OVERVIEW

Penile rehabilitation involves medical and therapeutic treatments to restore penile health and function before, during or following surgery, trauma, illness, or even lack of use. It is a fairly new concept in sexual medicine. No matter what the cause, penile rehabilitation is an important component in helping men regain satisfactory sexual function.

For the prostate cancer patient, erectile dysfunction, loss of penile size, changes to your sex life, and challenges to your masculinity are all legitimate concerns. Having a penile rehab program in place is very important, whether you are newly diagnosed with prostate cancer, or treatment ended long ago. Taking action and having a workable plan in place can help emotionally, mentally and especially, physically. Life is too short to spend month after month, waiting to see if things improve on their own. If you are willing to work, we are committed to helping you reach your goals.

A good penile rehab program will include medical treatment and sexual education to allow you to maintain a healthy sex life while you are healing. Physical therapy will assure that your penis is being used and exercised so that you can optimally improve.

WHAT YOU SHOULD KNOW

What are the goals of a penile rehab program?

Our goal is to help you get back to a normal sex life as soon as possible.

  • We want to accomplish this with the least medical intervention needed
  • We want to limit long term damage which can occur from neglect or lack of use
  • We want to equip you to manage your own sexual health for the rest of your life
When should a penile rehab program start?

In short, the sooner the better. Ideally, penile rehabilitation would start before you have surgery or treatment. But, at the very least, it should begin as soon as possible after surgery or trauma.

When you start a penile rehab program, the effects of surgery and treatment can often be better contained and the outcomes may be significantly better. However, we know the reality is that many men wait until there have been existing problems for months, if not years, before they come in for treatment. If that’s you, don’t despair. There are still many treatment options available to you. It’s never too late to start.

What is the success rate of a penile rehab program?

It is hard to quantify success rates. Because men begin rehab programs with varying degrees of impairment, it is difficult to compare one person’s improvement to another. However, we do know that the impact of medical intervention on your penile health is greatly underestimated and that men who begin rehab prior to their treatment recover significantly better than those who wait. And we know that the faster you go for help, the less likely it is that you will have lasting damage. A “wait and see” approach does not work for penile health!

What will my first visit look like?

The first visit to the program will be a broad assessment of your current situation and functioning. You are encouraged to bring your partner. It will take approximately an hour and a half.

  • You will be given questionnaires that focus on your current sexual functioning but also on a broader array of issues including depression, sleep and nutrition. We have found that if we have a full picture of your lifestyle, we can be more helpful in terms of providing solutions that work for you.
  • You will meet with a sex counselor who will take a sexual history and assess your current sexual functioning. He may also suggest short term, immediate interventions you can use to improve your sex life immediately.
  • You will meet with both a PA and an MD who specialize in erectile dysfunction and, depending on your circumstances, have additional testing and/or begin treatment immediately.
What would my penile rehab program look like?

A penile rehab program needs be tailored to each individual and will vary significantly depending on what problems you are having and what procedures you are undergoing. You will be given treatment modalities that may include education, penile exercises, vacuum erection devices, oral medication and penile injections (that are virtually painless). Your treatment will always begin using the least invasive methods of treatment and more invasive options will be offered to you if you are not seeing the results that you would like.

Our goal will always be for you to have an active sex life as soon as possible. Ultimately, we want to give you the best chance of having satisfactory function with the least intervention.

What changes in sexual function may occur after a prostatectomy?

Erectile Dysfunction

In the short term, all men will have some level of erectile dysfunction. Studies have found that ,in the long term, there is not a significant difference between the erectile function of men undergoing surgery and those undergoing radiation. However, the radiation takes longer to damage erectile function. The surgical technique is not as important as we once thought and the sexual side effects from open surgery vs. robotic surgery are nearly identical.

Penile Length Shortening

No, it is not a myth. Right after the surgery, many men notice that their penis has shortened, or retracted, into their body. This is not actual shortening of the penis, because no aspect of the surgery shortens the penis. Then what causes it?

There are two events happening concurrently which need to be sorted out. The first event is considered acute, or sudden, but temporary. The second event is caused over time and is more permanent.

