"Penile Rehabilitation": What Most Docs Won't Tell You After Prostate Cancer Treatment (1)

Readers who may have read the republished comment of an RN  ('Prostate Cancer Corruption') in my blog from last Sunday, will have perked up to the key point that getting enough information before a prostate cancer procedure can be tricky. In many cases, urologists tend not to give men the full lowdown of what lies in wait, including mortality rates as high as 1 in 100 for radical prostatectomy - many deaths coming as a result of post-op infections, including from accumulation in the abdominal cavity of a lymphatic fluid called "lymphocele" - whereby tubes must be inserted in the patient's abdomen to secure drainage.

But given 99 of every 100 guys survive the radical prostatectomy, the next most abundant concern remains quality of life issues. Here, as I noted, the full info tends not to be conveyed, i.e. in terms of incontinence (50% of men have some form, that never abates) and sexual function.  I elaborated a lot pertaining to the latter in my blog last week, but more needs to be said.  Especially after my own experience in the wake of my own treatment (more on that in Pt. 2). Let me say in light of this is that any sex activity after a prostate cancer treatment is not going to be "uneventful" or normal. But let me go to the main issues.

Dr. John P. Mulhall, author of an academic monograph entitled: "Sexual Function in the Prostate Cancer Patient,"  also wrote a less technical book for actual prostate cancer patients and their significant others, entitled: "Saving Your Sex Life: A Guide for Men with Prostate Cancer".  (Note: Dr. Mulhall is the Director of the Sexual & Reproductive Medicine Urology Service based at the Memorial Sloan- Kettering Cancer Center.)

In this book, Dr. Mulhall takes the 'bull by the horns' and shows what men who've had prostate cancer treatments - whether radical prostatectomy, radiation or hormone therapy, actually face and the work they will have to do in order to overcome the attendant sexual problems. Let me say he pulls no punches. And, if any men are faced with the disease - which kills 30,000 a year-  I strongly recommend they get hold of the book.

Let's first cover those who face surgery or who have opted for the radical surgery. Let's understand that in this surgery the entire prostate gland is removed along with some ancillary erectile tissue, nerves as well as the urethra being severed in 2 places (the urethra passes through the prostate). Thus, in the course of the surgery the base of the bladder has to be resected to the remaining part of the urethra that was excised from the prostate base.  Given all this 'interference' it's no surprise that sexual functions, erectile capability etc. are disturbed.

Apart from incontinence, the greatest risk that surgical patients face post-op is loss of erectile ability.The incipient damage is called "atrophy" which increases in probability the longer a patient goes without erection post-surgery. (p. 98) Atrophy is, in fact (ibid.):

"a scarring of the erectile tissue, and if the erectile tissue scars, the patient will never get his own erection back and will always struggle with medication".

Dr. Mulhall goes on to note (ibid.) that "the incidence of erectile tissue damage, as measured by the presence of venous leak is very uncommon before the fourth month after surgery. However, at eight months after surgery it "occurs in about 30% of men and at one year 50% of men".

This is why it's essential, if men care at all about their future sex lives, they do everything possible to ensure erections of some mode (they are graded on a scale of 1-10 for hardness) occur before the 4th month after radical surgery. Why do erections need to occur? Because the absence of blood, and hence oxygen getting into the penis, leads to ongoing and progressive atrophy and tissue scarring. Mulhall invokes the "use it lose it" saying here.

In this regard, he observes that a concerted effort at  "penile rehabilitation" is needed to help keep the erectile tissue healthy and "waiting for the nerves to recover from the trauma of surgery". In this regard, his Chapter 7: 'Penile Rehabilitation and Preservation' comprises a very key chapter in his book.

Dr. Mulhall notes (p. 99) the average healthy male gets 3-6 erections every night of his life, during sleep, but after surgery this isn't the case because of "nerve injury". He goes on to observe that the penile rehabilitation program aims to ensure or at least encourage, men to get at least 2-3 erections per week at a level of at least 6 (e.g. 6/10) on the hardness scale. He emphasizes that neither orgasm or penetration as in intercourse is required, just ensuring the erection,  to get blood and O2 into the penis.

In the structure of the penile rehab program, the pre-op use of PDE5 inhibitors is implemented up to two weeks before surgery. Recall the chemical pathways here: the cavernous nerves close to the prostate gland secrete nitric oxide which stimulates release of an enzyme (cyclic GMP) inside the smooth muscle cells, which promotes relaxation of smooth muscles and erection. An enzyme known as PDE5 prevents this, since else there may be a prolonged erection. Hence, a PDE5 inhibitor works to suppress secretion the PDE5 enzyme.


Mulhall notes that the pre-op use of PDE5 inhibitors is a novel concept called "endothelial preconditioning, whereby the endothelium (the lining of the erection spaces) is in some way protected by pre-treatment. Typically, the patient then gets a prescription for a PDE5 inhibitor the day the Foley catheter is removed.  He is then "told to take a full dose of Viagra (100 mg) or Levitra (20 mg) once per week with adequate accompanying stimulation to attain at least a 6/10 erection. On the other 6 nights he's told to take a low dose pill (50 mg Viagra or 10 mg Levitra) before going to bed.

The aim throughout is to protect the erectile tissues from degeneration. If these rehab procedures don't work then more radical methods have to be considered such as: 1) penile injections, 2) intra-urethral suppositories, 3) vacuum devices, or 4) penile implants. None of these is exactly "enjoyable" but the alternative may be quite depressing and also pose latent health risks.

For example, Mulhall recommends a 29-gauge needle 1/2" in length for penile injection, and he provides a close-up diagrammatic view of where to inject on p. 145, noting the '10 o'clock'  position based on a frontal cross-section view.  He notes (ibid.): "You need to inject only one side of the penis to get an erection of the whole penis". The primary danger or side effect is possible priapism. The medications he recommends for injection are Trimix or Bimix. (The posture and positioning for injection is depicted on p. 142.)

Part 2: What the radiation treatment patient can expect.