Sexual Dysfunction after Pelvic Surgery

Early Penile Rehabilitation

Introduction

The introduction of prostate screening programs, which include annual digital rectal examinations and PSAs, has led to earlier detection of most prostate malignancies. Earlier detection has significantly improved cancer cure, allowing us to redirect our focus towards quality of life issues. It has become apparent that erectile function is a significant problem following RP. Currently, potency rates range between 30 and 60% in the reported literature. Potency rates from the experienced surgeons would indicate that, even after a considerable volume of experience, ED following nerve injury is a major problem.

Urologists have been the pioneers in recognizing the impact of radical pelvic surgery on sexual dysfunction. Multiple authors have reported their techniques on nerve-sparing RP from the retropubic, perineal or laparoscopic approach. These reports have provided the stimulus for the other surgical fields to perform the nerve-sparing technique. In the world of colorectal surgeries, exciting new techniques for the treatment of rectal cancer has evolved like autonomic nerve preservation with TME. The concept of sexual dysfunction is evolving in the field of radical and as well as simple hysterectomies also. More urologists performing transvaginal sling procedures are recognizing female sexual dysfunction as an important issue. The concept of nerve-sparing surgery will soon be followed in radical and simple hysterectomy as well. These other disciplines will soon discover what urologists have learned, that despite anatomical nerve sparing there is still dysfunction due to the period of neuropraxia.

When analyzing potency rates following RP, it would appear that our focus should be into the rehabilitation and nerve recovery rather than looking for the further advances in the surgical technique. Urologists have led the way into early rehabilitation programs to promote the nerve recovery and nerve regeneration. These programs will soon evolve into other disciplines that are performing pelvic surgeries. Performing anatomical nerve-sparing procedures rarely guarantees immediate postoperative recovery of potency. So the other disciplines will soon develop early rehabilitation programs. We will discuss our experience with various early programs intended to shorten the period of neuropraxia after RP.Role of Oral Medications in Early Penile Rehabilitation

There is a growing interest among urologists regarding the early use of daily oral sildenafil. This was first reported by Padma-Nathan et al.,[95] who conducted a randomized controlled study in 76 men (oral sildenafil daily (50 mg, n=23; 100 mg, n=28), placebo=25) who underwent nerve-sparing RP with normal preoperative erectile function. Sildenafil was given for 36 weeks in the study group. After 48 weeks (~11 months) follow-up, 14 of 51 (27%) patients receiving sildenafil demonstrated return of spontaneous erections compared to one of 25 (4%) in the placebo group. This study revealed that oral daily sildenafil increased the return of erections to seven-folds compared with placebo group and was well tolerated. However, this study has been criticized because the return of spontaneous erections in the placebo group was only 4%, which is very low compared to the other reported series in the literature. Further multicenter randomized studies are ongoing to investigate the potential benefit of daily sildenafil following radical RP.Early MUSE

We recently completed a prospective nonrandomized study on the use of early MUSE after RP at the Cleveland Clinic Foundation. To our knowledge, this is the only report in literature. We included a total of 91 patients. Of the 91 patients, 56 received early MUSE and 35 (Control group) did not receive any early treatment. Patients in the early MUSE group received 125 µg 3 times/week for the first 6 weeks. At 6 weeks, the MUSE dose was titrated to 250 µg, 3 times/week for 4 months. Patients who could not tolerate the 250 µg doses remained at 125 µg for 4 months. Treatment efficacy was analyzed by the patient's response to the Sexual Health Inventory of Men (SHIM) questionnaire. In the MUSE Group, 38/56 (68%) continued MUSE treatment. At 6 months, 28/38 (74%) of the patients resumed sexual activity, 15/28 (53%) had natural erections sufficient for vaginal penetration without MUSE and 13/28 (47%) continue to use MUSE as an adjuvant treatment for successful intercourse. Overall, including those who discontinued MUSE, at 6 months 27% (15/56) achieved natural erections sufficient for sexual intercourse. The MUSE discontinuation rate was 32% (18/56). Nine of the 18 (50%) discontinued because of inadequate erections, five (28%) due to loss of sexual interest and four (22%) due to local pain/burning. In the Control Group, 13/35 (37%) resumed sexual activity, 4/13 (30.7%) had natural erections sufficient for vaginal penetration, 9/13 (69.3%) were dissatisfied with the erections and used oral therapy/erectaids as adjuvant treatments. Overall, in the control group 11% (4/35) at 6 months achieved natural erections sufficient for satisfactory sexual intercourse.

