Penile Rehabilitation after Prostate or Pelvic Surgery or Radiation
posted: 04/14/2011 12:09 pm
Dear Dr. Myrtle,
I have heard that there are things I can do to avoid full or partial erectile dysfunction after Prostate removal surgery, or in the presence of diabetes or heart disease. What do you recommend?
for men with erectile dysfunction caused by diabetes, heart disease, pelvic surgery or radiation
Health problems like diabetes, heart disease and cancer may have a direct impact on a man’s ability to achieve a penile erection. Many men can take important steps toward improving, maintaining, or recovering erectile function, as long as they understand how the penis works, and which techniques improve function. This article outlines techniques that can improve your specific situation.
How Do Erections Happen?
Sexual arousal is a response to stimulation produced by several mind and body systems working together. An erection is one sign of a man’s sexual arousal, when the clitoral body swells with blood and the penis becomes stiff and hard. (Women get erections, too, but since their clitoris is placed differently in their genitals, you see the vulva swell instead.)
- Intact physical structures: The clitoral body inside the penis is a unique structure. There is a fiber-like flexible shell on the outside that stretches during erection, small curled blood vessels that occasionally open to let oxygenated blood in, and stretchy sacs that hold blood during erections. It is the stretch, tension and blood flow that makes a penis hard and erect. All of these parts have to be healthy, flexible, and free from inflammation or scarring in order to create a firm erection.
- Specific biochemistry: Small curled blood vessels in the clitoral body relax in response to a chemical called nitric oxide, which allows blood to flow into the penis. Nitric oxide can be produced either by stimulation of nerves of the pelvic plexus, or in the walls of the clitoral blood vessels when they are stretched and massaged.
- Low overall body inflammation: Nitric oxide is a sensitive chemical, and doesn’t work when we eat junk food. Really. It also doesn’t work if we don’t get daily exercise. Eating a healthy diet and walking every day supports sexual arousal, helping nitric oxide do its work.
In a healthy person, these different systems work together to create a penile erection. The loss of function of any part of the system means that attempts at sexual arousal—and erection—may be unsuccessful.
Finally, it’s important to get complete deep sleep every night. During the dreaming phase of sleep, nerves activate swelling of the penis approximately 4-6 times per night. Penile swelling exchanges oxygenated blood for non-oxygenated blood within the clitoral caverns, and is critical to maintaining the health of the clitoral body. The final swelling of the penis each night results in the “morning erection” that many men wake up with—this is a good indication that all physical systems and structures are functioning properly.
Why Do Erections Stop Happening?
Erectile dysfunction (ED) is the inability to develop or maintain a penile erection sufficient for sexual penetration. It’s fairly common, occurring in 21-46% of all men. Common causes include metabolic dysfunction or surgical trauma.
- Metabolic disorders—Heart and blood vessel disease, metabolic syndrome, and diabetes are the most common causes of ED. The inability to get reliable erections is an early sign that something isn’t working right, and is often a man’s first warning that he is at risk for a heart attack within 3-5 years.
- Surgical Trauma—Another common cause of ED is anything that damages, stretches or cuts the pelvic plexus nerves deep in the pelvis, which commonly happens during surgical or radiation intervention for prostate, colon or rectal cancer. Prostate cancer therapies cause ED (radiation therapy 43%; radical prostatectomy 58%), because the therapies damage nerves, blood vessels and/or clitoral components. Minimally-invasive surgical approaches may reduce complications right after surgery, but they still increase post-surgical ED.
- Some Men Have Both—It’s common for men with prostate cancer to have pre-surgical metabolic ED. Men who had trouble getting erections before the surgery often have more difficulty recovering after the surgery, because the underlying erectile dysfunction impairs recovery from surgery.
