Getting back erection for such a patient is called Penile Rehabilitation Therapy, PRT.

TREATMENT OPTIONS ARE

I
Giving daily medicines is one method of treatment hoping to bring recovery in the damaged smooth muscle tissue.
II
Giving medicine as required before sexual intercourse is another treatment option. Though both these methods, (1) giving medicines daily and (2) giving medicines only before sexual intercourse, not daily have been studied scientifically and debated hugely for the last 10 years, no definite conclusion is arrived about which is the better or correct method to lessen or reverse the damage caused by radical prostatectomy.

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What medicines have been used to treat Erectile Dysfunctions following radical prostatectomy?

[1] Oral PDE – 5 inhibitors medicines such as Sildenafil, Vardenafil, Tadalafil
[2] Intracavernous injection of Vaso Active Drugs (drugs like papaverine), ICIVAD.
[3] Intraurethral alprostadil administration MUSE

How was the treatment efficacy measured?

• IIEF-5 validated Questionnaire
• Rigiscan testing
• Nocturnal Penile Tumescence and Rigidity (NPTR) testing
• Percutaneous penile biopsies
• rat model to test
  • penile shaft collagen content
  • functional and histologic changes in the penis

Note
While there have been many studies in the rat model showing the benefits of local vasoactive therapies, the crossover to clinical significance in the human has been more difficult to prove.

Ideally the tests should be carried out before and after the surgical procedure.

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What is the mechanism of ED that follows RP?

• Primary Neurogenic Damage (Nerve Damage) (despite meticulous nerve sparing surgery)

  [3] Klien et al were the first to show (in rat model) nerve damage causes penile apoptosis (atrophy and fibrosis)
  [4] In 2003, User and McVary etal demonstrated this.

• Secondary Smooth muscle atrophy is the underlying cause of
  • penile atrophy,
  • veno-occlusive dysfunction, and
  • fibrosis.

First study showing benefit with ICIVAD came in 1997 from F. Montorsi, G. G. Luigi, L. F. Strambi, et al., [1]

By performing percutaneous penile biopsies at the time of RP and 6 months later, Schwartz et al. were the first to demonstrate that early use of 100 mg of sildenafil after RP may preserve intracorporeal smooth muscle content

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Mechanism: How PDE – 5 benefit in recovering penile tissue damage?

PDE-5 inhibitors promote penile rehabilitation by stimulating smooth muscle cell replacement via a cGMP mechanism and reducing collagen synthesis via phosphokinase G activation

Which is better regular daily vasoactive medicine or medicine on demand before sexual intercourse?

The benefits of regular daily PDE 5 over before Sexual Intercourse is not confirmed according to abstract presented at 2006 annual meeting [5] of the American Urological Association by the same Dr. Montorsi who in 1997 published first study on benefit of Intracorporal alprostadil Injection.
No significant difference was found in the mean IIEF score between patients treated with daily therapy versus on demand therapy.

[6] A. Bannowsky et al from Germany concluded in 2008 that in cases of early penile erection, daily low-dose sildenafil leads to a significant improvement in the recovery of erectile function.

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[7] Montorsi et al recently did the largest randomized, double-blind, double-dummy, multicenter, parallel study done to date. Montorsi et al. recently reported on a vardenafil trial after bilateral nerve-sparing RP that on demand dosing is more effective in improving both erectile function and sexual intercourse completion rates within this patient population prompts reconsideration of the current practice of prescribing nightly PDE 5 inhibitor therapy, as on demand use of vardenafil if equally effective in men with ED following NSRP.

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Interesting story

HOW MEDICAL RESEARCH IS DONE?

Medical Research is not a sacrosanct declaration by a God man to be followed without questioning for centuries.
Interestingly powerful arguments have been put forth concluding that damaged penis (chronic hypoxia = continued lack of oxygen and ischemia lack of blood supply) cannot be reversed. Abraham Morgentaler from Harvard University listed several intriguing arguments [8].

