The return and quality of sexual function is a major concern for men undergoing radical prostatectomy. New research on the etiology of post-prostatectomy erectile dysfunction is shaping new rehabilitation strategies for prostatectomy patients, according to John P. Mulhall, MD, who discusses current and future rehabilitation strategies and his own approach to post-prostatectomy ED in this exclusive interview.
Q. How common is erectile dysfunction after radical prostatectomy?
A. In the most recent 20 papers in the literature that look at open, laparoscopic, or robotic prostatectomy, the incidence of reported ED ranges from 30% to 90%. Could it be that one center is just so much better at doing radical prostatectomy than another? The answer is no.
For example, Mr. Smith comes to see me before surgery, and he has a fully rigid erection: 10/10 on a visual analog scale. Eighteen months after surgery, without the use of drug therapy, he rates his erections a 6/10. He can have intercourse, but he has had a 40% reduction in rigidity. Patients such as this routinely will use a drug and if they are already using a medication, they will switch to another agent.
The second issue is consistency. If Mr. Smith is able to have sex one out of every five times, is that level of consistency good enough for him not to use a pill? Probably not. The Society for Urologic Oncology and the Sexual Medicine Society need to get together and convene a panel to define what we should be reporting.
Q. What has your research uncovered about the pathophysiology of ED after RP?
Q. In a patient who is not able to have intercourse or erections after prostatectomy, should we perform a specific evaluation prior to initiating therapy, or simply initiate therapy?
A. If your therapy is oral PDE-5 in-hibitor-based, you want to make sure the patient has enough cardiac reserve to use a PDE-5 inhibitor. Can he walk up two flights of stairs briskly? Is he on nitroglycerin? Has he had sudden blindness? If the answer to the first question is yes, and the answer to the second and third questions is no, then no specific evaluation is needed.