Why Penile Rehabilitation?
Penile rehabilitation is also called erectile function recovery therapy or penile rehabilitation therapy and is done following radical prostatectomy (surgical removal of the entire prostate gland). It is done to restore natural erectile function.
Erectile dysfunction is the failure to obtain an erection or erection that is appropriate for penetration. It is a common complication associated with prostate cancer treatment in men, especially in the case of the surgical removal of the prostate. Erectile dysfunction is seen even in cases of bilateral nerve-sparing radical prostatectomy.
The nerves involved with erection are close to the prostate gland and get affected during surgical prostate removal. This injury to the cavernosal nerve leads to hypoxia and fibrosis of the penile tissue. The restoration of erectile function may take around 1.5 to 2 years after the surgery. Other factors contributing to erectile dysfunction include:
- The age of the patient.
- The surgery procedure (nerve-sparing or not).
- Erectile function before surgery.
- Lifestyle and habits.
- Hormones.
- Medications.
The penile tissue requires an oxygen-rich blood supply to prevent scarring and fibrosis. The interventions taken after surgery help prevent scar tissue formation in the penis.
What Are the Medications for Erectile Dysfunction?
Phosphodiesterase (PDE-5 inhibitors) are used for treating erectile dysfunction. PDE-5 inhibitors cause the relaxation of blood vessels in the penis that aids in a natural erection. However, these medications work only in the presence of adequately functioning nerves when sexual stimulation occurs. The associated side effects include the following:
- Headache.
- Nose stuffiness.
- Facial flushing.
- Heartburn.
There are available in tablet form and include the following:
- Tadalafil.
- Sildenafil.
- Vardenafil.
To obtain the required result, the medication should be taken for a minimum of three months regularly. Tadalafil has a longer duration of action, and usually, a dose of 20 mg is given thrice a week. Sildenafil is to be taken daily, and the dosage range from 25 to 50 mg. Vardenafil is taken thrice weekly, and its effects last for around 24 hours.
When to Start Penile Rehabilitation and What Are the Different Rehabilitation Programs?
About two months after prostatectomy surgery, the patient discusses the sexual function with the cancer specialist nurse and undergoes penile rehabilitation if needed. The sooner the repair is started, the better. The different penile rehabilitation programs include the following:
1. Phosphodiesterase (PDE-5 inhibitors):
Phosphodiesterase(PDE-5 inhibitors) are used as first-line therapy except when the patient is under nitrate medication for angina or other conditions. This is because PDE-5 inhibitors can suddenly drop blood pressure.
2. Vacuum Erection Devices:
Vacuum Erection Devices are used for penile rehabilitation along with PDE inhibitors. They are in the form of an external cylinder and are placed at the bottom of the penis after applying lubricant to prevent damage to the penile tissue. They are used for achieving and maintaining an erection.
Blood flow to the penis is enhanced on the placement of the device due to creating a vacuum within the cylinder. On removal of the pump, the penis becomes flaccid. The pump is used twice daily for 10 to 15 minutes.
For sexual use, the device is used to increase blood flow to the penis. Once the required erection to attain penetration is reached, a constriction band is used to maintain the erection. The benefits of using a vacuum erection device include the following:
- Penile length maintenance.
- Facilitate early return of natural erection.
- Early partner sexual satisfaction.
3.Intracavernosal Injections:
Intracavernosal Injections(ICI) are used as first-line therapy in patients who have undergone non-nerve-sparing prostatectomy. They are also used in cases where the patient does not respond to PDE inhibitors and where PDE inhibitors are contraindicated.
This injection causes smooth muscle relaxation and dilatation of arteries, increasing oxygen-rich blood flow to the penile region. This causes blood trapping within the corpus cavernosa, resulting in an erection.
The cancer specialist nurse will provide the dosage and instructions on using the injection. The usual dose is to be administered thrice weekly, the erection lasts 45 minutes, and the penis returns to normal in two hours.
The complications associated with ICI include the following:
- Scar tissue development.
- Priapism - A long-lasting painful erection lasting more than two hours without sexual stimulation.
If a painful erection lasts more than three hours (priapism), immediate medical attention is required.
4. Penile Prosthesis:
Penile prosthesis or implants are expensive and considered only in cases where the first and second-line therapy have failed, that too only after a notice period of at least one year after surgery. This is because implants can cause permanent damage to penile tissue, so if they turn unsuitable or become a failure, it is impossible to regain normal erectile function.
The different types of implants used are:
- Malleable Implant:
Malleable implants consist of rods inserted into corpora cavernosa, resulting in a permanent erection. They are bent forward during sexual use and bent away when not needed.
- Inflatable Implant:
An inflatable Implant consists of rods that are inserted into corpora cavernosa. It also includes a reservoir and a pump that are inserted into the scrotum. The pump inflates the rod, and a release mechanism drains the fluid.
5. Pelvic Floor Exercises:
The medical team will give the instructions for doing pelvic floor exercises, and the patient is advised to start exercising as soon as possible. These exercises increase the tone of pelvic floor muscles and blood flow to the region, thus contributing to faster healing.
6. Intraurethral Alprostadil :
Intraurethral Alprostadil is applied to the urethra. The medication dissolves and gets absorbed locally and benefits in achieving an erection that is sufficient to produce penetrative intercourse.
Conclusion
Following prostatectomy, the main problem faced is erectile dysfunction. Two months post-surgery penile rehabilitation programs are started for correcting erectile dysfunction. The earlier it is started, the better. The patient is provided with personalized programs under the guidance of the physician and specialist nurse. PDE inhibitors are given as first-line therapy, and vacuum erection devices as second-line therapy. Penile implants are used only in cases where all other treatments fail.
