Common Treatments for Erectile Rehab

Soon after completing their treatment for prostate cancer, most men will begin a period of erectile rehabilitation. It is an important step that empowers men physically and emotionally on their journey from cancer patient to cancer survivor—nurturing the body’s healing process and boosting self-confidence. “We know that erectile function continues to improve for up to four-and-a-half years after prostate cancer treatment,” says Richard Bevan-Thomas, M.D., director of USMD Prostate Cancer Center. “That gives a good window of opportunity to focus on improving oxygenation and blood flow to the penis so it can become easier for patients to get erections over time.”

Erectile rehab uses five well-established treatments designed to stretch the penis, prevent scar tissue, dilate blood vessels, increase blood flow and improve oxygenation—important contributors to they physiology of erections rigid enough for intimacy. They include oral phosphodiesterase-5 inhibitors, vacuum erection device, urethral suppository alprostadil, penile injections and penile implants. Several may be used together to deliver optimal results. Here’s how they work:

Oral Phosphodiesterase-5 Inhibitors

Phosphodiesterase-5, commonly referred to as PDE-5, is an enzyme that is naturally produced by the body. When the body produces too much PDE-5, it has an adverse effect on cyclic guanosine monophosphate (cGMP)—a messenger nucleotide that signals smooth muscle cells that line blood vessels in the penis to relax during sexual arousal. Without enough cGMP, the muscle cells can’t relax and blood flow to the penis is restricted—preventing erections. Oral PDE-5 inhibitor medications such as Viagra, Cialis and Levitra reduce the amount of PDE-5 so cGMP can do its job and blood can flow into the penis. Depending on the rehab regime prescribed by your physician, oral PDE-5 may be used every day or several times per week—except by men who take nitrates, alpha blocker medications, or who have serious liver, kidney or heart conditions.

“There is a common misconception that PDE-5 medications trigger erections on their own, but this is not true,” says David Shepherd, M.D., a board-certified urologist with USMD Prostate Cancer Center. “In order for PDE-5 medications to be effective, the bundle of nerves near the prostate that signal the penis during an erection must be left intact during treatment for prostate cancer—including the cavernosal nerves largely responsible for erections. If these nerves have not been spared during treatment, PDE-5 medications will not be effective.”
Even men who have undergone nerve-sparing treatments for their prostate cancer may not develop erections right away with the use of Viagra, Cialis or Levitra if the cavernosal nerves largely responsible for erections sustain neuropraxia, a temporary paralysis caused when the nerves are deprived of oxygen.

If this is the case, it is important not to become discouraged and stop taking PDE-5 inhibitors. Remember, Viagra, Cialis and Levitra are being used to encourage blood flow to the penis as part of erectile rehab. As the cavernosal nerves recover from temporary paralysis, the oral PDE-5 inhibitors become more effective. It is also important to remember that sexual arousal is also required in order for PDE-5 inhibitors to work. Sexual thoughts or genital stimulation is necessary to activate the chemical cascade of cGMP that leads to an erection.

Vacuum Erection Device

Most men aren’t thrilled by the prospect of using a vacuum erection device (VED), but it provides important physical therapy for the penis after prostate cancer treatment. Patients are provided with a prescription for a VED—a plastic cylinder that is closed on one end and fitted with a seal around the open end. The penis is inserted into the cylinder through a hole in the seal. When pressed against the body, the cylinder creates a vacuum using either a hand pump or small battery-operated pump. “The vacuum draws blood into the penis causing an erection,” says Dr. Bevan-Thomas. “This stretches the penis to help prevent the loss of penile length and the development of scar tissue. It also improves blood flow and oxygenation which are vital to the return of sexual function.” A retaining band can be transferred from the VED to the penis to maintain the erection after the VED is removed. Nightly use of a VED can make a significant impact on the ability to develop erections sufficient for intimacy.

Urethral Suppository Alprostadil (MUSE)

Unlike PDE-5 inhibitors which require functioning nerves to increase blood flow and oxygenation to the penis, “medicated urethral system for erections”—known as MUSE—does not. It uses a small pellet containing alprostadil, a potent vasodilator that widens arteries so they can carry more blood. “MUSE is very effective at producing erections, but because it is so potent, it must be administered directly into the penis,” says Scott Thurman, M.D., a urologist who is also part of the USMD Prostate Cancer Center team.

Patients use a tube like applicator to deposit a small alprostadil pellet directly into the urethra. The alprostadil is absorbed through the membrane that lines the urethra promoting increased blood flow and oxygenation in the penis. An erection develops in about 10 minutes and lasts for about 30 minutes. Although some men report mild pain while the alprostadil is being absorbed, it decreases with each application. The number of MUSE treatments per week will vary depending on the individual patient and their prescribed rehab regimen. In some instances, MUSE may be used along with a PDE-5 inhibitor. In fact, one recent study found that patients on combined MUSE and Viagra therapy were nearly five times more likely to achieve an erection sufficient for penetration at three months after surgery than patients using Viagra alone.

Penile Injection Therapy

For patients who do not respond to oral PDE-5 inhibitors or other treatments, penile injection therapy is a good option. “The thought of giving yourself a shot in the penis may seem really unpleasant to most men, but there are actually very few nerves at the base of the penis. As daunting as it may seem, this therapy has a very high efficacy rate because it doesn’t involve nerve stimulation. Studies show that 80 percent of men who have penile injections develop a fairly natural feeling erection firm enough for intimacy,” says Dr.Thurman.

Penile injections are fast-acting. Immediately prior to intimacy, the patient or their partner injects a vasoactive medication into the side base of the penis. The proper dosage is determined by the physician. The injection causes blood vessels to dilate and the penis to become erect within five to 10 minutes. Erections typically last for approximately 30 minutes. In some instances, priapism—a prolonged erection may develop. Men who develop an erection lasting for more than four hours should call their doctor or go to the emergency room.

Injections should not be used with a vacuum erection device because it can cause excessive bleeding. Some men may experience mild pain—not from the needle insertion, but rather from the medication. For men who feel pain from the needle prick, a topical anesthetic can be applied before the injection. Because the injections are self-administered, you or your partner must physically be able to see the injection site and have the manual coordination to safely administer the injection. Penile injections are not an option for men with a hypersensitivity to vasoactive medications or who suffer from sickle cell anemia, multiple myeloma or leukemia.

Penile Implant

Once cumbersome and awkward, penile implants have come a long way from the crude models introduced in the 1970s. Today, a state-of-the-art, three-piece inflatable implant can be totally concealed within body. Most importantly, the implant can be discreetly inflated and deflated on demand via a squeezable pump that is placed in the scrotum. The pump controls the flow of fluid from a small reservoir implanted next to the bladder to a pair of inflatable cylinders in the penis. The fluid actually inflates the implant.

When the implant is inflated, the penis expands in length and girth, and has the rigidity and appearance of a natural erection. When it is deflated, the implant is soft and flaccid and totally concealed within the body. And unlike oral medications, an implant lets the wearer decide when he wants to have an erection and how long he wants it to last.

Of course, as with any surgical procedure, there are some risks. A mechanical failure or infection could require that the implant be removed. But the benefits seem to far outweigh the risks—especially for men who haven’t had success with other types of treatment for erectile dysfunction. “Implants allow wearers to be spontaneous with their partners and have sex when the mood strikes,” Dr. Shepherd says.


If you would like to know more about erectile rehabilitation following the treatment of prostate cancer, call us at 1-888-PROSTATE for more information, or to schedule an appointment with one of our board-certified urologists.

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