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WHY CLAIMS OF RESTORING TISSUE DAMAGE BY VASOACTIVE MEDICINES ARE INCORRECT

First, he questioned the theory that penile rehabilitation helps to reverse the chronic hypoxia and ischemia of the flaccid penis following RP.

“But why is there reason to suspect that the flaccid penis is hypoxic, despite having venous oxygen tension? After all, the endothelium of all venous structures suffers no ill effects despite a lifetime of exposure to oxygen levels that are well below those seen in arterial blood.

Second, there is no reason to believe that the penis is ischemic following RP. If it were ischemic, would it not eventually become necrotic?

Furthermore, PDE-5 inhibitors do not increase blood flow to the flaccid penis, so how can benefit occur?”

[9] In a more recent point-counterpoint debate at the 2008 AUA Annual Meeting in Orlando, Fla, Craig Donatucci from Duke University was charged with providing the contrary argument as whether penile rehabilitation was effective after RP.

Craig described the pitfalls of the clinical trials that have been presented thus far.

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WE CONCLUDE

with what CRAIG DONATUCCI from Duke University stated in 2008:
“There is not yet enough evidence to declare penile rehabilitation effective; but I am not sufficiently convinced of the ineffectiveness of penile rehabilitation to recommend against it. My opinion is that the benefits of penile rehabilitation are “not proven”; yet it is currently the standard of care”.

[10] This is a review of
Penile Rehabilitation Therapy with PDE-V Inhibitors Following Radical Prostatectomy: Proceed with Caution by
M. Eric Brewer Jr. and Edward D. Kim

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REFERENCES

[1]
F. Montorsi, G. G. Luigi, L. F. Strambi, et al., “Recovery of spontaneous erectile function after nervesparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial,”
The Journal of Urology, vol. 158, no. 4, pp. 1408–1410, 1997.

[2]
E. J. Schwartz, P. Wong, and R. J. Graydon, “Sildenafil preserves intracorporeal smooth muscle after radical retropubic prostatectomy,”
The Journal of Urology, vol. 171, no. 2, part 1, pp. 771–774, 2004.

[3]
L. T. Klein, M. I. Miller, R. Buttyan, et al., “Apoptosis in the rat penis after penile denervation,” The Journal of Urology, vol. 158, no. 2, pp. 626–630, 1997.

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[4]
H. M. User, J. H. Hairston, D. J. Zelner, K. E. McKenna, and K. T. McVary, “Penile weight and cell subtype specific changes in a post-radical prostatectomy model of erectile dysfunction,” The Journal of Urology, vol. 169, no. 3, pp. 1175–1179, 2003.

[5]
F. Montorsi, A. Salonia, A. Gallina, et al., “There is no significant difference between on-demand PDE5-I vs PDE5-I as rehabilitative treatment in patients treated by bilateral nerve-sparing radical prostatectomy,” The Journal of Urology, vol. 175, p. S225, 2006.

[6]
A. Bannowsky, H. Schulze, C. van der Horst, S. Hautmann, and K.-P. Jünemann, “Recovery of erectile function after nerve-sparing radical prostatectomy: improvement with nightly low-dose sildenafil,” BJU International, vol. 101, no. 10, pp. 1279–1283, 2008.

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[7]
F. Montorsi, G. Brock, J. Lee, et al., “Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy,” European Urology, vol. 54, no. 4, pp. 924–931, 2008.

[8]
J. P. Mulhall and A. Morgentaler, “Penile rehabilitation should become the norm for radical prostatectomy patients,” The Journal of Sexual Medicine, vol. 4, no. 3, pp. 538–543, 2007.

[9]

J. P. Mulhall and C. Donatucci, “Is penile rehabilitation effective in improving erectile function after radical prostatectomy? Point-counterpoint debate,” in Proceedings of the American Urological Association Annual Meeting, Orlando, Fla, USA, May 2008.

