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consensus: algorithm for erectile rehabilitation after Pca treatment

Table 3. Timelines and benchmarks post-surgery Additional insights from the literature should be con -
Timeline Benchmarks using the Erectile Firmness Scale sidered when counselling patients about erectile recovery
(1–10; 1=flaccid, 6=just hard enough to achieve in order to promote adherence to and acceptance of the use
penetration, 10=full erection) of pro-erectile therapies. For example, in the general popula-
Prior to Evaluate baseline erectile function (poorer tion, sustained use of PDE5i is better when prescribed with
treatment function at baseline may require more
aggressive approach)* the knowledge and involvement of the patient’s partner. 45
6 weeks post- 1–3: Lack of natural sex function to be expected Given the overly optimistic mindset of patients about the
treatment probability of experiencing ED and the ease of treatments
10 weeks post- 1–3: Lack of natural sex function to be expected for ED, patients need adequate preparation before starting
treatment pro-erectile therapy. The algorithm was designed with the
4 months post- 1–4: Some early recovery of mild to moderate explicit purpose of being embedded in sexual health pro-
treatment tumescence in <10% of patients gramming for PCa patients. 18
6 months post- 2–6: Some early recovery of mild to moderate The most common reason for discontinuation of PDE5i is
treatment tumescence in <10% of patients lack of treatment efficacy (e.g., hardness of erection); there-
27
12 months 3–7: 20–40% recover natural erectile function fore, in a context when the need to re-challenge is the norm,
post-treatment hard enough for penetration
18 months 4–7: 20–40% recover natural erectile function patients need to be forewarned that PDE5i may not work for
post-treatment hard enough for penetration all patients immediately and that the likelihood of effective-
24 months 5–8: 30–50% recover natural erectile function ness increases the further out the patient is from surgery. 16,46
post-treatment hard enough for penetration In the context of RT, the opposite effect is observed. Patients
Use of pro-erectile aids or devices encouraged at all time points. Consider time since often do not understand that tactile stimulation is necessary
treatment and expectation management. *Some men experience ED post-diagnosis/pre- to prompt an erectile response even with the use of PDE5i,
treatment due to stress and anxiety. ED: erectile dysfunction.
47
and that spontaneous erections are unlikely. Furthermore,
recommended, with the possibility of combined treatment patients should be informed that none of the pro-erectile
with ICI and/or VED. 36 therapies promote sexual desire or interest.
The following considerations were identified for inclu- In addition, a variety of psychosocial factors are listed
sion in the content of the sub-algorithms: climacturia, throughout the Table 2. Ideally, good erectile rehabilitation
dysorgasmia, alterations to penile anatomy, and reduced should be provided in a bio-psychosocial context. Where
sexual desire. Other psychosexual factors that interact with this is not possible, clinicians may wish to read the evidence-
patient preferences were considered for inclusion, such as based literature for suggestions on enhancing the likelihood
the importance of sexual activity and intimacy, expecta- of successful sexual recovery.
tions for recovery with pro-erectile therapy, performance The long-term goal is to use the treatment algorithms in the
anxiety, and recognition of the impact of loss and grief. development of the web-based TrueNTH SHARe-Clinic. The
Important highlights included interventions to communicate opinion of the panel was that the application of a personal-
the importance of persistence to therapy; these are required ized clinical treatment tool with the TrueNTH SHARe-Clinic
to ensure patients can realize the full benefits of clinical will improve treatment for ED in PCa patients by tailoring
therapy. Psychosocial interventions are required to redefine individualized therapies in a clinical environment that pro-
a patient’s sex life, integrate the sexual partner(s) when pos- motes patient participation in decision-making. The web-
sible, and to focus on building on therapeutic gains. based clinic features tailored content, including personal-
Patients should be counselled about the likelihood of natur- ized sexual health coaching, a multimodal virtual library, and
al recovery of erections and timelines for recovery, including symptom monitoring with feedback mechanisms. Thus, the
the significant role of baseline erectile function prior to PCa TrueNTH SHARe-Clinic uniquely combines web-based sex-
treatment. In fact, baseline erectile function may have even ual health counselling with an ED therapy algorithm designed
more influence on erectile recovery than use of pro-erectile to provide patients and their partners with accessible, person-
43
therapies. Age is also a major predictor, with younger men alized, post-PCa long-term sexual healthcare.
showing better natural erectile recovery; 23,44 the percent prob-
ability of erectile recovery by 24 months, for men who have Conclusions
full erections at baseline is 63% in men ≤60 years vs. 37% in
men ≥65 years. In contrast, in men with recently diminished Because of the significantly high rate of ED after PCa treat-
erectile function at baseline, the percent probability is lower at ment, it is critical to establish practices guidelines for the
48% in those ≤60 years vs. 26% in those ≥65 years, and even management of ED in this patient population. There exist
worse for men who had partial erectile function at baseline a number of clinical guidelines to inform first-line through
(35% in men ≤60 years vs. 18% in men ≥65 years). Rates in fourth- or fifth-line therapies, however, to date, none of these
all categories increase slightly at 36 months. 23 guidelines attempt to directly incorporate patient values into

CUAJ • August 2019 • Volume 13, Issue 8 243