Penile rehabilitation refers to the use of scheduled therapies before, during, or upon completion of prostate cancer (PCa) treatment with the goal of enhancing erectile function recovery (EFR).¹ This includes pharmacologic options, such as phosphodiesterase 5 inhibitors (PDE5i) and intracavernosal injections (ICI), and nonpharmacologic options, such as a vacuum erection device. Rehab differs from on-demand treatment for erectile dysfunction because these scheduled therapies are used to provide regular physiologic stimulation of the penis.¹ Most of the literature on penile rehab focuses on radical prostatectomy (RP) patients, so that will be the focus of this article as well.

Penile rehab is commonly used. A survey of members of the International Society of Sexual Medicine showed that 87% were performing penile rehab. Those who weren’t cited cost as the most common reason.² A similar survey in the AUA noted 86% of urologists were using rehab for their patients. Most started after Foley removal and continued for 12 to 18 months post-RP.³ The most common regimen was PDE5i daily or 3 times a week.⁴

To understand the complexities of penile rehab data, one must first understand the limitations in the EFR literature. Rates of EFR vary widely from 20% to 90%. These discrepancies can be explained in part due to different patient populations, surgical factors, methods of assessing erections, and the definition of EFR.³ Patient factors include age, comorbidities, and baseline erectile function (EF), while surgical factors include operative approach, surgeon experience, and nerve-sparing status. Methods of assessment range from patient-reported, use of a numeric erectile hardness scale to judge rigidity, or questionnaires, the most common being the International Index of Erectile Function. With regard to the definition of EFR, there are dozens of different definitions used, and about one-third of papers don’t declare how they define recovery.^5,6 The data are further complicated by the fact that many studies fail to monitor compliance with rehab, don’t account for consistency of response, and don’t distinguish whether EF is reported with or without PDE5i or ICI.³ These factors make it difficult to compare results across studies. One meta-analysis selected only studies with ≥ 50 men who had normal EF at baseline, RP as a monotherapy, and ≥ 12-month follow-up. Twenty-two studies and nearly 5000 men were included with an overall EFR rate of 58%. Patient factors predicting recovery included robotic approach, bilateral nerve-sparing surgery, and age < 60 years old.³

Given the limitations in the EFR literature, it is unsurprising that the data on penile rehab are mixed. While there have been numerous reviews of the topic, there have been 2 high-quality sets of guidelines published by medical societies that deserve special mention. The first was written by the International Consultation of Sexual Medicine (ICSM). They include the following statements: “There are conflicting data as to whether penile rehabilitation with phosphodiesterase type 5 inhibitors improves recovery of spontaneous erections” and “The data are inadequate to support any specific regimen as optimal for penile rehabilitation.”^7,8 The ICSM goes on to state that any use of PDE5i, whether for rehab or on-demand, is better than no intervention. They also recommend establishing baseline evaluation, discussing erectile dysfunction risk with all patients pre-RP and using validated questionnaires to assess EF.^7,8

More recently, the True Nth (pronounced True North) guidelines were published. While this is a comprehensive discussion of all sexual side effects of PCa treatment, there are 5 guideline statements specifically addressing the efficacy of penile rehab. The first is similar to the ICSM guideline and includes “Penile rehabilitation should not be equated with treatment for the recovery of unassisted erectile function.” The next guideline states, “Use of [PDE5i] for penile rehabilitation in the early postprostatectomy period (up to 45 days post surgery) does not improve rates of unassisted and PDE5i-assisted EFR at 12 months compared to placebo.”¹ Additional statements endorse that there is insufficient evidence regarding non-PDE5i forms of rehab, the role of rehab in mitigating penile volume loss, and rehab in men after radiation therapy.¹

While the data fail to show a significant improvement in EFR with penile rehab, there are significant limitations to these data, as discussed previously. Rehab is still recommended to be offered to all patients, and it is commonly used. This is because the benefits of rehab vastly outweigh the cons. Given the data limitations, all we can say definitively is that rehab may be beneficial, both in terms of improving EFR and mitigating penile volume loss.¹ However, there is a tremendous psychological benefit to rehab that isn’t captured in studies using EFR as an end point. Engaging in rehab empowers men and enables them to have a more active role in their recovery.^1,9 Men participating in rehab generally attempt sex sooner after treatment and discuss sex more with their partners and providers. The reasons for not participating in rehab are few. While costs were historically a factor,⁹ PDE5i are now available in generic formulations, and ICI medications can be purchased from compounding pharmacies at low costs. Additionally, the time commitment of using PDE5i or ICI is minimal. While there can be side effects from these treatments, they are generally mild.¹

It’s clear that high-quality evidence is needed to fully understand the benefits of penile rehab. Future research should include baseline EF and assess EF using validated questionnaires. Men should answer based on spontaneous erections vs PDE5i- or ICI-assisted. Compliance with rehab must be assessed. Studies should also account for partial nerve sparing. Most simply categorize patients into nonnerve sparing vs unilateral vs bilateral nerve sparing. However, it is possible to partially resect the nerves, and this is rarely presented in the literature. Clinical recommendations are similar. Providers should establish baseline function, discuss sexual side effects with patients prior to PCa treatment, and use validated questionnaires. All men should be offered rehab prior to treatment. Hopefully, by continuing to provide rehab and presenting the data in a more rigorous fashion, we can better understand its utility in the future.

Disclaimer: The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense, or the US Government. The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.