Early Penile Rehabilitation Helps Reduce Later Intractable Erectile Dysfunction

October 21, 2005

Oct. 21, 2005 (Montreal) — Early penile rehabilitation, particularly use of intraurethral alprostadil (MUSE), can help maintain healthy penile tissue after radical prostatectomy, allowing for improved responses to oral erectile dysfunction (ED) treatments later on.

"Early penile rehabilitation is a very new concept that has been going on for one or two years now [that prostate surgery has advanced to the point of consistently sparing the penile nerves] and maintaining continence level," said study presenter Rupesh Raina, MD. "With aggressive screening of prostate cancer, we are now picking up patients who are very young, like aged 50 or 52, which was not the case before. With these new young patients, when they get operated, their concerns are continence...but their main concern is sexual activity." Dr. Raina is an attending physician in the department of internal medicine and pediatrics at MetroHealth Medical Center, Case Western Reserve University, in Cleveland, Ohio.

Dr. Raina explained that oral ED therapies such as sildenafil are not effective during the six to 12 months after radical prostatectomy surgery because the penile neural pathway has not had time to regenerate. After 6 to 12 months, without early penile rehabilitation, the efficacy rate with sildenafil is about 30%. Early penile rehabilitation is designed to improve this efficacy rate, he said.

Because of the damage to the neural pathway after radical prostatectomy, patients lose their natural nocturnal erections, resulting in less blood flow to the penis and eventually fibrosis of the penile tissue. Early penile rehabilitation is designed to increase blood flow to the penis so that the penile tissue is maintained while the neural pathway regenerates, allowing for a much higher likelihood that oral therapy will be effective.

As part of a prospective nonrandomized study, patients who had recently undergone radical prostatectomy for localized prostate cancer and subsequently underwent one of three forms of early penile rehabilitation were followed to determine which approach led to the best outcomes.

Overall, 68 patients were offered MUSE, and 38 were compliant with this therapy. Seventy-four patients were offered use of a vacuum constriction device (VCD), and 60 were compliant. Twenty-two patients were offered intracavernous injections (ICD), and all were compliant with this treatment. In addition, 18 of the 22 patients using ICD also used sildenafil. Thirty-five patients who did not undergo any early penile rehabilitation were used as a comparison group. Dr. Raina presented the results here this week at the annual meeting of the American Society of Reproductive Medicine.

While all early penile rehabilitation efforts were effective, MUSE offered the best outcomes. After a mean follow-up of about six months, 39% of patients compliant with MUSE were able to have a natural erection sufficient for vaginal penetration, and 74% were sexually active. Among those compliant with VCD, 32% had natural erections sufficient for vaginal penetration, and all were sexually active. For patients using ICD with or without sildenafil, 50% had natural erections, and 96% were sexually active. In contrast, among patients who underwent no early penile rehabilitation, 11% were able to have natural erections and 37% were sexually active.

Early penile rehabilitation did more than improve patients' ability to have an erection up to a year after surgery. "The flip side of this study was that patients can have sexual activity at two or three months after surgery [with early penile rehabilitation], whereas before they had to wait at least 12 to 18 months," said Dr. Raina.

"Urologists should use these non-oral treatment options, MUSE, VCD, and ICD," Dr. Raina said. "Most urologists are confused that you can give sildenafil citrate early, [but] it doesn't work because...there is no neural pathway. It will work after six to 12 months, not initially. To maintain the vascular integrity, do these non-oral treatment options to maintain the integrity of the penile tissue; then eventually you can switch to oral therapy," he concluded.

ASRM 2005 Annual Meeting: Abstract O-323. Presented Oct. 19, 2005.

Reviewed by Gary D. Vogin, MD

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