A cancer diagnosis of any kind can be very distressing — but for men told they need surgery to remove a tumour that has invaded their prostate, the threat of being left impotent by the procedure can be almost as bad.
A radical prostatectomy involves removing the walnut-sized prostate gland — which is located between the bladder and rectum — in order to clear the cancer.
But the surgery carries a high risk of damage to sensitive nerves and arteries that keep the penis in good working order.
Around 5,000 men a year in the UK undergo prostatectomies, and although modern techniques — known as nerve-sparing surgery — can reduce the risks, the charity Prostate Cancer UK warns that up to 80 per cent of these patients later experience erectile dysfunction severe enough to jeopardise their sex lives and put their relationships under strain. They can also experience incontinence.
But mounting evidence suggests the risk to men’s sex lives could be radically reduced if they were put on a ‘pre-habilitation’ programme before surgery, involving treatments and exercises to prevent or significantly limit any loss of virility.
A radical prostatectomy involves removing the walnut-sized prostate gland — which is located between the bladder and rectum — in order to clear the cancer
These include regular doses of an erectile dysfunction drug, Cialis (generic name, tadalafil), several weeks before surgery to dilate the tiny blood vessels supplying the genitals, improving their condition.
Daily exercises to strengthen a man’s pelvic floor muscles are also recommended, as is regular use of a vacuum pump device to build stronger erections by drawing blood into the penis, causing it to become erect.
The NHS already routinely sanctions most of these measures as part of a GP-supervised rehabilitation programme to help men try to repair any surgical damage after they have had their prostate removed. But a growing number of studies show the benefits are potentially much greater if these steps are taken long before patients enter the operating theatre.
‘It’s a no-brainer really,’ says Dr Geoff Hackett, a former consultant in urology and sexual medicine at Good Hope Hospital, Birmingham, and former president of the British Society for Sexual Medicine.
‘What’s the point in doing all this when the damage has already been done during the surgery? You get much quicker healing and recovery in erectile and urinary function if the nerves, blood vessels and muscles that control them are in a healthier condition going into the surgery.’
A study by researchers at the Korea University College of Medicine in Seoul, published in the journal Oncology in April 2022, compared outcomes in 20 men who were put on a daily 5mg dose of tadalafil two weeks before having their prostates removed, with 21 men given the drug four weeks after their operation.
Twelve months after surgery, 80 per cent of men given the drug in advance had recovered most of their erectile function, compared with 71.4 per cent in the post-op treatment group.
‘This suggests pre-operative penile rehabilitation may lead to better erectile function than a post-operative approach,’ the researchers concluded.
Dr Hackett says giving drugs such as tadalafil in advance helps to improve blood flow in the penis, increasing the chances of regaining full erectile function after the operation.
But he says the drug works better where a surgeon plans nerve-sparing surgery, minimising damage to the tiny bundles of nerves near the prostate which control a man’s erections.
Conventional prostatectomy — where a wide margin of tissue is removed as well as the prostate, in case malignant cells have spread — is more invasive, destroying delicate nerves and blood vessels and limiting the drug’s effects.
However, daily tadalafil is currently sanctioned only for post-operative rehabilitation by health watchdog the National Institute for Health and Care Excellence (NICE).
‘The trouble is that there are no major large-scale trials yet demonstrating its effectiveness before surgery, so it’s very difficult to persuade NICE to endorse it,’ says Dr Hackett.
‘So men wanting advance treatment usually need to obtain tadalafil on a private prescription. I see patients like this all the time, and I recommend they start, ideally, two to three months before surgery.’
Likewise, other studies have found starting simple pelvic floor exercises before prostate surgery yields better results than afterwards, when the patient is often in too much discomfort to do them properly.
The Pelvic, Obstetric and Gynaecological Physiotherapy group — a body for physiotherapists specialising in pelvic floor exercise tuition — says the exercises strengthen two main muscles: the bulbocavernosus, which wraps around the base of the penis, and the ischiocavernosus, a group of muscles that ‘act like guy ropes’ in holding up the penis when it’s erect.
Clare Bourne, a London-based private physiotherapist who specialises in helping men prepare for prostate surgery, says the exercises can be done at home or on the train to work, ideally at least six weeks before surgery.
‘One exercise is to imagine you are trying to hold in wind,’ she says. ‘This contracts the muscles in the pelvis.
‘Another is to gently raise the testicles by contracting the pelvic floor muscles. Do these five or ten times, and repeat three times a day.’
She says the exercises stimulate the release of a protein, vascular endothelial growth factor, which encourages nerve regeneration in the penis and enhances muscle power. Regularly contracting muscles in the pelvis also boosts blood flow to the genitals.
Aside from the physical benefits, Clare Bourne believes pelvic ‘prehab’ also helps men psychologically.
‘For many, it’s the first time they have ever been told to exercise their pelvic floor muscles — and they often benefit mentally from knowing they are doing everything they can before surgery to save their sex lives afterwards.’
For a guide to men’s pelvic floor exercises to prevent erectile dysfunction, visit thepogp.co.uk
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