The motto, Use it or lose it, is spot on for prostate cancer patients recovering from surgery. The nurses who specialize in penile rehabilitation at Memorial Sloan-Kettering Cancer Centers Male Sexual Health and Reproductive Medicine Program regularly use the saying to remind patients that failing to achieve an erection following prostatectomy can cause permanent damage and even shrink the penis.
We want [erections] four to six months post-operatively because if theyre not getting the oxygenated blood flowing into the penis shaft it can have structural changes, says Joseph Narus, RN, ANP, staff nurse in the urology department at Memorial Sloan-Ketterings Sexual Health and Reproductive Medicine Program. One of the ways we define [penile rehab] to patients is that its physical therapy for the penis. If you were to break an arm and have it in a cast, your muscle will undergo atrophy and youll have to re-strengthen it. Post-operatively if youre not able to get an erection we have to look at what is the next remedy to get the muscle built back up again.
Just before or immediately following prostatectomy during which the surgeon removing the cancerous gland and tissues must handle and might damage the nerves flanking the prostate men are almost universally started on low-dose PDE-5 inhibitors, such as Viagra, Cialis or Levitra.
[The inhibitor] is going to bring the blood supply down to the penis, says Eileen Kochis Wittman, RN, CURN, staff nurse in the urology department at Hackensack (N.J.) University Medical Center. Its not necessarily going to give them an erection, but it will help after the surgery because the increased blood supply is going to keep all the tissues oxygenated and viable. Even if the surgery is nerve-sparing, the nerves are still manipulated and sometimes there is temporary paralysis of the nerve, so you need to keep the blood supply up so it doesnt scar.
A typical dose of Viagra is 25 milligrams daily for the first month after surgery, nurses say. After one month, many doctors advise patients to continue taking the low dose, but to increase the dosage to 100 milligrams on the days sexual activity is attempted.
Although the majority of men dont report achieving an erection hard enough for penetration until about six months after surgery, the sooner the patient is able to achieve any type of erection most nurses say they encourage patients to attempt one just one month post-op the better the patient will be able to preserve his sexual function.Stephanie Matlin, RN
If the erectile tissue is not able to stretch out, patients can end up with a venous leak where blood will flow into the penis but cant maintain an erection because the valve that controls the blood flow has weakened and allows the blood to flow right back out again, Narus says.
Whats more, without engorgement the penile tissue can atrophy and diminish in size, adds Joe Kiper, RN and CRN at in the James Buchanan Brady Foundation Department of Urology at New York Presbyterian/Weill Cornell Medical College in New York City.
Weill Cornells prostate cancer patients also are encouraged to practice pelvic and diaphragmatic muscle stretches, yoga and visualization to recover sexual function and urinary continence, says Fran Conway, RN and RVT in the James Buchanan Brady Foundation Department of Urology.
I always go over with people the procedure and encourage them to do Kegel exercises pre-op so they can get into that muscular groove and develop that muscle memory, says Conway, who also is the director of Weill Cornells Holistic Health Center. And I spend time with them and their wives to teach them how to do pelvic tilts, which also brings blood to the area.
In some cases if oral medications fail to provide patients with an erection, the patient receives a penile pump. The device is affixed to the penis using a venous occlusive device and uses vacuum suction to draw blood into the penis.
Continued failure in achieving an erection despite the oral meds and penile pump prompt most doctors to prescribe intracavernous injections. The shot, which is administered directly into the penis shaft using either a 29- or 31-gauge syringe, take between 10 and 20 minutes to produce an erection. Depending on the medical facility, the injections are prescribed at three, six or 12 months post-op.
At Weill Cornell, physicians administer the first injection and evaluate the quality of the erection, Kiper says. The second injection is typically self-administered as part of a training exercise patients undergo. Following the training, the patient is advised to self-inject up to three times a week.
There are a few patients who have a problem with the injections, but by far most of them have no issues, Kiper says. You have to be very patient because a lot of times they can go through the whole set up and drawing up the medication, but when it comes time to do the actual injection they might be a little hesitant so you have to do some kind of coaching.
For nurses who specialize in penile rehabilitation, coaching, as well as cheerleading, is just part of the territory.
Sexual function is a barometer of health, and its something that needs to be discussed, says Stephanie Matlin, RN, BSN, nurse clinician in the Section of Urologic Oncology at the Cancer Institute of New Jersey in New Brunswick. We tell everyone at the initial visit that we want to get you back to where you were before surgery. We dont want to get you back to being a teenager the doctor is not a magician but to where you are right now.
The honest and open rapport nurses develop with patients during their recovery doesnt end when they leave the office.
I had a patient call me just a month after his catheter was removed and tell me he felt like he was 17 again because he had an erection hard enough for penetration and he and his wife had intercourse, Matlin says. Hearing something like that really, truly makes us happy.