Page 2 - Algorithm for erectile rehabilitation following prostate cancer treatment

elterman et al

accounts for patient and partner values and goals for erectile 3. Poorly managed patient expectations can be demotiv-
recovery, type of PCa treatment, time since treatment, nerve- ating in sustaining use of pro-erectile therapies.
sparing status, and also includes thematic recommendations 4. While the best time to introduce erectile rehabili-
for psychosocial support tation remains unclear, pre-PCa treatment psycho-
education on sexual dysfunction and available ED
Methods therapies is a necessity. 19-22
5. Post-PCa treatment ED recovery typically occurs over
A pan-Canadian panel of men’s sexual health experts con- a minimum of two (or more) years. 23
vened for the TrueNTH Sexual Health and Rehabilitation 6. Desired pace of return of ED function and willingness
Initiative Meeting to develop a consensus in managing ED to engage in invasive treatment varies across patients
in patients treated for localized PCa. The consensus panel and partners. 24,25
meeting was held on October 31, 2016 in Toronto. A lim- 7. Exclusive focus on achieving erections via any means
ited peer esteem snowballing technique (PEST) was used to may overlook the values or goals of patients and their
identify expert opinion panellists based on research or clin- partners.
ical expertise in sexual dysfunction post-PCa treatment. A 8. The uptake and adherence to pro-erectile therapies
13
17-member expert opinion panel provided commentary on is generally poor. 26-28
variation in ED treatment approaches through various pro- 9. Detailed education on the systematic use of pro-
grams and services across Canada. The group represented erectile therapies is often lacking in post-PCa sexual
a wide range of backgrounds, including nursing, urology, health care. 19
urologic oncology, radiation oncology, psychology, psych- 10. Inclusion of the partner in the recovery process is
iatry, and patient advocates. optimal. 24,29-31
The meeting involved several key decision-making 11. The process of ED therapy re-challenging over the
components. Before the consensus meeting, all panelists recovery period is necessary to achieve optimal erect-
reviewed the evidence-based medical literature on ED, par- ile functioning and to manage perceived treatment
ticularly concerning physiology, pathophysiology, diagnosis, failure. 32
and treatment of ED following PCa treatment. The meeting 12. Maintaining regular sexual activity (penetrative or
began with a discussion of various cancer-related sexual non-penetrative) during the course of erectile recov-
health rehabilitation programs that exist across the country. ery is advantageous for individual’s and couple’s
Special attention was paid to patients’ concerns about the well-being. 33,34
current practice of ED therapy and management following
PCa treatment, specifically the advantages and disadvan- Algorithm
tages of existing practices. Subsequently, the latest clinical
guidelines on sexual rehabilitation after PCa treatment were The algorithm for managing ED is illustrated in Table 1. The
reviewed and summarized. 14-16 algorithm focuses on therapeutic strategies to erectile recov-
Patients’ perspectives and feedback regarding gaps in cur- ery, with psychosocial considerations at each stage of treat-
rent practice and desired practice were incorporated into ment. The focus of the algorithm is split based on patients’
the development of the TrueNTH SHARe Clinic algorithm. values or goals for erectile recovery. Further considerations are
Possibilities for content and structure were outlined and dis- offered based on the cancer treatment (radiation or surgery),
cussed. Proposed strategies for the uptake of the algorithm nerve-sparing status, preference for less invasive vs. more
to the medical community were also outlined. aggressive treatment approach, and inclination for a phar-
maceutical vs. mechanical approach to pro-erectile therapy.
Results
Section 1: Algorithm process
The TrueNTH Sexual Health and Rehabilitation Initiative Patients will choose a management pathway (Table 1) based
Consensus Meeting established that a tailored, comprehen- on the type of PCa treatment received (surgery or radiation),
sive ED therapy algorithm for patients (and their partners) followed by the patients desired level of invasiveness (low
after localized PCa treatment should recognize the following: or high), and the nerve-sparing status (bilateral nerve-sparing
1. Real-life results are often more modest than reported [BNS], unilateral nerve sparing [UNS], and non-nerve spar-
in the literature. ing [NNS]), and lastly if they prefer a pharmaceutical vs.
2. Patients are overly optimistic about the likelihood mechanical approach to pro-erectile therapy. Thus, vacuum
that they will be in the minority of patients who do erection devices (VED) are available in each quadrant for a
not experience ED and about the ease with which non-biomedical approach. The inflatable penile prosthesis is
they will adapt to use of pro-erectile therapies. 17,18 available for patients who are refractory to both biomedical

240 CUAJ • August 2019 • Volume 13, Issue 8