VED Therapy for erectile dysfunction following Prostate Surgery
Why are Vacuum Erection Devices (pumps) used during Penile Rehabilitation?
Penile Rehabilitation refers to optimising and preserving penile tissue integrity. It is most commonly recommended after a medical procedure such as Prostate Surgery, which results in Erectile Dysfunction due to cavernous (‘erection’) nerve trauma.
While these nerves are in a state of trauma, penile rehabilitation intends to prevent penile tissue damage, such as fibrosis, Peyronie’s Disease, venous leakage.
Maintaining regular oxygenated blood flow to the penile tissue during ED after prostate cancer treatment, helps prevent these structural changes (including penile shrinkage).
The hope is that once the cavernous nerves heal and are ‘back online', the penile tissue is in good condition to support natural erectile function again.
Using a vacuum erection device (VED) is one non-invasive way of establishing oxygenated blood flow into the penile tissue.
The pros of using a VED as part of penile rehabilitation are:
Pumps are less invasive and time consuming than penile injection therapy to create erections. Note: keep in mind though that Injection Therapy is also a great way to bring highly oxygenated blood into the penis for rehabilitation purposes. You can use a vacuum device as well as penile injections as two strategies in your rehab toolkit.
You can safely use a pump every day (or even twice a day) to replace nocturnal erection activity. Injection therapy is usually recommended at a maximum frequency of three times a week (please consult with your urologist for their opinion on frequency). This is to avoid scarring within the penis that may occur with too frequent use of injections (Book ref: ‘Prostate Cancer; 3rd Edition’, Associate Professor Prem Rashid)
With an effective constriction system used after pumping, you can maintain the erection for pleasure and intercourse if so desired. But you could also just use it for a 10 minute VED-therapy session just for exercise.
Studies suggest that daily vacuum erection device use may help restore penile length after Prostatectomy. (please see full list of references below. Key literature: Dalkin & Christopher, 2007)
That last bullet point is very important. Many men that I have consulted with say the most devastating sexual side effect of this procedure is the shortening to their penis. Some men even say they can no longer stand up to urinate, a daily reminder of what they have lost.
When should you start using a VED pump post Prostatectomy?
Earlier is better. Start as early post surgery as your medical specialist recommends. In general, the literature suggests beginning rehabilitation within the first 6 months post surgery (ref: Kohler and colleagues, 2007). There is also evidence that the structural integrity of the penile tissue changes within the first 2 months post Prostatectomy (ref: Iacono and colleagues, 2005) , so bring the conversation of Penile Rehabilitation up with your medical team early after surgery, or even better, before surgery, so you can start to think about your options.
It is safe to start penile rehabilitation while incontinent - and may help you get dry. Using a vacuum pump does not disrupt bladder control. One clinical study even started men on the vacuum device daily as early as 1-day post catheter removal. (ref: Dalkin & Christopher, 2007). There is also increasing evidence suggesting that improving oxygenation levels to the pelvic region/pelvic floor using methods like a VED, positively impact continence recovery (Gandaglia and colleagues, 2013; Meissner and colleagues; 2020).
How often should you use a vacuum pump for erectile dysfunction rehabilitation?
Gold standard = Daily. Using a pump for rehabilitation every day replaces the activity of nocturnal erectile function. You lose roughly 2000 nocturnal erections every year when you have erectile dysfunction following post-prostate surgery ED. There isn’t an exact clinical standard at this point for the number of full erections to create during a pumping session. However, as the idea is to replace nocturnal activity, men generally create around five erections per night, so that is a guideline to discuss with your healthcare provider.
Regain length lost during surgery = Daily for 90 days. In one study, almost 50% of men noticed a reduction in penile length of 1cm or more following Prostatectomy (ref: . The exact cause of this is still unknown. Some theories include the loss of some of the urethra that is cut during surgery, or alterations to the tunica albuginea (the penile tissue casing) due to nerve damage during surgery. Studies have found significant increase in size/preservation of length when men using a vacuum pump every day following surgery (ref: please see clinical literature section below, also pg. 158 of ‘Prostate Cancer; 3rd Edition’, Associate Professor Prem Rashid)
Pump for 2 weeks before applying a constriction ring system for intercourse. This gives the penile tissue time to adjust to the pressure and get used to being engorged and stretched again. It can take time for your body and mind to get used to a vacuum pump. If you are struggling to create erections using the pump after a few sessions, try tweaking the process/technique/equipment using this guide.
When should you stop using a pump?
