Hi All,
Over the past year I’ve done a lot of research on issues relating to sexual function after RP. I started out with this because my dear husband was rendered impotent by his surgery. The doctor had given him the usual treatment: a prescription for Viagra, which we kept on renewing.
We watched and waited, and there was some progress, but not enough. W knew it took time and were confident that the “miracle” would happen tomorrow. After 7 months had elapsed and dear husband was still unable to function, we called the surgeon, who referred us to an ED doctor who was a colleague of his. Anyway, the doc didn’t work out. After three months he hadn’t even finished the “testing.”
I was fed up with all of this, so I decided to look for a competent impotence specialist on my own. I remember spending 3 hours in the library reading Castle Connolly’s Metro NY Top Doctors book. But it worked: I got some good prospects. DH went to see two doctors, and the second one turned out to be just right. His name is Arnold Melman, and he is a world-renowned expert on ED. He has written many books, including one on Viagra. And he was pleasant and unpretentious.
We found out from Dr. Melman that a lot of men who have RP are not given optimal treatment afterwords to help them function sexually or prevent long-term ED. He also said that the benefits of nerve-sparing RP were exaggerated. I felt that I was privileged to have access to a doctor of this caliber, and so I wanted to share what I had learned with the public. The first thing Dr. Melman told Ted was:
“You don’t need the Viagra
[in his case, because it wasn’t working]. You’re just giving a gift to the drug company.”Anyway, this doc gave us some good “insider” advice, which I decided to share. My first post on this subject, “Sex After Surgery” was written back in November 2006. I try to keep up with the research.
I will be discussing “penile rehabilitation” a lot and also impotence after RP in general. I want to share with you something I wrote today in response to a question about using a pump (VED) after RP:
It’s no secret that many men suffer from impotence after RP. It’s hard to pin down the actual numbers, because they play games with the statistics. For example, how do you define “erectile function?” Let me count the ways. Does it include men who can have intercourse unaided, or only with meds. And just how hard does the tumescence have to be? You get the picture.
On the other hand, there *are* men have no problems with erections after surgery — take the surgeon, for example (:-). Other guys are able to function sexually using Viagra or other oral meds. This message is directed towards men who have not had success with the above.
There are two issues involved in “penile rehabilitation”:
(1) enabling a man to have an erection after surgery
(2) helping to speed up or restore natural erectile function, thereby preventing long-term ED.
I am talking about second topic here.
If you are unable to have intercourse after two months, you should see an ED doctor. (For help in finding a competent one, see my post on “Sexy Secrets For Finding An ED Doctor.”)
There’s a lot we don’t know about penile rehab, but the best prospects at this moment appear to be *injections* along with Viagra. The following is from Dr, Raina et al, renowned experts on ED:
“Early cavernosal injections following RP facilitated sexual intercourse, patient satisfaction and potentially early return of natural erections. Early combination therapy with sildenafil allowed a lower dose of intracavernous injections, minimizing the penile discomfort.”
www.nature.com/ijir/journal/v18/n5/abs/3901448a.html.
*Note that there is no mention of the VED (pump).
So why are so many guys told to use the pump after RP? Makes me want to jump out the window.
Here is an example of the “gold standard” in penile rehab today. A *top* expert in sexual medicine at Sloan Kettering, Dr.John Mulhall, prescribed this for a new RP patient recently:
====>Re: *Before Surgery*
Six weeks before surgery, the patient was advised to take 25 mgs. of Viagra six nights a week, to be taken before bed (a 100 mg. pill cut in fourths to save money) to increase blood flow to the penis prior to the operation.
======> Re: *After Surgery*
*Dr. Mulhall and his associate Dr. Nelson Eddie Bennett, Jr., both made it clear that they saw no benefit in using a vacuum erection device (VED) after RP for penile rehab because it only “circulated old blood” to the penis*
Scardino says the same thing on page 366 of “The Prostate Book”:
“VED’s do not produce an actual physiological erection and therefore don’t promote the circulation of fresh, oxygenated blood. Therefore, they may not help avoid fibrosis [scarring] after radical prostatectomy.”
So even if the VED doesn’t work for penile rehab, most men are told to use it anyway, with or without pills. No mention of injections (I call it “the Pinprick.”)
I have seen info in the medical lit which says that the pump *does* work for penile rehab, but they do not point to specifics. And, in the last few days, I have *again* reviewed all the articles I have on this subject, and I have not seen any proof of the above. My husband is from the “Show Me” state, so I gotta see the “beef.”
