Introduction
This page describes Phase 1 of PR3 – the Pelvic Rehab Restoration Roadmap, and explains how pelvic surgery can affect both erections and bladder control and how to preserve them. Things are organized in a question/answer format and have been broken into two sections with the first addressing erectile preservation and the second addressing bladder and urine control. Please remember that each of the exercises and therapies discussed here should be ideally started prior to surgery and continued throughout the healing process in the months following.
If you ever have any questions or concerns, please feel free to call the Urology Partners Center for Men’s Health at (866) 367-8768.
Daily
How often exercises and therapies should be done to address erectile preservation and bladder/urine control.
3-4
Number of erections that occur in healthy men while sleeping or upon waking up.
Section 1: Erectile Preservation
How do erections work?
In regards to sexual function, the male erection is essentially the result of two inflatable tubes that start in the pelvis and extend down the length of the penis. These tubes are known as the corpora cavernosa.
When a man is aroused, an electrical signal travels from the brain, through the deep nerves of the pelvis, to the arteries that supply these inflatable tubes. These arteries then open and allow the rush of blood that provides an erection. The veins around the penis then need to close to keep the blood in and prevent the erection from going away.
How does pelvic surgery affect erections?
The nerves that govern erections run right along the backside of the prostate and are densely attached. Completely removing them disrupts the pro-erectile electrical signal that comes from the brain, preventing erections. As a result, many men now undergo what are known as ‘nerve-sparing’ procedures if their anatomy and their cancer allow it. With this approach, these nerves are gently separated from the prostate, leaving them attached, which improves men’s chances of recovering sexual function.
However, even in the most skilled hands, just the peeling-off of these nerves is enough to stun them, and many men will still experience a temporary ‘paralysis’ of these nerves that can take several months to as much as a few years to resolve. This does not affect sensation, but it will prevent men from achieving erections immediately following surgery. This presents a challenge that we must work to overcome.
Like any other muscle in the body, the soft, spongy tissue inside the erection tubes (which contains smooth muscle), requires significant blood flow to stay healthy. In healthy men, this “exercise” is provided by the 3-4 erections most men achieve while sleeping or upon waking up – “morning wood.” These daily erections go away when a man undergoes pelvic surgery. Even if a man’s nerves are spared and are only temporarily ‘paralyzed’, this lack of regular blood flow can cause significant scarring inside the erectile tubes. Like a muscle that you don’t work out, it will shrink – “use it or lose it” is real. Ultimately, this leads to a loss of penile length, a loss of penile girth, and ultimately worse erectile function even if man’s pelvic nerves eventually recover from surgery.
The goal of phase 1 of the Pelvic Prehab Active Roadmap is to exercise and preserve this tissue to keep it as healthy as possible as the pelvic nerves recover from surgery. This gives men their best chance to preserve their natural sexual function.
How can we preserve the erectile tissue while the pelvic nerves recover?
There are three main components to erectile tissue preservation following pelvic surgery:
- Daily use of a vacuum erection device (also known as a VED)
- A daily dose of tadalafil (Cialis) 5 mg – for improving penile blood flow
- A daily dose of 2000mg – 3000mg of L-citrulline – for improving penile blood flow
What is a Vacuum Erection Device (VED)?
A VED is an external pump that a man can use to achieve an erection and an important part of penile rehabilitation following prostate removal.
How does it work?
By creating a seal with the skin and evacuating air from within the cylinder, blood is pulled into the erectile bodies of the penis. This is essentially simulating an erection – bringing in blood flow to the penis to oxygenate the tissues, stretch the chambers, and essentially “exercise” the penis. Regular use of the VED following surgery can help keep a man’s erectile tissues healthy while his nerves are recovering. This helps to reduce the loss of penile length and girth many men report following surgery and minimizes scarring within the erectile bodies caused by lack of regular blood flow.
What are the side effects of the VED?
Bruising
As a result of suction
Discomfort
While first learning how to use it
Brusing is typically mild, but men who are on blood thinning medication (like coumadin, Warfarin, rivaroxaban, Xarelto, clopidogrel or Plavix) may have more severe bruising.
Which VED should I use?
There are many different types and brands of VED. The VED can either be a manual pump or battery powered. Although no particular type or brand of VED has been shown to be superior for penile rehabilitation, battery powered devices are generally preferred as they are quicker and easier for patients to use.
