How effective are penile rehabilitation protocols with VEDs after radical prostatectomy?
Executive summary
Vacuum erection devices (VEDs) are a well-established component of penile rehabilitation after radical prostatectomy (RP) that consistently show benefits for preserving penile length and facilitating erections for intercourse, with more modest and variable effects on restoring spontaneous erectile function; much of the evidence supports use especially when started early and when combined with other therapies such as phosphodiesterase‑5 inhibitors (PDE5i) [1] [2] [3]. Confidence is tempered by heterogeneity in study designs, small randomized trials, and inconsistent outcome definitions, which limits firm conclusions about the magnitude of benefit for natural erectile recovery [4] [5].
1. What VEDs do and why that matters biologically
VEDs work by applying negative pressure to the penis to increase arterial inflow, distend corporal sinusoids, improve oxygenation and reduce hypoxia-induced fibrosis and smooth muscle apoptosis—mechanisms shown in animal models and summarized in multiple translational reviews supporting an anti‑apoptotic, anti‑fibrotic effect that underpins the rehabilitation rationale [6] [7] [1].
2. Evidence on erectile function recovery: mixed but promising for assisted erections
Clinical studies and systematic reviews find that VEDs reliably produce usable erections for intercourse when used with a constriction ring or as an assisted method, and some trials report improved erectile scores when VED is added to medications; however, improvements in spontaneous, unassisted erectile function after RP are inconsistent across trials and meta‑analyses, so VEDs are better characterized as an effective tool for assisted erections than a guaranteed means to restore natural erectile capacity [8] [7] [3] [2].
3. Penile length and tissue preservation: the clearest consistent benefit
The strongest and most consistent clinical signal is preservation of penile length and girth—multiple randomized or prospective studies and reviews report less penile shortening in early or regular VED users, with some cohorts showing markedly lower rates of length loss among VED “responders” compared with non‑responders (for example, 23% vs 85% reporting length loss in one analysis) [9] [10] [11] [3].
4. Timing and combination therapy: early start and synergy with PDE5 inhibitors
Several analyses and randomized comparisons indicate earlier initiation (within weeks to months after surgery) may yield better preservation of penile dimensions and potentially better patient compliance, and combinations of VED plus PDE5i often outperform PDE5i alone for erectile hardness and IIEF scores—supporting a multimodal rehabilitation strategy rather than monotherapy, although exact timing and schedules vary across studies [9] [7] [4] [2].
5. Limits of the evidence and unanswered questions
Quality concerns persist: many trials are small, protocols for VED duration and frequency differ, endpoints range from subjective patient reports to IIEF scores and length measures, and long‑term randomized data comparing standardized regimens are limited—systematic reviews explicitly call for larger RCTs and harmonized outcome measures before precise effect sizes can be declared [5] [4] [12].
6. Practical interpretation and clinical implications
Clinically, VEDs should be presented as a low‑risk, non‑invasive strategy that reliably enables assisted erections, has a reproducible benefit in preserving penile length, and likely improves outcomes when used early and in combination with oral therapy; patients and clinicians must weigh compliance, device tolerance, and the imperfect evidence for restoring spontaneous erections when choosing a rehabilitation plan [8] [1] [13].