Cognitive Therapy Boosts Penile Injection Compliance Post-Prostatectomy

SCOTTSDALE, Ariz. — A targeted kind of cognitive behavioral therapy appeared to boost confidence in men who were wary of penile injection regimens to ward off impotence after prostatectomy, a researcher reported.

At 8 months, patients in the therapy program were giving themselves a mean of 1.2 injections per week compared with 0.7 in the control group (P=0.03, d=1.08).

Those in the therapy group also had statistically significant changes in measurements of sexual self-esteem (up 9.1 points on a scale of 0-100 vs controls; P=0.05, d=0.70) and prostate cancer treatment regret (down 3.9 points on a scale of 0-25 vs controls, P=0.02, d=0.93).

“The therapy generally works by giving men a new framework to use to help them reduce avoidance of injections,” said Christian J. Nelson, PhD, of Memorial Sloan Kettering Cancer Center in New York City, who presented the findings via video at the annual scientific meeting of the Sexual Medicine Society of North America.

“We have found that this therapy can help men utilize injections more frequently than men who have not participated in this therapy,” Nelson told MedPage Today. “We have also found it helps other aspects related to sexuality, such as increasing sexual satisfaction.”

Penile injections are an alternate treatment for men with erectile dysfunction (ED) who don’t respond to drugs like sildenafil (Viagra) and tadalafil (Cialis). But injecting one’s own penis, to put it mildly, is not as easy as popping a pill.

“Some men just refuse and won’t give it a try,” although those who do usually admit it’s not as painful as they feared, said Aram Loeb, MD, of University Hospitals in Parma, Ohio, who wasn’t involved with the study. “The discontinuation rates are very high among those who do get started on it due to inconvenience, cost, mixed results, etc.,” he told MedPage Today.

According to Nelson and colleagues, research has found that only 16% of men who undergo prostatectomy return to their baseline erection strength. “Penile rehabilitation” programs aim to restore erections via 2 to 3 injection-assisted erections each week. But many men drop out of these programs, and the wide majority don’t inject themselves as often as recommended.

Many men are anxious about having ED and feel “pressure to perform,” Nelson said, leading them to avoid sexual activity. “If men do not have consistent erectile activity after prostatectomy, it can impede the erectile recovery process.”

Nelson and colleagues adapted a form of “mindfulness” training known as Acceptance and Commitment Therapy (ACT) to improve compliance with the penile injections. “The impetus for using ACT is that it has a nice way to think about reducing avoidance to activities we are anxious about,” he explained. “It just seemed like it fit really well with men’s experience with ED and using erectile aids after surgery.”

For the study, the researchers randomly assigned 53 men after prostatectomy to penile injection training plus either ACT designed to treat ED or phone calls with a nurse practitioner (control group). Another 31 men declined to participate. The average age of participants was 60, 82% were white, 18% were Black, and 73% were partnered.

Over 4 months, patients in the ACT arm took part in four individual sessions of 30 to 45 minutes in person or by phone plus three check-in calls of 5 to 10 minutes. In the control group, men participated in seven phone calls with a nurse practitioner on the same schedule as the ACT.

At the end of 4 months, 71% of men in both groups remained in the trial. The mean number of injections per week was higher in the intervention group than the control group (1.7 vs 0.9; P=0.001, d=1.25), as was adherence to recommendations of at least two penile injections per week (44% vs 10%; P=0.04).

But by 8 months, there wasn’t a statistically significant difference between the groups in terms of adherence (18% vs 0%, respectively; P=0.18).

Psychologists who specialize in cancer provided the intervention sessions, and the program was free to participants, Nelson said. He couldn’t be reached to provide further information about the cost to the institution.

Loeb called the study findings promising. However, “we normally have 5 to 10 minutes with each patient and 30 patients to get to during the day, so having the time or resources such as ancillary staff to administer this therapy would be very difficult. Large institutions may have those capabilities, but many places don’t,” he noted.

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    Randy Dotinga is a freelance medical and science journalist based in San Diego.

Disclosures

The study was funded by the National Institutes of Health.

The study authors and Loeb reported no disclosures.

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