**3. Rehabilitation of erectile function after prostatectomy**

Climacturia, an orgasmic dysfunction, is one of the affected aspects of the sexual quality of life of prostatectomized patients. Before it manifests, it has erectile

**157**

**Table 2.**

*Post-prostatectomy sexual disorders.*

*The Pelvic Health Physical Therapy and the Prostatectomy*

lence of orgasm difficulty was 45% (**Table 2**) [19].

within its limitations. This is the beginning of sexual rehab [20].

these frames are taken into account for the treatment [21].

nocturnal erections did that no longer occur [22].

treatment time is over 6 months.

dysfunction (ED), highly prevalent in the second postoperative month, reaching around 90%. Complaints about the quality of erection remain frequent even after 12 months postoperatively in around 75% of patients. At the same time, the preva-

When talking about the post-prostatectomy sexual quality of life, before the complaint of climacturia, which may be presumed that there is penetration, the patient usually presents with a severe erectile dysfunction. The impact on sexual life may be even greater when ED is associated with urinary loss, requiring a much more integral approach to the case, since the patient begins to have an affective distancing from the partner and consequently sexual avoidance. The sexual behavioral approach (**Figure 5**) is necessary in order to keep the patient stimulated sexually,

Once the behavioral framework is handled, the erectile rehabilitation comes to the scene. Because it is a multifactor ED, which begins with neuropraxia of the cavernous nerve, which promotes pro-apoptotic and pro-fibrotic factors in the penile tissue, thus evolving into a veno-occlusive dysfunction, resources that act in

Penile vacuum therapy (**Figure 6**) is a physical rehabilitation resource, therefore a physiotherapy, which aims to promote, through a negative pressure, daily erections with the protective function of the erectile tissue, in the same way that

By getting into the place of nocturnal erections, which were daily, penile vacuotherapy also needs to be performed daily. In the Engel [22] and Raina and collaborators [23] studies, the mean time of application of the therapeutic vacuum is 10 minutes. However it is known that in 5 minutes of use, the arterial blood is equivalent to the venous one, becoming poor in oxygen. It is also known that a rest of 30–60 seconds in the vacuum normalizes penile oxygenation, suggesting that the application should be done intermittently, with rest between one application and another. The therapeutic pressure is between −150 and −200 mmHg [24]. The

Due to the safety of the patient, the prescription and orientation of use should be made by a professional qualified to do so, thus avoiding possible intercurrences during the application, such as penile pain, edema, and hematoma. The patient is taught to perform the penile vacuotherapy, recognizing the perceptions and sensations, regarding the sensitivity, size, and color of the penis, being performed by the

Sound therapy has been used in the treatment of ED. The main treatment currently offered is extracorporeal shock wave therapy. But it is common to the treatment by sound waves; this includes the therapeutic ultrasound, to cause mechanical stress and microtrauma in the place of its application. This vascular stress and microtrauma, which generates a shear stress, induce a cascade of biological

**Sexual function 2 Mo 6 Mo 12 Mo** Poor erections 88% 80% 67% Difficulty with orgasm 62% 51% 45% Erections not firm 90% 84% 75% Erections not reliable 83% 75% 60% Poor sexual function 83% 74% 61% Overall sexuality problem 59% 59% 50%

physiotherapist in the office, in order to make home treatment safe.

*DOI: http://dx.doi.org/10.5772/intechopen.86979*

*Male Reproductive Health*

**Figure 3.**

**Figure 4.**

*Parasacral electrodes.*

**156**

the voiding residue present in the bulbar urethra. The treatment consists of the therapeutic exercises of this musculature, aiming to acquire greater muscular force for the expulsion of the urine of the urethra, after the urination. The urethral milking maneuver and bulbar massage may also be associated, but the effectiveness of

The loss of urine during orgasm, climacturia, is not uncommon in these patients. The inevitable surgical damages generated in the bladder neck, as well as the event in the sympathetic fibers, responsible for contraction of the bladder neck and relaxation of the external sphincter during the ejaculation expulsion phase, are one of the suggested mechanisms for climacturia [18]. And the proposed physiothera-

Climacturia, an orgasmic dysfunction, is one of the affected aspects of the sexual quality of life of prostatectomized patients. Before it manifests, it has erectile

bulbospongiosus muscle contraction is greater [5].

