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Penile Rehabilitation: The Evolutionary Concept in the Management of Erectile Dysfunction

  • Prostate Cancer (D Parekh, Section Editor)
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Abstract

A compromise in erectile function is commonly experienced after radical prostatectomy and has been attributed to injury to vascular, neurogenic, and smooth muscle. The concept of rehabilitation after organ injury is not a novel concept and is one that has been applied to all aspects of medicine. Penile rehabilitation has been classically defined as the use of a device or pharmacologic agent to aid erectile function recovery after radical prostatectomy. Here we redefine penile rehabilitation as the use of any device, medication, or intervention to promote male sexual function as a primer before and after any insult to the penile erectile physiologic axis. We also review the epidemiology, rational and current literature on penile rehabilitation after prostatectomy.

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Abbreviations

ED:

Erectile dysfunction

RP:

Radical prostatectomy

cGMP:

3’5’-guanosine monophosphate

VED:

Vacuum erection devices

ICI:

Intracavernosal injection

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lue TFH. S. Pathophysiology of erectile dysfunction. Campbell-walsh urology. Amsterdam: Elsevier Inc; 2000. p. 668–70.

    Google Scholar 

  2. Setter SM, Iltz JL, Fincham JE, Campbell RK, Baker DE. Phosphodiesterase 5 inhibitors for erectile dysfunction. Ann Pharmacother. 2005;39(7–8):1286–95.

    Article  PubMed  CAS  Google Scholar 

  3. Budaus L, Huland H, Graefen M. Controversies in the management of localized prostate cancer: radical prostatectomy still the standard of care. Crit Rev Oncol Hematol. 2012;84 Suppl 1:e24–9.

    Article  PubMed  Google Scholar 

  4. Stanford JL, Feng Z, Hamilton AS, Gilliland FD, Stephenson RA, Eley JW, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA: J Am Med Assoc. 2000;283(3):354–60.

    Article  CAS  Google Scholar 

  5. Penson DF, McLerran D, Feng Z, Li L, Albertsen PC, Gilliland FD, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol. 2008;179(5 Suppl):S40–4.

    Article  PubMed  Google Scholar 

  6. Hu JC, Elkin EP, Pasta DJ, Lubeck DP, Kattan MW, Carroll PR, et al. Predicting quality of life after radical prostatectomy: results from CaPSURE. J Urol. 2004;171(2 Pt 1):703–7. doi:10.1097/01.ju.0000107964.61300.f6. discussion 7-8.

    Article  PubMed  Google Scholar 

  7. Eilat-Tsanani S, Tabenkin H, Shental J, Elmalah I, Steinmetz D. Patients' perceptions of radical prostatectomy for localized prostate cancer: a qualitative study. Israel Med Assoc J: IMAJ. 2013;15(3):153–7.

    PubMed  Google Scholar 

  8. Kendirci M, Bejma J, Hellstrom WJ. Update on erectile dysfunction in prostate cancer patients. Curr Opin Urol. 2006;16(3):186–95.

    Article  PubMed  Google Scholar 

  9. Kury P, Stoll G, Muller HW. Molecular mechanisms of cellular interactions in peripheral nerve regeneration. Curr Opin Neurol. 2001;14(5):635–9.

    Article  PubMed  CAS  Google Scholar 

  10. Leungwattanakij S, Bivalacqua TJ, Usta MF, Yang DY, Hyun JS, Champion HC, et al. Cavernous neurotomy causes hypoxia and fibrosis in rat corpus cavernosum. J Androl. 2003;24(2):239–45.

    PubMed  Google Scholar 

  11. Segal R, Burnett AL. Erectile preservation following radical prostatectomy. Ther Adv Urol. 2011;3(1):35–46.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  12. Mulhall JP, Parker M, Waters BW, Flanigan R. The timing of penile rehabilitation after bilateral nerve-sparing radical prostatectomy affects the recovery of erectile function. BJU Int. 2010;105(1):37–41. This paper examined the timing of penile rehab.

    Article  PubMed  Google Scholar 

  13. Iacono F, Giannella R, Somma P, Manno G, Fusco F, Mirone V. Histological alterations in cavernous tissue after radical prostatectomy. J Urol. 2005;173(5):1673–6.

    Article  PubMed  Google Scholar 

  14. User HM, Hairston JH, Zelner DJ, McKenna KE, McVary KT. Penile weight and cell subtype specific changes in a post-radical prostatectomy model of erectile dysfunction. J Urol. 2003;169(3):1175–9.

    Article  PubMed  Google Scholar 

  15. Gontero P, Fontana F, Bagnasacco A, Panella M, Kocjancic E, Pretti G, et al. Is there an optimal time for intracavernous prostaglandin E1 rehabilitation following nonnerve sparing radical prostatectomy? Results from a hemodynamic prospective study. J Urol. 2003;169(6):2166–9.

