New options for treating erectile dysfunction

Penile rehabilitation after treatment for prostate cancer

Studies indicate that anywhere from 30% to 70% of men who undergo radical prostatectomy or external beam radiation therapy, and 30% to 50% of men who opt for brachytherapy, will develop impotence after treatment. Recent insights into why this happens have led to a whole new approach in treating men who are interested in preserving their sexual function. The new therapies are often referred to collectively as penile rehabilitation, a concept first introduced by European physicians in 1997. Since then, penile rehabilitation has gradually evolved and is now being offered at a number of major teaching hospitals; it is less likely to be offered in the community setting. Although exact regimens vary, penile rehabilitation typically consists of oral or injected medications, alone or in combination with other interventions, to restore and preserve erectile function before any long-term damage occurs.

But this therapy remains controversial. Although preliminary results look promising, only a handful of reliable studies evaluating various types of penile rehabilitation have been published — and these have used different types of interventions, for different periods, so it is difficult to compare one method with another. Moreover, no consensus yet exists about which approach is best for a particular patient. Even so, penile rehabilitation may be something worth asking your doctor about if you have just been diagnosed with prostate cancer or are currently undergoing treatment. This article briefly reviews options in penile rehabilitation and the limited scientific evidence.

New insights into erectile dysfunction

When erectile function becomes impaired following radical prostatectomy, the problem has traditionally been attributed to nerve damage. The nerves that trigger erections may become damaged during surgery (even during so-called nerve-sparing surgery), leading to a problem known as neuropraxia — a temporary loss of function that theoretically should recover in time. The problem is that it can take as long as two years for the nerves to recover sufficiently to enable a man to have a spontaneous erection, and by then other damage may have occurred.

Recent research suggests that when the penis is flaccid for long periods of time, and therefore deprived of a lot of oxygen-rich blood, the low oxygen level causes some muscle cells in the columns of erectile tissue (corpora cavernosa) to lose their flexibility and gradually change into something akin to scar tissue. This scar tissue, moreover, seems to interfere with the penis’s ability to expand when it’s filled with blood. In fact, imaging studies indicate that blood may drain away from the penis rather than fill it.

Less research has been done about impotence after radiation therapy, but it appears that the underlying cascade of damaging events is similar to what occurs after radical prostatectomy. Radiation damages the lining of the small blood vessels, but this damage may take months or even years to manifest itself.

What all this means is that the traditional advice given to men — essentially to wait for erectile function to return on its own — may not be adequate. Simply put, erections seem to work on a use-it-or-lose-it basis. To prevent the secondary damage that may occur if the penis remains flaccid for a prolonged period, researchers now think that a better approach is to intervene soon after treatment to restore erectile function. (For more information about the studies highlighted here, see “For more information: Penile rehabilitation,” below.)

For more information: Penile rehabilitation

Gontero P, Fontana F, Bagnasacco A, et al. Is There an Optimal Time for Intracavernous Prostaglandin E1 Rehabilitation Following Nonnerve Sparing Radical Prostatectomy? Journal of Urology 2003;169:2166–9. PMID: 12771740.

Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of Spontaneous Erectile Function after Nerve-Sparing Radical Retropubic Prostatectomy with and without Early Intracavernous Injections of Alprostadil. Journal of Urology 1997;158:1408–10. PMID: 9302132.

Mulhall J, Land S, Parker M, et al. The Use of an Erectogenic Pharmacotherapy Regimen Following Radical Prostatectomy Improves Recovery of Spontaneous Erectile Function. Journal of Sexual Medicine 2005;2:532–40. PMID: 16422848.

Ohebshalom M, Parker M, Guhring P, Mulhall JP. The Efficacy of Sildenafil Citrate Following Radiation Therapy for Prostate Cancer: Temporal Considerations. Journal of Urology 2005;174:258–62. PMID: 15947650.

Raina R, Agarwal A, Allamaneni SS, et al. Sildenafil Citrate and Vacuum Constriction Device Combination Enhances Sexual Satisfaction in Erectile Dysfunction after Radical Prostatectomy. Urology 2005;65:360–4. PMID: 15708053.

