Managing Erectile Dysfunction After Robotic Prostatectomy: Role of Penile Rehabilitation

Abstract

The ultimate goal of penile rehabilitation is to minimize the physical and emotional impact of sexual dysfunction and loss of penile length postprostatectomy. This can only be accomplished by defining optimal management strategies for the treatment and possible prevention of these significant side effects. When considering the available objective data, there is no current consensus or clinical evidence to support any specific penile rehabilitation program. What is the best drug or device regimen to use? When should one begin the rehabilitation regimen and for how long should it continue? How can one objectively measure success of a particular rehabilitation regimen? Is the potential financial impact to the US health care system justified? Despite these questions, there is consensus that early, aggressive intervention, whether pharmacologic or by device, probably affords post-prostatectomy patients the best opportunity for maximal recovery of sexual function. Certainly, there are benefits to the patient and partner (aka “the couple”) in terms of improved quality of life, overall satisfaction, and maintaining intimacy during a tumultuous period in their lives. In the end, large,prospective, multicentered, placebo-controlled trials with long-term follow-up will be needed to answer these questions.

Appendix A

1.1 Patient Brochure: Post-Prostatectomy Penile Rehabilitation Protocol

Penile rehabilitation after a prostatectomy for prostate cancer is an important part of your ­recovery. The following booklet provides you with the specifics you will need to fully utilize the ­rehabilitation program.

• 1. Introduction – A brief overview of what the penile rehabilitation program is and why you will want to participate in this.

  Overview of treatments used in the penile rehabilitation program – This section will outline the various medications and devices that we commonly use in our rehabilitation program. Remember that the program will be tailored specifically to you.

• 2. Phase one – This section explains the use of oral medications that you may have been prescribed, along with explaining the common side effects.

• 3. Phase two – This section explains the role and use of the vacuum erection device in your penile rehabilitation program. Most will be prescribed this device; however, it is not implemented until 6 weeks postoperatively.

• 4. Additional treatments – This section will briefly cover the additional medications and devices that you may or may not need. These will be discussed with you on an “as needed” basis but please do not hesitate to ask if you have any questions regarding them.

• 5. FAQs – Contains some commonly asked questions.

1.2 Introduction

Congratulations! Your surgery is now behind you and you are on your way to recovery! Inside this brochure, you will find information on what a “penile rehabilitation” program is, why we do it, and how to participate in it. This program is started in all men after prostatectomy; however, it may be altered to fit YOUR specific needs!

It is important to keep in mind that although some patients may have erections soon after the surgery, the time frame varies from patient to patient. Even when you have had a nerve-sparing surgery, there is still a process of recovery that occurs secondary to removal of the prostate itself. It takes time to heal, so be patient! The other part of this involves your preoperative erectile function, health status, and age. We will also take these factors into consideration and tailor the program to fit your individual needs. Remember, this program is designed to maximize YOUR chances of a quick and complete return of your erectile function!

1.3 Treatments Used in the Rehabilitation Program

1.3.1 Oral Medications

Three oral medications are used in the rehabilitation process: Viagra^®, Levitra^®, and Cialis^®. Initially, these medications are not used for sexual activity. The medications are prescribed in order to increase penile blood flow, to help keep the penile tissue healthy while the nerves are healing postoperatively. As prescribed, you will take one of these medications daily or 2–3 times a week at bedtime, until your sexual function returns. Remember, if these medications are to be used for sexual activity, the dose may need to be adjusted and they require sexual stimulation for maximal efficacy. It is best to take these medications about an hour before sexual activity. We will discuss the specifics of how to take these medications in the “Phase One” section of this brochure.

1.3.1.1 Side Effects

Common side effects of these medications include the following:

• Mild headaches (may take Tylenol to relieve these)

• Stomach upset

• Blue halo around bright lights

• Mild muscle aching

These are normal and usually go away with continued usage. If the side effects are too bothersome, we will adjust your medication.