You can stop using a pump for rehabilitation purposes when you notice consistent morning erection, nocturnal erection activity, and spontaneous erections from arousal (note: you are welcome to keep using a pump for intercourse if that’s enjoyable for you, or to ‘top up’ an erection. There are no strict rules!). However, you might want to still pump occasionally for rehab (like continuing a gym regime for maintenance purposes) in order to keep that penile tissue in the best condition possible as you age. Melissa Hadley-Barrett explains this idea in more detail here.
If you’re not seeing any progress and it's been over two years: remember, erection recovery from Prostatectomy is measured in years not months. It can take a long time for the erection nerves to recover, and spontaneous nocturnal/arousal erections rely on those nerves. Book in with a penile rehabilitation specialist to discuss your options.
If you're a few years down the line post surgery and you are not experiencing any spontaneous erectile function: it's still worth doing some activity to keep blood flow established. This helps avoid developing scar tissue buildup, which could lead to Peyronie's Disease (curvature of the penis).
As an idea, while your spontaneous/nocturnal erections are not online, think of penile rehabilitation like going to the gym. It’s an activity you do to keep all of your muscles in the best possible condition and needs regular tending, rather than something that is finite.
What is the best VED protocol for penile rehabilitation?
Doing rehabilitation exercises in ‘sets’ - just like push ups (but for your penis). Currently there is no standardised protocol that says how many sets you should do, how long for, how long to hold the erection in the pump etc. However, studies using a vacuum protocol tend to recommend doing a few ‘sets’ of erection creation per day. When you are starting out, listen to your penis, and take it slow. If it hurts, stop, and try again in a few days time. It can take time to condition the penile tissue, especially if it’s been a while since you had a full erection.
Here is a protocol for penile rehabilitation you might consider adopting with the Vacurect pump: Use the L/1/2 sized ring, whichever ring is most comfortable for you, but does not constrict the erection (you do not need to ‘keep’ the erection up using a ring when you’re using the pump for rehab purposes). Create an erection to 50% in the cylinder. Hold the erection in the cylinder for one minute to allow for blood to circulate. Remove the cylinder, the erection will go down. Re-attach the cylinder after 2 minutes. Pump up again to 75% this time with the same routine. Then repeat again to 100% erection. This process should take between 5-15 minutes.
Please listen to your penis! This is the most important point. Even if your vacuum device instructions you get say ‘10-20 pumps will give you an erection’, this is only a guideline and not an exact measure. It is important you take it very slowly at first - leave one whole minute between each pump - and always stop if you feel pain.
Choose a comfortable ring size for rehab (different to a tight ring for intercourse): for more information about choosing the best sized Vacurect ring, check out the video below:
Is it ever too late to start using a vacuum device?
It is never too late to use a vacuum device to create erections. I’ve had clients buy the Vacurect 10 years after surgery with great success (even when pills and injections did not work for them).
Using a vacuum device daily may still bring back some length and size, even when it’s been years post surgery. One study investigated the effects of men using a vacuum device daily for month before undergoing implant surgery (ref: Canguven et al., 2017). Penile length significantly increased during this time, and the surgeons performing the implant reported an easier surgery (what’s a penile implant?)
That being said - Bringing in a vacuum erection device for the first time is something you always need to discuss with your urologist.
The penile tissue is smooth muscle tissue, you can develop fibrosis and venous leakage if this part of the body is left ‘under-exercised’ for a long time.
This is why the phrase 'if you don’t use it, you lose it' is common in this space, and why we go on about doing ‘penile exercise’ after surgery to prevent these changes from occurring.
There is currently no estimations of who these side effects might happen to and after what sort of time frame, that’s why it’s important to listen to your own body and keep in touch with your medical team, especially if you notice any physiological changes on your post prostate treatment journey.
Does using a Vacuum Device bring oxygenated blood into the penile tissue?
There is a rumor about that Vacuum Devices are not suitable for rehabilitation purposes because they bring venous (de-oxygenated blood) into the penis, rather than arterial (oxygenated blood).
Honestly, I’m not sure where this rumor originated!
VEDs do indeed bring some venous blood in with the pumping motion. But more importantly, they also bring in more oxygenated blood than in the flaccid state.
One study (Lin, 2013) directly measured the difference in VED-induced blood in an animal-model. Specifically, applying to rats who have undergone cavernous nerve injury.
Yes, you now have an image of a rat using a tiny vacuum pump, sexuality research truly is weird and wonderful!
