Treatment options for patients who have undergone radical
prostatectomy include oral drug therapy, drugs that are injected into the penis,
drugs in the forms of suppositories or pellets that are deposited in the urethra
of the penis, a vacuum pump device, and surgery to insert penile implants or
prostheses. The success rates of any of these treatments are dependent on such
factors as the type of surgery (nerve-sparing or non-nerve-sparing), the age of
the patient, and whether the patient received hormone therapy prior to surgery
or additional therapies such as radiation therapy, either prior to or after the
surgery.
Drug therapy
Three oral drugs have been used in patients who have had radical
prostatectomy for prostate cancer. These three drugs are Viagra, Levitra, and
Cialis. While success rates with these drugs have varied, patients who have
achieved the most benefit are those who have had bilateral nerve-sparing radical
prostatectomy. Up to 70 percent of these patients may respond to one or more of
these three drugs (response to each individual drug may from person to person).
Success is less likely in patients who have had only a single nerve spared, and
is very unlikely in patients who have had no nerves spared during surgery.
Success rates with oral therapy are also higher in younger patients and are
probably better in patients who do not have other risk factors for erectile
dysfunction, such as cigarette smoking, hypertension, high cholesterol, and
coronary artery disease.
When oral medications are unsuccessful, the following devices and alternative medication delivery routes are other options.
Vacuum constriction devices
Vacuum constriction devices consist of an acrylic cylinder that is placed
over the penis. A lubricant is used to create a good seal between the body and
the cylinder and a pump mechanism is used to create a vacuum inside the
cylinder, which allows a patient to achieve an adequate erection. If an adequate
erection is achieved, a band or ring is then placed over the base of the penis
(the part of the penis closest to the body), which is used to help maintain the
erection. Although some men find these devices helpful for achieving
intercourse, many men find the band at the base to be uncomfortable or find the
device to be somewhat cumbersome. These detractions tend to limit the number of
men who choose this therapy following radical prostatectomy.
Intracavernous or penile injections
Penile injections are probably the most widely used non-surgical method when
oral therapy fails to produce an adequate response and, in particular, are the
most widely used medical treatment option amongst patients who have had a
radical prostatectomy. This method will work in patients regardless of their
nerve-sparing status. Penile injections are successful in approximately 80
percent of patients who try it. The patients do need to inject each time they
want to have sex and the drug is injected directly into the erection tissue.
With proper technique, the injections themselves are not painful. However, after
radical prostatectomy, the most commonly used medication for injection,
alprostadil, results in an erection that is painful in a significant number of
men. Complications of injection therapy include a prolonged erection (which
would require injecting additional medication into the penis to make it flaccid
or soft again) and the possibility of scar tissue (which could result in
curvature of the penis). Drug-induced prolonged erections are rare, fortunately.
Scar tissue development seems to be related to both the frequency of injections
and duration of use of this therapy. Although this is a successful therapy,
there is a significant dropout rate over time.
Intraurethral therapy
This therapy involves using an applicator to place a suppository or pellet
into the urethra (or tube that carries the urine). The small applicator is
placed into the tip of the urethra through the opening at the end of the penis.
The insertion is usually not uncomfortable. The medication contained in the
pellet is the same as that used in penile injection therapies but contains 50 to
100 times more medication. This is because the medication has to be absorbed by
the urethra and travel into the erection chamber.
While this medication can, at times, produce an adequate
erection, in most men, the erection produced is generally felt to be
unsatisfactory. In addition, the higher amount of medication that needs to be
inserted and absorbed causes considerable discomfort in many men, particularly
after radical prostatectomy. This alternative, therefore, is not an attractive
option for most men who are post-prostatectomy. Sometimes intraurethral therapy
is combined with oral medication when either one of these therapies fails as
single therapy. However, relatively few men respond to this combination, and the
combination is quite expensive.
Penile implants or prostheses
Clinical studies have demonstrated a high degree of patient satisfaction
with penile prostheses. Patients who have had bilateral or unilateral
nerve-sparing surgery are usually counseled to wait a year to see how their
recovery progresses. Sometimes the degree of recovery combined with a
non-surgical alternative can achieve a satisfactory response and reduce the need
or desire for surgery.
Patients in whom non-surgical therapies fail or who find other
options unacceptable, even if they do get a response, may be candidates for a
penile prosthesis. Problems that can occur with prosthetic devices include
infections (in which case the device needs to be removed and a new one inserted)
or device malfunction (which also results in the need to remove the device and
consider inserting a new device).
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 6/8/2009…#11806
