Justification of vacuum prophylaxis as part of the penile rehabilitation in patients after nerve-sparing radical prostatectomy

Introduction. In healthy men, a significant increase in pO2 in the cavernous tissue occurs during episodes of nocturnal erections. This process ensures sufficient oxygenation and high-pressure substances such as prostaglandin-E1 and nitric oxide. These substances suppress the expression of transforming growth factor β1, thereby preventing collagen synthesis and the development of cavernous fibrosis. In patients undergoing nerve-sparing radical prostatectomy, nocturnal erections are absent, hypoxia inhibits the production of PGE-i, and neuropraxia inhibits NO. Thus, cavernous fibrosis develops through the production of pro-apoptotic and profibrotic factors, resulting in persistent erectile dysfunction. The importance of a vacuum in penile rehabilitation for the prevention of penile cavernous hypoxia is not fully understood. This is due to the deficiency of data on the gas composition of cavernous blood when a vacuum-induced erection is achieved.Purpose of the study. To investigate the cavernous blood at the time of vacuum-induced erection, to analyze the obtained results with the International Index of Erectile Function score and with the values of penile hemodynamics.Materials and methods. The study included i5 patients with prostate cancer and preserved sexual function. The average age of all men was 57.87 ±4.36 years. All patients underwent a preoperative comprehensive assessment of erectile function: International Index of Erectile Function questionnaire, dynamic duplex penile ultrasound. Immediately prior to the surgery, penile blood was collected at the time of achieving a vacuum-induced erection. The gas composition and oxygenation were assessed using the values of the partial oxygen pressure, carbon dioxide and saturation in accordance with the approved standards to differentiate arterial and venous blood. Statistical data processing was carried out using the PASW Statistics 22 software (IBM SPSS, IBM Corp., Chicago, IL, USA)Results. All patients were divided into 3 groups depending on the gas composition and oxygen level of the cavernous blood. Group I included 4 (26.6%) patients with a predominance of arterial blood, group II — 4 patients (26.6%) with venous blood and group III — 7 patients (46.6%) with a mixed composition of cavernous blood. The average International Index of Erectile Function score in group I was 23.5 [2i.0; 25.0], in group II — 22.0 [2i.0; 24.0] and in group III — 24.0 [i9.0; 25.0]. Peak systolic velocity (cm/s) in group I was 40.i [35.i; 45.2], in group II — 35.9 [29.5; 50.2], in group III — 32.5 [32.5; 34.4]. End-diastolic velocity (cm/s) in group I was 2.52 [0.55; i0.5], in group II — 8.3 [2.9; i0.8], in group III — 7.5 [7.5; 9.0]. Resistive index in group I was 0.87 [0.77; 0.98], in group II — 0.75 [0.63; 0.94], in group III — 0.75 [0.73; 0.75].Conclusions. Vacuum prophylaxis may be the method of choice for penile rehabilitation in patients after nerve-sparing radical prostateectomy, especially in the early postoperative period during neuropraxia. The use of vacuum devices should be prescribed to patients with preserved veno-occlusive mechanism, which should be confirmed by dynamic duplex penile ultrasound.

Penile rehabilitation in patients after radical prostatectomy

Introduction. Prostate cancer (PCa) is one of the most common cancers in men. Radical prostatectomy (RP) is one of the main treatment modalities for localized PCa. Erectile dysfunction (ED), being a consequence of surgical treatment, can have detrimental effects on both physical health and psychosocial status and significantly impair the quality of life of patients and their partners. The risk of ED in the postoperative period in patients undergoing RP, according to the modern literature, is about 60–70%. Materials and methods. The paper describes in detail the pathogenesis of ED after RP. The main components of penile rehabilitation (PR) and their mechanism of action are described, literature data confirming their effectiveness is presented. Results. Currently, after nerve-sparing radical prostatectomy, the following penile rehabilitation methods are used - the use of inhibitors of PDE-5 type, shock wave therapy, vacuum erection therapy (VED), intracavernous injections, penile prosthetics and a combination of these methods. Combined rehabilitation programs promote EF recovery after RP with better results compared to monotherapy. Conclusion. We see a perspective in the development of combined approach strategies for the rehabilitation of erectile funktion (EF) after RP. Further improvement of the surgical technique of nerve-sparing RP, as well as a deeper understanding of the implementation of the postoperative process is crucial to develop an algorithm for the EF restoration program.

