erectile dysfunction and use these methods as a prevention strategy?
Urologists base their choices on a series of studies and their outcomes. According to one study published in The Journal of Sexual Medicine, these patients are more likely to benefit from penile rehabilitation (4):
- Patients undergoing a unilateral nerve-sparing technique
- Early presentation of erectile problems after surgery
- Younger males
- Patients without significant vascular problems
A more recent study showed that the ideal candidate is a patient with an intermediate risk of erectile dysfunction. But how do you know that you have an intermediate risk?
They are (5):
- Patients aged 66-69 years.
- An international index of erectile function (IIEF) of 11-25. This measurement evaluates male sexual function. It recognizes ED symptoms and their severity.
- A Charlson Comorbidity Index (CCI) lower than 1. This is a method to estimate the risk of death after 10 years. Higher numbers indicate a higher risk.
As you can see, opinions are different between investigators. Urologists may also have a different view. If you’re not sure whether you’re a candidate, asking your doctor is the best way to find out.
What can penile rehabilitation help with?
Penile rehabilitation helps the patient recover their normal erections and penile length. It also has other benefits (6):
- PDE5 inhibitors are known to reduce fibrosis in the cavernous bodies
- They also increase the proportion of vascular smooth muscle in the penile tissue.
- Penile rehabilitation closely after surgery improves future response to erectile dysfunction treatment.
- This type of management reduces the incidence of Peyronie’s disease.
What does a penile rehabilitation program involve?
Your doctor will explain what methods you will use depending on your case. Every clinic and every doctor may have a different approach and use different medications. However, the most common strategies are (2):
- Oral medications: They include different types of phosphodiesterase type 5 inhibitors. This is the most common approach, and most studies are based on sildenafil and similar drugs. Commercial names include Viagra, Cialis, and Levitra. They all improve penile blood flow by triggering dilation in the arteries.
- Penile injections: They work similar to oral medications, but they are administered directly into the penis. They are injected drugs with a faster response. In this case, the patient will receive training to know how to inject whenever needed.
- Vacuum erection devices: These devices consist of plastic cylinders where the penis is placed and then secured. After that, the user has access to a pump to create a vacuum by drawing out the air. Erections are achieved through mechanical traction.
- Pelvic floor exercises: Studies suggest that pelvic floor muscles contribute to penile blood vessel function. The bulbocavernosus muscle maintains erections. The ischiocavernosus muscles facilitate erectile function. Thus, training these muscles through Kegel exercises can be helpful, at least theoretically. Many users have had good experiences with Kegel exercises, and studies are still undergoing. They should always be used in combination with the options above.
Other methods still under research include (2):
- Penile Vibratory Nerve Stimulation: It uses a vibrating device next to facilitate erections. It is more commonly used in cases of anejaculation.
- Low-intensity Extracorporeal Shockwave Lithotripsy: It is a painless procedure that administers very low energy levels to the penis. This triggers tissue remodeling and improves blood flow in the penis.
- Hyperbaric Oxygen Therapy: Studies show that this technique may help your penis form new blood vessels. They will increase the penile blood flow and improve erections.
- Aerobic training: Aerobic exercise is known to increase and improve blood flow throughout the body. The penis blood flow may also improve. This method could also provide stress relief and improve psychogenic erectile function.
- Yoga: Some studies have also used yoga interventions when patients are undergoing radiation therapy. They are known to reduce fatigue, and patients tend to have some improvements in sexual function.
Keep in mind that the first methods in the list have more evidence. Thus, they are more commonly used. Still, you could benefit from experimental treatment, as long as it is combined with oral medications, vacuum erection devices, or intra-cavernous injections.
Does it work?
According to many randomized control studies, penile rehabilitation is effective in many patients. The most commonly studied method is oral medications. One study included 76 patients who received either nightly sildenafil or a placebo every night. The study was scheduled to be continued for 36 weeks. After week 8, patients receiving sildenafil had significant improvements in unassisted erectile function (7).
A more recent study included a review and meta-analysis of 11 randomized controlled clinical trials. Most studies were focused on PDE-5 inhibitors, intracavernosal injections, and vacuum erection devices. They found that men who underwent penile rehabilitation had twice as frequent improvements in erectile function (8).
Benefits
In a nutshell, the benefits of penile rehabilitation for patients after radical prostatectomy include:
- Improvements in penile erection strength
- Longer maintenance of erections
- Improved sexual satisfaction among couples
- Improvements in unassisted erectile function
- Fibrosis reductions in the cavernous bodies
- Vascular smooth muscle increases in the penile tissue
- Improvements to future response to erectile dysfunction treatment
- Incidence reduction in Peyronie’s disease after radical prostatectomy
Risks
One of the main problems of penile rehabilitation therapy is related to fear of needles. Many patients require intra-cavernous injections because oral medications are not enough for them. But they either report injection pain or feel afraid of administering the injection.
Another problem with this type of therapy is related to the increase in costs. Keep in mind that most patients will cover the costs associated with ED treatment. Thus, it is recommended to consider the cost-benefit ratio in every patient to see who will benefit from this therapy (2,6).
Conclusion
Certain prostate cancer treatments can make it difficult to get and keep an erection. Find out why this happens and which treatments can help. But there are ways to recover spontaneous erections. A penile rehabilitation program may aid in erectile function recovery.
Penile rehabilitation involves different methods to solve erection problems. They include sildenafil oral treatment, intracavernous injections, and vacuum erection devices.
Rehabilitation is an important step and can help improve sexual activity after cancer treatment. Studies show that the involvement of a partner is beneficial in making this process as smooth and successful as possible. Your partner can help and offer support, making the process easier.