**3. Rehabilitation of erectile function after prostatectomy**

peutic treatment is PFMT.

*Transcutaneous tibial nerve stimulation.*

dysfunction (ED), highly prevalent in the second postoperative month, reaching around 90%. Complaints about the quality of erection remain frequent even after 12 months postoperatively in around 75% of patients. At the same time, the prevalence of orgasm difficulty was 45% (**Table 2**) [19].

When talking about the post-prostatectomy sexual quality of life, before the complaint of climacturia, which may be presumed that there is penetration, the patient usually presents with a severe erectile dysfunction. The impact on sexual life may be even greater when ED is associated with urinary loss, requiring a much more integral approach to the case, since the patient begins to have an affective distancing from the partner and consequently sexual avoidance. The sexual behavioral approach (**Figure 5**) is necessary in order to keep the patient stimulated sexually, within its limitations. This is the beginning of sexual rehab [20].

Once the behavioral framework is handled, the erectile rehabilitation comes to the scene. Because it is a multifactor ED, which begins with neuropraxia of the cavernous nerve, which promotes pro-apoptotic and pro-fibrotic factors in the penile tissue, thus evolving into a veno-occlusive dysfunction, resources that act in these frames are taken into account for the treatment [21].

Penile vacuum therapy (**Figure 6**) is a physical rehabilitation resource, therefore a physiotherapy, which aims to promote, through a negative pressure, daily erections with the protective function of the erectile tissue, in the same way that nocturnal erections did that no longer occur [22].

By getting into the place of nocturnal erections, which were daily, penile vacuotherapy also needs to be performed daily. In the Engel [22] and Raina and collaborators [23] studies, the mean time of application of the therapeutic vacuum is 10 minutes. However it is known that in 5 minutes of use, the arterial blood is equivalent to the venous one, becoming poor in oxygen. It is also known that a rest of 30–60 seconds in the vacuum normalizes penile oxygenation, suggesting that the application should be done intermittently, with rest between one application and another. The therapeutic pressure is between −150 and −200 mmHg [24]. The treatment time is over 6 months.

Due to the safety of the patient, the prescription and orientation of use should be made by a professional qualified to do so, thus avoiding possible intercurrences during the application, such as penile pain, edema, and hematoma. The patient is taught to perform the penile vacuotherapy, recognizing the perceptions and sensations, regarding the sensitivity, size, and color of the penis, being performed by the physiotherapist in the office, in order to make home treatment safe.

Sound therapy has been used in the treatment of ED. The main treatment currently offered is extracorporeal shock wave therapy. But it is common to the treatment by sound waves; this includes the therapeutic ultrasound, to cause mechanical stress and microtrauma in the place of its application. This vascular stress and microtrauma, which generates a shear stress, induce a cascade of biological


**Table 2.** *Post-prostatectomy sexual disorders.*

### **Figure 5.** *ICI, intracavernosal injection; VED, vacuum erection device.*

### **Figure 6.** *Vacuum erection device.*

reactions that result in the release of angiogenic factors which in turn triggers tissue neovascularization with subsequent improvement of blood supply [25].

Penile electrical stimulation (**Figure 7**) has also been studied for penile rehabilitation. Its action consists in the endothelial action. The current generates release of endothelium-dependent nitric oxide, leading to increased blood supply and vasodilation. Favoring the action of endothelial progenitor cells, which secrete proangiogenic factors, induces neovascularization, repair, and endothelial function. Endothelial progenitor cells release vascular endothelial growth factor, acting as a mediator of angiogenesis [26].

