What is Penile Rehab?
When I first heard the term ‘penile rehab’, I had no idea what it meant (and I’m sure I wasn’t the only one). Turns out, it’s a treatment (or treatments) developed for men that have undergone prostatectomy surgery. With the common sexual dysfunction side effects that occur after surgery, recovery seems variable, but that hasn’t stopped researchers from trying to find a solution. I had only heard of Cialis or Viagra, but upon further exploration, I found that there are several courses of action available.
First, it is important to understand what happens during a prostatectomy. A prostatectomy becomes necessary when a biopsy reveals prostate cancer. There are two ways that the incision can be performed – either retropubic or suprapubic (through the lower abdomen), or in the perineum (through the skin and rectum). Once inside, the surgeon removes the prostate gland and seminal vesicles. The seminal vesicles are responsible for secreting semen, so once these are removed, ejaculation is no longer possible. One or more lymph nodes will typically be biopsied during the surgery as well, to determine if cancer is present – if it is, they’ll be removed immediately.
To keep the nerves intact, there’s a nerve-sparing prostatectomy. If both sides of the nerve are cut, then the man will not be able to have an erection. If only one nerve is cut, there may be ability to still have an erection although the overall function will be decreased. The best predictor for sexual function is pre-operative function; in other words, if there were issues before, it’s extremely likely that they will continue afterwards. It’s also important to note that during surgery nerves can be stretched and can take up to a year to recover.
So, what are the goals of penile rehab?
The objectives are three-fold:
- To promote early return of erection, either natural (spontaneous) or in response to oral medications.
- To prevent penile size reduction
- To improve cavernous oxygenation, which may help reduce fibrosis
And what can penile rehab treatment entail?
- PED5 inhibitor medications: This includes Viagra, Cialis, Levitra. These medications work by relaxing smooth muscle and allowing the corpus cavernosum of the penis to fill with blood. This allows for a stronger and longer erection. Side effects of this include a sudden drop in blood pressure and headaches.
- Penile injection therapy: Alprostadil is a prostaglandin (PGE-1). It works by relaxing certain muscles in the penis and widening blood vessels, which increases blood flow to the penis and helps to cause an erection. When the effect of the alprostadil wears off, blood flow returns to normal and the erection disappears. It can be difficult for some patients to use if there is a penile deformity and/or issues with dexterity, as it has to be placed into tip of urethra. PDE5 can also be injected into the penis directly, but this is usually reserved for later in treatment as it is more invasive.
- Vacuum devices: Also called penis pumps, these are vacuum type devices that are placed over the penis, then connected to a pump which will create a suction type effect, therefore creating an erection. There is also a band that fits around the base of the penis once its erect to help maintain rigidity. General usage is a few minutes to create an erection that is suitable for intercourse. Some side-effects can be bruising, unnatural feeling erections, and some men will need to shave to reduce hair at base of penis to get a better seal.
- L-arginine: An amino acid that can be taken that converts to nitric oxide which is important for penile tissue to be able to attain and maintain an erection. Supplementation of L-arginine may increase bioavailability. It can also improve effectiveness of oral PDE5’s(Viagra, Cialis, etc..) when used in combination.
- Penile prosthesis: This is usually the last resort. You’ve got the inflatable pump (hydraulic implant) includes an internal pump system, saltwater, inflatable plastic cylinders, a chamber to hold the saltwater. The pump can be filled and then deflated after intercourse. Then there are the semi-rigid implants, which include a type of metal or plastic rod that is implanted; the penis will hang at an angle where it is close to being fully erect but can be concealed under clothing. A rigid implant uses the same material as semi-rigid implants but the penis is permanently hard and erect.
The protocol for post-prostatectomy penile rehab will usually include:
- 2-4 weeks prior to surgery: ED risk assessment, prophylactic therapy with PDE5’s
- 10-14 days after surgery: Foley catheter is removed. Medical therapy is usually started to include: 2g/day L-Arginine, nightly PDE5, IUA, vacuum therapy 20 minutes/day.
- One month after surgery: continue with current therapy, start using PDE5 prior to intercourse; IUA titration/challenge.
- 3 months after surgery: Consider penile injection therapy 2-3x/week if previously used medications are not effective.
- 2 years post surgery: If none of these methods are effective, consider penile prosthesis.
And that’s penile rehab! I hope this information helps those men considering or undergoing prostate surgery. Please be sure to talk with your surgeon about post-op recovery and treatment, to be sure you are being treated prophylactically.