Penile rehabilitation

By Ginger Manley | Posted: Thursday March 7, 2013

Dear Ginger

My PSA is on the rise and I have been referred to a urologist to discuss the possibility of having prostate surgery. I am scared about having cancer but the thing that really scares me more is that I may never have erections again. My wife heard you speak recently about something called "penile rehabilitation." Can you tell us what that is?


Dear Boris

The PSA (prostate specific antigen) normally rises a little each year as a man ages but this does not necessarily mean cancer. Sometimes if the level rises quickly or reaches a very high level, it can mean the possibility of trouble and then a referral is made to a specialist. I am glad you are taking good care of yourself by following through on a referral to evaluate your prostate.

Even when you see a urologist and may be found to have a tumor, sometimes the best treatment is "watchful waiting" since cancer of the prostate is usually very slow growing and almost never requires urgent surgery. Some men are best treated with radiation through external beam or through implanted seeds. If radical prostate surgery is needed it will be one of three kinds--traditional open surgery or newer and less invasive laparoscopic surgery or robot-assisted (robotic) surgery. The surgeon will recommend the kind that is best for the man, based on the location of the tumor and how advanced it may be.

While all of these procedures are safe when done by experienced surgeons, there are still troublesome side effects that can linger for several months or years or in some cases longer. After surgery the penis has scar tissue, it is usually shorter than before, many men have urinary incontinence, and almost every man will have erectile dysfunction (ED).

If you have been reading my column for very long, you know that erections require good blood supply, adequate tissue flexibility, and good nerve conduction in order for the penis to function normally. Prostate surgery always disturbs these functions, causing impairment in erectile ability. ED used to be a permanent side effect for most men after radical surgery but in the early 1980's a kind of surgery called "nerve sparing" was developed and today, whenever possible, surgeons will do all they can to spare permanent injury to the delicate nerves that are essential for an erection to occur. Even with the best surgical techniques, however, nerves and blood vessels can be shocked or bruised and may require a long time to recover on their own.

Nowadays most urologists understand the importance of getting a man's erections back to function as soon as possible without waiting for nature to take its turn. For this reason, many men are started on a pre-operative course of erection-aid medications and penile exercises. After surgery, this program is continued and additional treatments are added, with the goal of fostering return to penetrative sexual experience by about 6-8 weeks after surgery. All of these measures taken together are called "penile rehabilitation."

To increase blood flow in the penis, a man is prescribed one or both drugs that promote erection--an ED pill (PED5 inhibitor) like Viagra and alprostadil (prostaglandin E1) given by inserting a small pellet of MUSE into the urethra or by injecting the drug directly into the base of the penis. The latter often causes lots of anticipatory wincing in most men, but actually is not nearly as uncomfortable as it sounds. In addition many men are taught to begin using a Vacuum Erection Device--VED or sometimes just "the pump." This device allows the penis to be enlarged manually to mimic the changes that occur in an erection. When a VED is used along with a penile constriction ring, the man may be able to sustain an erection for up to twenty minutes. Pelvic floor physical therapy is used to recruit and remobilize the internal muscles and nerves that were bruised or shocked during the operation. While these treatments before and after a prostatectomy are usually not preludes to penetrative activities, they do work to prime the penis and to begin restoring blood flow.

Here's the usual way penile rehabilitation is prescribed:

a) One week before surgery: Start low dose Viagra (25-50 mg) at bedtime nightly

b) Begin using a VED for practice

c) Initial session with pelvic floor physical therapist

After the catheter is removed:

a) Resume taking low dose Viagra nightly or every other night

b) Practice using the VED once daily, with or without constriction

c) Begin using MUSE on the nights Viagra is not used

d) Start pelvic floor exercises as soon after surgery as tolerated and continue as prescribed

If erections are not improving after 6 weeks, injection therapy may        be started.

Many larger urology practices have a sexual medicine practitioner available for pre-op consultation and/or rehab "coaching." In general, the younger a man and the more sexually functional he was prior to surgery, the better the likelihood of regaining good erections after prostate surgery. In my previous role as a sexuality therapist, I often coached couples to explore sex-positive activities other than intercourse as alternate means of enjoyment. Often they learned that engaging in "outercourse" or "othercourse" were wonderful ways to expand their sexual repertoires, especially during a long recovery from prostate surgery or just because there are hundreds of ways to be sexually loving without having an erection.

For a more detailed description of all of the above, with illustrations of some of the techniques, you may wish to order the booklet "Penile Rehabilitation" at



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