Erectile Dysfunction from Metabolic Disorders
All portions of a man’s erectile system are sensitive to metabolic disorders due to an inflammatory Western lifestyle. Eating a diet high in refined carbohydrates and low in healthy oils and proteins, plus limited voluntary exercise is a very dangerous combination for sexual health. Sexual health requires the peak performance of cardiorespiratory fitness, and many men aren’t aware of the effects of their daily choices.
Penile Rehabilitation is a group of specific techniques that can help maintain men’s sexual health. However, men with metabolic dysfunction need to go one step further. If your health status continues to include poor blood sugar control, high carbohydrate food choices and a lack of routine exercise, etc., you may not be able to benefit from the Penile Rehabilitation program to its fullest. A widely known treatment, the group of medications like Viagra, may not be available to you because your health prevents their use.
Make a careful assessment of your priorities:
Does your sexual health matter enough for you to make significant food changes?
Does a half-hour of walking every day still seem like a burden when it may mean the difference between reliable erections or not?
Your erections are accurate indicators of your overall health. If they aren’t working regularly any longer, your health is already less than you deserve. You can use techniques #2, 3, and 4 in this article. But in addition, we suggest you make serious changes towards better health (see p. 18).
Injury after Prostate Cancer Surgery
The path of the pelvic plexus—the delicate nerves that carry sexual arousal information between the penis and the lower spine—curves around the prostate, colon, rectum and bladder. When surgery is performed on the prostate, some nerves will be cut and some will be stretched. Even the most skilled and careful surgeon cannot avoid stretching the nerves. Stretched nerves become stunned, and although they are complete and in place, they cannot function until they recover. Though some men’s nerves may recover soon after surgery, the recovery process may take up to three years for others.
In the meantime, when the nerves stop working, oxygen-rich blood will stop flowing to the clitoral body inside the penis, and scarring can occur. It’s important to keep blood flowing to the nerves, small blood vessels, and the clitoral body inside the penis, so that the oxygen exchange still happens. This will allow the structures to work when nerve function recovers. We can’t know when nerve recovery will occur, so it’s worth it to facilitate blood flow to the penis for the whole three years after surgery. Fortunately, the techniques we outline here will help improve oxygen-rich blood flow to the penis even when nerves can’t do the work.
First experience after surgery
Surgery has a negative, time-limited effect on men’s erections that all men need to be aware of. A man goes into surgery with the penis length and function he is used to. When he wakes up after surgery, he will see the urinary catheter that has been placed inside his penis, which helps drain urine and keep the passage from the bladder to the penis open. This catheter also artificially stretches the length of his penis.
The clitoral bodies inside the penis won’t get any oxygen-filled blood after the surgery. Unavoidable nerve stretching and lack of oxygen will cause the penis to shrink, and when the catheter is pulled out (often right before hospital discharge), the penis may appear to be only half of its previous length. Shocking as that is, a man with good underlying function may recover his regular morning and on-demand sexual erections within days or weeks.
Sometimes, more extensive stretching and nerve shock or damage occurs, which happens during many pelvic surgeries. In this case, waiting alone will not get erectile function back. Working to restore erectile function becomes an important part of a man’s post-surgical recovery.
Goals of Penile Rehabilitation
Penile Rehabilitation (PR) is the process of regaining erectile function, erectile length and girth, and hardness. The main goals of PR are to:
- Increase daily oxygen exchange to the penis, and
- Maintain length and girth of the penis such that full erection size and hardness are possible once the nerves have recovered.
As mentioned earlier, consistent daily blood flow bathes the erectile nerves and blood vessels with oxygenated blood, keeping tissue healthy and preventing scarring of the clitoral body inside the penis. If appropriate, medications (see p. 6) should begin immediately after returning home from surgery. Try to begin the physical components of PR as soon as you feel physically comfortable enough to touch your penis, or within 2 months after surgery, whichever is sooner. There may be discomfort as internal scars heal; if any part of the process is uncomfortable at first, wait a few days before starting or restarting your program. However, if there is pain with PR, stop and consult your health care provider.
