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Penile Rehabilitation following Prostate Cancer Surgery by Dr Michael Gillman



so what I thought I'd do today is to just talk a little bit about what we do with the rehabilitation program for erectile dysfunction following prostate cancer surgery just just a quick disclosure slide and we will be talking about some medications tonight and though I'm on the advisory board for several of these medications that I'll talk about what do we mean by a bloke who has erectile dysfunction well we mean the inability to achieve or sustain an erection which is satisfactory enough for the man or his partner now penile rehabilitation what do we mean by that well it's defined as the use of any drug or device at or after prostate cancer treatment to maximize erectile function recovery and the whole aim of this is to prevent any of these smooth muscle changes which I'll talk about that can occur in the penis so that we actually maximize the chances of a man returning to his normal preoperative function so that's what we mean now is it important do you think it actually matters to a bloke many men that I see with prostate cancer all they're really interested in to start with is let's get rid of the cancer it doesn't really matter about all the other things such as the erectile dysfunction we'll think about that later but in fact we actually need to think about it nice and early because while it may not be important at the time it is actually important from the earliest of Ages as soon as a bloke finds his penis he's actually interested in it so it is important and I don't think it matters how old you get whether you're in your late teenage early 20s or even if you're old this is a nursing home with the lots is a little bit to the left please now erectile dysfunction is common anyway even if people don't have prostate cancer surgery even I can remember these figures you know we have 40% at age 40 50% at age 50 60% at age 60 so I don't want to live till I'm 100 because if you follow that through you can see exactly where I'm going to end up now we're not saying that 60% of men are totally impotent at age 60 but 60% do have some degree of difficulties with erections even without prostate cancer surgery it's common and many men that I see even before their surgery already have erectile dysfunction and we can see why on these figures it's now estimated excuse me it's now estimated that maybe ten percent of all patients that we see with erectile dysfunction have the cause of it as a result of some type of radical pelvic surgery and most typically nowadays that would be a radical prostatectomy when you look and Google these types of things and different types of specialists particularly coming out of the states they will actually quote potency rates anywhere between thirty to ninety percent the problem is that we probably know that a lot of this is over estimated with their potency rates and it's the way that the thing is defined it's the way they define erectile dysfunction which may be different to what a bloke depends on what he thinks is his good erectile function so what can happen with this the problem is is inconsistent data if a bloke gets a tiniest of erections after the surgery and then never gets them again does that mean that he had a rectal function following surgery so it depends on the way that we define it it depends on how the patients are selected if I was advertising my practice and if I was a urologist and I wanted to say that I get very good potency rates then I would only operate on very young people who had very good potency rates before hand who had very minimal cancer right and that would make my figures look good luckily in Australia we don't do that and you don't tend to find that people advertise their potency rates which is a good thing and I would go into that a little bit better but what I can say to you and I see patients from all of the different urologist in Queensland anyway there is no doubt that there are better outcomes with people who are experienced at doing the prostate cancer surgery there's no doubt about that so what are some of the things that we do see after surgery well we see erectile dysfunction as we're going to speak about and ejaculation and what's that mean you don't ejaculate you'd be surprised at the number of men I see having had surgery and they come in and say near listen something's wrong by orgasm but nothing comes out now I know that the urologist sees me I know that the urologist would have explained that they've removed the prostate and they've removed the seminal vesicles so there is no fluid left to ejaculate but this seems to go past with all the other information that's been given some people will get altered sensation when they orgasm it may be painful some people find it more pleasurable and some find it the same but there is often some type of change to the orgasm what we call dis orgasm ear we have penile length alterations and I'll speak about that in a little while why is it that sometimes the penis appears to be shorter after a radical prostatectomy and this actually matters to a bloke they don't want to have a shortened penis you know and so there are ways of actually maximizing that curvature some people will get an actual Bend when they get an erection so called Peyronie's disease and we'll talk about that as well and then climb actor ear which is urine leakage at the time of orgasm lots of people get very distressed about this leaking of urine they're quite happy to to ejaculate to semen right but not urine okay even though it's probably both sterile okay so why do people get erection problems after they have a radical prostatectomy for instance well it can be neurogenic because the nerves get damaged it can be that the arteries aren't working well what we call arterial genic it can be vented genic which means that the blood is leaking back out of the penis through the veins there's always a psychological component or it could be mixed with all of these things and we need to tease through this to work out what we're going to do as Phillip will I probably go through in his presentation what a lot of people don't understand is they think there's just a nerve that runs down the surgeon gets it out of the way takes out the prostate and the cancer and then it