Ep. 51 Management of Post-Prostatectomy Erectile Dysfunction with Dr. Darshan Patel and Dr. Mike Hsieh

In this episode of BackTable Urology, Dr. Bagrodia discusses erectile dysfunction (ED) in the setting of post-prostate cancer treatment with Dr. Mike Hsieh and Dr. Darshan Patel, two urologists from the comprehensive men’s health clinic at UC San Diego Health.

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SHOW NOTES

First, the doctors explain their typical workup of post-prostatectomy patients. They widely use questionnaires, especially the Sexual Health Inventory for Men Score (SHIM Score) to coordinate with oncology colleagues and keep their ED assessments standardized. Because ED treatment should be tailored to the goals and expectations of each patient, taking a thorough social history is also important. Both doctors concede that robotic surgery has improved post-procedure urinary symptoms but emphasize that not many therapies are able to lower the rate of ED as a post-operative complication. Additionally, a combination of radiation and androgen-deprivation therapy can lower libido. For this reason, an early sexual function rehabilitation approach is important. Dr. Hsieh equally prioritizes both goals of resolving a patient’s prostate cancer and preventing postoperative incontinence and sexual dysfunction.

There are many ED therapies available for prostate cancer survivors. Patients can be started on a vacuum erection device and low dose of PDE5 inhibitor (Cialis, Tadalafil) even before their prostatectomy procedures. Dr. Patel notes that timing of the PDE5 inhibitor is one of the most important factors to consider in penile rehabilitation. Vacuum erection devices are viable options to preserve penile size for single patients or patients who are not having sex. Next, the doctors discuss injection therapy. Dr. Hsieh and Dr. Patel usually show patients how to inject the first dose of Trimex in the office and advise patients against making big dosage jumps to prevent the development of priapism. Dr. Bagrodia mentions that pelvic floor physical therapy and sex counseling as good non-invasive and non-pharmacological options as well. Finally, the doctors discuss less common penile rehabilitation therapies, such as hyperbaric oxygen and shockwave therapy.

Lastly, they discuss how to manage patient expectations. Although early spontaneous erection and fullness is a good sign of recovery, the urologist should set three-, six-, and nine-month milestones for their patients. Usually, 80% to 90% of patients usually graduate from therapy within a year of their prostatectomy, and it is beneficial to use as many non-surgical options as possible to regain erectile function at first.