Table 4.
Summary recommendations for ED rehabilitation programme post-RT/BT/ADT
| Summary recommendations for ED rehabilitation programme |
|---|
| Pretreatment recommendations |
| Pretreatment discussion with the man and his partner of the impact of RT/BT/ ADT on sexual function, delayed ED development timelines and rationale for ED rehabilitation programme Ensure men and couples are sufficiently prepared for disruption to their sexual lives and expectations of EF recovery are realistically managed |
| The man and partner's current sexual function should be assessed as part of any ED management programme pre-and posttreatment. Partners may require medical/psychosexual therapy if they have concurrent sexual difficulties that may jeopardise rehabilitation efforts |
| Pretreatment assessment of a couple's readiness to engage in a ED rehabilitation programme is advisable |
| Pretreatment assessment of any comorbidities or concurrent medication that would affect sexual function |
| Assess patients’ contributory lifestyle factors (diet, BMI, alcohol/smoking and physical activity) |
| Check baseline testosterone level to exclude an existing testosterone deficiency |
| Posttreatment recommendations |
| Discuss the implementation of an ED rehabilitation programme with men and partners |
| ED management initiation time |
| Consider early initiation of PDE5-I (soon after start of RT/ADT) or within 3–6 months of treatment at least |
| ED management algorithm |
| See Figure5 for management algorithm recommendations for EF restoration after treatment with RT/ADT |
| Determine cause of ED – low sexual desire ± inability to get an erection? Are nocturnal/early morning erections occurring? |
| Consider conservative approaches: pelvic floor exercise and lifestyle changes |
| Consider first-line treatment with low-dose PDE5-I daily (with higher doses given, on demand × 1 per week minimum if required) Combination therapy may be needed for some patients (generally PDE5-I + VED) Psychosexual therapy, especially for patients on ADT with persistent low desire + individual/couple distress |
| Use the most effective PDE5-I at optimal dose level on at least eight occasions before switching drug/management strategy NB. sildenafil is now available in generic form |
| Add VED to PDE5-I monotherapy as a second line option |
| Add intraurethral alprostadil/ICI followed by implants if initial treatment strategies fail |
| Referral to appropriate psychological/psychosexual therapy services |
| Counselling to assist couples in adjusting to permanent changes in sexual function |
| Timetable sexual intercourse once a week to assist management of low desire |
| Re-assessment |
| Once ED management is initiated, re-assess at regular intervals posttreatment preferably every 3 months |
| ED management duration |
| Recommend trying one strategy on at least eight occasions (or approximately 3 months) before switching to another strategy unless the patient experiences adverse events warranting an early switch |
| Individualise duration of management for each man/couple as strict time limits are inappropriate in clinical practice Management duration can range from 3 months until the man no longer needs EF support |