should just come straight back again if they've spared the news he told me that he spared the nerves how come I can't get erections in actual fact these nerves are almost like a tissue or a cobweb of nerves that are attached on the side of the prostate and that's surgery these need to be peeled off and lifted out of the way and then take the prostate and the cancer out and the touching of the nerves the peeling off of the nerves in order to preserve them causes a temporary damage and the nerves become stunned and bruised for a while this can take 12 to 18 months to come back so it's nothing that happens quickly it can be 12 to 18 months while these nerves remain what we call neuropraxia it's similar to if you lie on your arm and you wake up and your arms dead you've got to kind of lift it out and wait for the feeling to come back in that's one of the common neuropraxia is that we can get from sleeping and this is what happens around the penis and it is now thought that if we don't do some type of rehabilitation that less than 10% of patients will return to their preoperative how they were before the surgery with their erectile function so this whole idea of rehabilitation has become very important now worldwide and I'll say why that's it happen why that's important as we go along but in essence the whole idea of the rehabilitation is to keep the blood flowing through the penis while we wait for these bruised and stunned nerves to kick back in again okay a male will get six to eight erections every night during rapid eye movement sleep when we wake up in the morning if you happen to wake in rapid eye movement sleep you'll have one of these morning erections that all men are familiar with a young baby also gets the same six to eight directions while it's sleeping during rapid eye movement sleep so why do we get that why do we get these six to eight erections during rapid eye movement sleep well we now know that this is the way the penis oxygenates itself this brings fresh oxygen into the actual erectile parts of the penis and if you were not to get that and if you were not to get that regular blood flushing through we start to get this scar tissue developing in the penis a term that we call fibrosis and if you get scar tissue less blood comes in more scar tissue less blood and it gets worse and worse now of course the nerves other things that open the arteries up and if they're stunned and bruised and we're not getting that regular blood flushing through we start to get the scar tissue developing so the whole idea of rehabilitation is to work out a way that we can get that fresh blood coming back into the penis to prevent that scar tissue from occurring in the first place now what about the age of blokes when they come in to get their prostate cancer we're seeing younger and younger men but we have to remember though that a lot of the men that I see even before the surgery already start to have some erectile dysfunction we spoke about before the 40% at age 40 50 percent at age 50 etc but we also know that people who have high cholesterol people who have high sugar people have a waist circumference bigger than they should around the belly all these things that can actually cause vascular problems such as heart attacks and strokes also cause erectile dysfunction and so a man may have many of these risk factors and then we play with the nerves as well and therefore they're going to have a lot more difficulty in regaining their function we also have to remember that most of these men have had a physical reason because the nerves have been peeled back but there is always a psychological component to this is this going to come up this time is it going to stay up am I going to disappoint myself my partner etc and what happens is we get the release of adrenaline from our adrenal glands which constricts the arteries adrenaline is a very powerful constrictor of these arteries and that makes it worse now I do see some men who have just purely psychological reasons why they get erectile dysfunction these men get good hard erections in the morning probably good erections by themselves but not with their partner like a patient I saw this morning mr. Schwartz it says mr. Schwartz the test shows you're not impotent your penis is just scared to death okay so this whole idea of rehabilitation where did this all start from probably the first person who did this was an Italian urologist by the name of Francesco Montes he and what he did is he got a group of patients and he injected them he put an injection into their penis three times a week of a stuff called prostaglandin or el prosthetic and then he had a control group on the side and there was they had no type of treatment which is waited for the nerves to come back and there was no doubt that the people who had the injections statistically had a better recovery of their erections and if you look at this sixty-seven percent versus twenty percent erection good enough for intercourse so that was with the injections then several other studies since that such as John molehole Herrin Pedro Nathan have shown that we can do this also with tablets such as the viagra cialis levitra so let's go through this very quickly we now know that probably 85% of men after originally or soon after they have their radical prostatectomy don't respond to the tablets 15 percent do but 85 percent don't respond initially particularly for the first six weeks interestingly though most of them do after around about two years 22 months and it can be anywhere in between that so what do I do what do I do if a bloke comes in and he's going to have his surgery or he's just had it and we now want to get the erections do I use tablets do I use injections what do we do well to date there is actually no formal analysis of how we do this we actually don't have a protocol that everyone follows the one that's most widely used is the one by John molehole from the Memorial sloan-kettering and this is a complicated slide but if you look at it we try and see the patient's before they have their surgery I explain what's going to happen to them why the most important thing is to get rid of the cancer but your two main side effects that you're going to get at the urinary incontinence and the erectile dysfunction and in 2013 it's no longer good enough for to say we'll get your