    Article  PubMed  Google Scholar 

  16. Mosbah A, El Bahnasawy M, Osman Y, Hekal IA, Abou-Beih E, Shaaban A. Early versus late rehabilitation of erectile function after nerve-sparing radical cystoprostatectomy: a prospective randomized study. J Sex Med. 2011;8(7):2106–11.

    Article  PubMed  Google Scholar 

  17. Raina R, Pahlajani G, Agarwal A, Zippe CD. Early penile rehabilitation following radical prostatectomy: cleveland clinic experience. Int J Impot Res. 2008;20(2):121–6.

    Article  PubMed  CAS  Google Scholar 

  18. Kuthe A. Phosphodiesterase 5 inhibitors in male sexual dysfunction. Curr Opin Urol. 2003;13(5):405–10. doi:10.1097/01.mou.0000088747.16181.4b.

    Article  PubMed  Google Scholar 

  19. Alwaal A, Al-Mannie R, Carrier S. Future prospects in the treatment of erectile dysfunction: focus on avanafil. Drug Des Dev Ther. 2011;5:435–43.

    CAS  Google Scholar 

  20. Carrier S, Zvara P, Nunes L, Kour NW, Rehman J, Lue TF. Regeneration of nitric oxide synthase-containing nerves after cavernous nerve neurotomy in the rat. J Urol. 1995;153(5):1722–7.

    Article  PubMed  CAS  Google Scholar 

  21. Yamashita S, Kato R, Kobayashi K, Hisasue S, Arai Y, Tsukamoto T. Nerve injury-related erectile dysfunction following nerve-sparing radical prostatectomy: a novel experimental dissection model. Int J Urol: Off J Japan Urol Assoc. 2009;16(11):905–11. This is one of the few ground-breaking rat models.

    Article  Google Scholar 

  22. Sirad F, Hlaing S, Kovanecz I, Artaza JN, Garcia LA, Rajfer J, et al. Sildenafil promotes smooth muscle preservation and ameliorates fibrosis through modulation of extracellular matrix and tissue growth factor gene expression after bilateral cavernosal nerve resection in the rat. J Sex Med. 2011;8(4):1048–60.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  23. Facio Jr F, Burnett AL. Penile rehabilitation and neuromodulation. Sci World J. 2009;9:652–64.

    Article  Google Scholar 

  24. Yuan J, Hoang AN, Romero CA, Lin H, Dai Y, Wang R. Vacuum therapy in erectile dysfunction–science and clinical evidence. Int J Impot Res. 2010;22(4):211–9.

    Article  PubMed  CAS  Google Scholar 

  25. Klein LT, Miller MI, Buttyan R, Raffo AJ, Burchard M, Devris G, et al. Apoptosis in the rat penis after penile denervation. J Urol. 1997;158(2):626–30.

    Article  PubMed  CAS  Google Scholar 

  26. Ferrini MG, Davila HH, Kovanecz I, Sanchez SP, Gonzalez-Cadavid NF, Rajfer J. Vardenafil prevents fibrosis and loss of corporal smooth muscle that occurs after bilateral cavernosal nerve resection in the rat. Urology. 2006;68(2):429–35.

    Article  PubMed  Google Scholar 

  27. Schwartz EJ, Wong P, Graydon RJ. Sildenafil preserves intracorporeal smooth muscle after radical retropubic prostatectomy. J Urol. 2004;171(2 Pt 1):771–4.

    Article  PubMed  Google Scholar 

  28. Padma-Nathan H, McCullough AR, Levine LA, Lipshultz LI, Siegel R, Montorsi F, et al. Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy. Int J Impot Res. 2008;20(5):479–86.

    Article  PubMed  CAS  Google Scholar 

  29. Montorsi F, Brock G, Lee J, Shapiro J, Van Poppel H, Graefen M, Stief C. Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. Eur Urol. 2008;54(4):924–31.

    Google Scholar 

  30. Bannowsky A, Schulze H, van der Horst C, Hautmann S, Junemann KP. Recovery of erectile function after nerve-sparing radical prostatectomy: improvement with nightly low-dose sildenafil. BJU Int. 2008;101(10):1279–83.

    Article  PubMed  CAS  Google Scholar 

  31. Aydogdu O, Gokce MI, Burgu B, Baltaci S, Yaman O. Tadalafil rehabilitation therapy preserves penile size after bilateral nerve sparing radical retropubic prostatectomy. Int Braz J Urol Off J Braz Soc Urol. 2011;37(3):336–44. discussion 44-6.

    Article  Google Scholar 

  32. Lee DJ, Cheetham P, Badani KK. Penile rehabilitation protocol after robot-assisted radical prostatectomy: assessment of compliance with phosphodiesterase type 5 inhibitor therapy and effect on early potency. BJU Int. 2010;105(3):382–8.

    Article  PubMed  CAS  Google Scholar 

  33. Zippe CD, Pahlajani G. Vacuum erection devices to treat erectile dysfunction and early penile rehabilitation following radical prostatectomy. Curr Urol Rep. 2008;9(6):506–13.