Remember: the sooner a man begins PR, the more likely the success. Men who had surgery within the last three years will still benefit from PR, particularly if they occasionally have soft morning erections. PR will help on-demand therapies work better (see p. 12). PR can also create erections hard enough for sexual penetration even when the nerves have been permanently damaged by using Vacuum Erection Devices with a erection/cock ring (see p. 12).
Techniques of Penile Rehabilitation
There are seven possible therapies used to help men regain erectile function after prostate cancer surgery. Since clinical studies show that combining different healing techniques increases the chance of success, we recommend using the following four techniques together:
- #1: A low nightly dose of PDE-5 Inhibitor medication,
- #2: Gentle stretching and massage of the penis,
- #3: Use of a Vacuum Erection Device (VED) twice daily,
- #4: Pelvic Floor Muscle Exercises
Three additional techniques require the supervision of a medically-trained urologist: a) prosthetic implants, b) MUSE-medicated urethral system for erections, and c) Intercavernosal injections (ICI) into the clitoral caverns of the penis. Because of the possible risks and side-effects, they are not described here, but you may discuss them with your health care provider.
Technique #1: Use a nightly dose of PDE-5 Inhibitor medications
Phosphodiesterase-5 Inhibitor (PDE-5 I) medications like sildenafil (Viagra) are not only useful for on-demand sexual activity. Small nightly doses are significantly more likely to help deliver oxygenated blood to the inside of the penis while you dream, and to move your recovery forward. These medications help your natural nitric oxide biochemistry work to facilitate erections, particularly while you sleep. Some men notice that nightly low dose use helps them recover spontaneous functional erections.
The preferred daily medications are:
- Sildenafil (brand name: Viagra) begin at 25 mg per day at bedtime, or
- Vardenafil (brand name: Levitra) begin at 5 mg per day at bedtime.
You should slowly work your way up to the maximum recommended dose for either medication (sildenafil up to 75mg; or vardenafil up to 10mg; at bedtime), but always start at the lowest dose to reduce any side effects you may experience. If the side effects of the higher dose become uncomfortable, resume the original low dose. Ask your health provider about any serious side effects. Since most health insurance plans do not cover daily doses of PDE-5 Inhibitors, ask your health care provider to write your prescription in the highest available dose, and split the pills to cover daily dosing.
PDE-5 I medication will not guarantee preservation of girth and length. Scarring may occur before erections begin to happen regularly on their own. Only Vacuum Erection Devices (p. 9) will preserve girth and length, so they should be used in combination with PDE-5 I medications.
These medications should be taken right before bed on an empty stomach to encourage natural penile swelling during sleep. If you wake up with soft morning erections, this is a sign that the rehabilitation is working. This may not happen right after surgery, but is a good sign if it does.
Common Side Effects of PDE-5 Inhibitor Medications include:
Diarrhea; dizziness; flushing; headache; heartburn; stuffy nose; upset stomach. Discontinue use and seek medical attention right away if any of these SEVERE side effects occur when using PDE-5 Inhibitor medications: Allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); chest pain; fainting; fast or irregular heartbeat; memory loss; numbness of an arm or leg; one-sided weakness; painful or prolonged erection; ringing in the ears; seizure; severe or persistent dizziness; severe or persistent vision changes; sudden decrease or loss of hearing; sudden decrease or loss of vision in one or both eyes.
Technique #2: Gentle stretching and massage of the penis
Stretch activates the vessels that bring blood into the penis, and massage decreases the risk that your penis will become unused to, or uncomfortable with, sexual touch. Achieving erection is not the goal, but a soft erection at the base of the penis is a positive sign.
- The massage should be pleasurable, not painful. Using the following steps, your massage should take about 10 minutes per day:
- Select a personal lubricant (for more information, please look at our article on Personal Lubricants). A lubricant should make massage more comfortable, and offer a balance between slide and friction.
- Holding the tip of the penis with one hand, use your other hand to gently squeeze and massage the shaft toward the body (removing blood from the penis).