[10]
Advances in Urology
Volume 2009 (2009), Article ID 852437, 4 pages
doi:10.1155/2009/852437

Review Article
Penile Rehabilitation Therapy with PDE-V Inhibitors Following Radical Prostatectomy: Proceed with Caution
M. Eric Brewer Jr. and Edward D. Kim
Graduate School of Medicine,
The University of Tennessee, Knoxville, TN 37920, USA

Received 19 June 2008; Revised 20 October 2008; Accepted 15 December 2008

Recommended by David F. Penson
Advances in Urology, vol. 2009, Article ID 852437, 4 pages, 2009. doi:10.1155/2009/852437

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• What is Vacuum Device?
• What does Vacuum Device look like?
• How does Vacuum Device work?
• What is the method of using Vacuum Device?
• Who should consider using Vacuum Device?
• What side effects can happen?
• Who should not use Vacuum Device?
• Technical Details
• Where not to buy?
• What is the price?
• Is it covered under Insurance?
• Further reading

VACUUM CONSTRICTION DEVICE(VD) is a small handy apparatus that consists of:
(1) There is a cylinder to place over the penis.
(2) There is mechanism to create negative pressure.
(3) A constriction ring/band is applied to the base of the penis to prevent back flow of blood.
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ENSURE that the instrument you are using is FDA approved so that you will not harm your penis.

First use is recommended in the Doctor’s office.

HOW DOES IT WORK – MECHANISM

Vacuum or negative pressure is created over the penis. A constriction band is applied at the base of the penis.
–>
The penis becomes hard and sexual intercourse can be done satisfactorily.
–>
Then remove the constriction band. The erection will disappear.

Creating vacuum is the opposite of what is done when Doctor uses sphygmo manometer – that is – Blood Pressure Measuring Device. For measuring Blood Pressure doctor pumps in to build pressure, whereas in Vacuum Device pumping creates negative pressure to suck blood in the penis.

The pump mechanism can be in the form of either a manually operated or a battery-operated system

The battery-operated device can be used with one hand. In this system, the trigger mechanism is on the top end of the cylinder and thus one hand can activate the pump and steady the cylinder at the same time. This is an important consideration for patients with poor manual dexterity or strength, such as men with Parkinson’s disease or rheumatoid arthritis.
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Note:
All FDA approved cylinders have pop-off valves, which limit the amount of pressure held within the chamber.

HOW TO USE VACUUM DEVICE

TECHNIQUE
1]
Water-soluble jelly is applied to the base of the penis. This maneuver prevents air from seeping into the chamber, by creating a water-tight seal, thus maintaining the negative pressure within the cylinder. Some men may find that trimming the pubic hair may aid achieving this water-tight seal.

2]
Place the cylinder over the penile shaft and hold firmly against the pubic bone. Use the pump either by hand or battery.
Let the negative pressure develop slowly. This prevents penile pain due to too rapid a build-up of pressure within the cylinder. The negative pressure causes an inflow of blood into the corporal bodies, both arterial and venous in nature. The latter blood is drawn into the erectile chambers in a retrograde fashion.
3]
Once the erection has been achieved, a constriction ring (band) must be applied to the base of the penis to act as an artificial valve, thus maintaining the blood within the corporal bodies. The rings come in a variety of shapes, sizes, and most importantly tension (tightness). Trial and error is used to define which ring size is most comfortable and efficient. Most manufacturers suggest that the constriction ring remain in place for no longer than 30 minutes. Once the ring is in place the plastic cylinder can be removed and sexual relations may commence.
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WHO CAN BENEFIT WITH VACUUM DEVICE

People with Erectile Dysfunction

1. who do not prefer oral medication or are advised against taking PGE 5 inhibitors (Sildenafil, Tadalafil, Vardenafil, Udenafil)
2. People with Erectile Dysfunction (ED) due to Diabetes, Depression, Other Medical Illness.

3. People with surgery for prostrate or colon cancer.

WHAT NOT TO FEAR

A black and blue mark or small area of bruising on the shaft of the penis. This is usually painless and generally will resolve in a few days.

