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.
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.
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