- Then, gently stroke and stretch the penis away from the body (allowing blood to flow back in). Some urologists recommend gently squeezing all parts of the penis up and down the length of the shaft, from all directions.
- Note: Do not sharply bend the penis—this could cause injury.
This massage should be gentle and comfortable. If you can, consciously focus on any massage motions that feel good, without making a hard erection your goal. Most men’s penises will remain soft during the massage, so remember that recovery takes time.
Technique #3: Vacuum Erection Device (VED)
Vacuum erection device (VED) therapy has a very high rate of consumer satisfaction (92%), and most importantly, is the only therapy that preserves both the length and the girth of the clitoral body inside of the penis. The pump’s vacuum stretches tissue inside the clitoral body, while breathing/pumping blood in—and out—of the penis. The goal is to gently draw oxygenated blood into the penis, then allow it to flow out again.
Stretching the penis as far as it will go, or holding a maximal stretch for too long, can reverse the benefits of vacuum pumping—new blood stops flowing in with sustained high pressure. Men who have metabolic ED respond well to vacuum therapy alone, but may have even better responses if they can also take a daily dose of PDE-5 I medication 1 hour before using their VED.
Depending on the fit of the VED, a testicle may be drawn up into the vacuum chamber; using a pump with a soft adaptive sleeve at the end of the vacuum tube will help prevent this, while making for a more comfortable fit.
Remember, when using a VED for Penile Rehabilitation, you are not trying to create an erection (if this is your goal, see Intimacy & Pleasure, page 12). Vacuum pressure stretches the clitoral body inside the penis so that it doesn’t “forget” how elastic it needs to be with full erections. VED therapy is the only way to provide this internal stretch.
We describe two restorative pumping methods here. Before pumping, perform the self-massage and gentle stretching of the penis as described on page 8. Both pumping methods draw fresh (oxygenated arterial), and stale (desaturated venous) blood into the penis, so the color of the penis will be bluer than a spontaneous erection. This is ok, since the new blood:
a) adds more oxygen than was there before,
b) exchanges inflammatory fluids in the pre-pumped blood, and
c) stretches the clitoral tunic sheath and maintains it’s flexibility.
It is normal to see your penis turn a slight blue color, but don’t hold the blood in too long. When the pump vacuum is released, follow with the self-massage technique to coax the blood back out (see p. 8).
Restorative pumping methods include Double Pumping, and Pump-3-Release. Double Pumping is easier to do—just be sure not to pump too quickly. The Pump-3-Release Method takes some counting, but this variation more effectively moves blood in and out of the penis.
1. Lubricate penis and gently perform a self-massage (p. 8).
2. Insert penis into chamber, then adjust chamber against the body to create a vacuum seal.
3. Slowly and gently pump to create a comfortable vacuum. This should take about 5 minutes.
4. At maximal comfortable vacuum level, pause for 10 seconds, then release the pressure.
5. Remove penis from pump, then holding the tip of the penis, massage from tip to base, gently squeezing blood out of the penis.
6. Repeat steps 2-5.
7. Repeat morning and night, or 3 times per day as time allows.
1. Lubricate penis and gently perform a self-massage (p. 8).
2. Insert penis into chamber, then adjust chamber against the body to create a vacuum seal.
3. Slowly pump 3 times. Release the vacuum and count to 5 (one-banana, two-banana, three-banana, etc…).
4. Slowly pump 3 times. Again, release the vacuum and count to 5.
5. This time, slowly pump up until you reach the maximal comfortable vacuum level without pain.
6. At your current maximum level, HOLD and count to 5.
7. Fully release vacuum, then take a deep breath.
8. Remove the penis, then hold the tip and massage from tip to base, gently squeezing blood out of the penis.
9. Repeat morning and night, or 3 times per day as time allows.
Technique #4: Pelvic floor muscle exercise
The pelvic floor is a sling of muscles that surround and anchor the base of the penis, helping to hold blood in the penis during erections. Exercising these muscles will strengthen them, allowing you maintain firmer erections. These muscles pulse with orgasm, so orgasms will be easier to feel when they are strong and flexible.