If you experience any of the following side effects from the medication, STOP the medication and notify our office immediately:

• Severe headaches

• Vision changes including blurriness or decreased vision

• Hearing loss

• An erection that does not go away after 4 hours – call the office and/or go directly to an emergency room

1.3.2 Vacuum Erection Device (VED)

The VED is a vital part of the rehabilitation program. Using the VED on a daily basis increases blood flow and helps expand the penile tissue. The VED mimics the male’s natural ability to have spontaneous erections (i.e., middle of the night, upon awakening) until this ability returns on its own. It is best to use the VED two times a day and continue to use it until you get back to preoperative functioning.

1.3.3 MUSE^® (Medicated Urethral System for Erections)

MUSE (alprostadil) is a medicated pellet about half the size of a grain of rice which is inserted into the urinary opening (meatus) using a plastic applicator. This medication allows the blood vessels to dilate or open up, thereby increasing blood flow to the penile tissue. After administration, it usually takes 5–15 min to produce an erection. You can use MUSE in conjunction with our other therapies (oral medications and the VED) for the greatest results. You will be given instructions in its use at your appointment.

1.3.3.1 Side Effects

Common side effects of this medication may include:

Urethral burning or vaginal burning in your partner (use a water-soluble lubricant such as K-Y jelly), redness of the penis due to increased blood flow, aching in the penis, testicles, legs, and in the perineum (area between the penis and rectum).

If you experience an erection lasting longer than 4 hours, call the office and go directly to an emergency room.

1.3.4 Intracorporal Injection Therapy

Intracorporal injection therapy involves the self-injection of medication directly into the tissue of the penis to achieve an erection. This injection is done with an insulin needle, which is very small and most men tolerate this without difficulty. You will be given a prescription to obtain the medication and then we will teach you how to draw up and administer it during an appointment in our office. It is important to remember that with injection therapy, you must wait 48–72 h between doses.

1.3.4.1 Side Effects

Common side effects of this medication may include

• Penile pain or discomfort

• Dizziness

• Priapism

If you experience an erection lasting longer than 4 hours, call the office and go directly to an emergency room.

1.3.5 Penile Implant/Prosthesis

A penile implant (or prosthesis) is a device that is concealed completely within the body and requires some degree of manipulation before and after intercourse to make the penis erect or flaccid. This option is usually not considered unless less invasive treatment options are deemed ineffective or contraindicated. There are numerous different types of implants available and your surgeon will review your options and choose the right one for you should you choose this option.

1.3.6 Phase One: Oral Medications

You will be given a prescription for one of the following medications after your catheter is removed:

• Viagra^® (sildenafil) 100 mg

• Cialis^® (tadalafil) 20 mg

• Levitra^® (vardenafil) 20 mg

If you were given Viagra^® or Levitra^®: Take one-half tablet before bedtime 3×/week

If you were given Cialis^® (tadalafil): Take one (1) tablet (20 mg) before bedtime 3×/week.

If you took one of these medications preoperatively, please let us know any good or bad experiences that you may have had with that medication.

1.3.6.1 Caution

• If you have been given nitroglycerin to take for possible chest pain, DO NOT TAKE Viagra, Levitra, or Cialis.

• Combining nitroglycerin with any of the above medications can be life threatening!

• Notify any emergency personnel if you have taken one of these medications within the last 48 h, if they attempt to give you nitroglycerin for chest pain.

Depending on your specific needs, you may continue these medications for 6 months to a year.

1.3.6.2 First Attempt for Intercourse

Four (4) weeks postoperatively, you may attempt to get an erection for intercourse. Follow the instructions below to maximize that attempt!

If you are taking Viagra ^® or Levitra ^®

• On the days that you have taken your normal rehabilitation dose, you may take an additional half (1/2) tablet, on an empty stomach and stimulate within 60 min of taking the medication.

• If you want to attempt on a day that you DID NOT take your normal rehabilitation dose, take one (1) full tablet, on an empty stomach and stimulate within 60 min of taking it.

