In order to maximize the likelihood of full sexual functional recovery, Dr. Scherr and his team embark upon penile rehabilitation for all patients following robotic surgery for prostate or bladder cancer. This allows for a more robust and earlier recovery.
Post Radical Pelvic Surgery Penile Rehabilitation
Beginning two weeks prior to robotic prostatectomy, all patients are started on daily medications to improve their penile recovery.At the six week mark after surgery, all patients will be recommended to initiate penile injection therapy. This allows for optimal erectile tissue preservation for patients undergoing radical pelvic surgery
Dr. Scherr employs a novel technique of total urethral reconstruction during a robotic assisted radical prostatectomy. This allows for almost immediate recovery of urinary control in most individuals.
Post Radical Pelvic Surgery Penile Rehabilitation
Radical pelvic surgery (prostate removal for cancer, bladder removal for cancer and bowel/rectum removal for cancer) is surgery that is associated with erectile function problems. In the early stages after such operations virtually every man has problems with erections good enough for sexual relations to have to wait for 12-24 months before any significant erection hardness returns. Recent information suggests that a penile rehabilitation program may increase the chances of a man having return of his own erections.
The cause of erection problems after these operations is multi-factorial:
(i) Nerve damage can lead to erectile dysfunction. Even though your surgeon may have done a “nerve-sparing” operation, the maneuvers that are used to protect the erectile nerves may temporarily cause the nerves to be damaged and it may be more than a year before they recover.
(ii) There is some evidence that these operations may cause decrease in blood flow to the penis.
(iii) Going long periods of time without erections is unhealthy for the tissue inside the penis (the erection tissue is a muscle) and is associated with damage to the tissue. The belief is that by encouraging a man to get erections using medication may keep the tissue healthy and this may lead to a better long-term erectile function after surgery.
The main determinants of long-term erectile function after such operations include:
Whether the nerves were spared or not: Some men have both of the nerves saved; others have one nerve spared, while others have a non-nerve sparing procedure. Sometimes the nerves cannot be spared. This is a decision that is made usually in consultation between the patient and the surgeon. Some men who are undergoing nerve sacrifice have gotten grafts placed at the time of their surgery.
Preoperative erectile function: the better a man’s erectile function before surgery, the better his chances of having return of functioning erections after surgery.
Patient age: the older the patient at the time of surgery, the less likely the patient is to have return of functioning erections.
Medical conditions associated with the erection problems (diabetes, high blood pressure, high cholesterol levels, etc.) limit the chance of return of an erection good enough for sexual relations.
Penile Rehabilitation Protocol: General Concepts:
The patient is encouraged to seek consultation early after surgery. In this program we like to see patients early after surgery (as soon as the urinary catheter is removed) generally within the first two months.
We encourage patients seek consultation even before surgery if they are anxious about their postoperative sexual function.
The patients are initially tried on oral medications for erectile dysfunction (such as Viagra, Levitra or Cialis). Realistically, about 20% of men respond to such drugs within three months of surgery, while 60% respond at approximately 18 months. Patients are given a prescription at the time of removal of their urinary catheter. They are encouraged to try out at least one such medication over the 2-4 weeks after their catheter is removed.
If a patient is getting a penetration hardness erection with pills they are encouraged to obtain three erections per week using this medication. This does not mean they need to have sex three times per week, as it is the erection itself (and not stimulation or orgasm) that keeps the erection tissue healthy.
If patients fail to respond to pills then they are encouraged to consider penile injections to give them erections. This therapy results in penetration hardness erections in 90% of men using them. The average erection occurs within five minutes and lasts approximately 20-30 minutes. Once again, the patients are encouraged to get three erections per week.
Because response to pills improves over the first 18-24 months, patients are encouraged to reattempt the pills (maximum dose on 1-2 occasions) approximately every two months.
Much interest exists among surgeons and patients in regular (daily or three times per week) use of erection pills after these forms of surgery. Early evidence suggests that this may be of some benefit. It is unlikely that this treatment alone will maximize the chances of erection function return. However, in the first year after surgery we use this as an addition to the main treatment.
First Phase Penile Rehabilitation
In the first month after surgery we want to know if you are responding to oral medication (pills).The usual routine is as follows:
Viagra 100 mgs on 3-4 occasions with sexual (self or partner) stimulation as described in the Viagra instruction sheet.
On the other occasions (the days/nights that you are not using 100 mgs), use Viagra 25 mgs (100 mgs split into four pieces) each night. No sexual stimulation is required with this nighttime dose.
Once you have tried Viagra 100 mgs at least three times, call Dr. Scherr’s office with your response.
If your response is around penetration rigidity (50%-60%) or better, we want you to continue to use Viagra with sexual stimulation to obtain erections three times per week.
If you have not responded to Viagra with at least 50%-60% rigidity, then we will discuss penile injections with you in greater detail.
Dr. Scherr would like to see you every four months until you have returned to your preoperative erectile function or are 24 months after surgery
Erectile Tissue Preservation for Patients Undergoing Radical Pelvic Surgery
The erection nerves travel along both sides of the prostate on their way to the penis. During the operation you are scheduled to undergo, these nerves are manipulated to allow access to and removal of the prostate gland. Even in cases of nerve sparing operation, some decline in nerve function occurs, lasting for up to 24 months. As a consequence of this nerve dysfunction, the erectile tissue in the penis may undergo atrophy (degeneration). Early treatment, starting even before the surgery, has been shown to protect erectile tissue and may facilitate the chances of erectile function recovery.
We suggest the following:
Take Viagra 25mg (a quarter of a pill) before bedtime, nightly. Start this treatment two weeks prior to the surgery. You should not expect any erection to occur at such a low dose.
Discontinue Viagra 25mg the night before surgery and during your hospital stay.
Resume Viagra 25mg nightly, after you are discharged home even with the catheter in place.
After catheter removal (usually at 7-14 days after surgery), switch to Viagra 25mg six nights per week and Viagra 100mg once per week. The Viagra 100mg dose should be taken in an effort to get an erection.
Take the pill on an empty stomach (we suggest two hours before your evening meal). The pill lasts at least 8 hours so you will have plenty of time to attempt stimulation.
Dr. Scherr would like to see you 6 weeks after surgery. At that time he will inquire as to how you responded to the Viagra 100mg dose.
Male Incontinence Post Prostatectomy
Definition of Male Incontinence:
Any degree of urinary leakage
Pads utilized to quantify degree of incontinence
Storage problem – detrusor hyperreflexia, small capacity, overflow incontinence
Emptying problem – Intrinsic Spincter Deficiency (ISD), Stress Urinary Incontinence (SUI)
Post Transurethral resection of the prostate (TURP)
Epidemiology of Male Incontinence:
Data depends on definition
Patient surveys estimate rate at 35% require a pad
75%-85% of men leak occasionally
350,000 new cases of prostate cancer per year
180,000 prostatectomies per year
– Avoid drinking excess fluids after dinner
– Frequent bladder emptying
– Kegel Exercises
– Electrical stimulation
– External penile clamps
– Lifestyle adjustment
– Collagen injection
– Artificial urinary sphincters
– Urethral sling
– Ostomy Products
Risk Factors of Male Incontinence:
Pre-existing voiding dysfunction
High Body Mass Index (BMI)
Previous Transurethral resection of the prostate (TURP)
Previous XRT (Radiation Therapy)
Bladder neck contracture/urethral structure
Inadequate surgical skill during prostate surgery
Please call Dr. Scherr for more information on dealing with male incontinence.