Rehabilitation Program Improves Erectile Function After Prostate Cancer Surgery
by Luis R. Rivera, MD
Prostate cancer has a significant impact on mens’ health in the United States. Each year, more than 230,000 new cases are diagnosed. Thankfully, in this modern era of early prostate cancer detection, physicians are finding the disease sooner and successfully treating it. With aggressive screening guidelines, many men as young as their fifties are now undergoing treatment and can expect long-term survival of several decades or more. Among these young men in particular, the return of continence and sexual function after prostate surgery is a major concern.
Recent advances in the understanding of the etiology of post-prostatectomy erectile dysfunction are shaping new rehabilitation strategies for patients facing this important quality-of-life issue.
In 1982, the introduction of the nerve sparing radical prostatectomy marked the first major advance in the preservation of patients’ sexual function. Today, this technique is employed consistently in men whose cancer is confined to a small area of the prostate. However, even the most meticulous dissection of the nerve bundles near the prostate does not guarantee that erectile function will be preserved.
Laboratory evidence uncovered in the last several years now leads urologists to suspect that damage to the neural pathways during surgery and the resulting loss of natural nocturnal erections causes decreased blood flow to the penile tissues. Theories suggest that this diminished oxygenation eventually leading to fibrosis or a hardening of the penile tissue and a decreased likelihood the patient will regain his potency.
Early sexual or penile rehabilitation therapy is designed to increase blood flow to the corporal tissues in order to maintain their health while the neural pathways regenerate — a process that can take up to a year or two. Protocols for penile rehabilitations are not standardized. Most involve frequent use of oral erectile dysfunction medications and possible use of a vacuum erection device starting four weeks after surgery, not for the purpose of intercourse but rather to stimulate the blood flow to the tissues.
For men who do not respond adequately to PDE-5 medications or who are not candidates for the drugs, urologists may prescribe injection therapy, which works for the majority of patients regardless of the degree of nerve preservation.
Data from studies evaluating the effec-tiveness of penile rehabilitation therapy suggests a beneficial effect on the cell function of men suffering from erectile dysfunction and a positive influence on the ultimate outcome of the patient’s recovery of spontaneous erections. Additionally, studies have consistently shown that without some intervention, patients are less likely to regain potency. In other words, the patients who wait for erectile function to return without treatment are less likely to see it happen.
Of course, the likelihood of restored potency is lower for men with poor qua-lity pre-operative erections, and patients and their partners should be counseled about realistic expectations. Still, even for those patients who do not respond to rehabilitation therapy can be treated with the surgical placement of a penile prosthesis — a satisfying solution for many men who have failed other therapies.
Research investigating the methods and mechanics of penile rehabilitation therapy continue. Current and future studies are focusing on improving rehabilitation therapy and enhancing nerve regeneration. In addition, researchers are developing drugs to help protect the nerves spared during prostatectomy, a novel approach that may help prevent post-prostatectomy erectile dysfunction.
Luis R. Rivera, MD practices with Urology San Antonio. He is board-certified in urology and specializes in treating prostate cancer and erectile dysfunction.