The erectile latency of the post-prostatectomy patient is variable in duration, and we already know the possible damage to penile erectile tissue. But from the perspective of the striated muscles, it is known that the penis muscles who have a veno-occlusive function, the ischiocavernosus and bulbospongiosus muscles (**Figure 8**), which, besides being in the process of sarcopenia inherent to the senility of the patient, may also pass through atrophy due to disuse.

**159**

function [27].

*(4) external anal sphincter muscle).*

**Figure 8.**

**Figure 7.**

*Penile electrodes placement.*

**4. Conclusion**

and erectile function.

*The Pelvic Health Physical Therapy and the Prostatectomy*

PFMT, focusing on the penile muscles, acts on the veno-occlusion favoring penile stiffness. However, the ischiocavernosus muscle in particular does not have great relevance in the penile intumescence phase. This suggests that to activate them in a functional PFMT, the penis would need to be at least in its maximum turgidity, considering that this patient has great impairment of the postsurgical erectile

*Perineal muscles ((1) ischiocavernosus muscles, (2) bulbocavernosus muscle, (3) transverse perineal muscle,* 

Several studies show the predictive factors for the evolution of both urinary incontinence and erectile dysfunction and that to date no conservative treatment has curative action in both situations. However, it is consensual in the rehabilitation process of the post-prostatectomy patient, offering treatments, based on the levels of evidence and recommendation grade, with the objective of improving the quality of life of the patient and whenever possible accelerate the recovery of continence

*DOI: http://dx.doi.org/10.5772/intechopen.86979*

*The Pelvic Health Physical Therapy and the Prostatectomy DOI: http://dx.doi.org/10.5772/intechopen.86979*

**Figure 7.** *Penile electrodes placement.*

*Male Reproductive Health*

**Figure 5.**

**Figure 6.**

*Vacuum erection device.*

*ICI, intracavernosal injection; VED, vacuum erection device.*

**158**

mediator of angiogenesis [26].

reactions that result in the release of angiogenic factors which in turn triggers tissue

The erectile latency of the post-prostatectomy patient is variable in duration, and we already know the possible damage to penile erectile tissue. But from the perspective of the striated muscles, it is known that the penis muscles who have a veno-occlusive function, the ischiocavernosus and bulbospongiosus muscles (**Figure 8**), which, besides being in the process of sarcopenia inherent to the senility

Penile electrical stimulation (**Figure 7**) has also been studied for penile rehabilitation. Its action consists in the endothelial action. The current generates release of endothelium-dependent nitric oxide, leading to increased blood supply and vasodilation. Favoring the action of endothelial progenitor cells, which secrete proangiogenic factors, induces neovascularization, repair, and endothelial function. Endothelial progenitor cells release vascular endothelial growth factor, acting as a

neovascularization with subsequent improvement of blood supply [25].

of the patient, may also pass through atrophy due to disuse.

### **Figure 8.**

*Perineal muscles ((1) ischiocavernosus muscles, (2) bulbocavernosus muscle, (3) transverse perineal muscle, (4) external anal sphincter muscle).*

PFMT, focusing on the penile muscles, acts on the veno-occlusion favoring penile stiffness. However, the ischiocavernosus muscle in particular does not have great relevance in the penile intumescence phase. This suggests that to activate them in a functional PFMT, the penis would need to be at least in its maximum turgidity, considering that this patient has great impairment of the postsurgical erectile function [27].

### **4. Conclusion**

Several studies show the predictive factors for the evolution of both urinary incontinence and erectile dysfunction and that to date no conservative treatment has curative action in both situations. However, it is consensual in the rehabilitation process of the post-prostatectomy patient, offering treatments, based on the levels of evidence and recommendation grade, with the objective of improving the quality of life of the patient and whenever possible accelerate the recovery of continence and erectile function.

*Male Reproductive Health*
