Sexual Rehabilitation After Prostate Surgery

Chris NelsonDr. Christian Nelson is a Clinical Psychologist at Memorial Sloan Kettering Cancer Center and liaison to the genitourinary and sexual medicine services.

Prostatepedia spoke with him about his clinical trial on helping men adhere to a sexual rehabilitation program after prostate cancer surgery.

Can you walk us through the trial you’ve been running?

Dr. Nelson: The trial is attempting to help men utilize penile rehabilitation following prostate cancer surgery. Just about every man is going to lose his erections right after surgery. There is hope of recovery. Ultimately, what helps that recovery is penile rehabilitation, which is based on the notion that all men will have difficulties with erections after surgery. Men do not get nocturnal or morning erections, nor do they get erections in a sexual situation after surgery. If that’s the case, the penile tissue can atrophy. When penile tissue atrophies, it’s a little different than other muscles that can be built back up.

Hopefully, the surgeon has done nerve-sparing surgery—sparing the two nerves that run bilaterally along the prostate to the penis, the nerves responsible for erections. If the prostate cancer is not close to those nerves, the surgeon can pry away from the prostate. The surgeon must then stretch, clamp, and pull the nerves out of the way. Then they remove the prostate, and the nerves adhere to the prostate bed. Even though the nerves have been saved, those nerves are injured intraoperatively. It’s that injury that causes the erectile dysfunction or the difficulty with erections.

It can take about 18 to 24 months for the nerves to heal. That’s a two-year recovery period. In that time, if men are not getting either nocturnal or morning erections nor erections in a sexual situation, then that penile tissue can atrophy. The idea is to help men get medication-assisted erections consistently in this period where the nerves are healing.

Which medications do they usually use?

Dr. Nelson: The first choice is pills: the PDE5 inhibitors like Viagra (sildenafil), Levitra (vardenafil), or Cialis (tadalafil). Those work off of the nitric oxide secreted from the nerves, so if the nerves aren’t healthy and aren’t secreting nitric oxide, then the mechanism of action for those pills isn’t there. For many men after surgery—especially right after surgery—those pills aren’t effective.

For most sexual medicine professionals who do this kind of rehab, the next step is to use penile injections to restore erections. The injections are used every time a man wants an erection. The injection is in the shaft of the penis, toward the base. It’s a very thin needle, so it doesn’t really hurt. For example, after the first injection, we’ve asked men how painful it was on a zero to 10 scale, where 10 is pain as bad as you could imagine. Men generally rate the pain between a zero and two on the pain scale. There’s anxiety associated with it, but after you do it a few times, the anxiety tends to dissipate.

The notion of penile rehabilitation then for most men is to use these penile injections about two or three times a week. The idea is that the injection will pull oxygen-rich blood into the penis, give the man an erection, and keep the penile tissue healthy. In terms of rehabilitation, what men do with the erection is up to them. It can be used in sexual situation or not. The idea is just to have an erection to keep the penile tissue healthy.

With injections, the goal is to get an erection two to three times a week through the recovery period, which is up to two years. The hope is this will give men a better chance to recover erections. We don’t know exactly what will happen. But the data suggests that this gives men a better chance of recovering erections on their own without medications.

Then if they don’t recover erections, they have a better chance of responding to pills, like Viagra (sildenafil), Levitra (vardenafil), or Cialis (tadalafil). That’s the rehab program.

Now, you can imagine that it’s hard for men to stay on that type of penile program.

How do you help men adhere to the rehabilitation program?

Dr. Nelson: Compliance is difficult with any type of medication, and now we’re asking men to self-inject their penis two to three times a week. Men say that difficulty with erections is a shameful experience. There is fear of entering into sexual situations with ED, and on top of this, the notion of injections causes fear.

Our intervention explains this process of avoidance, and then uses concepts such as why it’s important to recover erections in terms of his or the couple’s values. Maybe he wants to feel like a man again. Maybe he wants to just feel healthy again or whole. If a man is single and dating, maybe he wants to feel that he can still date. The idea is to start with the values and build from there.

Can you walk us through the trial you’ve been running?

Dr. Nelson: The trial is attempting to help men utilize penile rehabilitation following prostate cancer surgery. Just about every man is going to lose his erections right after surgery. There is hope of recovery. Ultimately, what helps that recovery is penile rehabilitation, which is based on the notion that all men will have difficulties with erections after surgery. Men do not get nocturnal or morning erections, nor do they get erections in a sexual situation after surgery. If that’s the case, the penile tissue can atrophy. When penile tissue atrophies, it’s a little different than other muscles that can be built back up.