One battery powered device is the Revive manufactured by Encore. Msquared, a local company from Mansfield, Tx, is a distributor of this item. Although more expensive than most manual devices, running about $150, it is well made and the company offers robust patient teaching to ensure each man can use his device effectively. In addition, on the first Friday of every month, we run a Vacuum therapy clinic here in our office, free of charge, where we provide group education on the proper use of the devices. If you are interested in purchasing the Revive device, please call Steve Miller at (214) 850-8519 or visit www.mycromed.com to learn more.
If the Revive device isn’t an option financially, it is much better to purchase a different, more cost-effective device rather than completely forego vacuum therapy following pelvic surgery. A number of manually operated and battery powered devices are available on Amazon for anywhere from $40-$60. Unfortunately, we cannot attest to the quality or reliability of these devices. Please note that due to the different number of available devices on the market, we are unable to offer troubleshooting for each of these different devices.
VEDs are typically not covered by most major insurance companies, but they can often be purchased using funds from a health savings account, also known as an HSA.
What if I’m on blood thinners and can’t use a VED?
For men who are on blood thinning medications and can’t use a VED, we recommend using a penile traction device. These are devices that gently stretch the penis. However, because they don’t utilize suction, bruising is rarely an issue. Although there are many different models, we typically recommend the PeniMaster Pro with the rod extender system or the RestoreX traction device. The PeniMaster Pro with the rod extender system is available at www.penimaster.com while the RestoreX traction device is available at www.restorex.com . We typically recommend the PeniMaster Pro for this application as it tends to be more cost effective than the RestoreX device. Men should apply and wear their device for at least 30 minutes a day, every day. Both the PeniMaster Pro and the RestoreX device come with detailed instructions and we encourage patients to refer to these when using their device.
When should I start my exercises?
Generally, we recommend that patients purchase their VED or traction device and start practicing their exercises as soon as 2 weeks prior to surgery. This allows men to get comfortable with their device as soon as possible. Following surgery, we recommend starting your exercises around 3-4 weeks post-op. That being said, this may not be possible for men who are experiencing significant urinary leakage. We recommend trying to void completely prior to starting your exercises and perform your first few sessions laying flat in bed with your head and shoulders supported by pillows. If you are still leaking, it’s ok to delay starting your exercises until this improves, although we strongly recommend that patients should try to start no later than 2-3 months following surgery. If you are still leaking slightly at this point, you can put some light absorbent material at the end of the cylinder to absorb any urine that leaks (toilet paper, facial tissue or cotton balls all work well and are light enough to not affect vacuum). This will help avoid urine being pulled into the diaphragm which could damage the pump mechanism.
What exercise schedule should I follow with my VED?
We recommend the following exercise regimen. Please note that although portions of these instructions may be specific to the Gesiva Medical VED, this regimen can be replicated with virtually any device.
- Please apply a water-soluble lubricant to the head of your penis, inside the cylinder (about finger length deep), and around the opening/rim of the cylinder (imagine you’re putting toothpaste on a toothbrush).
- Place your penis in the cylinder and give it a slight twist against your body to ‘seat’ the lubricant and ensure an air-tight seal.
- Press and hold the power button (grey button) for 3-5 seconds, then pause for 3-5 seconds and repeat. You will continue to pump in intervals of 3-5 seconds on and 3-5 seconds off until you achieve a full erection. This process usually takes about 1 ½ to 2 minutes. For manually operated devices, you will need to replicate the above process using the hand pump. Fully pump the device until you’ve achieved a full erection.
- Once fully erect, hold the erection in the cylinder for 30 seconds. After 30 seconds, press the release button to release the vacuum. This will allow your erection to come down.
- Please repeat steps 2-4 for 10-15 minutes – the goal is to try to create between 8-12 erections in that time span.
Frequency: We recommend that patient complete the above 10-15 minutes exercise regimen at least once daily for best results. If daily use is not possible, at least every other day usage should be considered.
What is the medication tadalafil (also known as Cialis)?
Tadalafil (the generic name for Cialis) is a medication known as a ‘phosphodiesterase inhibitor’. It is typically prescribed to men with mild erectile dysfunction as a way to boost the chemical pro-erectile signals in the penis. This can allow men with mild erectile dysfunction to achieve erections by improving blood flow to the penis.
In the context of penile rehabilitation, the prescribed daily dose of tadalafil is unlikely to cause regular erections immediately following surgery. Rather, it promotes blood flow to the erectile tissues which can help reduce scarring and shrinkage as the pelvic nerves recover. It should be taken every day leading up to and following surgery, regardless whether or not sexual activity is desired.
