Page 4 - Algorithm for erectile rehabilitation following prostate cancer treatment

elterman et al

Table 2. Timelines and patient goals for erectile recovery
Timeline Long-term penile health Short-term erectile function
Prior to treatment – Treatment flow post-treatment focused on – Treatment flow post-treatment focused on the patient’s
the patient’s desire to maintain penile health desire to achieve functional erections in the short-term
over the long-term
Psychosocial focus: Normalize use of pro-erectile aids, education on timeline of recovery, and success with use
of pro-erectile therapies exploring patient’s goal for erectile recovery*
6 weeks post-treatment – PDE5i first-line; dosage daily vs. PRN – Include penile stimulation in treatment flow
– Include penile stimulation in treatment flow – If immediate erection is the goal, consider ICI therapy
first-line, or possibly PDE5i full-dose if responsive
Psychosocial focus: Importance of regular sexual activity (penetrative or non-penetrative), education on
timeline of recovery, manage expectations for erectile recovery and success with use of pro-erectile therapies;
encourage couples to maintain sexual intimacy (penetrative or non-penetrative)
10 weeks post-treatment – PDE5i first-line; dosage daily vs. PRN – Include penile stimulation in treatment flow
– Include penile stimulation in treatment flow – If immediate erection is the goal, consider ICI therapy
first-line, or possibly PDE5i full-dose if responsive
Psychosocial focus: Assessment and treatment of partner concerns, encouraging adherence to pro-erectile
treatment plan; encourage couples to maintain sexual intimacy (penetrative or non-penetrative)
4 months post-treatment – For patients who do not respond initially to – Depending on response to PDE5i, consider continued
PDE5i, introduce ICI or MUSE or VED use of effective PDE5i or ICI or MUSE or VED
Psychosocial focus: Recognition of grief response to sexual losses or performance anxiety, acknowledge
impact on masculinity; encourage couples to maintain sexual intimacy (penetrative or non-penetrative)
6 months post-treatment – For patients who do not respond initially to – Depending on response to PDE5i, consider continued
PDE5i, introduce ICI or MUSE or VED use of effective PDE5i or ICI or MUSE or VED
Psychosocial focus: Re-visit expectations and goals, and explore level of patient’s bother due to ED; sexual
desire and fantasy; encourage couples to maintain sexual intimacy (penetrative or non-penetrative)
12 months post-treatment – Re-challenge with PDE5i as needed – Depending on response to PDE5i, consider continued
– For patients who do not respond to PDE5i, use of effective PDE5i or ICI or MUSE or VED
introduce ICI or MUSE or VED
Psychosocial focus: Redefining sex life and building on success
18 months post-treatment – Re-challenge with PDE5i as needed – Depending on response to PDE5i, consider continued
– For patients who do not respond to PDE5i, use of effective PDE5i or ICI or MUSE or VED
introduce ICI or MUSE or VED
Psychosocial focus: Confirming goals and expectations
24 months post-treatment – Re-challenge with PDE5i as needed – Depending on response to PDE5i, consider continued
– For patients who do not respond to PDE5i, use of effective PDE5i or ICI or MUSE or VED
introduce ICI or MUSE or VED
Psychosocial focus: Long-term goal setting and management; adaptation and acceptance;
satisfaction with pro-erectile therapy
Consider time since treatment an expectation management. *Patient goals should be continually evaluated. ICI: intracavernous injection; PDE5i: phosphodiesterase type 5 inhibitors;
VED: vacuum erection devices.

treatment flow, with emphasis placed on the patient’s desire sible retrial of PDE5i. Alternatively, treatment with VED can
to engage in strategies that would promote penile health and be used in place of ICI or PDE5i at any point in the recovery
improve capacity for natural return of erections with time. timeline, thus patient treatment preference should be priori-
This sub-algorithm also considers the patient’s tolerance of tized to guide long-term clinical management.
treatment invasiveness. Consistent with treatment guidelines, In response to direct feedback from patients and clinicians
phosphodiesterase type 5 inhibitors (PDE5is) were identified on the panel, patient preference for expedient recovery of
as first-line treatment for ED post-RP with either daily or as- erections was identified as an alternative goal to long-term
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needed dosing. Daily PDE5i dosing has been demonstrated penile health. In this scenario, the short-term erectile func-
to be an effective alternative to as-needed dosing in patients tion component of the algorithm should be followed (right
who had an incomplete response to therapy with maximum- column). The first increment of the treatment timeline should
dose as-required PDE5i. If patient response to PDE5i is poor be 1‒3 months. Patients motivated to achieve an erection
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at three months, the introduction of intracavernous injection immediately should initiate ICI therapy as first-line treat-
(ICI) treatment can be introduced as an option, with the pos- ment. Otherwise, if treating with PDE5i, a higher dose is

242 CUAJ • August 2019 • Volume 13, Issue 8