prostate cancer out but you'll wear an incontinence pad from now on and you won't get erections anymore but that's just the way it is at least we saved your life and got rid of your prostate cancer that's not good enough in 2013 we want 3 outcomes we want the trifecta no cancer normal erections and normal continents but the only way that you're going to get these other two things are if we do some type of rehabilitation program the pelvic floor exercises for the encanta net cetera and the getting of the blood through the penis to stop at scarring so we see them we explain all this the idea is that what we want them to do is to maximize their erections before the surgery if they already have erectile dysfunction and many of the patients I see do then I will start them off on some type of treatment before surgery so that I can get as much blood into the penis beforehand so we're starting from the highest possible point then what happens is they go into surgery they have a catheter in the catheter is in for a week and it comes out unless there's some complications but it comes out after a week I then want to see them a month after the catheter comes out and I want them to try each one of the tablets what in essence I want to know is are they a tablet responder or not if they respond to the tablets and they get a good erection then we'll go down that pathway if they don't I move immediately over to the injections sorry I've got they're on the wrong way I'm looking the wrong way this is the non-responder we go right to the injections and then we keep going back and trying the tablets because you know what it doesn't matter how we get the blood into the penis just as long as we do so we're bringing that fresh oxygenated blood in in order to prevent it from scarring so in essence what we're after is are you a tablet responder or not as I said to you before don't be surprised if initially the tablets don't work and we do find that up to 85% of men do not respond initially I want a bloke to get two to three erections per week until the Nerds recover that's what we want two to three erections a week it doesn't mean you have to have and if I got the partner beside me I say to them it doesn't mean you have to have sex with him two to three times a week if you don't want to but I want you to have two to three erections a week to keep the blood flowing through and that's what's going to stop it from scarring up we may start on the tablets we may go to the injections and we may swap back and forward and what will happen is it's important that we see the men every couple of months and adjust and refine our treatment but the underlying principles of treatment are two to three good erections a week until the nerves come back okay so to summarize that very quickly optimize the erections for two weeks before surgery commence the tablets from the day the catheter comes out or as soon they're as possible I review them at four to six weeks after the catheter comes out and I decide are they a tablet responder or not if they are not we go to the injections and we periodically re-challenge with the tablets now what else should I do that for blokes got erectile dysfunction as a result of the prostate cancer surgery what about all the other things we have high blood pressure high cholesterol high sugar smoking increased abdominal circumference all of these things contribute to a bloke having erectile dysfunction and it's important that we address all those because that's going to maximize our chance of recovery more and more of the patients that I see these days are like this right now a bloke who has central obesity increased waist circumference diabetes high blood pressure and high cholesterol if a blokes got all four of those the so called metabolic syndrome or the awesome foursome or the deadly quartet what are they at increased risk of having a heart attack or stroke but what else are they at increased risk of having erectile dysfunction and in fact the erectile dysfunction occurs before they have a heart attack or stroke because the arteries are smaller right and they're the ones that get affected first so it's all very well for me to be treating them with tablets and doing all that and yet if in the background they've got these other things that are actually contributing to the erectile dysfunction well where waist at time so we need to be holistic about this and treat all of it so in essence if a person has a post radical prostatectomy erectile dysfunction do I treat them differently than I treat any man who has erectile dysfunction and the answer's no we treat them the same you correct all the risk factors get them to get rid of the gun get them to get rid of the smokes look they've been told for years you may get a heart attack you may get lung cancer they keep smoking your penis may not work oh I better get rid of them then you know it's often a very powerful reason for blokes to stop smoking and to get rid of these risk factors we start them off on the tablets if the tablets don't work we go with the injections if the injections start to work in the morning erections we go back to the tablets if none of these work or if the patient's looking for a permanent solution to their erectile dysfunction then we have the implants in the surgery which Philip coddled Aras will talk about what about a vacuum device what do I think about vacuum devices for the recovery after a radical prostatectomy well I don't think it's probably as important it will certainly give an erection but what the vacuum devices do is they bring old venous blood from the veins back into the penis predominantly and what I'm after for a rehabilitation is the fresh oxygenated blood through the arteries having said that they they do produce an erection the way they work is this we have a cylinder which goes over the penis and it has a little pump that sits either on the base of it or held in the hand and what the bloke does is he operates this pump it creates a vacuum in the chamber and the blood gets sucked back into the penis and you'll get an erection there is a little rubber band which sits around the base of this tube it gets lifted off onto the penis to trap the blood in need but rather than being red and warm this erection is blue and cold right and from here down is erect but from here back is not and so if that