In our last blog post, we explained the causes of erectile dysfunction after prostate cancer treatments such as radiation therapy and radical prostatectomy. This post will focus on techniques aimed at optimizing or restoring sexual function following these treatments.
Normal erectile function is provided by the neurovascular bundles (NVB). The NVB are anatomic structures consisting of nerves and blood vessels that lie behind the prostate on the right and left sides. For men who undergo radical prostatectomy, preservation of the NVB can minimize negative erectile function side effects. Studies clearly demonstrate that nerve-sparing surgery results are better than a non-nerve sparing procedure. Studies also show that bilateral (both sides) nerve-sparing surgery results are better than unilateral nerve-sparing surgery.
Men who have normal sexual function prior to prostate cancer treatment are certainly more much more likely to maintain function afterwards. Penile rehabilitation is important for all men after treatment, to help maintain and/or recover erectile function. The concept of penile rehabilitation involves providing ongoing penile stimulation to promote normal healthy smooth muscle function within the penis. Recent studies show that atrophy and fibrosis (or scarring) of the muscles within the penis are ultimately the cause of postoperative erectile dysfunction. Nerve injury during surgery can sometimes take up to 2 years to recover. Without continued stimulation of the penile smooth muscle during this time, erectile function may never recover. For this reason, penile rehabilitation is critical. This can be done by a number of different techniques:
- Oral agents (Viagra, Cialis, Levitra, etc.): These medications work by promoting increased blood flow to the penis with external stimulation.
- Vacuum Erection Device (VED): These consist of a plastic cylinder connected to a vacuum-generating source (manual or battery-operated pump). After the penis is engorged by the negative pressure, a constricting ring is applied to the base to maintain the erection.
- Urethral Suppositories (MUSE): These are tiny pill-shaped pellets that are inserted into the tip of the penis. The medication is released through the urethra and into the penis, resulting in increased blood flow.
- Penile Injection Therapy (Papaverine, Phentolamine, Prostaglandin-E): These medications can be injected directly into the side of the penis with a tiny needle to stimulate increased blood flow and a nearly instant erection.
The key for penile rehabilitation is to begin early after surgery and continue for a prolonged period of time. Again, recovery of erectile function has been shown to continue for up to 2 years after surgery.
Another challenge patients encounter after surgery is penile shortening. While this was previously believed to be psychological, it is now clearly documented in 15-70% of patients after surgery. Nerve-sparing procedures that preserve erectile function seems to correlate with preserved penile length. Postoperatively, this might be minimized with penile rehabilitation.
As with any medical procedure, it is important to understand the options available when treating prostate cancer. The combination of nerve sparing procedures and penile rehabilitation has helped improve erectile function for many prostate cancer patients.