If you are taking Cialis ^®

• On the day you wish to attempt sexual intercourse, in lieu of your rehabilitation dose, take one (1) full tablet (20 mg) approximately 1–2 h prior to sexual activity. There are no restrictions related to food intake but remember sexual stimulation is required in order to achieve an erection.

1.3.7 Phase Two: Vacuum Erection Device

At your follow-up visit (generally 4–6 weeks after your catheter is removed) you may be prescribed a vacuum erection device. A vacuum erection device (VED) uses a vacuum mechanism to pull blood into the erectile tissue to maintain penile health. Some are manual; others are automatic. If you were prescribed one, start using it at least once daily – twice is best! Pick a time of day that is best for you, such as before showering. You do NOT need to use a constriction ring with these exercises.

Here are the instructions for using a VED

• Manual model:

  Pump slowly three times, pause, and wait for 5 s. Then pump slowly three more times, pause, and wait 5 s. Continue to do this until you feel fullness. Tightness and pressure are normal, but avoid pumping to the point of pain.

  When you have reached an erection, pause, wait 30 s, and then press and hold the pressure release button. After the penis has decreased in fullness, repeat the above process four times.

• Automatic model:

  Press and hold the button for 3 s, then pause and wait for 5 s. Continue as stated above.

This is about quality, not how quickly you can get it done!

You may not achieve an erection within the first few sessions. Be patient; this is normal. An erection will often occur as the tissue stretches with continued rehabilitation.

Helpful hints when using the VED

• Trim the pubic hair at the base of the penis and immediately surrounding the base to allow for the best vacuum seal.

• Be consistent with your rehabilitation program. Optimal results are achieved when you follow the instructions and use it up to 2× daily.

• Use the lubricant provided or other water-soluble lubricant EVERY time you use the VED. You can purchase more through the company or another brand at your local pharmacy. If you do not purchase from the company, just be sure that the lubricant is NOT petroleum based (Vaseline) as this may damage the unit.

1.3.8 Phase Three: Additional Treatments

Additional treatments utilized to obtain an erection include MUSE, injection therapy, and penile implants, as previously discussed. If during the rehabilitation process you find that you want a firmer erection, we can discuss the addition of either MUSE or injection therapy. Remember, we will tailor this program to best suit your needs so please don’t hesitate to ask us about these options. These are good, well-tolerated options that can be utilized as needed.

1.4 FAQs – Frequently Asked Questions

• Q. What does my health status have to do with my erectile function after a robot-assisted laparoscopic radical prostatectomy?

• A. Your overall health status directly affects your erectile function. Men who are overweight, eat fatty foods and don’t exercise have a higher risk of permanent ED! Talk to your primary care provider about starting a diet and exercise program that fits your needs. We now also know that erectile dysfunction can be the FIRST presenting symptom of coronary artery disease, so make sure that you are getting regular physical exams. Review all medicines you are taking with your erectile dysfunction specialist, since they can affect your erectile function as well.

• Q. What about surgery to “save the nerves?”

• A. The main goal of the surgery is to remove ALL the cancer if possible. Your surgeon will decide if it is safe to leave the nerves (if he feels that the nerves do not contain cancer). If it is safe, he will stretch and move the nerves away from around the prostate gland. The penile rehabilitation program is designed to help those nerves recover more quickly.

• Q. When can I attempt sexual activity again?

• A. You can attempt to have an erection approx­imately four (4) to six (6) weeks after your ­prostatectomy, unless your surgeon recommends otherwise.

• Q. Sexual function is not an issue for me … do I still need to do the rehabilitation program?

• A. Even if you are not sexually active, the penile rehabilitation program is encouraged to help decrease the incidence of atrophy (shrinkage) of the penile tissue. Erections help to keep the penile tissue healthy by providing good blood flow. You should continue the program until you have return of spontaneous erections.

• Q. I have seen that I can buy the “generic” form of the erectile medications much cheaper online … is it ok to purchase these?

• A. We do not advocate that you buy these medications online. They are not approved by the FDA, therefore we cannot guarantee the components or safety of the medication.