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Treating erectile dysfunction after surgery for pelvic cancers

Objectives of treating erectile dysfunction post surgery

  • The goal of an erectile function management strategy is the return of assisted and non-assisted erectile function, and prevention of changes to penile length and girth
  • Treating erectile dysfunction (ED) includes:
    • minimising extent and duration of ED
    • improving blood flow and delivery of oxygen to the penis
    • protecting penile tissue
    • preventing or minimising any changes to the size and girth of the penis
  • Erectile function rehabilitation programmes, especially if initiated early on after surgery, are effective in improving or restoring sexual function

Predictive factors for recovery

  • The recovery of erectile function depends on the following factors:
    • age of man and partner—younger patients are likely to have better results
    • phosphodiesterase type 5 inhibitor (PDE5-I) induced erectile function—men with normal erectile capacity, who take PDE5-I tablets before surgery and continue to take them, have the potential to have better erectile function after surgery than those who don't
    • presence of other health problems—comorbidities increase the risk of ED after surgery (e.g. diabetes, hypertension, and cardiovascular disease)
    • surgical technique—nerve-sparing versus non-nerve-sparing surgery
    • prostate-specific antigen (PSA) level—lower levels are associated with better results
    • grade of the cancer—cancers of lower risk/grades are associated with better results
    • ethnicity—black men are likely to have better results
    • weight—men of a healthy weight (lower body mass index) are likely to have better results
    • testosterone levels—normal levels are important for recovery of erectile function

Preoperative recommendations

  • Discuss the impact of surgery and proposed ED rehabilitation programme with the patient and, if they wish, their partner
  • Assess the patient and partner's current sexual function
  • Assess the couple's readiness to engage in an ED rehabilitation programme
  • Assess comorbidities, concurrent medications and lifestyle habits that could affect sexual function
  • Assess biomedical components, including the disease, treatment, current medications, current medical history, previous medical and surgical history, and ED medication history
  • Assess psychological factors (sexual self-esteem/confidence), relationship issues and any social factors that could impact on sexuality or that are affected by sexual dysfunction

Postoperative recommendations

  • Discuss the implementation of an ED rehabilitation programme with the man and his partner
  • Re-assess baseline sexual function at catheter removal or up to 10 days post surgery

Treatment pathway

Two weeks before surgery
PDE5-I (sildenafil 25mg/tadalafil 5mg) nightly
Sildenafil is the most cost effective initial choice of PDE5-I as it is now generic
VED + ICI/topical or transurethral alprostadil +/- psychosexual therapy and counselling§
PDE5-I not generally useful in this patient population
First line Early initiation of PDE5-I
Combination therapy:
  • PDE5-Is on demand/daily use for 12 weeks or as long as needed
  • +/- VED 5-10 min on daily basis
  • +/- psychosexual therapy and counselling§
  • PDE5-I low dose daily +/- PDE5-I standard dose on demand or once a week
    or PDE5-I on demand only
    or PDE5-I daily or every three days
  • + at least six initial tablets for every on demand option
Second line Add VED/ICI/topical alprostadil/transurethral alprostadil (preferred option versus ICI)
Pelvic floor exercise advice also provided by health professionals
Third line ICI/penile prosthesis (after trying ICI)
PDE5-I=phosphodiesterase type 5 inhibitor; VED=vacuum erection device; ICI=intra-cavernosal injection.
*Pathway is a collation of survey responses of individual clinical practice.
Tablets can be started before surgery if pre-existing sexual problems are identified during initial assessment or they can be started immediately after catheter removal.
The most effective combination depends on patient and partner needs, but the commonest favoured combination is VED + PDE5-I. Daily and on demand PDE5-I used simultaneously is an off-label recommendation.
§Psychosexual therapy and counselling provided as an adjunct to ED treatment.

Responsibility for prescribing specific treatments is determined at local service level

Duration of treatment
The decision to stop treatment depends on each patient, as the recovery time differs from man to man. Ideally, a treatment should be given until it's no longer needed

Treatment initiation

  • Initiate treatment preferably as soon as catheter is removed, and definitely within the first three months of surgery
  • In some cases, PDE5-Is can be initiated before surgery—if pre-existing problems are identified at presurgical assessment—or at catheter removal to improve outcomes

Psychosexual therapy and psychological counselling

  • Enable access to psychosexual therapy or psychological counselling for the patient and his partner pre and postoperatively, particularly where biomedical strategies are ineffective and/or there is patient or couple distress
  • Encourage partner support for the rehabilitation programme through ongoing psychosexual therapy and couples counselling
  • Include partners in all decision-making processes if possible


  • Once ED management is initiated, re-assess at regular intervals for example at eight weeks, three months and six months—the re-assessment schedule can coincide with the cancer review schedule

Treatment duration

  • Try each strategy on at least eight occasions before switching to another strategy, unless the patient experiences adverse events warranting an early switch
  • Individualise duration of treatment for each man, as strict limits are inappropriate in clinical practice
  • The duration of any treatment can range from three months until the man no longer needs treatment

Assessment of erectile function

Recommendations for assessing erectile function before and after surgery include:

  • Assess (patient's/partner's) sexual function pre- and post surgery, verbally or using validated sexual questionnaires|
  • Discuss ED with the patient during consultations before surgery, including the potential risks, and the treatments available
  • Discuss sexual rehabilitation programme with the patient and his partner, if possible
  • Assessment can start before surgery or at catheter removal, or up to three months after surgery
  • Once ED treatment is started, patients should be re-assessed regularly—at least every three months

Useful sources of information

Professional support

  • Face-to-face and online training for health professionals: visit prostatecanceruk.org/education for further information
  • Free educational resources are available in Macmillan's Learnzone, including 'Sexual Relationships and Cancer', an online module on how to talk to patients about the issues surrounding sexuality and cancer—visit learnzone.org.uk for further information

Patient information and support

| Routinely available questionnaires include: the International Index of Erectile Function (IIEF); Sexual Health Inventory for Men (SHIM); Female Sexual Function Index (FSFI); Erection Hardness Score (EHS); Self-Esteem And Relationship (SEAR) questionnaire; Sexual Life Quality Questionnaire (mSLQ-QOL); Miller Social Intimacy Scale (MSIS)

full guideline available from...

Prostate Cancer UK and Macmillan Cancer Support. Treating erectile dysfunction after surgery for pelvic cancers. A quick guide for health professionals: supporting men with erectile dysfunction.
First included: January 2016.