Chronicle of urology sexual medicine-Penile Rehabilitation after Pelvic Cancer Surgery

The Sexual Medicine fellowship program at the Brady Urological Institute is an inaugural program that was put into effect in July The training program aims to provide a framework consistent with the trainee attaining cognitive and technical skills necessary to be competent in the practice of sexual medicine. The prototypical training program consists of two major phases or assignments , which aligns with the 2 year duration of the program: basic training and advanced training. Basic training 12 months consists of full-time, continuous in-office and operating room exposure regarding basic diagnostic and therapeutic management of sexual disorders. Advanced training 12 months similarly consists of full-time, continuous in-office and operating room exposure for diagnostic and therapeutic management of sexual disorders although the training will be performed at an advanced level.

Chronicle of urology sexual medicine

El-Bahnasawy et al. How to Apply. Havenga K. Kalsi J. Nippon Hinyokika Gakkai Zasshi. Montorsi et al. International Journal of Impotence Research. Chronic therapy with both long- and short-acting PDE5I can prevent corporo-veno-occlusive dysfunction Chrnoicle underlying histological changes induced by neurapraxia [ 3132 ]. Penile rehabilitation after radical prostatectomy: where do we stand and where are we going?

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It is estimated that 20 million men in the United States suffer from sexual dysfunction. Graham, Jr. The SMSNA strives to promote, Tiny squirt and support the highest standards of practice, research, education, and ethics in the study of anatomy, physiology, pathology, diagnosis, and treatment of human sexual function and dysfunction. Organic ED is due to physical defects and You may alternatively request an appointment to see a physician via our online form at any time. Another type Chronicle of urology sexual medicine penile implant is the semi-rigid implant. At Wayne State University, Department of Urology, we have done more than penile implants with a very low complication rate. The semi-rigid implant is also implanted inside the penis and is not visible from the outside. Alexis E. Aulitzky, M.

Erectile dysfunction is the most common complication after pelvic radical surgery.

  • Classically, sexual dysfunction was synonymous with erectile dysfunction.
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  • It is estimated that 20 million men in the United States suffer from sexual dysfunction.
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Erectile dysfunction is the most common complication after pelvic radical surgery. Rehabilitation programs are increasingly being used in clinical practice but there is no high level of evidence supporting its efficacy. The principle of early penile rehabilitation stems from animal studies showing early histological and molecular changes associated with penile corporal hypoxia after cavernous nerve injury. The concept of early penile rehabilitation was developed in late nineties with a subsequent number of clinical studies supporting early pharmacologic penile rehabilitation.

These studies included all available phosphodiesterase type 5 inhibitors, intracavernosal injection and intraurethral use of prostaglandin E1 and to lesser extent vacuum erectile devices.

However, these studies are of small number, difficult to interpret, and often with no control group. Furthermore, no studies have proven an in vivo derangement of endothelial or smooth muscle cell metabolism secondary to a prolonged flaccid state.

The purpose of the present report is a synthetic overview of the literature in order to analyze the concept and the rationale of rehabilitation program of erectile dysfunction following radical pelvic surgery and the evidence of such programs in clinical practice. Emphasis will be placed on penile rehabilitation programs after radical cystoprostatectomy, radical prostatectomy, and rectal cancer treatment.

Future perspectives are also analyzed. Cancer remains one of the leading causes of morbidity and mortality worldwide. It is predicted that, by , the number of new cases of cancer in the world will increase to more than 15 million [ 1 ].

Improvements in cancer diagnosis and treatment have led to an increased life expectancy; but cancer diagnosis and treatment carry serious physical and psychological consequences that can dramatically decrease quality of life [ 2 ]. However, after the World Health Organization definition of health, attention of the scientific community shifted from the mere focus on the body and its organic affection processes to the patients and to the repercussions in patients whole being [ 3 ]. Sexual dysfunction represents a prevalent long-term complication among cancer survivors with a wide spectrum of manifestations and a huge impact on quality of life [ 4 ].

Owing to the anatomical location of the sexual organs and their innervations, radical surgery for pelvic cancers has understandably been associated with sexual dysfunction.

Among men, these include erectile dysfunction ED , penile shortenings, penile curvature, dysorgasmia, and ejaculatory disorders including retrograde ejaculation, loss of or alterations in ejaculation, and urine leakage at the time of orgasm climacturia [ 5 ].

In addition, relatively nonspecific problems such as changes in level of sexual activity, a lack of sexual enjoyment, and alterations in body image have been also identified in men following diagnosis or treatment of pelvic cancer [ 6 , 7 ]. Moreover, sexual function remains important to men, who often continue to be interested in sex even in their final decades of life [ 8 , 9 ], and ED represents the most frequent and documented sexual dysfunction after radical pelvic surgery [ 7 ].