thing is not is halfway down that the for instance you'll get this hinge effect or this whirlybird phenomenon and if you're trying to have sex with something that's waving around like that right it'll bounce on the side buckle tear and all the rest I'm not a big fan of the vacuum devices right but if you don't mind a blue cold penis that's quite unstable it's four you know what about the injections you know I've never had a bloke sit in my office and say can I put an injection into my penis please never all right and yet we have thousands of men currently on the injections they are very good treatment we use a diabetic syringe like the children with the diabetes inject their insulin or like an EpiPen or like the Kleck saying if you have to inject yourself after surgery or after being on a plane flight to stop clotting that's the color of the needle we're talking about and if it's done correctly it is actually quite painless so the side effects of this is mainly due to technique we always used to say scarring was one of the side effects of the injections but in fact when you look at the evidence of this there's very little evidence to show that the injections themselves can cause scarring in fact not getting the blood into the penis is the main thing that causes the scarring by not getting it oxygenated and if you do this correctly and you go from side to side as we instruct them in very carefully to do then the incidence of scarring is probably not that high prior pisum is it's a prolonged erection and this is probably the true emergency of the injections if you give yourself too much you may get one of these erections that hang around and don't go down and we don't want that it is a medical emergency and it can cause damage to the penis so we're going to be very careful bruising if you hit a blood vessel the penis may bruise on the surface and the other thing is pain we find that a large percentage of men will get pain from a particular stuff the prostaglandin mixture that we put into there and if that's the case that doesn't mean we don't use the injections we can just use other mixes but all I really want as I've said is to make sure the blood keeps coming through the penis if I've got a bloke on injections I follow them up carefully so that they're doing it properly and if instructed if they're doing it properly it's very safe and it's very effective so for those of you who are on injections and some of you will be in the room what's the trick to doing it to make it painless and so that it works well firstly it's got to go in the right spot what I tell people is Meijin this is a clock face that would be 12 o'clock 3 o'clock 9 o'clock when you inject we want you to come in and either the 10 o'clock or the two o'clock angle at right angles to the shaft of the penis the needles not aiming back towards you it's not aiming away directly in at either the 10 o'clock or 2 o'clock angle and the secret is you must pull the head of the penis forward firmly so you're grass but by the head of the penis and you stretch it forward as hard as you can the needle goes in a lot easier that way if you've got a foreskin you pull the foreskin back grab it by the head and pull it forward if you're feeling it hurt when you put the needle in you pull it forward a bit harder right and you have control over any discomfort you feel that is the trick to injecting and making it not hurt what we don't want is a private ism these prolonged erections and that's probably the only real side effect of the injections so what do we define as a private ism well a prolonged erection that's actually not associated with sexual stimulation and it is possible that after 24 hours that may become permanent now I get blokes in my room saying aw that sounds like a great thing you know wouldn't that wouldn't worry me that would worry you it's painful it's sore and it can be dangerous so we do not want it and we start low and work up but we need to have an action plan so what's the action plan if the erections up for two hours I want them to take 260 milligram sudafed tablets now instantly this creates problems they go into the chemist with this erection that won't go down they ask for sudafed the pharmacist thinks they're running a meth lab and won't sell it to them so they've got to try and convince them that they're having it for real reason so I write them all a letter and they can give it to the pharmacist discreetly and get their pseudoephedrine if another two hours goes by it's now been up for four they take two more and if it's been up for five hours then they need to go to the accident emergency department they don't want to go to the accident emergency department they think they'll be lying in cubicle three and all the nurses we say never look at the bloke in cubicle three with a big erected and that's exactly what would happen all right so they say at home with this thing and that's when they I'd go in and have a look myself everyone came in but see the thing is that they don't want to do it they stay at home and this is where they run into trouble it does not normally happen with the tablets right with the tablets you need to be aroused so the shows that you see on TV where a bloke takes one of the tablets like viagra and gets his erection that won't go down that's nonsense it's the injections that cause it not the tablets unless you've got some rare type of priapism inducing condition such as sickle cell anemia or one of the leukemias I won't talk about the implants because Philips going to do that but it's an extremely good treatment and it's a permanent but the main thing that most blokes want to get on is causes the tablets and the first one that came out was viagra right now viagra was originally meant to be an anti anginal agent it was for blokes who had angina now didn't work but they wouldn't give their tablets back because all of a sudden they could get erections again now why did these blokes who were in a cardiovascular thing with heart conditions why did they find that it worked because they all had erectile dysfunction they had a reptile dysfunction because it's the same risk factors that caused their heart problem that caused the erectile dysfunction and of course once the company found out what this could certainly make a lot more money zazz worked out what it could do they