I do know of one knowledgeable person online who is the moderator of a newsgroup but certainly not a doctor, who described state-of-the-art treatment for penile rehab as injections plus oral meds *and the use of the pump 15 minutes a day.” I doubt there is any harm in using the pump and it can give you an erection.
Ideally, injection therapy should start about six weeks after RP. Naturally, men don’t like the prospect of shooting up there, but you *can* get over it. Give yourself a chance. Also, you can have a sex life right away. (For more info, see the post on my blog, “How I Became the Trimix Lady.”.)
I have to add that there is a risk of scarring or “fibrosis” from using penile injections. Some men get “Peyronie’s Disease,” which results in curvature of the penis. They say this is rare, but I don’t believe it. In my husband’s case, after about 8 mongh,. his penis started to bend in the middle at a 45 degree angle. I guess the advantage is that you can fold it easily :-). (Husb has refused to consult his ED doc about this)
*So you have to be careful of how you inject — do it on both sides. (I will be posting specifics about this.)
A final note: I have no medical training at all. So you should ask an ED doctor about all this just to be sure.
And just for fun:
This is my favorite story in the world: how I came up with the word “pinprick” as a substitute for “injection”. I was looking for a way to convey to guys that shots for ED aren’t so bad after all. So I told them the injection is just a “pinprick, no big deal. I think it worked for some people.
What made me think of this word?
When I got engaged to my husband, the first thing we did was call both of our parents to tell them the news. We conferenced everybody in on the same line.
The first question my very devout mother asked after they were introduced was: “Did your son have a “Bris?” In other words, was he circumcised? Great way to get acquainted. (I never heard the end of that.)
His stepmother replied after a pause, “I think so, but it was done by a doctor, not in any ritual way. Isn’t that right, Chuck?”
Well, my mother wasn’t satisfied with this. She insisted that Ted had to be circumcised *properly.* So I asked her, “How can a man be circumcised twice?”
She replied, “It’s no big deal — just a ceremonial thing. All they’ll do is give him a ‘pinprick’. And maybe recite a blessing. Then we’ll all have a little celebration.”
Anyway, T. wasn’t interested in having a “circumcision party,” and he refused to get it done, even for me. Just to get my mother off my back.
And that’s probably why he got the PC — measure for measure. Ted had refused the “pinprick” then, and now he’s getting pricked all the time
My mother always gets her way.
Best to you all and have fun.
All you need to know about PC: Get It From a Wife!
Thanks. I’m 66, six weeks removed from RPS and no partner. very informative and comforting that you and others are sharing details of your stories. I am hopeful and more confident of regaining my EF using the information and tools you have discribed.
Clearly I received bad advice after RPS. I am only 49 and had my surgery three years ago. No luck yet. I am worried now that finding your advice might be too late for me.
It may not be too late. Consult a topnotch ED doctor. See my post, “How to Find a Good ED Doctor”.
I also recommend that for excellent information about issues of sexual function, consider joining prostatepointers.com’s “PC and Intimacy Group” and posing the question there. There are people there who know more than the docs.
Leah
Your opinion is wrong on so many different levels. Perhaps it’s because this particular post is old, or maybe it’s due to your ignorance on the mechanics of an erection (whether naturally or artificially induced).
Present research clearly points to the VED as the main staple of post-prostatectomy penile rehabilitation.
Jeff and all,
Jeff,
there is data to support the usefulness of VEDs after RP — for the purpose of preserving penile length. Maybe it works for other things. I’m giving you updated info and you could decide for yourself.
I consulted a respected PATIENT expert”, Michael Holland, who is an *engineer* by trade but who has done a ton of research about ED and is well regarded by many in the online PC forums. (see prostatepointers.org/pcai). Much of what he has written has been stored on a “wiki” at the above site. This is what he wrote me:
Hope it helps — I don’t have the time to revisit this issue now.
————————————————————-
Leah,
The short answer is that no one has shown that the VED pulls in enough oxygen to prevent collagen deposition and other problems related to lack of oxygen in the cavernosa. The article I link below is a good one for a discussion of the importance of oxygen in the cavernosa.
There have been some studies that indicate the VED might be useful for maintaining size/preventing atrophy.
So, it is not that the VED is useless or harmful, it is just not good as the ONLY therapy. You need erections with PDE5 inhibitors or injections to provide oxygen from arterial sources, in addition to the VED use.
Doctors who tell their patients that all they have to do is use the VED and wait for erections to return are ignorant of more current penile rehab thinking, and rob their patients of the ability to better or faster recovery, avoiding venous leak and other issues.