When your body is under stress, it sends out signals through part of your nervous system called the sympathetic system. This is often called the “fight or flight” response. The sympathetic nervous system is responsible for all of the symptoms you have when you are anxious or angry (e.g. sweating, increased heart rate, sweaty palms). This is what occurs during the substantial trauma, or stress, of surgery. In the penis, this stress causes the smooth muscle in your erection chambers to contract dramatically (which is why anxiety is not good for erections). This makes your penis retract. As your body heals, this acute shortening of your penis should improve.

Separately, some time after surgery, you may notice permanent shortening of the penis. Some men lose girth; some lose length, and most lose a bit of each. The penis in its flaccid (unerect) state has very little blood flow and very little oxygen. With erections, fresh oxygenated blood is brought into the penis. If you are not getting erections, either with sleeping (nocturnal erections) or with sexual excitement, then you are not getting enough blood and, ultimately, not enough oxygen into the penis. This causes cells and tissue to die and this results in fibrosis of the penis, loss of flexibility,  and ultimately shortening of the penis. This fibrosis may be very difficult or impossible to reverse. It is extremely important to combat fibrosis by initiating regular erections as soon as possible after surgery.

Peyronie’s Disease

We don’t know all the reasons, but up to 10% of men will develop scar tissue of the penile sheath (lining of the erection chambers) after prostatectomy. This may lead to penile curvature when erect, penile pain and worsening erectile dysfunction. This seems to occur more frequently in younger men. Learn more about Peyronie’s disease and its treatment.

Anejaculation

The prostate and the seminal vesicles, which produce much of the semen, will be removed at the time of the surgery. The vas deferens (the tubes that carry the sperm) will be cut (just like in a vasectomy). Your urethra now attaches directly to your bladder. At the point of sexual climax, there is no semen, prostatic fluid, or sperm to be ejaculated – you will have a “dry orgasm”. You will still feel the pleasure of an orgasm; muscles will still pump, but you will not ejaculate. This often takes getting used to, but it is not a medical problem. Some men find it very difficult to adjust to, others don’t mind it at all.

However, you still may find that when you are sexually excited, sticky fluid continues to come out of the tip of the penis as it did before your surgery. This is pre-ejaculate (or in popular vernacular “pre-cum”). It is produced by the glands that line the urethra when a man is sexually excited. There are no sperm in the pre-ejaculate after a prostatectomy, so there is no chance of pregnancy.

Sperm Banking

Of course, loss of ejaculate means that you can no longer achieve a conception, or pregnancy, through intercourse. If you think there is a chance you will want children in the future, it is worthwhile to bank your sperm prior to the surgery.

Your body collects the sperm in ducts, and there are usually more than 60 million sperm in a single ejaculation. These sperm, if of adequate number and quality, can be frozen and stored until you decide to have a child. This sperm is then thawed and put into a partner’s uterus, a process called intrauterine insemination (IUI), to attempt a conception.

If you do not bank sperm preoperatively, but decide later you would like a child, there are still ways to accomplish this. Even if your sperm ducts are blocked, you continue to make sperm in your testes. Sperm is simply unable to get out through ejaculation. Sperm can be harvested (from the testis or its collecting ducts). However, because the body is not concentrating them naturally, only a few can be retrieved. They will only be usable in a process called IVF/ICSI. This involves taking the eggs out of a woman’s body and then injecting a single moving sperm into each egg. This is, of course, more expensive and invasive than using sperm that had been frozen prior to your surgery.

Orgasm Changes

You may notice that ,following surgery, it is more difficult to achieve orgasm or its intensity may be diminished. Sometimes there’s pain with orgasm, typically in the tip of the penis. With time and treatment, this will usually improve, as will the intensity of your orgasms. Some men even find that their orgasms gradually become longer and more profound than before surgery.

Leakage of Urine with Orgasm

You may have some urinary leakage with orgasm after your prostatectomy. However, most of the time, this will resolve during the first year. For about 20% of men, this will continue, but it can be managed. The easiest thing is to use a condom. If this is not effective, a specialized tourniquet can be placed around the penis. Medications can also be used to stop the urinary leakage.