marketed it you know it came out in America at the same time that Titanic did and what happened is all the ladies were lined up to get their Titanic tickets you know and the blokes lined up outside the pharmacies now while this is a this was published in one of the magazines that's actually what happened they sold out people were actually trying to get these in from the pharmacy because remember up until the tablets all we had was injections vacuum devices and surgery the real problem is though that when all this came out not long after came all the snake oil salesmen and you will get the same ads that I do you will ring to see the same billboards that I do right of all these different types of things that are going on where they take your credit card take as much money out of your credit card as possible right for things that are completely unproven and untrue if you have any type of troubles with erections please go and see your GP don't answer advertisements and billboards and things like that right or you will be parting with money lots of it so how do these tablets work I'm not giving you a biochemistry lesson here but I just wanted to point out the whole mechanism of getting an erection is quite complex and where the tablets work is down here they inhibit a particular substrate but you have to have an intact nerve system and sometimes when these nerves are bruised these tablets don't work initially in fact 85% of men they don't respond within the first four to six weeks so you need to have an intact nervous system and what's the next thing you need to do you need to be aroused right I get blokes come inside tried the tablet didn't work so what did you do well I took it and I sat there and I waited and nothing came up right it doesn't work like that you need to take the tablet and you need to take it at least 90 minutes before trying to get an erection well let it get in the system at least 90 minutes so if you took it at 5 o'clock anytime from 6:30 through til probably midnight right even though it says 4 to 6 hours it works a lot longer than that in the penis itself but you've got to give it time to get in the system and you need to be aroused if you're not aroused you won't get an erection with these things they do not make it artificially pop up people always worried about these thinking they're going to kill them right although I don't want to take that I've heard it gives you heart attacks and strokes and things it doesn't right this is my death by viagra slide and the reason I put that up there was to remind everyone that these tablets do not cause heart attacks or strokes if anything they're protective remember what they were made for originally angina they open the arteries so what was all this bit about people dying took it if you are on a medication group called nitrates these are the things you spray under your tongue if you get angina or a patch that you wear or a long-acting tablet like in do you must not take the tablets if you're on those who's those tablets dilate the arteries so do the viagra cialis and levitra but together they can dramatically dilate everything up and drop your blood pressure catastrophic ly and people have died from that so if you are on nitrates you don't take the tablets right it's as simple as that even if you carry it around in your pocket and just use it infrequently I do not give people these tablets because I don't trust a bloke to get an enjoin or attack and say geez when did I take that last tablet I should be right and spray it under your tongue you can die from it right so we don't use it in those people but they themselves do not cause heart attacks or strokes so as we said with the tablets they need a sexual stimulation you need to have an intact nerve pathway right and that sometimes takes a bit of time to come back after a radical prostatectomy what's the difference between them people say to me you've been doing this for a long time which tablet do you reckon is best and I have been doing it for a long time but I still can't pick a bloke he walks in and say you know what you look like a viagra into me and the next blade comes in and says I reckon you're levitra boy right I can't pick it and if there was one tablet that worked better than any of the others that's the one I'd use but I can't pick it so what I do is I give blokes all three of them they take them away and try and with their partners and they come back and tell me which works best for them and what's better for them we've got daily dosing we've got on-demand we got all sorts of tablets and we try them what's the real difference is one of them has a longer half-life called cialis so it lasts in the system for 36 hours it gives you a bigger window of opportunity to have sex so the bloke says to me well that's good I can have sex tonight and tomorrow night and the next night they can't because their partner won't let them I'll have sex once and that'll be when their partner says they can but the bottom line is if it works it does give you a bigger window of opportunity but if it doesn't give us firm in direction I choose one of the other ones all right we want two to three good erections a week and what we try and do is to see which is best for the man respond it is important to persist with this 12 to 18 months is a long time right and I'll get blokes who are all enthusiastic to start with I see them at nine months and they say oh look I haven't been bothered no this happened on back at work and you know you've got to think of this as writing yourself up a gym program for your penis right we want two to three erections a week no matter how we do it and if something's not working go back and see your doctor and get something else two to three erections a week till the nerves come back because if you don't and if it scars up then it may not work anymore and we do not want this to be the definition of retirement my new key days are over my pilot light is out wood used to be my sex appeal is now my water spout time was from its own accord from my trousers it would spring but now I have a full-time job to find the blasted thing it used to be embarrassing the way it would behave for every single morning it would stand and watch me shave but as old-age approaches it sure gives me the blues to see it hang its withered head and watch me tie my shoes okay