Plus, injection erections are natural and a lot of fun to use compared to VED erections.
Mulhall summarizes in an article:
Penile Rehabilitation Following Radical Prostatectomy (Mulhall 2008):
http://www.medscape.com/viewarticle/576471
Vacuum Device Therapy
Vacuum device therapy has been around for more than a century and has continued to play a role in management of ED. A number of centers have studied the role of vacuum device therapy for the preservation of postprostatectomy penile length as well as for rehabilitation. It has been well-documented that the pO2 and pCO2 levels in the cavernosal sinusoids following the application of a vacuum device remain in the venous range.[35] Indeed, oxygen saturation of approximately 80% is achieved with these devices. If one believes that cavernosal oxygenation is critical to erectile tissue health and penile rehabilitation outcomes, this finding would support the role of vacuum device therapy as a rehabilitation strategy. Raina and coworkers[36] studied the effect of the vacuum device in 109 patients who had undergone either nerve-sparing or non-nerve-sparing RP; 74 used the vacuum device and 35 received no erectogenic treatment. At 9 months, recovery of natural erections was similar in the 2 groups — 32% of patients in the vacuum device rehabilitation group versus 37% in the observation group — but ability to have intercourse was significantly higher in patients who used the vacuum device vs those who did not — 70% vs 29%.
Dalkin and colleagues studied the effect of vacuum devices on postoperative penile length.[37] Thirty-nine men with good preoperative erectile function who had nerve-sparing RP were included in the analysis. Stretched flaccid penile length was evaluated by a single examiner before surgery and at 3 months after surgery. The vacuum device was used daily starting the day after catheter removal and was continued for 90 days. In men using the vacuum device on more than 50% of the possible days, only 3% had a decrease in stretched flaccid penile length of greater than 1 cm. Of the 3 men with poor vacuum device compliance, 67% had a penile length reduction of more than 1 cm. They concluded that their findings “strongly support a role for early intervention with the daily use of a VED in men wishing to preserve penile length…”
Köhler and coworkers[38] studied the effect of the early use of the vacuum device on recovery of erectile function and penile length after RP. The 28 men included in this study were randomized to 2 groups: an early intervention group, who started use of the vacuum device 1 month after surgery, and a control group, who began using the device 6 months after surgery. International Index of Erectile Function (IIEF) scores and stretched flaccid penile length were measured at baseline and every 3 months after surgery. At 6 months (ie, before the control group had begun using the device), IIEF scores were significantly better in the early intervention group than in the control group — 12.4 vs 3.0. There were no significant changes in stretched flaccid penile length measured at 3 and 6months after surgery. In the control group, mean penile length loss at 3 and 6 months was approximately 2 cm. Although these small studies offer a solid rationale for analysis of the vacuum device as a rehabilitation strategy in a large, multicenter, randomized, controlled trial, the current evidence does not, in my opinion, support the role of vacuum devices as monotherapy in penile rehabilitation.
There may be more in his book “Saving Your Sex life”.(Dr. John Mulhall’s book.)
Leah,
OMG, you are a GOD send. I can’t believe what I’m reading and I hope it’s not too late for my 2 years post surgery husband.
Angeline
Your remarkable enthusiasm for intra-corporeal injection as a treatment for post-prostatectomy impotence is unfortuantely not shared by a great many men who are completely importent (yes, I know, the more up-to-date term is ED) post radical
prostatectomy.
For better or for worse, many men simply do not like the treatment. Studies have shown that maybe 15% of men simply refuse to even try it at home, and the drop-off rate is very high. At one year, the percentage of men continuing to inject themselves to get an erection is maybe 30%. The five year rate of men using ANY kind of treatment for post-RP importence is maybe 20%.
A major problem with injections is the high complication rate (including Peryronies Disease). There is an increased incidence of this disease in all men post RP, but the incidence is especially high in men who inject themselves frequently. And for all intents and purposes, there are no effective treatments for this condition and the curved penis is permanent.. I will not mention the other real problem related to injections, which is prolonged erection requiring emergency treatment and happens more often than you might think. The margin between the dose needed for a decent erection and a permanent one is quite small in many cases.
Vacuum erection devices may or may not be effective, but for sure they are inexpensive and cause no harm. The oral PDI-5 inhibitors probably don’t work in most men, but again, they rarely cause any problems. But every single time a penis is injected, micro-trauma to the cavernosal tissues results, and this may – or may not – result in serious complications which you have chosen to ignore in your paen to these same injections.