Mechanism of ED After Prostatectomy

Nerve Damage

The current standard of surgery now involves nerve-sparing prostatectomy in which the nerves which control erections are not cut. Surgeons may refer to “nerve bundles” but studies have shown that the nerves are not arranged in neat little bundles; they surround the prostate in a fine, hair-like net. Because of this, a very careful technique must be used in order to spare as many of them as possible. Nerves may not always be able to be spared, however, due to certain characteristics of the cancer, either known before the surgery or discovered at the time of surgery. The ultimate goal of surgery is to make sure that all of the cancer is removed. If the cancer involves the nerves, they cannot be spared. If these nerves need to be taken,  this does not mean that you will not be able to get erections with treatment, but you will not be able to get them on your own. Even in a nerve-sparing prostatectomy, nerves that not have been cut may have been stretched, damaged, or traumatized. These nerves may be temporarily or permanently injured.

Damage to the Penile Blood Supply

A good blood supply is necessary to get a good erection. In general, the blood supply to the penis is spared during a typical prostatectomy. However, many men have unusual blood vessels (called accessory pudendal arteries). These may supply much or even most of the blood flow to the penis. If these are interrupted by the surgery, there may be inadequate blood flow to the penis which may further complicate erections.

Inability of the Penis to Trap Blood (Venous Leakage)

In order to get an erection, the blood has to be able to get to your penis, and it has to be able to  stay there. (The analogy we use for our patients is a bathtub. You have to turn on the water and put in the stopper in order to fill the tub.) Without regular erections, the penis does not get proper oxygenation which means that the tissue that traps the blood does not get enough oxygen over time and is damaged. This causes it to become less pliable and less able to store the blood. Even if an adequate amount of blood gets into the penis, if it cannot be stored adequately, you will not be able to get and/or maintain a rigid erection.

Factors Affecting Penile Rehabilitation

What was your sexual function like before surgery?

Most men who are having a prostatectomy are not having erections of the quality and duration that they had when they were younger. Many are already encountering erectile dysfunction, which may or may not have responded to oral medications. Since a prostatectomy necessarily diminishes the quality of the erections a man will have after the surgery, you have to consider what your starting point was when looking at your prognosis.

Surgical Technique

 If the nerves are not spared in a prostatectomy, it is impossible to regain spontaneous erections (though remember, there are always ways to treat EVERY man with erectile dysfunction). When you take into account all of the differences between patient risk factors, the most important factor is the skill of the individual surgeon. As a surgeon himself (though he does not do prostatectomies), Dr. Werner advises that you should pick the surgeon, not the technique.

TREATMENT

Why is a penile rehabilitation program needed?

One of the most important factors in determining the quality of your post-operative erections,  is your commitment to rehabilitating your penis. A recent study of men who committed to a program of penile rehabilitation showed that 52% of them recovered unassisted functional erections (i.e. they could get and maintain an erection strong enough for penetration without medication). Compare this to a recovery of 19% in the group that did not participate in rehabilitation. In this same study, 64% (versus 24%) responded adequately to Viagra, and 95% (versus 76%) responded to injections8.

Who should put the rehabilitation program into place?

The ideal is for this treatment to be performed by a urologist specializing in erectile dysfunction. Oncologic urologists (those specializing in urologic cancers like prostate cancer) will often not have the same level of expertise with erectile dysfunction as they have with cancer. These are two very different areas of expertise and both require extensive training and experience.

When should you begin?

Studies have conclusively shown that the sooner you start treatment after the surgery, the faster your recovery, and the better the final results will ultimately be. For example, the incidence of post-surgical venous leakage (as described above) increases as the amount of time without treatment increases—30% at eight months and 50% at 12 months.

How do you involve your partner?

Studies show that the involvement of a partner is beneficial in making this process as smooth and successful as possible. A partner’s motivation and interest are often driving factors in the rehabilitation. Your partner can help with every aspect of therapy and even incorporate therapy into love-making. When stress and anxiety surrounding penile function are reduced, recovery is better.

There are two parts of a penile rehabilitation program:

Medical Treatment

Oral Medications

This includes preoperative use of a PDE5 inhibitor (i.e. Viagra, Levitra, or Cialis) which is thought to protect the lining of the blood vessels. Studies show that these medicines can actually increase the amount of smooth (involuntary) muscle in the penis (the muscle responsible for trapping the blood during an erection).