Semen will not spurt out. Ejaculation will be oozing of semen. When the constriction band is removed all semen leaks out. The pleasure or orgasm is same. Does not harm sperms in the semen.
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WHO SHOULD NOT USE VACUUM DEVICE (VD)

1
Patients who have reduced sensation in their penis, as those who have spinal cord injury. They are at risk for trauma with repeated use of the constriction band. They should apply the ring for only short periods of time.

2
Men with significant degree of curvature of penis as those with Peyronie’s disease (acquired penile curvature) or congenital penile curvature.
Reason: The straight cylinder may exert significant stress on the curved penis resulting in trauma to the already bent shaft of the penis.

3
(i)
Patients with hematologic forms of venocclusive priapism (sickle cell disease, thalassemia, or leukemia) should not use a vacuum device under any circumstances.
(ii)
Men who are using blood-thinners or have a history of bleeding disorders.
(iii)
Anticoagulant therapy may cause the patient to develop bruising and swelling in the penis due to rupture of the superficial veins on the shaft of the penis (this can happen in normal men as well, but body repairs it) resulting from the constriction ring.
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DETAILS

• This pressure is approximately 200-250 mmHg.

• The surface temperature of the penis during use of VD is 1⁰C lower than the temperature prior to application of the device because of constriction of blood vessels.

• The average man using such a device will typically take 10-20 minutes to obtain a significant erection of penetration rigidity.

Warning

If you fall a prey to advertisements that claim to increase the size of the penis or to give super power erection you may be buying ‘penis developer’. Penis developer work with the same principle as vacuum device, but are not standardized for safety. Your penis is at risk of excessive pressure that can cause temporarily or permanently damage. Often these devices can be obtained through mail order via internet.

PRICE

$300 to $ 500
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GOOD NEWS

Most insurance policies, including Medicare, cover at least part of the costs of a vacuum constriction device, especially if a medical cause for ED has been documented. Medicaid, however, does not cover the device.
copyright ©

http://www.medicinenet.com/penis_prosthesis/page2.htm

Source
Courtesy:
http://www.cornellurology.com/sexualmedicine/ed/vacuum.shtml

The Cleveland Clinic Taussig Cancer Center.
Edited by John M. Baird, FACS, MD, January 1, 2007.
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Reading 1 Marmar JL. Vacuum constriction devices. In W.J.G. Hellstrom (ed), Male Infertility And Sexual Dysfunction. Springer Verlag, New York, pp 409, 1997.
2 Bosshardt BJ et al. Objective measurement of the effectiveness, therapeutic success and dynamic mechanisms of the vacuum erection device. British Journal of Urology. 75:786, 1995
3 Katz PG et al. The effect of vacuum devices on penile hemodynamics. Journal of Urology. 143:55, 1990
4 Sidi AA et al. Patient acceptance of and satisfaction with an external negative pressure device for impotence. Journal of Urology. 144:1154, 1990
5 Bataci S et al. Treating erectile dysfunction with a vacuum tumescence device: a retrospective analysis of acceptance and satisfaction. British Journal of Urology. 76:757. 1995
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---

2009 copyright © creative commons
Free to use, modify for non commercial, educational purpose. Attribution required.

Wrong Diagnosis Of Male Sex Problems

• Premature Ejaculation,
• Penis is not as stiff as it used to be,
• Erectile Dysfunction,
• Impotence,
• Looses Erection just at the time of insertion,
• Small Size of Penis,
• Decreased Sexual Desire.

I am not able to satisfy my wife sexually.
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Ask him -THIS IS IMPORTANT-if he is newly married.

Newly wed man says because of above mentioned sex problem, that is because of his Erectile Dysfunction (Poor stiffness/hard on in penis), he has not been able to do sexual intercourse.

“I loose my erection even before I can penetrate.”

