Post-Radical Prostatectomy Pharmacological Penile Rehabilitation: Practice Patterns Among the International Society for Sexual Medicine Practitioners

Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.
Journal of Sexual Medicine (Impact Factor: 3.15). 05/2009; 6(7):2032-8. DOI: 10.1111/j.1743-6109.2009.01269.x
Source: PubMed


Despite the fact that there is minimal evidence-based data supporting it, the concept of pharmacological penile rehabilitation following radical prostatectomy (RP) is receiving great attention.
To define attitudes and practice patterns of clinicians who were members of the International Society for Sexual Medicine (ISSM) and/or its affiliated societies.
Members of the ISSM and its regional affiliates were invited to participate in a web-based survey.
Demographic factors, current practice status, and opinions regarding post-RP erectile dysfunction and penile rehabilitation. The statistical methods used included chi-square, Student's t-tests, and logistic regression analysis.
Three hundred-one physicians from 41 countries completed the questionnaire (82% were urologists). Sixty-five percent of the responders had formal sexual medicine specialty training, 44% had uro-oncology specialty training, and 60% performed RPs. Eighty-seven percent performed some form of rehabilitation. As part of the primary rehabilitation strategy, 95% used phosphodiesterase type 5 inhibitors (PDE5), 30% used vacuum device, 75% used intracavernosal injections, and 9.9% used intraurethral prostaglandin. Fifty-four percent commenced rehabilitation immediately/just after urethral catheter removal, and 37% within the first 4 months after RP. Neither the number of years in medical practice, clinician age, nor country/region of practice differed between rehabilitation performers and non-performers. With regard to the primary reason for avoiding rehabilitation: 50% responded said it is the cost; 25% said the fact that it is not evidence-based; and 25% said they were not familiar with the concept. Performing rehabilitation was positively associated with urologic oncology training (P = 0.03), performing RP (P < 0.001), and seeing over 50 post-RP patients per year (P = 0.011).
Among ISSM members post-RP penile rehabilitation is widely practiced, commenced early, and based predominantly on PDE5 inhibitors and intracavernosal injections. Clinicians who perform RP or see over 50 such patients per year are the most likely to perform rehabilitation. Cost represents the most common reason for rehabilitation neglect.

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    • "The practice of erectile rehabilitation is commonly performed in the clinical setting and previous reports have found that up to 87% of physicians utilize some form of erectile rehabilitation.26 Unfortunately, guidelines for this form of therapy are lacking, and this has led to wide variation in practice patterns, including PDE5 inhibitors, intracavernosal injections, vacuum devices, and intraurethral medications. "
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    ABSTRACT: Success of cancer surgery often leads to life-changing side effects, and surgical treatment for malignant urologic disease often results in erectile dysfunction (ED). Patients that undergo surgical prostatectomy or cystoprostatectomy will often experience impairment of erections due to disruption of blood and nerve supply. Surgical technique, nerve sparing status, patient age, comorbid conditions, and pretreatment potency status all have an effect on post-surgical ED. Regardless of surgical technique, prostatectomy results in disruption of normal anatomy and nerve supply to the penis, which governs the functional aspects of erection. A variety of different treatment options are available for men who develop ED after prostatectomy, including vacuum erection device, oral phosphodiesterase 5 inhibitors (PDE5I), intracorporal injections, and penile prosthesis. The vacuum erection device creates an artificial erection by forming a vacuum via suction of air to draw blood into the penis. The majority of men using the vacuum erection device daily after prostatectomy, regardless of nerve-sparing status, have erections sufficient for intercourse. Phosphodiesterase 5 inhibitors remain a common treatment option for post-surgical ED and are the mainstay of therapy. They work through cyclic adenosine monophosphate and cyclic guanine monophosphate pathways and are recommended in all forms of ED. Intracorporal injections or intraurethral use of vasoactive substances may be a good second-line therapy in men who do not experience improvement with oral medications. Surgical placement of a penile prosthesis is typically the treatment strategy of choice after other options have failed. Semi-rigid and inflatable devices are available with high satisfaction rates. With careful patient counseling and proper treatment selection, patient satisfaction and improved erectile function can be achieved. We advise that patients use a vacuum erection device daily in the early postoperative period in combination with an oral PDE5I. For patients who do not respond to a vacuum erection device or PDE5I, consideration should be given to intraurethral alprostadil, intracorporal injections, or a penile prosthesis.
    Full-text · Article · May 2014 · Research and Reports in Urology
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    • "Most of the data available on PR address the use of PDE-5 inhibitors [20]. For many practitioners they are considered the first-line therapy for rehabilitative purposes as well as ED, relating to their ease of use and safety [16] [17]. Bannowsky et al. [21] showed a benefit for nightly low-dose sildenafil (25 mg) in the recovery of erectile function in patients after nerve-sparing RP in a small study; 43 patients, after catheter removal at 7–14 days from RP, were studied, with 23 patients randomised to sildenafil 25 mg nightly starting the day after catheter removal, and a control group of 18 were followed with no sildenafil administration. "
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    ABSTRACT: We review the current strategies used for penile rehabilitation (PR) after a radical prostatectomy, where PR is defined as the attempt to restore spontaneous erectile function so that the patient can generate erections with no need for erectile aids. We searched PubMed for relevant reports, using the keywords ‘radical prostatectomy’, ‘penile rehabilitation’, ‘phosphodiesterase inhibitors’, ‘vacuum erection device’, ‘injection therapy’, ‘urethral suppository’, and ‘erectile dysfunction’. In all, 155 articles were identified and reviewed, and had a level of evidence ranging from 1b-4. The use of PR strategies should be based on the patient’s goals after a thorough explanation of realistic expectations, and the risks and consequences of the various treatment options. While a multitude of studies suggest a benefit with PR strategies, there are no established, proven regimens. Further research is needed to establish the optimal approaches to PR.
    Full-text · Article · Sep 2013 · Arab Journal of Urology
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    • "Treatment cost is an important factor for patient compliance in low-income households, despite the fact that the treatment is highly effective and improves the partner relationship [70]. In addition, cost is the most common reason for rehabilitation neglect in patients who have undergone RP [71]. The influence of costs of daily PDE5 inhibitors is not yet established in men with ED but could negatively influence patient compliance. "
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    ABSTRACT: Oral phosphodiesterase type 5 (PDE5) inhibitors have provided non-invasive, effective, and well-tolerated treatments for patients with erectile dysfunction (ED). However, many patients with ED are unresponsive to 'on-demand' PDE5 inhibitors. In addition, the lack of spontaneity and naturalness of the on-demand regimen could be a reason for decreased compliance with PDE5 inhibitors. Recently, tadalafil and udenafil were approved for low-dose daily administration for the treatment of ED. Since the introduction of the concept of daily administration of PDE5 inhibitors, several reports have supported the potential benefits of this therapy for disease modification, improvement of the treatment response in difficult-to-treat populations, spontaneity, and safety, although further research is needed to better address these hypotheses. In this article, we reviewed the daily administration of PDE5 inhibitors in terms of pharmacokinetics, safety, efficacy, and distinct features.
    Full-text · Article · Jun 2012 · Korean journal of urology
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