What are the treatment options for erectile dysfunction (ED) after radiation therapy (RT) or radical abdominal perineal prostatectomy (RALP)?

Treatment Options for Erectile Dysfunction After Radiation Therapy or Radical Prostatectomy

PDE5 inhibitors should be the first-line treatment for erectile dysfunction following radiation therapy or radical prostatectomy, with additional therapies including vacuum erection devices, intraurethral alprostadil, intracavernosal injections, and penile prostheses available in a stepwise approach for those who fail to respond. 1

Understanding Post-Treatment ED

ED is a common complication after prostate cancer treatment:

• After radical prostatectomy: ED occurs immediately and may improve gradually over 2-4 years 1
• After radiation therapy: ED typically develops more gradually, with onset 6-36 months post-treatment 1

The mechanisms differ:

• Prostatectomy: Direct neurovascular bundle injury during surgery
• Radiation: Progressive vascular damage and local neurovascular changes 1

Treatment Algorithm

First-Line: PDE5 Inhibitors

• Start with sildenafil, vardenafil, or tadalafil 1
• Vardenafil has demonstrated efficacy specifically in post-prostatectomy patients (47-48% success rate for penetration vs. 22% with placebo) 2
• Key counseling points:
  • Sexual stimulation is necessary for medication effectiveness
  • Multiple trials may be required before establishing efficacy
  • Dose titration is often necessary for optimal results 1
  • Early use (penile rehabilitation) may improve long-term outcomes 1

Second-Line: Vacuum Erection Devices (VED)

• Non-invasive option that creates negative pressure to draw blood into the penis
• Use only devices with vacuum limiters to prevent injury
• Common side effects: penile bruising, discomfort, difficulty with ejaculation 1
• Caution in patients on anticoagulants or with bleeding disorders 1

Third-Line: Intraurethral Alprostadil

• Involves inserting a prostaglandin E1 pellet into the urethra
• Success rates range from 29.5% to 78.1% 1
• Requires in-office test dose before prescribing for home use
• Good option for patients who prefer to avoid injections 1

Fourth-Line: Intracavernosal Injections

• Self-administered injections of vasoactive medications into the penis
• Requires in-office testing and training
• Higher efficacy than oral medications but more invasive 3

Fifth-Line: Penile Prosthesis

• Surgical implantation of inflatable or malleable rods
• Most invasive but highest satisfaction rates
• Consider for patients who fail or cannot use other therapies 3

Special Considerations

Timing of Treatment

• Early intervention is critical: Untreated ED after radical prostatectomy is associated with penile atrophy and further diminished function 3
• Penile rehabilitation should begin early after surgery to preserve tissue health and improve long-term outcomes 1

Combination Therapy

• Consider combining therapies for improved results:
  • PDE5 inhibitors with vacuum devices
  • Testosterone therapy with PDE5 inhibitors in men with low testosterone 1

Testosterone Evaluation

• Men with ED and testosterone deficiency should be informed that PDE5 inhibitors may be more effective when combined with testosterone therapy 1
• Note that testosterone therapy alone is not effective for ED 1

Counseling Patients

Important discussion points:

• ED affects up to 50% of men after radiation therapy 1
• ED affects most men after radical prostatectomy, with recovery depending on age, nerve-sparing technique, and baseline function 1
• Recovery may take up to 2-4 years 1
• Orgasm is often preserved after surgery but without ejaculation 1
• Partners should be included in discussions about sexual recovery 1

Monitoring and Follow-up

• Regular assessment of treatment efficacy
• Willingness to try different options if initial treatment fails
• Psychological support for both patient and partner
• Consider referral to a urologist or sexual health specialist for patients who fail PDE5 inhibitor therapy 1

By following this stepwise approach and providing comprehensive counseling, most men with post-treatment ED can achieve satisfactory sexual function, significantly improving their quality of life after prostate cancer treatment.