    Article  PubMed  Google Scholar 

  34. Basal S, Wambi C, Acikel C, Gupta M, Badani K. Optimal strategy for penile rehabilitation after robot-assisted radical prostatectomy based on preoperative erectile function. BJU Int. 2013;111(4):658–65.

    Article  PubMed  CAS  Google Scholar 

  35. Yuan J, Lin H, Li P, Zhang R, Luo A, Berardinelli F, et al. Molecular mechanisms of vacuum therapy in penile rehabilitation: a novel animal study. Eur Urol. 2010;58(5):773–80.

    Article  PubMed  CAS  Google Scholar 

  36. Montorsi F, Guazzoni G, Strambi LF, Da Pozzo LF, Nava L, Barbieri L, et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol. 1997;158(4):1408–10. This paper first started the paradigm of penile rehab.

    Article  PubMed  CAS  Google Scholar 

  37. Raina R, Pahlajani G, Agarwal A, Jones S, Zippe C. Long-term potency after early use of a vacuum erection device following radical prostatectomy. BJU Int. 2010;106(11):1719–22.

    Article  PubMed  Google Scholar 

  38. Kohler TS, Pedro R, Hendlin K, Utz W, Ugarte R, Reddy P, et al. A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. BJU Int. 2007;100(4):858–62.

    Article  PubMed  Google Scholar 

  39. Shen YJ, Ye DW, Yao XD, Zhang SL, Dai B, Zhang HL, et al. [Penile rehabilitation with vacuum erection device for erectile dysfunction after radical prostatectomy]. Zhonghua nan ke xue Natl J Androl. 2012;18(8):723–6.

    Google Scholar 

  40. Sellers T, Dineen M, Salem EA, Wilson SK. Vacuum preparation, optimization of cylinder length and postoperative daily inflation reduces complaints of shortened penile length following implantation of inflatable penile prosthesis. Adv Sex Med. 2013;3:14–8. This paper is a ground breaking regarding the use of VED to place a larger penile implant.

    Article  Google Scholar 

  41. Lehrfeld T, Lee DI. The role of vacuum erection devices in penile rehabilitation after radical prostatectomy. Int J Impot Res. 2009;21(3):158–64.

    Article  PubMed  CAS  Google Scholar 

  42. McCullough AR, Hellstrom WG, Wang R, Lepor H, Wagner KR, Engel JD. Recovery of erectile function after nerve sparing radical prostatectomy and penile rehabilitation with nightly intraurethral alprostadil versus sildenafil citrate. J Urol. 2010;183(6):2451–6.

    Article  PubMed  CAS  Google Scholar 

  43. Montague DK, Jarow JP, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, et al. Chapter 1: the management of erectile dysfunction: an AUA update. J Urol. 2005;174(1):230–9.

    Article  PubMed  Google Scholar 

  44. Mydlo JH, Volpe MA, MacChia RJ. Results from different patient populations using combined therapy with alprostadil and sildenafil: predictors of satisfaction. BJU Int. 2000;86(4):469–73.

    Article  PubMed  CAS  Google Scholar 

  45. Nehra A, Blute ML, Barrett DM, Moreland RB. Rationale for combination therapy of intraurethral prostaglandin E(1) and sildenafil in the salvage of erectile dysfunction patients desiring noninvasive therapy. Int J Impot Res. 2002;14 Suppl 1:S38–42. This paper examined the role of combination therapy in the treatment of penile rehab.

    Article  PubMed  Google Scholar 

  46. Mulhall J, Land S, Parker M, Waters WB, Flanigan RC. The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med. 2005;2(4):532–40. discussion 40-2.

    Article  PubMed  CAS  Google Scholar 

  47. Chung E, Brock G. Sexual rehabilitation and cancer survivorship: a state of art review of current literature and management strategies in male sexual dysfunction among prostate cancer survivors. J Sex Med. 2013;10 Suppl 1:102–11.

    Article  PubMed  Google Scholar 

  48. Mulhall JP, Bivalacqua TJ, Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. J Sex Med. 2013;10(1):195–203.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Dr. Tariq S. Hakky, Dr. Adam S. Baumgarten, Dr. Justin Parker, Dr. Yin Zheng, Dr. Mike Kongnyuy, and Dr. Daniel Martinez each declare no potential conflicts of interest relevant to this article.

Dr. Rafael E. Carrion serves as a section editor on Current Urology Reports.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Department of Urology, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA

    Tariq S. Hakky, Adam S. Baumgarten, Justin Parker, Yin Zheng, Mike Kongnyuy, Daniel Martinez & Rafael E. Carrion

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  1. Tariq S. Hakky
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  2. Adam S. Baumgarten
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Correspondence to Rafael E. Carrion.

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This article is part of the Topical Collection on Prostate Cancer

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Hakky, T.S., Baumgarten, A.S., Parker, J. et al. Penile Rehabilitation: The Evolutionary Concept in the Management of Erectile Dysfunction. Curr Urol Rep 15, 393 (2014). https://doi.org/10.1007/s11934-014-0393-6

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  • DOI: https://doi.org/10.1007/s11934-014-0393-6

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