Although tadalafil is incredibly safe, it should NOT be taken by men who are also taking ‘nitrate’ containing medications. Some examples of these include nitroglycerine tablets, isosorbide mononitrate, and nitroglycerine patches. If you’re unsure if you’re taking one of these medications, please call our office at (317) 564-5104 to review your medication list before you start taking this medication.
Depending on your insurance, your pharmacy may state that a ‘prior authorization’ is required prior to filling your prescription. Our office does NOT submit prior authorizations for this medication. If your pharmacy tells you this, please download the smartphone app ‘GoodRx’ (www.goodrx.com) and use the provided coupon for an affordable cash price. Your pharmacy can help you with this process. You may need to ask your pharmacy to send the script to a different pharmacy to get the best price (Kroger is typically the cheapest).
Like the VED, we recommend that men start taking their daily tadalafil script as soon as 2 weeks prior to surgery.
What about the supplement L-citrulline?
L-citrulline is a dietary supplement that is readily available over-the-counter and does not require a doctor’s prescription. Similar to the tadalafil mentioned above, it has been shown in studies to boost the chemical pro-erectile signals in the penis, although it does so in a slightly different mechanism. That’s why we recommend that men take L-citrulline in addition to their daily tadalafil.
We recommend a dose of 1500 mg twice daily. Although we do not recommend any particular brand, L-citrulline can be purchased easily from most health food stores or ordered online from Amazon (https://amzn.to/2XJeAAu). As with both the VED and daily tadalafil, we recommend that patients start taking their twice daily L-citrulline as soon as 2 weeks prior to surgery.
Section 2: Bladder and Urine Control Preservation
How does bladder control work and how does prostate surgery affect it?
Bladder control, also known as continence, is the ability to hold urine without leaking. This is mostly controlled by a small muscle known as the urinary sphincter. This muscle wraps around the urine tube, known as the urethra, and squeezes it shut, preventing urine leakage.
The sphincter is very close to the prostate and, as such, can be stressed when the prostate is removed. In addition, the prostate itself helps with urine control. As a result, most men will experience some degree of bladder leakage following prostate removal as the sphincter recovers from surgery and works to control urine flow by itself as the prostate is no longer there to help it.
How can we promote early recovery of bladder and urine control?
The sphincter is a muscle and, like other muscles, gets stronger with regular exercise. The ideal exercises that can help with the recovery of urine control are known as Kegel exercises. These are a type of pelvic contraction that work the sphincter and other pelvic muscles that assist with bladder control. Here’s a step-by-step regimen for performing Kegel exercises:
- Locate your pelvic muscles. Pretend you are trying to avoid passing gas or, when urinating, try to stop your urine stream. If you’ve identified the right muscles, you’ll feel the contraction more in the back of the pelvic area than the front.
- Choose your position. Start by lying on your back until you get the feel of contracting the pelvic floor muscles. When you have the hang of it, practice while sitting and standing.
- Work on contracting while relaxing your other muscles. Contract your pelvic floor muscles for 3-5 seconds. Relax for 3-5 seconds. Repeat the contract/relax cycle 10 times. Don’t contract your abdominal, leg, or buttock muscles, or lift your pelvis. Place a hand gently on your belly to detect unwanted abdominal action.
- Extend the time. Gradually increase the length of contractions and relaxations. Work your way up to 10-second contractions and relaxations.
- Aim high. Try to do at least 30 to 40 Kegel exercises every day. Spreading them throughout the day is better than doing them all at once. Since these are stealth exercises that nobody notices except you, try to sneak in a few when waiting at a stoplight, riding an elevator, or standing in a grocery line.
- Diversify. Practice short, 2 to 3 second contractions and releases (sometimes called “quick flicks”) as well as longer ones.
- Kegel exercises in an emergency. After surgery, if you leak urine when you cough, sneeze, laugh, bend over or lift something heavy (known as stress incontinence), doing one or more Kegels before a ‘trigger’ may be enough to prevent any leakage. If you have the urge to urinate and doubt you are going to make it to the toilet, doing Kegels may get you safely to a restroom.
As with our other interventions, we recommend that men start practicing their Kegel exercises as soon as 2 weeks prior to surgery and resume them once more after their catheter has been removed.
Conclusion
That’s it! Those are the key exercises and interventions for both erectile and bladder/urine control preservation. Although complete recovery is never guaranteed, these practices give men their best chance possible at recovery following pelvic surgery. Learn more about Phase 2 (Perform) and Phase 3 (Prevail) of the Pelvic Rehab Restoration Roadmap by clicking the following buttons:
If you ever have any questions or concerns about anything discussed above, please don’t hesitate to call us at (866) 367-8768.