There are three PDE5 inhibitors available at this point (though several more are being developed). We recommend Cialis to our patients because it is the longest acting. With Cialis, there are constantly reasonable blood levels of the medicine in your blood stream, which is preferable for a protective medication. Cialis is approved for daily use, and is usually available through a pharmacy plan in the 5mg daily dose. However, depending on your medical condition and the availability of the medication to you, 10mg per day can also be used. Ideally, the Cialis is continued throughout your post-operative period. Your surgeon will indicate if he wants you to stop it preoperatively, and when you can restart it postoperatively.

Penile Injections

If you are not getting rigid erections adequate enough for penetration using a PDE5 inhibitor alone, we will advise more aggressive treatment starting one month after surgery. You will be encouraged to use a treatment that gives you good erections, adequate for penetration, such as penile injections.

This often sounds scary to the patient and not particularly appealing. However, in reality, the technique does not involve a traditional syringe and does not hurt. Often, once a patient understands the reality of his treatment, he is willing to consider this highly popular and effective treatment technique.

It works like this. The medication goes into the penis with a device that is  similar to the ones used by diabetics. The use of this device is one of the most important ways to make this technique palatable to men. A disposable syringe is placed on the injector, the device is placed against the side of the penis, and you press a button. A spring pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis.

Most men will tell you that the “injection” doesn’t hurt. They describe it as either painless or as if they have been flicked with a rubber band. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). And since the side of the penis doesn’t have many pain receptors, there is little sensation.

The three most common medications used for injections are papaverine, phentolamine, and prostaglandin E1. All three act by relaxing the smooth muscles and causing the arteries to dilate. This activates the trapping mechanism which maintains the erection.

 

Possible complications from injections include the development of scar tissue and the possibility of a prolonged erection. However, those risks are significantly minimized if you are under the care of a physician who is very experienced with this treatment option and the appropriate dosing levels. The risk of scarring is also greatly reduced if the penis is compressed for five minutes after the injection and the site of the injection is varied.

Our experience with injectable medication tells us that many men are successfully treated this way. Their erections are often much stronger and more reliable than those from the oral medications. In some ways, the injection is a more spontaneous solution for treating impotence since it can be used right before a sexual encounter.  Also, studies suggest that men who use the injections on a regular basis have a high likelihood of seeing improvements in their spontaneous erections.

Therapeutic Treatment

Therapeutic Treatment

Physical therapy treatment for penile health is a relatively new approach and field of treatment. Recent studies support anecdotal evidence that a penis which is regularly used, exercised, and stimulated experiences better recovery.

In the early stages of treatment, exercises are mild and gentle. These consist of simple stretching and massaging activities to encourage the penis to fill with blood. As recovery continues, slightly more aggressive exercises are instituted.

Vacuum devices are a significant part of the therapy process. Getting the penile tissue regularly engorged with blood will combat tissue damage, fibrosis, and atrophy. Daily use of a vacuum therapy regime not only helps with blood flow, it is often the first step in getting men to engage sexually with their body.

Vibration Therapy is very new to the recovery process. By use of special vibrators, the penis is stimulated to help awaken dormant nerves and retrain existing nerves to aid in the erection process. Orgasms are encouraged fairly early on since the nerves which register sensation are just under the skin and are separate from the nerves in charge of erections. Regular stimulation through vibration therapy can not only restore your erections, they can also help you reclaim your sexual pleasure.

If you have experienced loss of penile mass, there are also exercises and therapies designed to restore as much as possible of your former size. These treatments may require stretching devices worn several hours each day. If implemented early, these stretching exercises, along with vacuum therapy and physical therapy can often fully restore penile size. But even if you begin therapy much later, there is still reason to hope for restoring at least some of your lost length and girth.

Sexual Therapy

Regular, therapeutic masturbation, regular stimulation from a partner, and maintaining intimacy are vital in the recovery process. A sexuality educator will help couples find fulfilling ways to create intimacy during the recovery process.

Maintaining your sexuality and staying sexually active and fulfilled are crucial to your recovery. You will be counseled in ways to satisfy each other sexually as you are recovering. Innovations, activities, marital aids and even just new ways of thinking about sex will be topics of discussion at every appointment. Many men report that their love lives have never been better than after therapy.