Penile rehabilitation…is that like a witness protection program…what did it do wrong?


 

 
None of the various penile rejuvenation, I mean rehabilitation protocols have been proven to work. In the case of post-prostatectomy ED how a particular patient will do depends on if the nerves were spared. So any study trying to figure out if a penile rehab program works would need to know the status of the nerves.  You can’t determine the status of the nerves and that is the problem. You really only know if the nerves were spared if you begin to get partial erections. Because pretreatment erectile function varies between patients, because of age and other medical conditions, any study would be marred by not comparing similar patients i.e. obviously a well performed prostatectomy, good pretreatment function patients are going to do better than a poorly performed prostatectomy and poor pre-treatment erectile function. For a study to mean anything all of the apples have to be matched to apples. You can see how just setting up the study would be problematic.
 
Here’s a secret for you. You read on various message boards that ” My nerves were spared,” or ” My doctor took one side and spared the other.” In most cases of a prostatectomy you don’t actually see the nerves. You know where they are, that is posterio-lateral to the prostate and you spare that. Even if a urologist felt absolutely great about how well the surgery went and the anatomy was ” kind” to him, he cannot tell you he spared the nerves and that he salvaged your erections untill you actually are having erections. In my experience, the best sign of spared nerves is a partial erection or ” fullness” that occurs at some point in the follow-up from the surgery. An erection around the catheter is an excellent sign, I have had patients with an erection in the recovery room. If there are no nerves the best rehab program in the world won’t help. ( A hardened criminal so to speak-no pun intended.)
 
Having said all this… I encourage the rehab program. The nice thing about Cialis is that with the 36 hour window, a patient can take one every three days and have the PDE5 inhibitors in the system. It ain’t gonna hurt nothing and may help. The vacum device is nice because it will work without the nerves and has the benefit of allowing the patient to get back to having erections and his sex life while the nerve situation evolves.
 
So…after your surgery start on Cialis every third day, about twelve a month, (insurance will usually pay for 6 so you get the 20 mg tablet and break it in half and that will cover the month), get the vacuum device and start using it when your soreness is gone, and hope for the best…and a little luck. There are other regimens that utilize Muse, a intraurethral pellet, and that would be an option as well. Post on ED and 6 things you can do.
 
From PubMed
In the modern era of early prostate cancer detection, erectile dysfunction after radical prostatectomy is becoming an ever more important topic of discussion. A major advance in the preservation of sexual function after radical prostatectomy was the development of the nerve-sparing procedure by Walsh and colleagues. More recently, the concept of penile rehabilitation after surgery has generated substantial interest. Central to discussions of penile rehabilitation after radical prostatectomy is evidence demonstrating significant fibrotic changes in the corpus cavernosum after a prolonged period of penile flaccidity. Despite the theory that hypoxia is the inciting factor in these fibrotic changes, the exact etiology of this process remains unknown. Even in the absence of a mechanistic explanation, however, many practitioners are using some type of erectogenic treatment after radical prostatectomy in an effort to enhance the return of sexual function.
Several studies have been published evaluating the efficacy of various pro-erectogenic agents used for early penile rehabilitation after radical prostatectomy. The limited data regarding intracavernosal injections and VCD suggest that an increased percentage of treated patients experienced a return of natural erections compared with patients who received no treatment. However, no studies to date have included an adequate placebo control group, and the number of subjects evaluated has been limited. Longer, prospective, randomized, placebo-controlled studies will be needed to confirm the utility of these treatments in improving long-term sexual function after radical prostatectomy.
Contemporary studies evaluating the chronic use of oral PDE-5 inhibitors suggest a beneficial effect on endothelial cell function among men suffering from erectile dysfunction due to a variety of causes. Limited data suggest that this effect might be seen among post-prostatectomy patients, suggesting a possible role for these agents in enhancing the return of sexual function in such individuals.
On the basis of data accumulated thus far, it is reasonable to discuss the implementation of a “penile rehabilitation” program with patients undergoing radical prostatectomy. Preliminary data suggest that such therapy might positively influence the ultimate outcome with regard to sexual function. Patients should be aware, however, that the exact benefit imparted, as well as which treatment regimen would be most effective, will remain highly controversial until better data become available.
Main Points

  • Patients are typically counseled that it may take up to 2 years for return of maximum sexual funtion after radical prostatectomy.
  • Although the relative hypoxia thought to be associated with penile flaccidity may contribute to erectile dysfunction after radical prostatectomy, the etiology of post-prostatectomy erectile dysfunction appears to be multifactorial and is incompletely understood.
  • Several studies have been performed to evaluate the effect of artificially induced erection after surgery to prevent permanent damage, with modalities including prostaglandin E1 injection, vacuum constriction devices (VCD), and phosphodiesterase type 5 (PDE-5) inhibitors.
  • The limited data regarding intracavernosal injections suggest that an increased percentage of treated patients experience a return of natural erections compared with patients who receive no treatment.
  • Although it is not certain that the early use of VCD will improve overall return of erectile function, data suggest that fibrotic changes leading to penile shortening and possible venous leakage might be minimized.
  • The global improvement in endothelial cell function observed with chronic sildenafil treatment suggests a possible role for PDE-5 inhibition even during the period of neuropraxia after nerve-sparing radical prostatectomy

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when god shuts a door....he opens a window

 

One Reply to “Penile rehabilitation…is that like a witness protection program…what did it do wrong?”

  1. John you are absolutely right in comparing apples with apples.
    The pump at least “exercises Mr. penis which would help considerably if one was lucky enough to get erections after a nerve sparing prostatectomy. If Mr. penis was allowed to fibrose/atrophy during the long slow recovery of the nerves it would be sad if he wasn’t up to it.
    For most men, based on my initial survey, would try anything even if it meant trying for 2 years.

    I think I told you Dr. Brosman, head or prof. of Urology UCLA, at a recent presentation stated that there is a secondary mechanism to get an erection even if everything is removed. This functions up to about 45 ( I think he said) to protect the function of procreation vital to the survival of the species.

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