What are the treatment options for erectile dysfunction (ED) after prostatectomy?

Erectile Dysfunction Treatment After Prostatectomy

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, or avanafil) are the first-line treatment for erectile dysfunction after prostatectomy, with all agents showing comparable efficacy in this population. 1

First-Line Treatment: PDE5 Inhibitors

Medication Options and Dosing Strategy

Start with conservative dosing and titrate to maximum doses for optimal efficacy: 1

• Sildenafil: 50-100 mg on-demand, taken 30-60 minutes before sexual activity 1
• Tadalafil: Either 10-20 mg on-demand OR 5 mg daily (both equally effective) 1, 2
• Vardenafil: On-demand dosing with comparable efficacy 1
• Avanafil: On-demand dosing; has lowest dyspepsia rates among PDE5 inhibitors 3, 1

For post-prostatectomy patients, start at the higher end of the dosing range since this population typically requires higher doses due to more severe baseline dysfunction. 3, 1

Expected Efficacy in Post-Prostatectomy Population

The evidence from FDA trials demonstrates that in bilateral nerve-sparing radical prostatectomy patients treated with tadalafil 20 mg: 2

• 54% achieved successful vaginal penetration (vs 32% placebo)
• 41% maintained erections for successful intercourse (vs 19% placebo)
• Mean IIEF-EF score improved by 5.3 points (vs 1.1 placebo)

Response rates are significantly lower than the general ED population (where 60-80% respond to PDE5 inhibitors) because post-prostatectomy patients have more severe baseline dysfunction. 3, 1

Critical Patient Education Requirements

Patients must understand these key points to avoid treatment failure: 1

• Sexual stimulation is necessary for PDE5 inhibitors to work
• Multiple attempts over 4-8 weeks are required before declaring treatment failure
• Erectile function recovery can continue for 2-4 years after surgery, so revisit PDE5 inhibitor trials even if initially unsuccessful 4, 1

Absolute Contraindication

PDE5 inhibitors are absolutely contraindicated with concurrent nitrate use due to risk of life-threatening hypotension. 3, 1

Penile Rehabilitation Approach

Early PDE5 Inhibitor Use

Although controversial, early penile rehabilitation with PDE5 inhibitors may assist with smooth muscle preservation through increased tissue oxygenation. 4, 1 However, clinical trials have not demonstrated improved unassisted erectile function with this approach. 1

The American Cancer Society guidelines note that early administration of PDE5 inhibitors may prevent end-organ penile damage due to neurovascular injury and fibrosis, though the evidence remains mixed. 4

Timeline for Recovery

• Erectile function recovery is gradual and can continue for 2-4 years post-surgery 4, 1
• In contrast to surgery, radiation-induced ED has delayed onset (6-36 months) and worsens progressively 4

Adjunctive Testosterone Therapy

Consider testosterone supplementation only if serum testosterone is <300 ng/dL AND the patient is not on active surveillance or androgen deprivation therapy (absolute contraindication). 1

Combination therapy (PDE5 inhibitor + testosterone) is more effective than PDE5 inhibitor monotherapy in hypogonadal men. 1

Essential Supportive Interventions

These interventions enhance PDE5 inhibitor effectiveness and should be implemented concurrently: 1

• Lifestyle modifications: Smoking cessation, weight loss, increased physical activity, reduced alcohol consumption
• Aerobic exercise: PDE5 inhibitors combined with aerobic exercise are more effective than PDE5 inhibitors alone
• Pelvic floor physical therapy: May improve sexual function outcomes
• Psychosexual counseling or couples therapy: Addresses psychological components and improves treatment outcomes

Risk Stratification by Nerve-Sparing Status

Patients who did not undergo nerve-sparing surgery are at highest risk of poor erectile function recovery and respond less robustly to PDE5 inhibitors. 4, 1

Baseline erectile function and comorbidities (diabetes, cardiovascular disease) significantly impact recovery potential. 4, 1

Second-Line Treatment Options

If PDE5 inhibitor therapy is ineffective after proper dosing and adequate trial period (4-8 weeks at maximum dose), refer to urology for consideration of: 4, 1, 5

• Intraurethral prostaglandin pellet (alprostadil/MUSE)
• Intracavernosal prostaglandin injection
• Vacuum erection device
• Penile prosthesis
• Combination therapy (e.g., sildenafil + vacuum constriction device)

Vacuum Erection Devices

Vacuum constriction devices showed significantly higher IIEF-5 scores than control at 6-9 months post-prostatectomy (mean difference 6.70 points). 6

Intracorporeal Injection Therapy

Intracorporeal injection therapy appears to have similar efficacy to PDE5 inhibitors and serves as an effective alternative when oral agents fail. 6

Common Pitfalls to Avoid

• Declaring treatment failure too early: Patients need 4-8 weeks of maximum-dose therapy with multiple attempts before concluding PDE5 inhibitors are ineffective 1
• Inadequate patient education: Most treatment failures result from incorrect use, not true pharmacologic failure 3, 1
• Ignoring testosterone levels: Hypogonadism significantly impairs PDE5 inhibitor response; check testosterone in non-responders 1
• Forgetting the recovery timeline: Natural recovery can occur up to 2-4 years post-surgery, so periodically retry PDE5 inhibitors even after initial failure 4, 1

Additional Quality of Life Considerations

Patients should be counseled about other common post-prostatectomy sexual changes: 4

• Anejaculation (dry orgasm) occurs but orgasm ability is often preserved
• Climacturia (urine leakage at orgasm) is more common within the first year; mitigate by emptying bladder before sexual activity or using condoms
• Penile shortening has been documented after surgery