Hopefully, the surgeon has done nerve-sparing surgery—sparing the two nerves that run bilaterally along the prostate to the penis, the nerves responsible for erections. If the prostate cancer is not close to those nerves, the surgeon can pry away from the prostate. The surgeon must then stretch, clamp, and pull the nerves out of the way. Then they remove the prostate, and the nerves adhere to the prostate bed. Even though the nerves have been saved, those nerves are injured intraoperatively. It’s that injury that causes the erectile dysfunction or the difficulty with erections.

It can take about 18 to 24 months for the nerves to heal. That’s a two-year recovery period. In that time, if men are not getting either nocturnal or morning erections nor erections in a sexual situation, then that penile tissue can atrophy. The idea is to help men get medication-assisted erections consistently in this period where the nerves are healing.

Which medications do they usually use?

Dr. Nelson: The first choice is pills: the PDE5 inhibitors like Viagra (sildenafil), Levitra (vardenafil), or Cialis (tadalafil). Those work off of the nitric oxide secreted from the nerves, so if the nerves aren’t healthy and aren’t secreting nitric oxide, then the mechanism of action for those pills isn’t there. For many men after surgery—especially right after surgery—those pills aren’t effective.

For most sexual medicine professionals who do this kind of rehab, the next step is to use penile injections to restore erections. The injections are used every time a man wants an erection. The injection is in the shaft of the penis, toward the base. It’s a very thin needle, so it doesn’t really hurt. For example, after the first injection, we’ve asked men how painful it was on a zero to 10 scale, where 10 is pain as bad as you could imagine. Men generally rate the pain between a zero and two on the pain scale. There’s anxiety associated with it, but after you do it a few times, the anxiety tends to dissipate.

The notion of penile rehabilitation then for most men is to use these penile injections about two or three times a week. The idea is that the injection will pull oxygen-rich blood into the penis, give the man an erection, and keep the penile tissue healthy. In terms of rehabilitation, what men do with the erection is up to them. It can be used in sexual situation or not. The idea is just to have an erection to keep the penile tissue healthy.

With injections, the goal is to get an erection two to three times a week through the recovery period, which is up to two years. The hope is this will give men a better chance to recover erections. We don’t know exactly what will happen. But the data suggests that this gives men a better chance of recovering erections on their own without medications.

Then if they don’t recover erections, they have a better chance of responding to pills, like Viagra (sildenafil), Levitra (vardenafil), or Cialis (tadalafil). That’s the rehab program.

Now, you can imagine that it’s hard for men to stay on that type of penile program.

How do you help men adhere to the rehabilitation program?

Dr. Nelson: Compliance is difficult with any type of medication, and now we’re asking men to self-inject their penis two to three times a week. Men say that difficulty with erections is a shameful experience. There is fear of entering into sexual situations with ED, and on top of this, the notion of injections causes fear.

Our intervention explains this process of avoidance, and then uses concepts such as why it’s important to recover erections in terms of his or the couple’s values. Maybe he wants to feel like a man again. Maybe he wants to just feel healthy again or whole. If a man is single and dating, maybe he wants to feel that he can still date. The idea is to start with the values and build from there.

Subscribers can read the entire conversation in their September 2017 issue.

Not a member? Subscribe to learn more about Dr. Nelson’s trial and the type of patients he’s recruiting.


2 Comment

Don Wanamakaer

I just read your Sep 19th Post. I had a radical prostatectomy late 2010 (computer assisted- by Dr. Samadi). Had complications (during recovery afterwards) due to the catheter placement. Since then I have tried to maintain an erection twice (once while on vacation 3 yrs ago) with my wife. She ‘closed the door’ on that aspect of our relationship. Since that time, I have woken up with a firm erection. Is there still time (age 65)? I am also registering with the VA ‘agent orange roster’… and have some questions regarding ‘agent orange/dioxin’ (DaNang harbor 1970)… re: prostate cancer and possible other concerns (for either myself and/or spouse and two grown children).

Posted: Sep 25, 2017

Roger

Is there a stem cell injection treatment that has any success with regenerating the nerves? Unable to inject due to essential tremor and pills don’t work for me.

Posted: Sep 22, 2017

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