In recent years, numbers of investigators have increasingly focused on ED after radical pelvic surgery. They directed their efforts toward searching for interventions that might improve sexual function. Various coping strategies and rehabilitation programs have been suggested and applied with different success rates. The rehabilitation program to increase the success rate and to shorten the interval to regain spontaneous erection is the most studied and documented program in the contemporary literature.

Penile corporal hypoxia due to the loss of daily and nocturnal erections during rapid eye movement sleep leads to penile atrophy, smooth muscle apoptosis, venoocclusive dysfunction, and penile scarring and fibrosis that limit further oxygenation [ 13 ]. To break this vicious cycle, the concept of early intervention to oxygenate the penile corporal, termed penile rehabilitation, was first suggested in a paper written in by Montorsi et al. This novel idea had gained interest in many cancer centers worldwide while others remain reluctant which further points out the necessity of working out an optimal treatment strategy in order to rapidly evolve beyond the proof of concept.

The present report is a synthetic overview of the literature in order to analyze the concept and the rationale of rehabilitation program of ED following radical pelvic surgery and the evidence of such programs in clinical practice. Emphasis will be placed on penile rehabilitation programs after radical cystoprostatectomy RC , radical prostatectomy RP , and rectal cancer treatment.

The mechanisms underlying ED after radical pelvic treatment are partially elucidated and thought to be multifactorial in aetiology. In the early s, Walsh et al. They evaluated retrospectively in a small case series of 12 patients who underwent a nerve sparing RP the postoperative sexual function.

All of them have experienced erections and six have achieved successful vaginal penetration and orgasm. Of the six patients with sexual partners who have been followed up for 6 months or longer, five were fully potent. They demonstrated that ED was of neurogenic etiology due to cavernous nerve transaction [ 15 ].

However, regardless of the surgical technique, spontaneous erectile function was frequently impaired in the early postoperative period, probably because of a reversible injury of the cavernous nerves due to traction, exposure, or dissection, a process known as neurapraxia or transient cavernosal nerve dysfunction.

This temporary deficit can abolish any form of erection and can last up to two years [ 16 ]. More recently, a vascular etiology of postsurgical ED has generated increasing interest, suggesting that loss of daily and nocturnal erections might lead to irreversible damage to the cavernous tissue. Several animal and clinical studies corroborated these findings.

In early studies, smooth muscle cell apoptosis was demonstrated as early as the first postoperative day after bilateral and unilateral cavernous neurectomy in a rat model compared to a more delayed smooth muscle cell apoptosis after cavernous nerve crush injury [ 17 ]. Mulhall et al. Another consequence of neurapraxia is alteration in the smooth muscle-collagen ratio with increased levels of collagen types I and III as well as elevated levels of transforming growth factor b1 [ 20 , 21 ].

These changes have previously been associated with prolonged tissue hypoxia, leading many investigators to propose a causal relationship between hypoxia and the cavernosal changes seen in men with a prolonged flaccid state after NSRP [ 22 ]. However, the role of persistent failure of cavernous oxygenation in penile fibrosis after NSRP remains a topic of debate. Critics of the hypoxia theory point out that the effects of physiologic penile hypoxia associated with a flaccid penis on cavernosal tissue remain theoretical [ 23 ].

To date, no studies have proven an in vivo derangement of endothelial or smooth muscle cell metabolism secondary to a prolonged flaccid state. Patients with known injury to the neurovascular bundles likely proceed through a continued cycle of smooth muscle cell death, leading to irreversible venoocclusive disease.

Similarly, patients with preserved neurovascular bundles might demonstrate progressive fibrosis of the cavernosal tissue during the period of neurapraxia, leading to the same endpoint of venous leak.

It is this latter group that is targeted with penile rehabilitation to decrease the fibrotic changes associated with the temporary period of nerve dysfunction. It had been demonstrated that prostaglandin E1 PGE1 and phosphodiesterase type 5 inhibitors PDE5Is may promote the recovery of erectile function by providing cavernosal oxygenation [ 24 , 25 ]. It had been also hypothesized that these medications even in the absence of an erection can induce cavernosal oxygenation and thus could be used to preserve smooth muscle after cavernous nerve injury [ 26 ].

By performing percutaneous penile biopsies at the time of RP and 6 months later, Schwartz et al. They were able to demonstrate that early use of sildenafil after surgery may preserve intracorporeal smooth muscle content [ 27 ].

