Prostate Cancer and Rehabilitation

Prostatectomy Patients

Reversal of Non-use Atrophy

Erectile dysfunction following most forms of radical pelvic surgery is thought to be secondary to damage to the cavernous nerves and the reduction of arterial inflow. The combination of nerve damage and decreased arterial inflow will cause hypoxia and ultimately lead to programmed cell death resulting in penile shrinkage.

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The Penis Gym

Penile rehabilitation via SOMAerect

Prostate cancer is now the most common cancer in men in the UK. Over 47,000 men are diagnosed with prostate cancer every year – that's 129 men every day. 1 in 8 men will get prostate cancer in their lifetime. Over 330,000 men are living with and after prostate cancer. Vacuum Erection Device penile structural rehabilitation / therapeutic application post-prostatectomy is also well established and supported by the BSSM / MacMillan / PCUK. Regular V.E.D. usage equates to a penile gym effect – oxygenation and mechano-receptor stimulation (which has an anti-apototic effect) prevents dis-use atrophy (cavernosal fibrosis) and reverses penile shrinkage: a recent study showed that vacuum erectile device (VED) therapy has improved erectile function and preserved penile size in rats with bilateral cavernous nerve crush (BCNC) injuries, using blood gas and tissue to samples to establish the beneficial effect of VED therapy is related to antihypoxia by increasing the cavernous blood oxygen saturation.

The concept of penile rehabilitation via SOMAerect customizable Vacuum Therapy is now widely accepted in clinical practice.

The goals of penile rehabilitation are to improve penile oxygenation, prevent programmed cell death and promote early recovery of erection. Currently penile rehabilitation methods include the use of phosphodi-esterase type 5 inhibitors, intra-cavernosal injection, vacuum erectile device or combination therapy. [1]

Early use of a SOMAerect Vacuum Therapy Device (VTD) following surgery facilitates early sexual intercourse, early patient/spousal sexual satisfaction, and maintenance of penile length/girth and, potentially, an earlier return of natural erections. Sexual activity that occurs during the first 9 months after surgery helps maintain the sexual interest and comfort between the couples that existed preoperatively. Patients who are motivated and sexually potent pre-operatively, and interested in maintaining post-operative potency should be encouraged for early prophylactic treatment options. The advantage of a VTD is that the erections produced are independent of endogenous vasoactive substance such as nitric oxide (NO) production, which is impaired by nerve damage. [2-5]

Vacuum therapy also appears to be more cost-effective compared with frequent use of oral medications or frequent penile injections. [6]

This therapy can also be used for patients with erectile dysfunction due to non-nerve sparing radical prostatectomy, radical cystectomy, rectal cancer surgery, radiation and cryrotherapy for prostate cancer, [16] regular device use maintaining penile size and preventing penile shrinkage. [6]

SOMAerect Therapeutic Application - Protocol Details

1 - Assessment and device training by iMEDicare Technician 8 weeks post-surgery (radical prostatectomy) or shortly after radiotherapy. 2 - Daily SOMAerect Vacuum Device Therapeutic application for 10-20 minutes for 4 weeks. Daily program: 10-20 full erections consecutively (penis push-up) each to maximum filling comfortable and sustained at this level for not more than 5 secs in the device cylinder at full engorgement. Aim is to increase degree of filling with each progressive inflation incrementally in a way that remains comfortable. 3 - Sexual activity 4-6 weeks after initiation of program. 4 - Continued therapeutic SOMAerect application alternate days in the longer term. 5 - Monitoring of progress – spontaneous nocturnal or sexual erections? Full recovery?