Options after radical prostatectomy

Preliminary studies indicate that penile rehabilitation for men who undergo radical prostatectomy is most effective when it begins soon after surgery and involves a combination of therapies.

A study published in 2005 in the Journal of Sexual Medicine, for example, reported the results of 132 men who were followed for 18 months after radical prostatectomy. A total of 58 men enrolled in a penile rehabilitation program within six months of surgery and took sildenafil (Viagra) or penile injections (see Figure 1) to achieve erections three times a week. When investigators followed up 18 months later, 52% of the men in the penile rehabilitation group said they could have spontaneous erections firm enough for intercourse, compared with 19% of the men who did not seek intervention. A larger proportion of men who underwent penile rehabilitation also said they responded to sildenafil when they needed to take it: 64% of the rehabilitation group responded versus 24% of the untreated group.

Figure 1: Injection therapy

Injection therapy

Using a small needle (about half an inch long, the same size as those used to inject insulin), a man can inject one or more prescription drugs into the side of the penis. The injected drugs all work by relaxing the smooth muscle tissue of the penis and allowing blood to flow into the erectile tissue.

Although the study was not randomized — and thus its results could be influenced by patient self-selection or investigator bias — it confirmed the results of an earlier small study conducted by the European team that first pioneered the concept of penile rehabilitation. In 1997, researchers from Italy reported in the Journal of Urology that they had followed 30 men who underwent nerve-sparing radical prostatectomy, who were then randomized either to an observation group or to one that received penile injections three times a week, starting within a month after surgery. When investigators assessed the men at a six-month follow-up exam, they found that 67% of those who completed the entire schedule of injections reported spontaneous erections firm enough for intercourse, compared with 20% of men who did not receive injections. Imaging studies with ultrasound also indicated that the men who did not receive penile therapy had developed nerve, tissue, and vascular damage that may have contributed to their higher rates of erectile dysfunction.

Although both studies were small, they provide evidence that early intervention to restore erectile function may be important. Exactly when treatment should begin, though, is still an open question. One small study has looked at various intervention points. As reported in the Journal of Urology in 2003, investigators enrolled 73 men who underwent radical prostatectomy and randomly assigned them to receive injections at various times (within a month, 2–3 months, 4–6 months, or 7–12 months) after surgery. A total of 36 men received injections within the first three months, while 37 received injections between months 4 and 12. When the men were examined 5, 10, and 20 minutes after receiving the injection, the investigators found that 70% of the men who received an injection within the first three months after surgery could achieve erections firm enough for intercourse, compared with 40% of men receiving an injection after three months.

The results of this study are sometimes used to support the opinion that penile rehabilitation is most effective for men following radical prostatectomy if it begins within three months of surgery. However, it’s important to point out that the study involved only a single injection given within particular time frames after surgery; it’s not clear that the men would continue to respond so dramatically later on.

In addition to looking at the timing of treatment, investigators are conducting studies to determine the best mode of treatment. So far, the results indicate that a combination of therapies is probably best. For example, in 2005, investigators reported in Urology that men who had undergone radical prostatectomy and were not able to obtain erectile function after trying a vacuum constriction device (see Figure 2) might benefit by taking sildenafil before using the device. The study involved 31 men who began taking 100 mg of sildenafil an hour or two before using the vacuum device. At an 18-month follow-up, researchers found that seven men did not benefit from treatment, but 24 said that by using this combination therapy, they were able to have erections again.

Figure 2: Vacuum device

Vacuum device

This technique creates an erection by way of a vacuum pump. A man lubricates his penis and puts it into an airtight plastic cylinder attached to a hand-held pump. Air is pumped out of the cylinder to create a vacuum, which increases blood flow to the penis and causes an erection. An elastic band placed at the base of the penis maintains the erection.

