For Which Indications Is Penile Rehabilitation Appropriate?

Hélène Joubert

March 20, 2023

MONTPELLIER, France — Penile rehabilitation is a measure for secondary prevention. The aim is to prevent erectile dysfunction (ED) from becoming chronic once it has occurred or been diagnosed after a critical episode. Is the concept of penile rehabilitation after radical prostatectomy, where it has been most studied, applicable to other populations? Stéphane Droupy, MD, urologist and andrologist at Nimes University Hospital in France, addressed this question during the French-language conference on sexology and sexual health.

Prostate cancer is emblematic of diseases that cause sexual disorders, particularly ED. Could diseases that affect other organs that are less commonly associated with these conditions also benefit from rehabilitation of this type?

What's Penile Rehabilitation?

Penile rehabilitation involves early treatment of ED post-radical prostatectomy. Its aim is to improve the quality of erections during the recovery period (around 2-4 years), providing, of course, a nerve-sparing technique has been used, as well as to allow the patient to resume his sex life during the postoperative period and, perhaps, to avoid permanent aftereffects. The concept has been developed over the years, with intracavernous injections (ICI) only starting to be used regularly in the late 1990s, daily phosphodiesterase 5 inhibitors (PDE5Is) over the long term, and comprehensive integrated care (PDE5I, ICI, vacuum therapy, sex therapy, supplements to treat testosterone deficiency).

"Even now, 25 years after the first article was published on this topic, there is still no global consensus on the protocol for penile rehabilitation," Droupy acknowledged. What we do know is that, regardless of the technique, the outcome depends on the time and quality of the vascular-nerve sparing, with erection recovery between 30% and 85% in cases of bilateral preservation, and 15% to 55% for unilateral preservation.

Manage Expectations

To date, research into drug-based recovery post-prostatectomy in clinical practice has not yielded convincing results, probably in part because most studies do not last longer than 9 months. One study lasting 18 months suggests that a proactive attitude is beneficial, with quantitative and qualitative improvements seen in nonpharmacologically assisted erections (52% of patients in the rehabilitation group vs 19% of patients in the nonrehabilitation group).

The efficacy of PDE5Is (sildenafil/Viagra) was better in patients who had followed a rehabilitation program (64% vs 24%). How early this rehabilitation began is important. Immediate treatment with sildenafil 100 mg (prescribed for 3 months) gives better results than sildenafil 100 mg started 3 months post-operatively (for 3 months), in terms of erection quality at 12 months (41.1% vs 17.7%).

"A multitude of factors affect recovery," said Droupy. "The determining factor for the quality of erection postoperatively (rehabilitation with tadalafil [Cialis] 5 mg for 9 months) is patient satisfaction with his sexual relationships prior to surgery, the use of a robot-assisted device during the procedure, and nerve sparing."

Cancer, Pelvic Fracture, Stroke

Sexual function is significantly worse after brachytherapy, especially if it has been used in conjunction with chemical castration and radiotherapy.

All prostate cancer treatments impact a patient's sex life, especially the quality of his erection. In one publication, "radiotherapy teams tested rehabilitation, with the use of daily PDE5Is over 6 months (sildenafil 50 mg/day vs placebo, 2:1) in 279 patients," said Droupy. After 24 months, 81.6% of men on sildenafil and 56% of men taking a placebo reported functional erections with or without treatment (P = .045). "There was no difference between treatment with brachytherapy and with radiotherapy. In fact, during the recovery period, erections are better in subjects taking sildenafil, but once the medication is stopped, the quantity and quality of erections are similar for all men. So, this study doesn't prove the utility of penile rehabilitation, despite its positive conclusions."

Another study conducted with tadalafil was no more successful in preventing ED becoming a chronic condition.

Finally, in 2015 the UK's radiotherapy society came out in favor of early penile rehabilitation with PDE5Is, psychotherapy, use of vacuum therapy, et cetera.

"To sum up, although it's difficult to prove the concept of penile rehabilitation, we still think it's better to let patients benefit from it," said Droupy.

Regarding penile rehabilitation after cystectomy, a comparative study of 160 patients having undergone cystectomy, with or without nerve preservation, tested no treatment vs treatment with PDE5Is alone, intracavernous injections alone, and the combination of PDE5Is and ICIs. "Overall, the different solutions for rehabilitation do little more than nothing," said Droupy, "and the main condition for hoping to recover satisfactory erections is still nerve preservation."

Two relatively recent studies (with sildenafil and udenafil) seem to point toward a small benefit of penile rehabilitation after rectal cancer, a disease with a huge rate of sexual dysfunction, but this benefit remains to be proven. And with few studies, low sample numbers, and studies of only a few months' duration, demonstrating this benefit is not easy.

After a cerebrovascular accident (CVA), no study has focused on a pharmacologic-based intervention.

The usefulness of penile rehabilitation is slightly better documented following a pelvic fracture. The rate of ED is estimated at 35%, at 48% for patients with a bladder injury, and 58% for those with urethral rupture. A study published in 2022 somewhat supports the utility of such rehabilitation via the use of PDE5Is.

Finally, after myocardial infarction (MI), for which the rate of ED fluctuates between 50% and 79%, improvement of erectile function is evidenced by the resumption of physical activity (here, walking for 60 minutes, 4 times per week). The authors noted that PDE5Is were associated with reduced mortality in patients with a stable ischemic heart condition, as well as in those who had recently had an MI. Randomized studies are needed to better understand how PDE5Is function post-MI.

Multidisciplinary Care Plan

"Finally, there are very many indications for penile rehabilitation, since the critical episodes at the root of the ED or leading to its diagnosis are varied," said Droupy, "like the different types of cancer in a relatively comprehensive way (although there are no studies in lung cancer patients), including those treated with chemotherapy, radiotherapy, immunotherapy, hormone therapy, or surgery, but also CVAs, MI, various types of ischemic accident, neurological accidents, pelvic fractures, decompensation of chronic conditions (diabetes, kidney or respiratory failure), following admission to an intensive care unit (in the form of a drop in testosterone levels), and even COVID-19."

The specialist recommends recognizing the symptoms, assessing them, informing patients, and establishing a comprehensive rehabilitation plan. This plan includes the improvement of communication and the relationships between couples and within the workplace; reducing alcohol use; increasing physical activity; stopping smoking; reducing salt intake; reducing blood pressure; managing diabetes and reducing BMI levels; and evaluating cardiovascular risk — and, therefore, reducing and treating risk factors without forgetting to investigate any possible iatrogenic drug-induced cause.

"Following a critical event, physicians should look for signs of ED," said Droupy, "and put in place a structured multidisciplinary treatment plan (therapy, an appointment with a sexual medicine/sexology specialist). If, according to the evidence-based medicine, drug-based rehabilitation over a period of 6-9 months with PDE5Is does not result in a significant improvement in maintaining erectile function at the end of treatment, early and extended treatment must be put forward and adapted at the request of the patient or couple. Finally, testing should be done to determine any testosterone deficiency, including in patients with prostate cancer."

This article was translated from the Medscape French Edition.

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