Pelvic Floor therapists developed exercises specifically to help men restore function of their pelvic floor muscles. Try to do these exercises as often and as consistently as possible. It’s fine to miss a day or a session—just get back to the routine when you can.
To locate the correct muscles, stand and look down at the penis. See if you can make the base of your penis move down and in. Sometimes it helps to feel the muscles by placing your hand against your perineum (the area between your scrotum and your anus), or by pretending to stop the flow of urine. If the penis moves up and down, then you are contracting the correct muscles. Your health care provider or a physical therapist can help you locate the muscles if you have trouble on your own.
To begin these exercises, find a comfortable reclining position, then:
1. Contract the muscles as firmly as you can and hold for a count of 5.
2. Release the contraction.
3. Take a deep belly breath and completely relax the muscles.
4. Repeat the contract-hold-relax-breathe cycle 5 times each session.
Do your exercises 3 times in the morning, and 3 times in the evening.
The relaxation portion of these exercises is as important as the contraction portion for two reasons. First, relaxation with a big deep breath allows blood to flow into the muscles, restoring oxygen and moving out any exercise-produced waste fluids. Second, muscle strengthening is most effective when the muscles are both strong and flexible, not tight and cramped. A deep belly breath allows you to completely relax the muscles.
Once your penis can visibly move when performing these exercises in a reclining position, try them while sitting, then standing, for three repetitions in each position in the morning and in the evening. You can also contract these muscles after urinating, to help strengthen the muscles that stop urine leakage. While walking, hold these muscles at half-strength for 10 steps, then relax for 10 steps, remembering to breathe during the session.
Intimacy & Pleasure
Many men who have had pelvic surgery or radiation are able to enjoy pleasure and orgasm without ever having an erection. This is important to remember, as men can enjoy many intimate activities without any erection at all. Some men choose to facilitate an erection by taking PDE-5 Inhibitor medication before sexual activity, and/or to use a Vacuum Erection Device (VED) and an erection ring to create an erection sufficient for penetration.
Full-dose PDE-5 Inhibitor
1. Sildenafil 25 - 75 mg. on an empty stomach 2 hours before activity, or
2. Vardenafil 5 - 10 mg. on an empty stomach 1 hour prior to activity.
Dosage: If you already take a PDE-5 Inhibitor daily and want to try for a full erection with only medication, you can take an additional dose of your regular medication. For example, if you take sildenafil 25 mg by mouth every night, you can take an additional dose of 75mg—bringing you up to the maximum dose of 100mg per day—2 hours before you are going to be intimate. (With vardenafil, you can take another 5mg dose 1 hour before sexual activity.) Remember to work up to a maximal dose. Higher doses may work better, but you will have more chance of headache, stomach upset or other side effects. Talk with your health care provider for more specific information.
Communication: Full-dose medication requires a little planning and communication with your partner(s), since you need to take it before the heat of the moment. This doesn’t have to be uncomfortable or awkward—try and find a way to talk with your partner about the medication, using it as a way to heighten the anticipation of sex. Letting your partner know in advance can help them feel included, and can lead to some fun foreplay (“I’ll take my medication, we’ll sit down to a candlelit dinner, and then move on to after-dinner delight...”).
On-demand VED with Erection Ring
Vacuum erection devices (pumps) help create erections, even if a man does not have spontaneous nerve function. In other words, VEDs work even if your nerves will not bring blood into the penis by themselves, or if PDE-5 I medication isn’t suitable for your health condition. You can use a VED with—or instead of—medication.
