11 November 2021
By Kalli Spencer
Penile rehabilitation is a well-established concept and is thought to counter the effects of hypoxia (oxygen deprivation) in the penile tissue and cavernous nerve neuropraxia (damage to penile nerve supply) after a radical prostatectomy (RP) which leads to fibrosis (scarring) and atrophy (shrinkage) of the smooth muscle cells of the corpora cavernosum (erectile chambers) of the penis. The variations to tissue cause veno-occlusive dysfunction and lower the probability of long-term recovery of erectile function. Techniques utilised include tablets such as phosphodiesterase type 5 inhibitors (PDE5-I), injections directly into the corpora cavernosa, gels administered into the urethra and vacuum pump erection devices (VED). In the absence of success with these therapies the final option would be a penile prosthesis implantation. Meissner et al from Germany expanded on previous research which considered masturbation as a potential penile rehabilitation strategy. This study aimed to examine a correlation between masturbation and functional outcome after a nerve-sparing radical prostatectomy(nsRP).
Most studies examining this research use the International Index of Erectile Function (IIEF-EF). As this score only has application for those engaging in sexual intercourse, the researchers have used the erection hardness score (EHS) as well. By utilising the EHS the researchers could include 33% more potent men in their analysis. They noted improved rates of erectile function, morning erections, and urinary continence in participants who masturbated (m-patients) in the postoperative course after nsRP compared to those who refrained from masturbation (nm-patients). Rates of morning erections were assessed as a supplementary aspect of erectile function and can be an indicator for sleep-related erections. The influence of mental factors on erectile function is reduced during sleep compared to during sexual activity, which might explain the slightly elevated rates of morning erections compared to rates of erectile function using the IIEF-EF/EHS amongst study participants (48.1% vs. 43.6% after 24 months). The rate of erectile function (IIEF-EF/EHS) 24 months after nsRP was numerically greater in m-patients compared to nm-patients (47.5% vs. 37.5%). This differential of 10.0% between the two groups is clinically pertinent, but not statistically significant due to the small sample size of 184 patients at 24 months after nsRP. In addition, the rate of morning erections showed analogous results, with an even greater variance in rates between m-patients and nm-patients after 24 months (54.6% vs. 34.9%). These outcomes might be explained by similar molecular mechanisms that are known to improve penile rehabilitation when using VED. The researchers believe that a combination of PDE5-I and masturbation could reveal a similar result since they enhance the blood flow during sexual stimulus and arousal and could result in improved oxygenation. They were not able to verify whether masturbation is the reason for the better erectile function or if better erectile function leads to more masturbation. The advantage of this treatment is absence of costs and undesirable effects. In the study at 12 months after nsRP, continence was 78.3% among all participants. They observed that in the masturbation group there were superior rates of urinary continence 12 months after nsRP than the non-masturbation group (83.1% vs. 70.2%). Preservation of the neurovascular bundle through nerve-sparing techniques is highly interrelated with urinary continence. This endorses the idea that cavernous nerves play a vital role in urinary continence recovery. Masturbation could also improve urinary continence through increasing pelvic blood flow and oxygen supply, with a favourable effect on sphincter function.
The authors have reported numerous limits to their study. They report it is difficult to do a randomised trial and forbid the control group from masturbating. Another limitation is that data of the main outcome measures are self-reported and at risk for overstatement and falsification. In addition, although they asked patients about their regularity of masturbation, the researchers could not examine whether there are different erectile function results among the subgroups, due to the low number of participants in each category. Finally, they did not assess whether study participants masturbated with an erect or soft penis.
In conclusion, this is the first study which delved into a correlation between masturbation and both better erectile function and urinary continence of patients treated with nsRP. If masturbation is the rationale for the better functional outcome or if a better functional outcome leads to more
masturbation remains indefinite and needs to be corroborated in future studies consisting of larger samples, since randomized controlled trials are difficult to achieve. Nonetheless, masturbation, which neither incurs any costs nor undesirable effects might be a promising approach for regaining erectile function and urinary continence, and patients could be encouraged to masturbate after nsRP.
Meissner VH, Dumler S, Kron M, et al. Association between masturbation and functional outcome in the postoperative course after nerve-sparing radical prostatectomy. Transl Androl Urol. 2020;9(3):1286-1295.
About the Author
MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)
Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.
Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.