Discussing Erectile Dysfunction After Prostate Cancer Treatment

At the 2026 Annual APP Symposium, hosted in Nashville, TN, Dan Silver, PA-C, spoke about Men’s Health to a room full of oncology professionals, ranging from oncologists to advanced practice providers to nurses. He covered topics ranging from erectile dysfunction to Peyronie’s disease.

Conversations regarding this topic, specifically erectile dysfunction (ED), remain prevalent in oncology settings because many treatments, specifically for prostate cancer, can cause ED. For prostatectomy, treatment for ED often begins soon after, and sometimes even before, treatment. Silver will start patients on tadalafil either before their surgery or at the first post-operative appointment. The conversation also touched upon the penile rehabilitation window, penis pumps, and intracavernosal injections, among other topics relating to men’s health following cancer treatment.

Silver is the lead APP at Arizona Urology in Scottsdale.

CancerNetwork: What was the primary focus of your talk on Men’s health, and why was it so important for this APP symposium?

Silver: My main focus was on erectile dysfunction, low testosterone, and Peyronie’s disease for this symposium. Mainly, the erectile dysfunction is important because a lot of guys treated with radiation, surgery, or even androgen deprivation therapy suffer from erectile dysfunction. It's my job to help them.

There's ongoing discussion about the penile rehabilitation window. In your clinical experience, how soon after prostatectomy should APPs be initiating those conversations?

Soon. Even before. I start people on daily tadalafil prior to surgery, and if they're not on it prior to surgery, I have them on it at their post-op appointment. At about 6 weeks, I start them on penile rehab with the vacuum pump, sometimes even sooner. Then, by 3 months, if they're still not getting erections, I offer them injection therapy.

What prostate cancer treatments are most likely to have ED as a potential adverse effect?

All of them. If someone's on androgen deprivation therapy, it drops their testosterone. That can cause erectile dysfunction. Obviously, prostatectomy [too]. Even though a lot of them are nerve-sparing now, they still stun the nerves, and they come back with erectile dysfunction, which could take up to 2 years to get their erections back. Then, with radiation, it's not as quick, but it could be more over time that they develop erectile dysfunction. The more that we do up front, the better off people are going to be.

How does ED treatment vary based on which prostate cancer treatment was received?

If someone's on androgen deprivation therapy, a lot of times the pills don't work. I'll try them, but a lot of times they don't work. I will go into either a vacuum pump or injection therapy with prostatectomy. I'll always start them on daily [tadalafil]. It may work, it may not, but again, we go to vacuum pumps, we go to injections. It's basically the same treatment regimen for all types of cancer. And I'm very individualized with the patients on what I do with them, depending on their past history and everything else.

Many clinicians prescribe vacuum erection devices (VED)/penis pumps for tissue preservation. Could you elaborate on the specific protocol for using a VED as a daily therapeutic exercise to prevent structural changes in the penis?

A vacuum erection device can be used either for rehab or for intercourse. For rehab, I start them early, within 6 weeks, and sometimes sooner, where I'll have them just pump their penis up, leave it pumped for about 5 to 10 minutes, and then deflate it, and they do that. I tell them to do it every day, if they can. If they want to use it for intercourse, they can slide the ring on and away they go. But no guy wants a shrunken penis, so a vacuum pump is a great way to go.

What supportive care measures can an APP implement to improve/ensure long-term adherence to ED treatment, like intracavernosal injection/vacuum erection device?

They need to work with the surgeon and build their own clinic. It's kind of like what I have, where these guys see me, either before they get their surgery or after. The APP needs to work with them and find out, “Do you want to preserve your actions?” Sometimes they won't, but if they do, we hit them hard, and we are their partner in this. I am their partner. I am with [them] through this, and we're going to get [them] through it. That's what the APP needs to do with these people.

How do you relay to them that you are with them throughout the whole process?

It's just my presence and how I come across to them. We want to be caring for these patients. Especially as a guy, we know how important erections are, and it's not only to them, but it's intimacy for their spouse too. I like for their spouses to come along and they can tell that I'm there for them and that this is what I do. I say, “This is what I do. I'm the erection guy. I got you. I'll get you an erection.” [The question is] just how we're going to do it.