Couples Coping with Prostate Cancer: Women and Men (Re)Negotiating Discourse of Gender, Sexuality and Intimate Relationships

This dissertation project investigates the ways in which men and their female partners navigate discourses of sex, gender, and relationships as they cope with recovery from prostate cancer and engage in penile/sexual rehabilitation. Study I involves a discourse analysis of online patient information sources for prostate cancer-related penile/sexual rehabilitation with a focus on how sex, erections, gender, patients, and relationships are depicted. Study II involves discourse analysis of in-depth interviews with prostate cancer survivors, female partners of men with prostate cancer, and couples, to explore the social norms and collective meanings they adopt when speaking about sex, their identity as a man/woman, recovery, and relationships. Analyses also explore discursive points of connection and discordance between the two studies. Penile rehabilitation is positioned in both studies as a medical imperative through close alignment with scientific empiricism. Sexual side effects (e.g., changes in erections) are framed in biomedical and mechanical terms, and penile rehabilitation is presented as a scientific and effective solution. Both Study I and Study II convey that one’s health and recovery are largely individual responsibilities. Ideal patients are framed as entrepreneurial, responsible, and informed in Study I, and Study II participants largely adopt these discourses. Online information sources situate sexuality within the realm of health and medicine so that changes in erections are positioned as medical issues best resolved using the expertise of medical specialists. The findings from Study II, however, challenge a purely biomedical or health-focused approach to erections. Many patients emphasize the relational and psychological aspects of sex and the inability of pro-erectile interventions to adequately address the injuries caused by prostate cancer treatment. Online materials from Study I reinforce narrowly defined views of masculinity/femininity and (hetero)sexuality. Masculinity and femininity are framed as complementary and distinct opposites, and intercourse is positioned as an essential sexual practice. Many participants frame prostate cancer as a major disruption to successful gender performance and to the sexual status quo. A number of participants resist medicalized/healthisized discourses of sex, and hegemonic masculine subjectivities. They espouse alternative definitions of what it means to be a lover and man/woman. Implications and recommendations are discussed.

Couples Coping with Prostate Cancer: Women and Men (Re)Negotiating Discourse of Gender, Sexuality and Intimate Relationships

This dissertation project investigates the ways in which men and their female partners navigate discourses of sex, gender, and relationships as they cope with recovery from prostate cancer and engage in penile/sexual rehabilitation. Study I involves a discourse analysis of online patient information sources for prostate cancer-related penile/sexual rehabilitation with a focus on how sex, erections, gender, patients, and relationships are depicted. Study II involves discourse analysis of in-depth interviews with prostate cancer survivors, female partners of men with prostate cancer, and couples, to explore the social norms and collective meanings they adopt when speaking about sex, their identity as a man/woman, recovery, and relationships. Analyses also explore discursive points of connection and discordance between the two studies. Penile rehabilitation is positioned in both studies as a medical imperative through close alignment with scientific empiricism. Sexual side effects (e.g., changes in erections) are framed in biomedical and mechanical terms, and penile rehabilitation is presented as a scientific and effective solution. Both Study I and Study II convey that one’s health and recovery are largely individual responsibilities. Ideal patients are framed as entrepreneurial, responsible, and informed in Study I, and Study II participants largely adopt these discourses. Online information sources situate sexuality within the realm of health and medicine so that changes in erections are positioned as medical issues best resolved using the expertise of medical specialists. The findings from Study II, however, challenge a purely biomedical or health-focused approach to erections. Many patients emphasize the relational and psychological aspects of sex and the inability of pro-erectile interventions to adequately address the injuries caused by prostate cancer treatment. Online materials from Study I reinforce narrowly defined views of masculinity/femininity and (hetero)sexuality. Masculinity and femininity are framed as complementary and distinct opposites, and intercourse is positioned as an essential sexual practice. Many participants frame prostate cancer as a major disruption to successful gender performance and to the sexual status quo. A number of participants resist medicalized/healthisized discourses of sex, and hegemonic masculine subjectivities. They espouse alternative definitions of what it means to be a lover and man/woman. Implications and recommendations are discussed.

Erectile dysfunction and penile rehabilitation after pelvic fracture: a systematic review and meta-analysis

ObjectiveTo investigate the rate of erectile dysfunction (ED) after pelvic ring fracture (PRF).DesignSystematic review and meta-analysis.MethodsA systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus and Web of Science Library databases was conducted in January 2020. Included were original studies performed on humans assessing ED after PRF according to the 5-item International Index of Erectile Function (IIEF-5) questionnaire and fracture classification following Young and Burgess, Tile or Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association. Furthermore, interventional cohort studies assessing the effect of penile rehabilitation therapy with phosphodiesterase-5-inhibitors (PDE-5-I) on IIEF-5 scores compared before and after treatment were included. Results were presented as forest plots of proportions of patients with ED after PRF or mean changes on IIEF-5 questionnaires before and after penile rehabilitation. Studies not included in the quantitative analysis were narratively summarised. Risk of bias assessment was conducted using the revised tool for the Quality Assessment on Diagnostic Accuracy Studies.ResultsThe systematic literature search retrieved 617 articles. Seven articles were included in the qualitative analysis and the meta-analysis. Pooled proportions revealed 37% of patients with ED after suffering any form of PRF (result on probability scale pr=0.37, 95% CI: 0.26 to 0.50). Patients after 3 months of penile rehabilitation therapy reported a higher IIEF-5 score than before (change score=6.5 points, 95% CI: 2.54 to 10.46, p value=0.0013).ConclusionDespite some heterogeneity and limited high-quality research, this study concludes that patients suffering from any type of PRF have an increased risk of developing ED. Oral intake of PDE-5-I for the purpose of penile rehabilitation therapy increases IIEF-5 scores and may relevantly influence quality-of-life in these patients.PROSPERO registration numberCRD42020169699.