Post-Prostatectomy: Calling Attention to Erectile Dysfunction

At a hair salon, I once saw a plaque that declared, “I’m a beautician, not a magician.” This crossed my mind while reading research on radical prostatectomy, as knowing the baseline penile function of men before surgery seemed challenging. Restoring something that may have been subpar prior to surgery can be a daunting task, and it can cause discrepancies in results of clinical trials. Despite this, two recent studies reviewed the current and future penile rehabilitation approaches post-radical prostatectomy.

Bratu et al.²⁰¹⁷ published a review referring to post-radical prostatectomy (RP) erectile dysfunction (ED) as a challenge for patients as well as physicians. They emphasized the use of the International Index of Erectile Function (IIEF) Questionnaire to establish a man’s baseline erectile function, which can be affected by factors such as age, diabetes, alcohol use, smoking habits, heart and kidney diseases, and neurological disorders. The higher the IIEF score preoperatively, the higher the probability of recovering erectile function post-surgery. The experience of the surgeon and the technique used were also factors involved in ED. Radical prostatectomy is a trauma to the pelvis that negatively affects oxygenation of the corpora cavernosum, resulting in apoptosis and fibrotic changes in the tissue, leading to ED. Minimally invasive surgery allows a significantly lower rate of post-RP ED with robot assisted radical prostatectomy (RARP) versus open surgery. The cavernous neurovascular bundles get hypoxic and ischemic regardless of the technique used; therefore, the authors emphasized early post-op penile rehabilitation to prevent fibrosis of smooth muscle and to improve cavernous oxygenation for the potential return of satisfactory sexual function within 12-24 months.

Clavell-Hernandez and Wang²⁰¹⁷ [and Bratu et al., (2017)] reported on various aspects of penile rehabilitation after radical prostatectomy. The treatment with the most research to support its efficacy and safety was oral phosphodiesterase type-5 inhibitors (PDE5Is), which help relax smooth muscle and promote erection on a cellular level. Sildenafil, vardenafil, avanafil, and tadalafil have been studied, either used on demand or nightly. Tadalafil had the longer half-life and was considered to have the greatest efficacy. Nightly versus on-demand for any PDE5I was variable in its results. Intracavernosal injection (ICI) and intraurethral therapy using alprostadil for vasodilation improved erectile function, but it caused urethral burning and penile pain. Vacuum erection devices (VED) promoted penile erection via negative pressure around the penis, bringing blood into the corpus cavernosum. There was no need for intact corporal nerve or nitric oxide pathways for proper function, and it allowed for multiple erections in a day. Intracavernous stem cell injections provided a promising approach for ED, and they may be combined with PDE5Is or low-energy shockwave therapy. Ultimately, the authors concluded early penile rehabilitation should involve a combination of available therapies.

Restoring vascularity to healing tissue is a primary goal in rehabilitation, and the sooner the better. Disruption of cavernous nerves and penile tissue post-RP demands rehabilitation, and some methods have more supporting clinical evidence than others. Newer approaches require more exposure and clinical trials for efficacy and long term outcomes. Clinicians should pay attention to updated research and consider taking continuing education courses such as Post-Prostatectomy Patient Rehabilitation or Oncology and the Male Pelvic Floor.

Bratu, O., Oprea, I., Marcu, D., Spinu, D., Niculae, A., Geavlete, B., & Mischianu, D. (2017). Erectile dysfunction post-radical prostatectomy – a challenge for both patient and physician. Journal of Medicine and Life, 10(1), 13–18.
Clavell-Hernández, J., & Wang, R. (2017). The controversy surrounding penile rehabilitation after radical prostatectomy. Translational Andrology and Urology, 6(1), 2–11. http://doi.org/10.21037/tau.2016.08.14