Furthermore, it had been shown that early use of PDE5Is decreased the numbers of apoptotic cells and prevented apoptotic cell death in the penis following denervation [ 28 , 29 ]. Several studies have provided important animal model documentation of the benefit of PDE5 therapy for prevention of histological changes in the penis after nerve injury [ 30 ]. Chronic therapy with both long- and short-acting PDE5I can prevent corporo-veno-occlusive dysfunction and underlying histological changes induced by neurapraxia [ 31 , 32 ].

It is noteworthy to mention that these medications and devices used in rehabilitation program are safe and well tolerated by patients without significant side effect profile which is demonstrated by the high rate of compliance with these rehabilitation strategies [ 33 ]. Distinguishing subgroups of patients who are in need for rehabilitation from those who are not good candidates for rehabilitation is an emerging concept in penile rehabilitation following pelvic cancer surgery.

It is evident that patients with preoperative erectile dysfunction not responding to pharmacological therapy should not receive penile rehabilitation following radical pelvic surgery [ 34 , 35 ]. It was also demonstrated that patients who undergo a non-nerve sparing radical prostatectomy did not benefit from pharmacological rehabilitation program [ 36 ].

The same authors suggested that penile rehabilitation may be more beneficial in older patients and patients with a diminished preoperative erectile function.

Briganti et al. The recovery of erectile function was improved with PDE5I overall in their study. Subsequent studies have supported the potential role of psychosocial interventions [ 39 ]. However, long-term improvements except regarding compliance with the pharmacological program had not been demonstrated [ 40 ].

This could be due to the standard method used independently from the patient personality. Other studies have attempted to assess the role of the partner in post-RP sexual dysfunction. It has been shown that a sexually functional partner is associated with better sexual outcomes after RP and that there is a strong correlation between male and female sexual dysfunction in couples where the man has undergone RP [ 41 , 42 ].

Another important point is the use of adjuvant therapy. The impact of adjuvant radiation therapy on the rehabilitation program is not clear and data are lacking in the literature [ 44 ].

This uncertainty stems from the fact that few studies have addressed the impact of radiation therapy on EF in post-RP patients and also from the fact that most men after RP do not have intact EF, making it difficult to determine whether adjuvant radiation therapy results in further loss of function.

However, the use of androgen deprivation therapy would have debilitation sexual side effects and renders the rehabilitation program more difficult [ 45 ]. The impact of nerve sparing radical prostatectomy on incontinence is contradictory in the contemporary literature. The presence of incontinence in patients with erectile dysfunction alters significantly their quality of life but its interference with penile rehabilitation program is not clear [ 46 , 47 ].

Historically, patients suffering ED after RP were observed and encouraged during the postoperative period to wait for the return of erectile function without the need for active intervention.

The results of such an approach were unsatisfactory both for the patient and for the physician. Gallina et al. Montorsi et al. However, preoperative erectile function had not been assessed in their studies and no validated questionnaire had been used. Furthermore, the long-term benefit was not evaluated due to short follow-up [ 14 ]. Bannowsky et al.

The findings obtained with the small patient sample of Padma-Nathan et al. These findings had also been confirmed, in clinical studies, for the other PDE5Is [ 51 — 53 ].

Intraurethral alprostadil had also been used in rehabilitation programs. Raina et al. This noncompliance rate indicates beside side effect disorders that men need encouragement to continue with therapies that may not have immediate results. The same authors reported on the use of vacuum erection device VED as a rehabilitation therapy [ 56 ].

However, the results were inconclusive. Further studies for VED as a rehabilitation therapy are needed especially because the mechanism of improving erectile function is unknown. The timing of rehabilitation is controversy in the literature. However, a general agreement is based on experimental studies stresses that any form of rehabilitation should begin as close to the surgery as possible.

Moskovic et al. In their studies, preoperative female partner sexual function correlated with greater patient compliance with the localized component of the ED rehabilitation program [ 58 ]. Some physicians used rehabilitation program with on-demand intake of PDE5I in order to reduce the cost. These physicians based their intervention on a randomized, double-blind, multicenter, parallel group study comparing 9 months nightly dosing of vardenafil and flexible-dose on-demand vardenafil in patients who had a bilateral NSRP [ 61 ].

Nightly dosing with vardenafil did not have any effect beyond that of on-demand use. Even more clinically relevant is the fact that this study confirmed that vardenafil taken when needed during the double-blind treatment period was associated with significantly better results compared with placebo.

Table 1 summarizes the different studies on penile rehabilitation following RP. Summary table of penile rehabilitation trials in patients undergoing pelvic cancer surgery. Although tailoring the surgical approach, such as nerve sparing RC, might improve outcomes according to recent studies, rehabilitation programs were found to be necessary to optimize recovery from erectile function [ 66 ].

