Treatment of ED after radical prostatectomy
The majority of men who have had a radical prostatectomy will have ED for at least a limited period, and some will have permanent problems that are resistant to oral therapies. They present a particularly challenging group to treat, and management strategies are still evolving.
The likelihood of a man experiencing post-radical prostatectomy ED is influenced by his pre-operative potency, his age (ED is more likely if over 65), and the achievement of intra-operative nerve preservation (ED is more likely if one or both cavernous nerves are sacrificed), Pre-operative counseling about sexual and erectile function should be included in the routine care of men facing radical prostatectomy, and it is preferable to involve their partners too. The type of post-operative treatment regiments offered should be discussed. If possible, they should have pre-operative treatment for any pre-existing ED; this will not only allow them to enjoy sexual intimacy but also give the physician an idea of ‘baseline’ erectile function.
Traditionally, men w i t h ED after radical prostatectomy would be offered the same treatment regiment as men with ED resulting from other causes (i.e. on-demand use of PDE5 inhibitors introduced at a time of the patient’s choosing after surgery). Pioneering research by Montorsi and colleagues in the late 1990s suggested that men who were restored to potency by the early post’operative introduction of intracavernosal injection therapy had a better chance of recovering normal erectile function, without medication. This suggested that an ‘erection rehabilitation program’ after radical prostatectomy might offer men a better chance of recovering normal erectile function. Further work by Mulhall and colleagues has shown that the early introduction of oral therapy may confer a similar benefit in men able to achieve at least a partial erection response to sildenafil 100 mg. Responsive patients were instructed to use sildenafil to obtain an erection three times a week. Non-responders were offered intracavernous injections as an alternative but were rC’challenged with sildenafil every 4 months after surgery. Subsequent responders were offered transfer to the oral therapy regime. There was a statistically significant difference (p<0.001) in the percentage of patients who could obtain a functional erection without medication at 18 months after surgery between those who had participated in the rehabilitation program (52%) and those \vho had not (19%). Although there are methodological flaws in this study, which were acknowledged by the authors, this striking difference has resulted in many centers offering similar rehabilitation programs to their patients.
It has been speculated that the mechanism by which this apparent benefit is achieved is through maintaining intermittent cavernous re-perfusion and oxygenation, resulting in a reduction in smooth muscle apoptosis. This prevents disruption of the veno occlusive mechanism of erection until cavernous nerve function has recovered adequately for normal erections to resume. Further research is necessary to confirm these interesting findings and to identify the optimal rehabilitation treatment regiment. Three erections a week was an arbitrary choice of convenience; normally potent men will have far more frequent nocturnal and stimulated erections. There is also the issue of cost, inconvenience to the patient, and the possibility of treatment-related adverse effects with oral therapy or, more likely, injection therapy In any event, it seems that rehabilitation programs may offer the hope of better recovery of erections in this difficult to-treat group of patients.
Tags: Better Chance, Likelihood, Majority Of Men, Management Strategies, Mulhall, Nerve, Nerves, Operative Treatment, Oral Therapy, Partial Erection, Pde5 Inhibitors, Pioneering Research, Potency, Prostatectomy, Radical Prostatectomy, Rehabilitation Program, Routine Care, Sexual Intimacy, Sildenafil, Treatment Regiment