Ask him -THIS IS IMPORTANT- if complete insertion of penis in vagina has happened . Even after months or years of wedding the marriage can be unconsummated. Wrong diagnosis can wreck the boy’s self esteem.
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DEPRESSION IN MAN WHO IS NEWLY WED
You will also discover symptoms of depression in this young man. He does not feel fresh when he wakes up in the morning. The whole day while at work he has to push himself to do the work. Before discovery of his inability to insert his enthusiasm during the whole day used to be high such that he could take up many activities. Now he tends to procrastinate, delegate, avoid work. Check this: HEALTHMETER®

Wrong diagnosis

of
Premature Ejaculation, Erectile Dysfunction, Impotence, Small Size of Penis is not uncommon in Newly Wed Male.
During honey moon or from the first sexual intercourse itself insertion (I am not using the word ‘penetration’***) of penis in vagina has never happened.

WHY WRONG DIAGNOSIS
The penis is visible and changes in size during erection and after ejaculation. Penis is the passenger. Vagina is the passage. There could be some difficulty in the passage goes unnoticed. This typically happens in vaginismus.

Simple way to check vaginismus
Find if her own or her husband’s one finger can go inside her vagina. If it pains, if it cannot go easily the diagnosis is vaginismus.

The fear and pain while attempting insertion of finger or penis is so evident that even Gynecologic Examination is unnecessary.

You will also discover that she cannot or will not use a tampon (o.b.tampon® Johnson & Johnson’s). Tampon serves the same purpose as sanitary napkins, which are worn during menses. Tampons are to be inserted inside the vagina.

In treatment I incorporate Finger Exercise.

I have not found necessary to send even a single woman for Per Vaginal, Per Speculum Examination (PV, PS) to Obstetrician Gynecologist.
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TREATMENT METHODS FOR VAGINISMUS
How Dildo helps in treatment: The diameter of dildo is gradually increased till it corresponds to diameter of erect penis (Dildo is penis sized and is shaped like penis. It is not sharp, but round and blunt so that it will not hurt the vaginal mucosa)

I have not found necessary the use of applicator or dildo that a woman is supposed to insert and keep in her vagina for some time for the purpose of treatment of unconsummated marriage due to vaginismus.

How and why of Fenton’s Operation for treatment of vaginismus?
In the past Fenton’s Operation was done as treatment of vaginismus.

Cruciate incision was taken at the vaginal orifice to increase the dimension of vaginal opening.
This operation is out dated because the dynamics of vaginismus is unaltered.

WHAT HAPPENS IN VAGINISMUS
In vaginismus there is subconscious, sudden contraction of pubococcygeous muscles at the time of insertion in vagina. It is a vagina in panic, screaming “NO ENTRY!”.

WHY THE OPERATION FAILS
Operation does not prevent the instantaneous, involuntary tightening of the pelvic floor muscles due to fear in anticipation of vaginal penetration. This reaction will occur if she expects pain during penetration (often even before attempting it!).
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SUMMARY
Erectile Dysfunction,
Stiffness is less,
Hard on not as before,
Diminished Sexual Desire,
Premature Ejaculation,
Penis is small in size,
kamjoori
ALL these
male sexual problems are wrongly diagnosed in Newly Wed Man who is not able to penetrate (Penis could not be inserted in vagina) during sexual intercourse.
ROOT CAUSE VAGINISMUS
The condition where couple during sexual intercourse are not able to accomplish insertion of penis in vagina is called UNCONSUMMATED sex.

***Penetration
In peno-vaginal Sexual Intercourse, why the word ‘Insertion’ is preferred instead of ‘Penetration’ (As in Penetrative Sex)?

My senior colleague, eminent Dr. J. V. Bhatt, who was Dean of Medical College in the University of Mumbai remarks, “Penetration sounds harsh, forceful. Whereas Insertion indicates easily going inside where it is supposed to go.” This difference between ‘insertion’ and ‘penetration’ is important. I therefore use the word ‘insertion’ instead of the commonly used word, ‘penetration’ to convey the above meaning where ever required in context of Sexual Intercourse.
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Useful Links
1 http://mysexdoctor.blogspot.com/2008/01/healthmeter.html

2first
sex unconsumated doctor’s
tips
3 FirstSex-FirstNight-Suhagrat_FirstHoneymoon
4 newly-wed-husband-refuses-sex

