Thyer Urology

Erectile dysfunction (ED) is a common issue for men over the age of 40 with a significant number of Australian men suffering from it. ED can understandably have an impact on sense of self and quality of life. There are many causes of erectile dysfunction and often the cause is multifactorial. Psychological factors such as life stressors, performance anxiety and depression are common causes of ED. More serious medical conditions causative of ED are vascular and metabolic disorders, such as narrowing of the arteries, high blood pressure and diabetes. Hormonal issues such as low testosterone and the use of prescription, recreational drugs, cigarette smoking and alcohol can cause ED. Lastly, neurogenic ED is caused by interference with the nerve function, such as with surgery for prostate cancer, leading to ED.

The erection pathway is a complex one encompassing vascular, hormonal, neurological and psychological components. There are two tubes of spongy tissue called the Corpora Cavernosa that run the length of the penis. The autonomic nervous system modulates constriction and relaxation, thus transitioning the penis between its flaccid and erect states. When the penis is flaccid there is limited arterial blood flow, arousal or stimulation triggers neurotransmitters from the cavernous nerves which results in relaxation of the smooth muscles, dilation of the arteries thus increasing blood flow so that the spongy tubes, the Corpora Cavernosa become engorged with blood. There is subsequent compression of the veins to stop the blood from leaving the penis. There is continued pressure increase in the penis until the stage of a rigid erection. At the completion of stimulation, the level of chemicals produced by the neurotransmitters fall and the penile blood flow returns to that of its flaccid state.

Dependent on your cancer you may or may not have a nerve sparing prostatectomy. Even with a nerve sparing prostatectomy the nerves will need time to recover. This recovery time can vary from a few months up to two years. Recovery of erections post prostatectomy is variable between patients but age, baseline sexual function, comorbidities and technical considerations with surgery will have an impact on your individual recovery. There are many interventions available to treat ED post prostatectomy. We will work with you to establish your individual goals and then implement an individualised treatment plan. For many men the goal of treatment is to achieve erections suitable for penetration, whereas some men who are not sexually active aim to maintain the length of their penis and to optimise the health of their penis. Pharmacologically or mechanically induced erections are important to avoid the adverse structural and physiological changes that can occur while natural erections are not occurring. If penile rehabilitation is initiated promptly local hypoxygenation and fibrosis can be prevented.

Many men and their partners wonder how things will be with altered erections. We refer to sexual renavigation as it is likely that the sexual experience will be different post prostatectomy. The nerves are damaged but libido and arousal remain, although there is dry ejaculate, men are still able to orgasm with or without an erection. Maintaining intimacy is important and many men and their partners find that intimacy and outercourse is pleasurable and they are able to maintain a good sex life. With the use of oral, injectable medications and / or vacuum pumps many men are able to achieve penetrative intercourse if they wish.

Pharmacologically and mechanically induced erections prevent the structural tissue changes associated with infrequent or no erections during the Post Prostatectomy period which can be up to 24 months. Evidence shows that a penile rehabilitation program may offer men a better chance at recovering normal erectile function. Intimate relationships are central to the human experience and we will discuss your individual goals with you, and discuss the importance of maintaining intimacy in the event of loss of erections. Managing anxiety related to lack of erections and performance issues is important as with anxiety there is an increase in catecholamine production and sympathetic vasomotor tone, opposing and potentially suppressing an erection. The treatment options available for ED range from simple non-pharmacological interventions such as a vacuum device, to the use of oral medications and in suitable patients the use of injectable medications and a penile prosthesis.

Medications such as Viagra and Cialis are PDE5 inhibitors and through various complex processes cause vasodilation to enhance erectile responsiveness. Taking these medications as instructed is crucial as the medications will not spontaneously provoke an erection, stimulation is necessary. There is evidence showing that using a low dose of a PDE5i daily as part of a penile rehabilitation regime will help with recovery of erections post prostatectomy. When using an ‘on demand dose’ (taken when an erection is wanted) men should try these on at lease 8 separate occasions before deeming them ineffective as the response to PDE5i increases with successive doses. Post prostatectomy as the nerves recover over time, PDE5i can be re-trialled if they have not previously worked. There are various different PDE5i available which come in different forms and it is important to ascertain which is best suited for you and your individual goals.

Sildenafil (Viagra) – best taken one hour prior to wanting to achieve an erection but erections may be achievable for up to 4 hours. Available in low and on demand doses.

Tadalafil (Cialis) – best taken one hour prior to wanting an erection but erections may be achievable for up to 36 hours after taking. Available in low and on demand doses.

Vacuum erection devices (VED) offer a safe, low cost and drug free option for both penile rehabilitation, achieving an erection and penetrative intercourse. The flaccid penis is placed in a cylindrical tube sealed at the base of the penis to enable suction. The pressure in the cylinder is reduced and venous blood is drawn into the corpora cavernosa leading to tumescence and an erection. A constriction band can be used to maintain the erection. The constriction ring should not be in place for more than 30 minutes else there is a risk of ischemic damage. VED are highly effective when used correctly and with the use of easy to manoeuvre devices can be incorporated into sexual activity. Pumping should not be vigorous as bruising can occur. The motion should be slow and steady and it is essential to use sufficient lubricant. Perseverance is the key to VED success.

Intracavernosal injections (ICI) involve injecting a medication such as Alprostadil into the penis. Patients are carefully educated about preparation of the medication and self-injection. You will be supported through dose titration until an appropriate dosage is established. These medications are not reliant on the nerves firing as with the oral medications so offer a great treatment option whilst the nerves are regenerating and in the event of a non-nerve sparing prostatectomy. Evidence supports establishing pharmacologically or mechanically induced erections on a regular basis to prevent tissue damage. Once the apprehension of self-injecting is overcome and adequate dosage is established ICI offers a great treatment option with a quick onset erection.

A penile prosthesis is a surgically implanted prosthetic device. An implant is placed into the corpora cavernosa which is connected to an implanted fluid reservoir and an activation button which is implanted in the scrotum. The penile prosthesis presents a great option for men who have failed less invasive treatment measures. The penile prosthesis is a last line treatment option as once the prosthesis is implanted, other treatment options would be ineffective.