Options after radiation therapy

The use of penile rehabilitation after radiation therapy has been less frequently studied, but one report in the Journal of Urology bears mention. In this study, 110 men who had developed erectile dysfunction after undergoing some form of radiation therapy were followed after they began taking sildenafil, at an average of eight months following cancer treatment. Investigators then checked in with them at three different times.

The investigators found that men who underwent brachytherapy had better results than those who underwent external beam radiation therapy. In the first year of penile rehabilitation treatment, 76% of men who underwent brachytherapy responded to sildenafil, and 60% reported erections firm enough for intercourse, compared with a 68% response rate among men who underwent external beam radiation therapy, with 50% reporting erections firm enough for intercourse. By the third year of treatment, however, response rates had fallen in both groups: Only 44% of the men who received brachytherapy were still responding to sildenafil, compared with 38% of men who received external beam radiation therapy. Likewise, only 26% of the men who received brachytherapy reported erections firm enough for intercourse, compared with 19% of those who received external beam radiation therapy.

What you can do now

Research continues in an effort to find new modalities for restoring erectile function following prostate cancer treatment. Some investigators are experimenting with ways to encourage nerves to regenerate faster, for example.

In the meantime, although the evidence isn’t perfect, you may want to ask your doctor about options for penile rehabilitation while you are discussing treatments. Although the field is still in its infancy, penile rehabilitation may help increase the odds that you will regain erectile function.

Originally published April 1, 2007; last reviewed April 22, 2011.

Comments
37
Jim,PhD

When de-sensitization is an issue, try using a superior penis health crème (health professionals recommend Man1 Man Oil) containing acetyl L carnitine, which helps with peripheral nerve damage issues.

john

2 years post nerve sparing RP with little or no erectile function. Currently using a tri mix injection that works, but don’t have length or girth of before. Reaching a point of wanting to give up and go the implant route. Hoping something new coming down the pipeline even if it is a clinical trial. Anyone know much about stem cell therapy?

fred pickett

is there certain type of food to eat for a better blood flow to penis after prostate surgery 2 and a half years ago

JAmes

After years of superior sexual performance with a large penis surgery has rendered me almost useless. Help

Craig mlagen

There is hope for you. I also had similar issues and i got a medicine that cured me from Dr. Hillary on hillaconn @ gmail. Com he can help you too.. I hope this information helps.

Art

Good summary. I have read some of the supporting research articles, too. 6 weeks now since robotic RP with nerves spared and totally dead down under now. This is normal but started rehabilitation with daily PDE5 (no erection from it, but again normal), L-Arganine, gym workouts, and daily vacuum device. Do NOT just wait around with flacidity or will result in permanent damage. Penis needs daily blood flow! Thinking about adding injections as some studies suggest a health affect. Don’T give up JAmes!

mark

Been a year since surgery. Been using pump about once a week for good erections. Using trimix for six months and I love it. Found that .40 ml is just right for very firm erections for sex and good climax. Lots of luck to you all.

MikeH

Guys.. vitamins and nutrients are key to sustained sexual health. The best way to get several of these directly into your penis skin is by using a penis health creme. I use one called Man1 Man Oil and my penis looks and feels better than it has in a very long time. Definitely check it out.

DonaldAO

3 months post op DiVinci RRP with nerve sparing. Doing sildenafil and vacuum pump. My sex partner also gives regular deep penile massage followed by lubricated hand jobs to orgasm. However, there is no show of ANY sort of rigidity, certainly nothing spontaneous. She really has nothing to hold on to. We had a great sex-life (every other day) before surgery. Penile length with the pump is down about 1.2 inches (as I started pumping before surgery.) Orgasms are VERY different from before even ignoring the lack of stimulation provided by the ejaculate. I liken them to female orgasms now: longer to achieve and more body-centric than penis-centric, still good. I think that multiple orgasms might be possible if we tried long enough. Alcohol inhibits orgasm and several attempts have been frustratingly unrewarding. I am thinking that for penetration the old fashioned way, the injections might be the next try. I don’t want to wait too long. I think I can endure the actual injection, but the cost might bring me down. On the bright side, my continence is about 99.9%.