Free profile in Find a Provider section of sexhealthmatters. Erectile dysfunction ED can be classified as organic, psychogenic or mixed. No-scalpel Vasectomy Vasectomy is a simple and effective method for providing permanent contraception. What is Erectile Dysfunction? Gerald J. Penile Fracture Abrupt bending of the erect penis can result in a tear in the tunica albuginea the lining of the erectile bodies. Jim C.

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine. AUA Resources

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Chronicle Of Urology Sexual Medicine Nhs Dating Login anal girl t

Josephs Health Centre and is extensively involved in developing and implementing educational programs for GPs, specialists and the general public. Over the last several years, Dr. Greenberg is a consulting physician for the Canadian Opera Company and former physician for the Toronto Argonauts football team.

Barkin sub-specializes in andrology, urologic oncology and mens health issues. He has been involved with over clinical trials in the field of urology. Barkin is also a writer and international speaker in the field of Andropause and all aspects of Urology, and speaks at countless different media venues.

Jay C. Major academic focus and areas of research include: male sexual dysfunction and male aging, female sexual dysfunction, and infectious disease. Jerzy B. His main interests are voiding dysfunction, incontinence, interstitial cystitis, erectile dysfunction and andropause. He has published over 50 papers and book chapters, and delivered over presentations on these topics. Alarie is a family physician who has been working in the field of sexual medicine for 30 years.

His fields of interest are continuing medical education CME , clinical research, medical practice and post-doctoral continuing education. He currently runs a large tertiary care erectile dysfunction clinic at St. In addition to his responsibilities of resident teaching, he runs a productive basic animal research lab evaluating the impact of disease on sexual mechanisms. Brock is the author of over peer reviewed publications, 20 book chapters as well as over 20 research prizes.

Christine has been involved with the development and delivery of numerous educational programs and articles for healthcare professionals and patients in a variety of therapeutic areas including hypogonadism, erectile dysfunction, prostate cancer, prostatitis and sexual health. Bebb is an Endocrinologist at St. He is a consultant Endocrinologist with research and clinical interests in disorders of male gonadal function and reproductions and a Clinical Assistant Professor at the University of British Columbia.

Casey is a graduate of the University of Western Ontario , completed the Gallie course in Surgery at the University of Toronto , and completed a post doctoral fellowship in Endocrinology at the University of Texas He established the Male Health Centres, a treatment facility for men with erectile dysfunction, in , and CMX research, a site management organization for urologic research, in He has participated in over 50 peer reviewed publications and is presently on the editorial board of the Canadian Urologic Association Journal and the Canadian Journal of Urology.

Casey continues to pursue his interest in male health as a community urologist in Oakville, Ontario. Stacy Elliott , MD Dr. Elliott is a Sexual Medicine Physician whose interests lie in the sexual and reproductive consequences of medical or surgical problems, particularly neurological disability.

Elliott participates on several advisory boards regarding treatment of erection, ejaculatory and hypogonadal disorders following surgery or injury, particularly prostate cancer and spinal cord injury. She has authored many peer-reviewed journal articles and book chapters. She is involved in many research trials as principle or co— investigator in the area of sexual functioning in prostate cancer and disability, and is an active faculty member and researcher of the International Collaboration of Repair Discoveries ICORD.

He has been an investigator in numerous clinical trials in the areas of diabetes, hypertension, obesity, and dyslipidemia, and is actively involved in CME. Since he has been a staff physician within the Division of Endocrinology and Metabolism at the Mount Sinai Hospital, a University of Toronto teaching institution. His primary academic and clinical focus has been reproductive and sexual medicine, especially in the male, including: male infertility, male hypogonadism, chemical contraception for men, aberrant sexual behaviour in the male.

For many years his attention has been increasingly concentrated on testosterone deficiency and hormone replacement therapy in the aging male. He was a founding member of the Canadian Andrology Society and its first president between and this society later merged with the Canadian Fertility Society to become the Canadian Fertility and Andrology Society in Major academic focus and areas of research include urologic oncology, tumor immunology, male sexual dysfunction and male aging.

Roland R. Professor Tremblay achieved his MD degree in at Laval University and subsequently started training there in physiology In , he joined Laval University and in this period he developed in the concept of bioavailable testosterone. Professor Tremblay is a member of numerous national and international professional scientific societies and has been active in many of them in several positions.

Recently, he became a member of the scientific advisory board and faculty of the International Society for the Study of the Aging Male. Hello Visitor! Latest News Blogs Resources Events.

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine

Chronicle of urology sexual medicine