Glenn Chapman

13 Comments

  1. You really never get it back after Radical Prostatectomy. Doctors never tell you the real data on this. You aren't going to die of prostate cancer which is the main thing!

  2. Thanks for a entertaining half hour on a subject most of us don’t want to discuss. I’ll share this vid on my channel where I’m discussing my prostate cancer 👍

  3. Very informative, my Specialist never really mentioned or outlined why injections or tablets where so important to my rehabilitation, now I know why, I will make it part of my regime in keeping the old fella well. Thanks Doc. Great presentation. Made something that is rather traumatic for a bloke to move on with a positive approach. Motivational positive outlook with light hearted approach to getting a grip on things again. Legend….

  4. I have MRI (roughly like an xray) every two years to monitor my Prostatic cancer. The PSA blood test and the DRE finger test are incredibly imprecise. Unfortunately this is not covered by the Australian Medicare system but is the best way to be monitored.

  5. The one thing that the medical profession fails to talk about: are the orgasmic sensation changes that happen, when affected by Prostatism and Prostatic Cancer. These changes are prior to any surgery and whilst not affecting erections or libido, the actual orgasmic sensation can be completely absent or decreased. The biological fact is that the prostate is responsible for male sexual sensations. It is amazing how many Doctors and Male patients are not aware of this biology.

  6. What I really can't stand about some of these videos ( including this one ) is the need to make jokes about very traumatizing experience. The jokes are senseless and not needed. I can't think of any other form of cancer / recovery where making fun of the ordeal would be tolerated. Why do people insist on attempting to become a comedian just because they have a microphone, a stage, and an audience?

  7. What I meant was the 8.7 psa count was the reason for the biopsy. The result was stages 1 and 2 for most of the pieces check and this was the reason for surgery.

  8. Elevated PSA  does not mean Cancer – but one of the tools to help diagnose problems with the prostate– I had robotic surgery two years ago still have ED problems , lost one NV bundle to one side but Viagra helps.  

  9. I am know in my 2nd week after prostate surgery and doing well. So I strongly recommend to all the guys out there to stay on top of your PSA counts, my highest count be for surgery was 8.7 so in other words I cut it very close. Take action before your count is that high.

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