This study found the following:
“The penile SO2 was increased by VED application compared to flaccid or traction groups. The calculated blood constructs in corpus cavernosum right after VED application were more arterial blood than venous blood. This study provides the direct basic scientific evidence that VED therapy increases arterial inflow.”
Another study by Welliver and colleagues (2014) replicated this finding in humans.
“Use of the VED significantly increased both glanular and corporal oximetry relative to the baseline values for the entire 60 minutes. An initial increase of 55% was seen in corporal oxygenation with VED use.”
A recent study by Meissner and colleagues (2020) summed up the research as follows:
“In humans, penile oxygen saturation in the flaccid penis is about 49% and increases to 67% after using VED.”
Possibly the myth around venous-blood is due to the purplish-tinge some men experience with an erection created by pumping (a side effect that is perfectly normal and nothing to worry about).
It is worth noting that the use of ICI (intra-cavernosal injections) leads to 78.5% penile oxygenation saturation level, and is therefore worth trialing as part of your penile rehabilitation strategy, even though they cannot be used on a daily basis.
REF: Welliver RC Jr, Mechlin C, Goodwin B, Alukal JP, and McCullough AR. ‘A pilot study to determine penile oxygen saturation before and after vacuum therapy in patients with erectile dysfunction after radical prostatectomy’. J Sex Med 2014; 11:1071–1077.
REF: Meissner, V. H., Dumler, S., Kron, M., Schiele, S., Goethe, V. E., Bannowsky, A., ... & Herkommer, K. (2020). Association between masturbation and functional outcome in the postoperative course after nerve-sparing radical prostatectomy. Translational andrology and urology, 9(3), 1286.
What are the side effects from using a pump?
There are five main side effects you might experience - but they are all easily avoided. Overall, using a VED is one of the safest and side-effect-free ways of creating erections after Prostate Surgery.
What clinical literature is published about the effects of using VEDs for Penile Rehabilitation:
“A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy” (Kohler and colleagues, 2007) → 28 men, daily protocol for 5 months, 10 minutes a day, compared starting 1 month post surgery vs 6 months post surgery. Read the PDF for free here.
“Preservation of penile length after radical prostatectomy: early intervention with a vacuum erection device” (Dalkin & Christopher, 2007) → 42 men, daily protocol for 90 days, started day after catheter removal, results suggest early use of VED daily preserves penile length following Prostatectomy. Read the PDF for free here.
“When men do not have nocturnal erections anymore (for example, after prostate surgery due to nerve trauma) they lose out on 2000 erections a year” Podcast interview between Dr. Jo Milios and Dr. Susie Gronski. Read my article about the interview, includes link to podcast - highly recommended listening.
“Effect on sexual function of a vacuum erection device post-prostatectomy” (Engel, 2011) → 23 men, 5 days per week VED + Cialis protocol vs just Cialis without VED, for 12 months. Significantly greater sexual function recovery with combination, Read the free PDF here.
“The science of vacuum erectile device in penile rehabilitation after radical prostatectomy” (Lin & Wang, 2013) → thorough scientific and physiological explanation for VED-induced erections post Prostate Surgery. Read the free PDF here.
“The Early Use of Vacuum Therapy for Penile Rehabilitation After Radical Prostatectomy: Systematic Review and Meta-Analysis” (Qin and colleagues, 2018) → Recent analysis of all the VED studies post Prostatectomy up to 2018. Read free PDF here.
“Is the daily use of vacuum erection device for a month before penile prosthesis implantation beneficial? a randomized controlled trial” (Canguven et al., 2017) → Use of vacuum device daily for 1 month pre-implant surgery increased length and size. Read free PDF here.
Limitations of the literature (the author’s perspective):
While these study results are promising, the sample sizes are very small. This makes it difficult to extrapolate the data to all men following Prostate Surgery, given the many variables involved in sexual function recovery.
Many of these studies experience high drop-out rates during their protocol. This has historically been a major drawback of vacuum device studies. Given that I now have a few years experience following men on their own sexual recovery journeys, my theory is that unless men are given full and proper instructions around how to use a vacuum device for pleasure and convenience - as well as being given a full choice of pumps and their pros/cons (most studies assign men to one standard medical-grade device, which is not always suitable for every person), then studies will continue to experience this issue.
It is also now widely accepted that studies investigating sexual function recovery for men post Prostatectomy should record data for at least 2 years post surgery, if not more, given the length of time it takes for neuropraxia (the recovery of erection nerves surrounding the prostate) to occur.
This guide was written by A Touchy Subjects’ Founder, Victoria Cullen, and last updated September 29th, 2021.