Rap

I am 44 yeras old and just had the DaVinci RP 11 days ago. The surgeon was confident that my nerves were spared. My catheter removed 3 days ago. To my surprise, no incontinence. I have gone the last two days without any pads and have had no leakage. I haven’t tried anything yet to gain an erection. I’m going to start low dose, 25mg daily, viagra along with pump in order to rehabilitate. I will try injections soon after. DonaldAO, the injections are not bad at all. I started them a couple of months prior to surgery and they were amazing. I was having problems getting/maintaining erections prior to surgery. The Trimix injections instantly fixed it. The shots were painless. The best erection I have had in almost 20 years. I was able to get perfect results with .10. I started with .20 and erection lasted for almost 4 hours….not fun. I’m sure I will have to use more post op. I hope I get the same results post surgery. If you haven’t tried the Trimix, I encourage you to do so. It is way worth it.

Bradley Hyde

I had DaVinci rp 11 months ago, right full nerve sparing, left partial. No erections so far. VED works well but isn’t very romantic; I use it almost every day for rehab. Have taken several months of daily Cialis but no joy. Doc says it will come back — age 68. Tried samples of 4 other ED meds, no joy. Tried 500 mg MUSE, some stiffening but not useful and when I used the VED, some aching pain. I may try the 1000 mg MUSE but am nervous. Orgasms often even without an erection, not like before but fun just the same. Occasional doubles with the VED and bands within the allotted 30 minutes with intercourse. Use of penile sleeves with VED greatly improves comfort, function, and angle for intercourse. Don’t like needles, especially there — but might be willing to try, especially if it offers better rehab prospects.

Craig mlagen

Reach out to Dr Hillary on hillaconn @ gmail. Com he helped me with his medicine and im sure it will work for you too.

MR JOHN HEATH

I had my prostate done when i WAS 48 YEARS OLD it was enlarged ,after I have not been able to hold or keep my erection for a satisfying intercourse , I am now 67years old and would like to have a good sex life with my wife.
Please can you give me some good advice on this matter,
Thank you John Heath

Andrew Makesh

In the past 7 years of my life i have never been so embarrassed in my emotional life, i get ridiculed by my partners and i have had 6 breakups due to this problem, during my early youth days i was into high masturbation and this really affected me and i began to have premature ejaculation and weak erection problems. I have tried a lot of therapies and medication but none of them worked. I was opportuned to read a post of appreciation to Dr Hillary by someone (amanda) how Dr Hillary helped her husband with a permanent cure and i contacted the doctor via his email and that was all. He sent me a very powerful medication which i used as he said. My erection is back real strong and with no side effects and i can perform crazily in bed now (lol). Do not hide in silence, weak erection (ED) has a permanent cure and i am a living witness of it. You too can contact him on (hillaconn @ gmail.com).

Carlos Bellamy

I just had prostate surgery(July 2016). Can you please provide me with more insight regarding this doctor and his medication? Thanks.

Newton Murray

For more than 12 years i have suffered from the problem of weak erection, and for that 12 years you have no idea what i went through in the hands of my various partners. It got to a point that i was running away from my duty as a man.I started searching for solution every were and i became addicted to some certain drugs all because i want to make a difference and show my strength sexually. One day i decided to open up to a friend of mine and that was how i was told about Dr Hillary. I was given his contact i contacted him and i was told what to do and how to get his products which i did and within the space of days i was cured permanently without any side effects. Today i am super active sexually (lol) and i can perform extensively in bed today as a real man. For his product on erectile dysfunction,premature ejaculation and weak erection problems contact him on (hillaconn @ gmail.com).