If you are using VED therapy to achieve an erection sufficient for sexual penetration, you’ll need to place an erection ring at the base of the penis before you pump (see p. 17 for examples). When you have pumped the vacuum to your maximal comfortable penis size, tighten the ring to hold in the blood. The ring can be worn for up to 20 minutes, and it helps the erection stay firm by preventing blood from leaving the penis.
To use VED therapy for on-demand erections:
1. Warm a sexual lubricant that is compatible with the ring’s material in a warm-water bath, or wrap the bottle in an electric heating pad.
2. Slip the erection ring over the opening of the pump’s chamber, or put an adjustable ring loosely around the base of the penis before inserting into the VED chamber.
3. Lubricate the penis, then gently stretch and massage.
4. Insert penis into chamber, and adjust chamber against body to create vacuum seal.
5. Pump either straight to maximum vacuum, or Pump 3 Count 5 (p. 10).
6. If you use an erection ring: when at maximal comfortable vacuum level, slip the ring from chamber to the base of the penis, releasing vacuum from chamber. This represents the beginning of the 20 minutes of ring use.
7. Proceed with intimacy, using warmed lubricant as needed.
8. Remove ring within 20 minutes, to allow new oxygenated blood to reach the clitoral body.
Note: After 20 minutes of use, the oxygen will be removed from the trapped blood in the penis, and without blood circulation some men notice that the penis becomes temporarily cold and discolored. If this is uncomfortable, you can warm your personal lubricant in a hot water bath, or remove the erection/cock ring and let blood re-circulate.
Don’t use a erection/cock ring for longer than 20 minutes, since lower oxygen levels may scar the inside of the penis. This is worsened if a ring is used longer than 30 minutes.
In men who can ejaculate, an erection ring may impair ejaculation, cause pain during ejaculation or retrograde ejaculation. If this happens, choose an adjustable ring and loosen or remove it prior to ejaculation. Men who do not ejaculate (due to removal of the prostate) may find that a tighter ring is suitable, since it prevents involuntary urine loss during sexual activity.
Alternatives to Spontaneous Penile Erections
What if three years have passed since my surgery? What if I know that the nerves going to my penis are not going to work?
Sometimes the function of nerves that control erection of the penis are lost, either from a very extensive surgery, or a combination of other factors. If you do not have soft morning erections three years after the surgery, then you may no longer have spontaneous erections.
If you and/or your partner(s) decide that penetration is an important part of your intimacy, there are a variety of options. In addition to VEDs, erection rings, and medication, there are a variety of tools and accessories that men can use to help maintain a desirable level of sexual intimacy. These include special sleeves that fit over a non-erect penis, harnesses and dildo combinations designed for men to wear, and vibrating toys. On page 6 is a list of techniques that you can discuss with your urologist.
Yes, it’s an adjustment. Some men choose technology to meet their needs because the effort is worth it to them and their partners. Others feel it isn’t worth the bother. It’s a decision that only you can make.
For men who lose spontaneous erectile function after surgery, these tools can help you continue to create hard erections, and learn to pleasure yourself and/or your partner(s). If you work with these techniques for three years and are unable to regain spontaneous function, you also know that you’ve done what you can for your health, and can discuss further options with your health care provider. For additional support and resources, men recovering from cancer can join their local Man to Man Prostate Cancer support group; contact the American Cancer Society by calling 1-800-227-2345 or visiting www.cancer.org, and locate a group near you.
Combining the techniques outlined in this booklet can help you rehabilitate your erectile function after pelvic surgery. Regular blood flow to the penis is important, even (and especially) when erections aren’t happening like they used to. Many men lose spontaneous erectile capacity after pelvic surgery because they didn’t know how to support their erectile function during the healing process. Although rehabilitation takes time and patience, many men do recover nerve and erectile function after pelvic surgery.
Pleasure for you and/or your partner(s) does not depend on your ability to create spontaneous erections. Intimacy is yours to define.
A Woman’s Touch Sexuality Resource Center, Myrtle Wilhite MD, MS
Copyright 2012. All rights reserved.
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