What are best practices for using VED plus PDE5i as penile rehabilitation after radical prostatectomy?
Executive summary
Combining a vacuum erection device (VED) with phosphodiesterase type‑5 inhibitors (PDE5i) is a commonly used strategy in penile rehabilitation after radical prostatectomy (RP) intended to preserve penile length, maintain corporal oxygenation, and improve chances of intercourse when nerve recovery occurs; evidence supports physiologic rationale and improvement in some patient‑reported outcomes but high‑quality trials proving long‑term recovery of spontaneous erections remain limited and results are mixed [1] [2] [3]. Clinical practice favors early, structured, and sustained use with attention to adherence, device technique, and individualized PDE5i dosing—while patients must be counseled about uncertain effects on unassisted erectile function and the need for realistic expectations [4] [5] [6].
1. Why combine VED and PDE5i: the mechanistic case and the clinical practice pattern
The rationale for using VED plus PDE5i is twofold: VEDs mechanically increase blood inflow and oxygenation of the corpora cavernosa—countering hypoxia and fibrosis after denervation—while PDE5i pharmacologically raise cGMP levels to protect cavernosal smooth muscle and facilitate drug‑assisted erections; together they address complementary pathways that may preserve tissue integrity during nerve recovery [1] [7] [8]. Surveys and practice audits show clinicians commonly employ regular PDE5i for 12–18 months after RP and often add VEDs as a supportive or second‑line option, reflecting wide adoption despite imperfect evidence [4] [1].
2. Timing and frequency: start early and maintain a schedule to maximize physiologic benefit
Most trials and expert practice recommend initiating rehabilitation early—often within weeks after catheter removal or soon after surgery—to maximize tissue oxygenation and limit fibrosis, with VED protocols frequently prescribed daily and PDE5i given regularly (daily or several times per week) for many months (studies used daily VED regimens and PDE5i courses of 36–48 weeks in some trials) [6] [9] [10]. Early initiation appears associated with better short‑term erectile function and penile length preservation in some studies, though the optimal exact schedule, dosing, and duration are not definitively established [11] [2].
3. Practical technique, adherence, and patient selection matter most for real‑world success
Best practice emphasizes patient training in VED use (proper seal, pump technique, and safe use of constriction rings only when indicated), routine follow‑up to troubleshoot pain or bruising, and programs to boost adherence because benefit correlates with consistent use; dedicated VED programs improve compliance and outcomes in published series [6] [8] [10]. Selection factors—nerve‑sparing status, baseline erectile function, partner involvement, and realistic expectations—should guide counseling since nerve injury severity predicts recovery potential and some men will still require injections or implants [3] [10].
4. PDE5i strategy: dosing, duration, and limitations
Evidence supports PDE5i use post‑RP as part of rehabilitation, with some trials showing advantages for daily tadalafil compared with on‑demand dosing on drug‑assisted erectile function, penile length, and patient satisfaction, and guideline panels recommending men be informed that early PDE5i may not restore spontaneous unassisted erections—highlighting benefit for drug‑assisted outcomes rather than guaranteed nerve recovery [9] [5]. Duration in trials varies, with common clinical practice spanning 12–18 months or longer; however, randomized data are conflicting about whether nightly versus on‑demand or longer versus shorter courses improve long‑term spontaneous function [9] [7].
5. What the evidence does and does not prove — be candid about limitations
Systematic reviews and randomized trials report improvements in IIEF scores, penile length preservation, and intercourse success when VED is used, often augmented by PDE5i, but high‑quality evidence that the combination reliably restores spontaneous, unassisted erections long‑term is lacking and heterogeneous trial designs prevent firm conclusions about optimal protocols [2] [12] [3]. Guidelines and expert commentaries therefore support offering VED+PDE5i as a reasonable, low‑risk rehabilitation strategy with clear counseling about uncertain long‑term benefit and the potential need for alternate therapies [5] [8].