Radical prostatectomy (RP) is often the initial treatment for men with prostate cancer. The effectiveness of the procedure in cancer cure or control is well documented, but it is associated with temporary and potentially lifelong sexual side effects. Although changes in orgasm, libido, and loss of penile length may occur, the most common sexual side effect of RP is erectile dysfunction (ED). Most men will experience this problem to some degree, at least temporarily, after their surgery.
Patient age, baseline erectile function, vascular risk factor status, and the health of the erectile tissue are important factors in the recovery of erectile function. The youth and health of the patient, good erectile function before surgery, and the precision of nerve-sparing surgery all contribute to improved postoperative recovery of erectile function.
Surgical techniques that protect and preserve the nerves in the neurovascular bundles (the small packages of nerves and blood vessels adjacent to the prostate) may actually cause short-term dysfunction in these nerves. This dysfunction is a temporary response to trauma called neuropraxia, and it may last for nine to 12 months after surgery. Recovery of erectile function may take an additional nine to 12 months.
Optimal recovery of erectile function typically occurs between 18 and 24 months after surgery. Many patients, particularly those who have undergone complete nerve-sparing surgery, may have functioning erections within the first month after the operation, but it is increasingly recognized that the poorest erectile function occurs somewhere between three and four months after surgery. The greatest concern about postoperative erectile dysfunction is that it may become permanent.Back to top
The concept of penile rehabilitation has been around for about 30 years. The purpose of penile rehabilitation is to protect erectile tissue from degeneration to maximize recovery of erectile function and, especially, to increase the likelihood that a man will return to his baseline (preoperative) level of erectile function. Rehabilitation is conducted during the period in which the erectile nerves are recovering from intraoperative trauma.
Although we do not yet have randomized placebo-controlled trials to define the utility of penile rehabilitation strategies, preclinical (animal) studies and numerous human studies have found that the use of phosphodiesterase-5 (PDE5) inhibitors (e.g., Viagra, Cialis, Levitra, Stendra) can help men to achieve early erections after RP as a first step in the long-term recovery of erectile function.
Penile rehabilitation involves two components, one minor and one major. The minor component consists of regular use of low-dose PDE5 inhibitors, which have been shown to protect erectile tissue, even in the absence of erection. (1), (2) In the first three months after surgery, approximately 85 percent of men taking a PDE5 inhibitor will fail to obtain an erection capable of penetration. The major component of penile rehabilitation is obtaining a sustainable erection. It is not essential that a man have sexual relations or an orgasm; erection is the critical component of penile rehabilitation.
Because most men fail to respond well to PDE5 inhibitors in the early months after surgery, they are faced with a decision about the use of penile injections. These injections have been available since 1982. (3) They are a safe and highly effective treatment, with more than 90 percent of men who receive penile injections within the first three months after RP achieving an erection capable of penetration. The erection occurs within five to ten minutes of the injection, and the average patient will maintain the erection for 30 to 45 minutes. Although the idea of injecting one’s penis is distressing to most men, using a diabetic syringe for an injection into the middle of the penile shaft is a virtually painless process.
The most important complication associated with penile injections is the risk of priapism, which is an acute medical emergency. However, if patients follow their doctor’s instructions for the injection, the risk of priapism is only about 0.2 percent.Back to top
Sexual & Reproductive Medicine at MSK
Our Sexual & Reproductive Medicine team takes a multidisciplinary approach to evaluating and managing each prostate cancer patient’s sexual complications. John Mulhall, MD, leads the team, which includes three nurse practitioners, a fellow, and a psychologist. Every patient is followed regularly for at least two years after surgery.
Appointments are available five days a week. For further information about penile rehabilitation or about the Sexual & Reproductive Medicine program at MSK, please call Dr. John Mulhall’s office at 646-888-6024 or visit www.mskcc.org.Back to top