Men’s Natural Sexual Function
This year doctors will diagnose nearly 219,000 men with prostate cancer. Many will undergo radical prostatectomy surgery. While radical prostatectomy provides an excellent cure, impotence (erectile dysfunction) is a common side effect. However early, postoperative penile rehabilitation can speed prostatectomy patients’ healing, achieve natural erectile function and improve their quality of life.
Studies show that even 24 months after prostate cancer treatment sexual dysfunction was the most important quality of life issue. “Increasingly doctors are finding quality of life issues important in the overall treatment of any disease, including erectile dysfunction,” said Dr. Skip Freedman, executive medical director for AllMed Healthcare Management.
Treating erectile dysfunction has changed over the last several years, and can offer men a confusing number of treatment choices. Today treatments can range from vacuum erectile devices, oral drugs and injection therapies to penile prostheses.
Working with postoperative patients, a doctor may choose either single or combined therapies based on a patient’s rehabilitation need and lifestyle. “Starting penile rehabilitation early after a prostatectomy prevents tissue damage, or fibrosis, by oxygenating the cavernosa or erectile tissue,” said Dr. Freedman.
Doctors commonly prescribe single oral therapies such as 5PDEI, or sildenafil (trade name Viagra). Studies of these drugs show early treatment with 50 to 100 milligrams a day (or every other day) improves sexual function and that higher doses produce better results. There’s also a health benefit. Using sildenafil early preserves the smooth muscles in the penis. At 100 milligrams a day, 5PDEI increases the smooth muscle content of the cavernosa. With oral therapies, patients often will accept a lower degree of sexual satisfaction.
After post-radical prostatectomy, vacuum erectile devices (VEDs) or vacuum constriction devices (VCDs) aid earlier recurring erections while preserving the penile length and girth that heightens sexual satisfaction for men and their spouses.
Injecting vaso-active substances, such as alprostadil (Prostaglandin E1, or PGE1), increases blood flow and expands blood tissue vessels. Studies on intracavernous injections of PGE1 show it can prevent long-term postoperative damage by periodically increasing oxygenation of the spongy cavernosa tissue. Intraurethral PGE1 (MUSE, or Medicated Urethral Suppository for Erections) can promote the earlier return of spontaneous erections and sexual activity.
Intracavernous PGE1 or VCDs are best used during the first postoperative months, because they allow sexual activity to begin earlier and facilitate long-term healing. However, because of the postoperative nerve damage (neuropraxia), 5PDE1 medications are rarely successful in producing erections. In time, their efficacy improves, however.
Tri-mix, or Triple P, is a combined injection therapy using varying concentrations of PGE1, phentolamine and papaverine. It allows patients to inject lower doses of each and with less pain. Early low-dose Triple P can produce more effective erections than early low-dose PGE1.
Combining oral and injection therapies, such as using oral 5PDEI and intracavernous PGE1 can increase early sexual activity and improve natural erections. The oral addition of sildenafil with the injections allows a lower dose of PGE1 and decreases the patient’s pain.
Today there are many treatment choices for men with postsurgical impotence. “Health insurers and re-insurers should consider their plan language, as well as the individual’s need to decide on the medical necessity of penile rehabilitation therapy,” said Dr. Freedman. “Insurers covering treatment for erectile dysfunction should also cover early penile rehabilitation, because after radical prostatectomy, all patients exhibit impotence.”