georgebenjamin

Unbelievable, i remembered i was once here in need of help on how to go about the problem of poor penis erection i was

having, i must say those years was so frustrating, the experience was something outside the world of being normal, i could

have sworn that i was witnessing my marraige crumbling to nothing, my wife had to join me in search of various kind of

help, and the search lasted for 1year 4months and like a dove sent from heaven , a cousin to my wife referred me to “Dr

christopher onome”, a specialist with a distance full of knowledge, with his vaccines/medications and his advice on what to

stay clear off and how to approach the problem , in less than 3 weeks i was doing fine sexually, am indeed proud to say am

now a father of a bouncing baby boy and up to this moment am still thinking this all some very big dream that everything is

actually back to normal, i believe i will forever be greatful for his guidance, so am recommending all those who are

currently in the condition i was in back then, or know someone who is in any related problems like unnecessary bleeding,

Virginia odour, poor penis erection, inability to release sperm (low sperm count), kidney problems, blood in the urine or

whatever is there that’s not normal should try and contact him through his email:christopheronome12@gmail.com

Steve

Skip the pills, get some good cardio, remove nearly all meat and dairy from your diet, eat more plant based whole foods, use a VAC daily. Read a book called the China Study and watch the documentary called Forks Over Knives. This is not the quick easy road but everything about you will improve including erectile function.

Alan Pickney

What type of meds are this DR. selling ? what do they cost? Is it a daily med or use before sex.

I tried what seemed like every treatment under the sun to get a firm erection, but it wasn’t until my doctor got me on bimix injections that I finally was able to have great sex again. It takes out some of the spontaneity, but having a great erection that easily lasts long enough makes up for it. Injections don’t sound pleasant but they have worked wonders for me.

Harold St Germain

I have tried everything to get and maintain an erection after prostate surgery removal. Not has worded, injections, vaccumm,
Pills like viagarnow I’m going to try 1000mg of MUSE. Can you suggest anything for me. I had the surgery 6 years ago, I am 65yrs.old

Craig mlagen

Try contacting hillaconn @ gmail. com you can see some comments below. He has a cure and can help. I have used this medicine.

capel nicolas

As a sign of gratitude i want to also reach out to others out there not lose all hope. 3 years ago I had a prostate cancer surgery. Since then I have not been able to have any erection to enable me have sex. Despite having taken various medications and supplements, I have not at all been successful. In my state of compliant i was opportune to speak to a cousin of mine because at first i was shy about the problem but this was almost tearing my marriage apart and my wife saw me as a half man who could not perform his duty as a man to satisfy her. He gave me the contact information on how to contact the doctor who sent this very powerful herbal medicine to his friend that had similar problem, i contacted him and he sent me the medication which i used too and that was all. In my life i never thought i would ever be able to have any erection not to talk about having sex again but i was proven all wrong and now i am so active like i am in my early 20’s. Do not suffer in silence or be shy you can contact him too on (info @ edlifepanacea. com or www .edifepanacea. com) He will sure be able to help you too.

Jeffrey

I am 63 post radical 3 and a half years. Pills worked at 13 months but gave me horrible headaches. Began using Trimix two months ago. Incredible results. Best erections since my thirties. Injections are nearly painless. Just a little freaky at first. I’m getting better night time erections. Wonder if starting injections sooner might have led to unassisted hard ons.

enzo lucas

4 years ago my prostate were removed because of cancer and 3 months later i could not achieve any erection, this was bad for me because i enjoyed sex alot. I tried to seek medical help from my family doctor and others who were introduced to me by friends but all failed. A colleague of my wife actually told her about ED life and she decided to give a try. They told her about a medication that can cure me and make me normal again, When my wife brought me the medication i was so reluctant to use it because i have suffered from chronic side effects from a lot of Viagra and stimulants. She talked me into taking it and when i was done with it, i must say it’s awesome. My erection comes hard naturally now no side effects and it’s been 2 years now and i am still very much okay. I decided to take this time out to reach out to people out there with this little story of mine to in return serve as a word of encouragement too. If you have a similar problem or any ED related problem do not hesitate to contact (info @ edlifepanacea. com) i am very 100% sure they can help you too.