In our experience, early MUSE therapy following RP increased the frequency of sexual activity, increased the incidence of spontaneous erections sufficient for intercourse and appeared to shorten the neuropraxia period.Early VCD

We recently completed a prospective nonrandomized study on the use of early VCD after RP at the Cleveland Clinic, which included 109 patients who underwent RP between August 1999 and October 2001.[96] Of the 109 patients, 74 (Group 1) patients used early VCD daily for 9 months and 35 observed without any erectogenic treatment (Group 2). Treatment efficacy was analyzed by responses to the SHIM. Patient outcome regarding the compliance changes in the penile length and circumference, return of natural erection and ability for vaginal intercourse was also assessed. After a minimum follow-up of 9 months, 80% (60/74) in Group 1 successfully used their VCD with a constriction ring for vaginal intercourse at a frequency of twice per week, with an overall spousal satisfaction rate of 55% (33/60). Of these 60 patients, 19 (32%) reported return of natural erections at 9 months, with 10/19 (52%) having erections sufficient for sexual intercourse. The abridged IIEF-5 score significantly increased after VCD use in both the NS and NNS groups. After a mean use of 3 months, 14/74 (18%) discontinued treatment. Overall, in the early VCD group, 14% (10/74) had natural erections sufficient for sexual intercourse.

In Group 2, 37% (13/35) of patients regained spontaneous erections at a minimum follow-up of 9 months after surgery. However, only four of these patients (29%) had erections sufficient for successful vaginal intercourse and the rest of the patients (71%) sought adjuvant treatment. Overall, in the control group at 9 months, 11% (4/35) achieved natural erections sufficient for satisfactory sexual intercourse. Note that 11% vaginal intercourse rates were identical in both the Group 1 and 2.

Interestingly, when assessing the penile length and girth after surgery, of the 60 compliant patients, only 14 (23%) reported a decrease in penile length and girth at 9 months (range, 4-11 months), with 12/14 (85%) noncompliant patients complaining of decrease in penile length and girth. In the control group, 22/35 (63%) reported decrease in penile length and circumference, demonstrating that routine early use of the VCD helps in preventing the decrease in penile length and circumference.

We concluded that early use of VCD following RP facilitates early sexual intercourse, early patient/spousal sexual satisfaction, potentially an earlier return of natural erections sufficient for vaginal penetration and preservation of penile length and girth.Early Injections

Montorsi et al.[97] from Milan, Italy, first reported their experience using intracavernous injections in 1997. Of the total 30 patients who underwent nerve-sparing RP, 15 were randomized into Group 1 (alprostadil injections 3 times/week for 12 weeks) and another 15 patients were randomized into Group 2 (observation without erectaids). The dose of PGE1 varies from 4 to 14 µg, with a mean dose of 8 µg. At 6 months, 67% of the patients in the injection group reported to have return of spontaneous erections sufficient for satisfactory intercourse compared to 20% in the observation group. We initiated a similar study in 2001 with a dose of 10 µg PGE1 at the Cleveland Clinic Foundation. Of the eight patients, six discontinued because of pain, which prompted us to discontinue our early PGE1 program 3 years ago.

Recently, we wanted to re-examine the role of early intracorporeal injections, with lower dose of PGE1 (4 µg/2-3 times/week) starting at 2 weeks after RP, combined with oral sildenafil (50 mg/day). We reduced the injection dose to 4 µg, to get partial erections with minimal, if any, pain. Our goal was to have a compliance of more than 90%. Further modifications have been made according to the tolerance of patient and response; the dose of PGE1 was reduced to 2 µg in some patients with the same response to minimize the adverse effects and maximize the compliance. We included a total of 18 patients in this study. Of the total 18 patients, 16 were using injections with Viagra and two were using daily sildenafil alone. Of the total 16 patients, two increased the dose up to 8 µg without any pain (one having mild discomfort), six patients continuing the same dose of 4 µg and the rest of the patients decreased the dose. Of the eight patients who decreased the dose, six are using 2 µg dose and two patients further reduced the dose to 1 µg. Patients who were not willing for the injections given daily 50 mg oral sildenafil alone. Two patients were started only on Viagra. We are currently investigating the role of injections and oral sildenafil in patients who underwent nerve-sparing RC also. We included two patients in the study. Until now, the compliance with this program is 100%. After a mean follow-up of 10 weeks (4-18 weeks), 15/16 patients were sexually active. One patient sexually inactive due to incontinence. Our early data revealed that lower doses of IC PGE1 (4, 2 and 1 µg) with sildenafil was as effective as high doses of PGE1 alone (8 µg), without any penile discomfort ( Table 4 ). The reasons for these high compliance rates are good counseling and follow-up by the physician and proper dose modification according to the patient's desire and side effects. Early injection facilitated early sexual intercourse, patient and spousal satisfaction.   Printer- Friendly Email This

Int J Impot Res.  2006;18(1):1-18.  ©2006 Nature Publishing Group
This is a part of article Sexual Dysfunction after Pelvic Surgery Taken from "Male Erectile Disfunction" Information Blog