5 no-insertion-of-penis-during-sex
6 sex-tips-before-marriage-boys

7 unconsumated-marriage

8 http://dictionary.reference.com/browse/vaginismus

9 Animated Picture showing Vaginismus

10 Large Animated Picture showing the mechanism of Vaginismus
11 Vagina in panic. www.womentc.com
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1. impotence resulting from a man’s inability to have or maintain an erection of his penis wordnet.princeton.edu/perl/webwn

2. Erectile dysfunction (ED or (male) impotence) is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis.
   There are various underlying
   causes, such as cardiovascular leakage and
   diabetes, many of which are medically treatable. …
   en.wikipedia.org/wiki/Erectile_dysfunction

3. The inability of a man to obtain or sustain an erection. Abbreviation: ED
   en.wiktionary.org/wiki/erectile_dysfunction

4. a consistent inability to sustain an erection sufficient for sexual intercourse. Also commonly known as impotence. …
   1stpropeciaprescription.com/Order/Order_Form/Medical_Definitions/medical_definitions.html

5. The loss of a man’s ability to have an erection. Some men may become impotent after having diabetes for a long time because the nerves or blood vessels have become damaged. Sometimes the problem has nothing to do with diabetes and may be treated with counselling.
   www.diabetesnsw.com.au/about_diabetes/diabetesdictionary.asp
6. Also known as “ED,” the loss of the ability to produce and/or sustain an erection (while desire for sex remains unchanged).
   www.dattolifoundation.org/glossary.htm
   Problems that a man may have in achieving an erect (firm) penis.
   www.spinalnet.co.uk/EEndCom/GBCON/homepage.nsf/(VIEWDOCSBYID)/1E68230AB2F65FF100256C59003EBE2C
   The inability to have or to maintain penile erection of sufficient firmness for coitus; also known as inhibited sexual excitement.
   www.crsupport.info/health_topics/sex-glossary-E.html

1
wordnet.princeton.edu/perl/webwn
2
en.wikipedia.org/wiki/Erectile_dysfunction
3
en.wiktionary.org/wiki/erectile_dysfunction
4
1stpropeciaprescription.com/Order/Order_Form/Medical_Definitions/medical_definitions.html
5
www.diabetesnsw.com.au/about_diabetes/diabetesdictionary.asp
6
www.dattolifoundation.org/glossary.htm
7
www.crsupport.info/health_topics/sex-glossary-E.html

* Systemic diseases associated with ED

o Diabetes.To Top of the Post

o Scleroderma

o Renal (kidney) failure

o Liver cirrhosis

o Hemochromatosis (too much iron in the blood)

o Cancer and cancer treatment.To Top of the Post

* Diseases of the nervous system associated with ED

o Epilepsy

o StrokeTop of the Post

o Multiple sclerosis

o Guillain-Barré syndrome

o Alzheimer disease

o Trauma.To Top of the Post

o Parkinson disease

* Respiratory disease associated with ED: Chronic obstructive pulmonary disease.To Top of the Post

* Endocrine conditions associated with ED

o Hyperthyroidism

o Hypothyroidism.To Top of the Post

o Hypogonadism

* Penile conditions associated with ED

o Peyronie disease.To Top of the Post

o Priapism (painful, abnormally prolonged erections)

* Mental conditions associated with ED

o Depression Top of the Post

o Widower syndrome

o Performance anxiety

* Nutritional states associated with ED

o Malnutrition.To Top of the Post

o Zinc deficiency

* Blood diseases associated with ED

o Sickle cell anemia.To Top of the Post

o Leukemias

* Surgical procedures associated with ED

o Procedures on the brain and spinal cord.To Top of the Post

o Retroperitoneal or pelvic lymph node dissection

o Aortoiliac or aortofemoral bypass.To Top of the Post

o Abdominal perineal resection

o Proctocolectomy

o Radical prostatectomy

o Transurethral resection of the prostate ([TUR] Prostrate Surgery).To Top of the Post

o Cryosurgery of the prostate.To Top of the Post

o Cystectomy