Clinical Documents

References

Wang R. Penile rehabilitation after radical prostatectomy: Where do we stand and where are we going? J Sex Med 2007;4:1085-97.
Wang R, Huber N, Madsen L, Wood C, Babaian R. Compliance to penile rehabilitation program following radical prostatectomy: One year data. J Sex Med 2006;3(suppl 2):151(Abstract-Not numbered).
R Raina, A Agarwal, S Ausmundson, M Lakin, KC Nandipati, DK Montague, D Mansour and CD Zippe, Early use of vacuum constriction device following radical prostatectomy facilitates early sexual activity and potentially earlier return of erectile function. International Journal of Impotence Research (2006) 18, 77–81
Huber N, Wood C, Babauan R, Madsen L, Shem Y, Wen S, Wang R. Recovering penile length and erectile function following radical prostatectomy. J Sex Med 2006;3(Suppl 1):21 (Abstract 60).
Montorsi F, Bringanti A, Salonia A, Rigatti P, Burnett AL. Current and future strategies for preventing and managing erectile dysfunction following radical prostatectomy. Eur Urol 2004;45:123-33.
Hinh P, Wang R. Overview of contemporary penile rehabilitation therapies. Adv Urol 2008 in printing.
Moreland RB, Traish A, McMillin, Smith B, Goldstein I, Saenz deTejada I. PGE1 suppresses the induction of collagen synthesis by transforming growth factor B1 in human corpus cavernosum smooth muscle. J Urol, 153: 826,1995.
Nehra A, Gettman MT, Nugent M, Bostwick DG, Barrett DM, Goldstein I, Krane RJ, Moreland RB. Transforming growth factor-Beta 1 (TGF-Beta 1) is sufficient to induce fibrosis of rabit cavernosum in vivo. J Urol, 162: 910-915, 1999.
Saenz de Tejada I, Moroukian P, Tessier J, Kim JJ, Goldstein I, Frohrib D. The trabecular smooth muscle modulates the capacitor function of the penis. Studies on a rabbit model. Am J Physiol, 260 (Heart and Cir.Physiol 29): H1590, 1991.
Nehra A, Azadzoi KM, Moreland RB, Pabby A, Siroky MB, Krane RJ, Goldstein I, Udelson D. Cavernosal expandibility is an erectile tissue mechanical property which predicts trabecular histology in an animal model of vasculogenic erectile dysfunction.
J Urol, 159: 2229-2236, 1998. McCulloch DK, Campbell IW, Wu FC, Prescott RJ, Clarke BF. The prevalence of diabetic impotence. Diabetologia, 18:279-283, 1980. Mcculloch DK, Young RJ, Prescott RJ, Campbell IW, Clarke BF. The natural history of impotence in diabetic men. Diabelogia, 26: 437-440, 1984.
Melman A, Christ GJ, Integrative erectile biology: the effects of age and disease on gap junctions and ion cannels and their potential value to the treatment of ED Urol clin North Am. 2001; 28: 217-231 Herman A, Adar R, Rubeinstein Z. Vascular lesions associated with impotence in diabetic and non-diabetic arterial occlusive disease. Diabetes, 27: 975-981, 1978.
Saenz De Tejada I, Goldstein I, Azadzoi K, Krane RJ, Cohen RA. Impaired neurogenic and endothelium-mediated relaxation of penile smooth muscle from diabetic men with impotence. N Engl J Med, 320: 1025-1030, 1989.
Pickard RS, King P, Zar MA, Powell PH. Corpus cavernosal relaxation in impotent men. Br J Urol, 74: 485-491, 1994. Pickard RS, Powell PH, Zar MA. Nitric Oxide and cyclic GMP formation following relaxant nerve stimulaton in isolated human corporus cavernosum.
Br J Urol, 75: 516-522, 1995. Seftel AD, Vazin ND, Ni Z, Razmjouei K, Fogarty J, Hampel N, Polak J, Wang RZ. Advanced Glycation end products in human penis: elevation in diabetic tissue, site of deposition and possible effect through iNOS and eNOS. Urology, 50: 1016-1026, 1997.
Mersdorf A, Goldsmith PC, Diederischs W, Padula CA, Lue TF, Fishman IJ, Tanagho EA. Ultrastructural changes in impotent penile tissue: a comparison of 65 patients. J Urol, 145: 749-758, 1991
Warbreck AJ, Burchell RC. Male sexual dysfunction associated with coronary heart disease. Arch Sex Behav, 9: 69-75, 1980.
Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and ist medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol, 151: 54-61, 1994
Greenstein A, Chen J, Miller H, Matzkin H, Villa Y, Braf Z. Does severity of ischaemic coronary disease correlate with erectile function? Int J Impot Res, 9: 123-126, 1997
Martin-Morales A, Sanchez-Cruz JJ, Saenz de Tejada I, Rodriguez R, Prevalence and independent risk for ED in Spain: results of the Epidemiologia de la Disfuncion Erectil Masculina Study. J Urol, 166: 569-574, 2001
Virag R, Bouilly P, Frydman D. Is impotence an arterial disorder? A study of arterial risk factors in 440 impotent men. Lancet, 1: 181-184, 1985
Azadzoi KM, Krane RJ, Saenz de Tejada I, Goldstein I, Siroky MB. Relative roles of cyclo-oxygenase and Nitric Oxide Synthase pathways in ischaemia induced increased contraction of cavernosal smooth muscle. J Urol, 161: 1324-1328, 1999.
Azadzoi KM, Krane RJ, Saenz de Tejada I, Goldstein I, Traish AM, Siroky MB. Mechanisms of ischaemia-induced cavernosal smooth muscle relaxation impairment in a rabbit model of vasculogenic ED. J Urol, 160: 2216-2222, 1998.