alvin justin

I got married to the love of my life and the man i love so much when i was 24 and i have always fantasized about how amazing our marriage is going to be together. Little did i know that this joy will soon be stolen away by his inability to father a child. He had watery sperm and his motility was low and because of that he could not get me pregnant for over 6 years and many friends and family had already tagged me as barren which was not true. We have searched far and wide for a cure/solution to his problem but to no avail, we visited several doctors, urologists bought different drugs but none seem to put the problem to an end. Still in our misery we went to see a cousin of ours on vacation when we brought the topic and he told us about someone who has a cure and he is very reliable. We contacted him and he sent us a medicine which my husband took and in a matter of weeks his sperm was thick and the count was more than average. Today we have two kids and we are living happily ever after. I decided to write my story to motivate those who have lost hope on ever getting a child, there is hope for you just contact him on (info@ edlifepanacea. com) i am 100% sure he can help you solve it permanently.

alvin justin

I got married to the love of my life and the man i love so much when i was 24 and i have always fantasized about how amazing our marriage is going to be together. Little did i know that this joy will soon be stolen away by his inability to father a child. He had watery sperm and his motility was low and because of that he could not get me pregnant for over 6 years and many friends and family had already tagged me as barren which was not true. We have searched far and wide for a cure/solution to his problem but to no avail, we visited several doctors, urologists bought different drugs but none seem to put the problem to an end. Still in our misery we went to see a cousin of ours on vacation when we brought the topic and he told us about someone who has a cure and he is very reliable. We contacted him and he sent us a medicine which my husband took and in a matter of weeks his sperm was thick and the count was more than average. Today we have two kids and we are living happily ever after. I decided to write my story to motivate those who have lost hope on ever getting a child, there is hope for you just contact him on info@ edlifepanacea. com i am 100% sure he can help you solve it permanently.

Brandon Ryan

Weak erection and low sperm is one of the most embarrassing problem in this world. This problem almost ruined my marriage and almost made me childless for life. All thanks to doctor Hillary who was able to come to my rescue using his herbal medication and saved my life and marriage. Today i have my third child. If you are still held bound by weak erection, low or watery sperm (azoospermia) feel free to contact him on (hillaconn @ gmail. com) he will be able to render professional advise.

Richard Hemsley

Richard Hemsley
I had radical surgery eight years ago and haven’t really had a proper erection since. After surgery the emphasis seemed to be more about bladder control than erections and it seemed like an age before treatment started. Strangely one week after surgery I had one perfectly normal erection, much to my and my wife’s delight. Sadly after that it was all downhill. I was given a pump, but even using the tightest restrictor band could not keep hard (and no I’m not unusually small) I tried Viagra and Cialis but both gave me splitting headaches and no erection. I was then prescribed Viradal, and experimented with different amounts. There was some success here, though even with increased dosage it doesn’t always work, and its effectiveness seems to be slipping away. Also the pain associated with a two to three hour erection is horrendous, and the weird disfigurement of the penis is scary. So is there anything new out there, I am 65 and would probably have just given up by now. However my lovely wife is a very young 53 and has stuck by me throughout, I owe her, so will keep trying.

Craig mlagen

I had a robotic prostectomy 12/6/16, with excellent results in regard to both continents and nerve sensation. However ED is still not working that well as yet. Reading all the reviews on this page I came ac cross a Dr Hillary Connor Odiha from ED Life Panacea which had glowing reports and promises to cure erectile dysfunction.
Be very wary of this scammer and his web site. After he extorted $650 usd of me I never heard from him again, the last email I received from him was telling me his email address has been linked to a scam and to not contact it again.
Don’t fall into his false promise of a cure, it will just cost you money with no product sent to you.

Craig mlagen

I complained about being scammed by Dr Hillary Connor. Well i want to use this medium to apologize to everyone here because i have received the medicine now and i am okay. The money i paid was not in vain. Please accept my apology. Thanks

Craig mlagen

He is a honest man and you can contact him too for your erectile dysfunction issues. He sure has an effective cure which has no side effects. Contact him on hillaconn @ gmail. Com

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