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Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors
ORIGINAL RESEARCH & REVIEWS
Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors Carolyn A. Salter, MD,1 Phil Vu Bach, MD,1,2 Eduardo Miranda, MD, PhD,1,3 Lawrence C. Jenkins, MD, MBA,1,4 Nicole Benfante, BS,1 Elizabeth Schofield, MPH,5 Christian J. Nelson, PhD,5 and John P. Mulhall, MD, MSc, FECSM, FACS1
ABSTRACT
Introduction: Orgasm-associated incontinence, climacturia, is one of the lesser studied radical prostatectomy (RP) complications. Little is known about patient bother related to this condition, specifically, its prevalence and predictors. Aim: To ascertain the prevalence and predictors of patient bother associated with climacturia. Methods: Patients presenting for the evaluation of sexual dysfunction after RP at a single center were queried on various domains of sexual dysfunction. This included orgasmic dysfunction and sexual incontinence (including climacturia and arousal incontinence). Patients were specifically asked about the frequency and amount of climacturia. In addition, questions addressed patient bother and the perceived bother of their partners. Descriptive statistics were used for patient characteristics. A t-test was used for comparing the frequency of patient and partner bother, and the Pearson correlation test compared relationships between bother and predictors. Multivariable analysis was conducted to define predictors of climacturia-associated bother. Main Outcome Measure: The main outcome measures was the prevalence and predictors of climacturiaassociated patient bother and perceived partner bother. Results: Climacturia was reported by 23% of 3,207 consecutive men analyzed. Bother of any degree was experienced by 45% of these patients, and 14% reported partner bother related to this condition. Patient bother was associated with perceived partner bother (P < .001) and inversely correlated with relationship duration (P < .001). The overall frequency and quantity of climacturia were also predictive (P < .001 for both). In the adjusted model, all of these factors remained significant. Clinical Implications: Given the prevalence of this condition and the bother associated with it, this complication should be discussed with patients preoperatively. Strength & Limitations: Strengths include a large study population and specific questions on climacturiaassociated bother. Limitations include the fact that it is a single-center study and no direct partner questioning occurred. Conclusion: Climacturia and its associated bother are common after RP. The predictors of patient bother include perceived partner bother, shorter relationship duration, and increasing frequency and quantity of climacturia. Salter CA, Bach PV, Miranda E, et al. Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors. J Sex Med 2020;XX:XXXeXXX. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine.
Key Words: Climacturia; Sexual Incontinence; Orgasm-Associated Incontinence; Orgasmic Dysfunction; Orgasm; Postprostatectomy Incontinence; Sexual Dysfunction
Received June 10, 2019. Accepted December 15, 2019.
4
1
5
Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA;
2
Division of Urology, Department of Surgery, University of Alberta Faculty of Medicine and Dentistry, Edmonton, AB, Canada;
3
Division of Urology, Federal University of Ceará, Ceará, Brazil;
J Sex Med 2020;-:1e6
Urology Service, Ohio State University, Columbus, OH, USA;
Departments of Psychiatry/Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine. https://doi.org/10.1016/j.jsxm.2019.12.016
1
2
INTRODUCTION Prostate cancer is a common malignancy in men, with a 1 in 9 lifetime risk of being diagnosed with prostate cancer in the United States.1 Treatment options for prostate cancer include active surveillance, watchful waiting, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy. RP is a commonly performed operation. A study evaluating inpatient discharges after RP in the United States from 2001 to 2013 found that this number could be as high as 88,381 annually.2 Sexual incontinence is a broad term encompassing both climacturia (orgasm-associated incontinence) and arousal (foreplay) incontinence. Climacturia refers to involuntary leakage of urine at the time of orgasm. Research on sexual incontinence in men is relatively new. The first study to address orgasm-associated incontinence after RP was by Koeman et al3 in 1996, and the term climacturia was first coined by Lee et al4 in 2006. The prevalence of climacturia varies in the literature based on the definition used, with prevalence rates ranging between 20% and 93%.3e9 While several series have evaluated climacturia prevalence, only 2 of these series have evaluated the prevalence of patient bother, with 44e48% of patients reporting significant bother and 21% perceived significant bother in their partners.3,4 The aim of this study was to evaluate the prevalence of patient bother, perceived partner bother, and the predictors of each. The prevalence and predictors of climacturia will not be addressed, as this has been extensively researched in the literature. Arousal incontinence will not be discussed, as this is the topic of another research project.
METHODS Study Population This was a retrospective analysis of data collected prospectively in our clinical practice which was approved by the Institutional Review Board (Protocol #16-469). Consecutive patients at a single center who presented for the management of postoperative sexual dysfunction between May 2006 and August 2018, who had previously undergone RP, constituted the study population. Only patients experiencing orgasm were included. Patients who underwent neoadjuvant, adjuvant, or salvage radiation therapy or androgen deprivation therapy were excluded. Patients who underwent salvage prostatectomy were also excluded. Comorbidity profile and demographics were recorded.
Salter et al
Self-reported subjective quantity was categorized as small (drops), moderate (<30 mL), or large amounts (30 mL). Frequency was categorized as never, rare (<25% orgasms), occasional (25e50% orgasms), and frequent (>50% orgasms). They were also asked about their degree of bother and the perceived bother in their partner, both of which were graded as mild, moderate, or severe.
Statistics Descriptive statistics were calculated for climacturia and bother characteristics. Baseline characteristics were compared between men who reported climacturia vs those who did not use a series of independent sample t-tests and chi-square tests. Analyses related to bother were limited to patients who reported climacturia. Unadjusted logistic regression models were used to assess associations between patient characteristics and the presence of bother, for either patients or partners. 2 final models were then fitted including all predictors found significant in the unadjusted models and an adjustment for age.
RESULTS Study Population A total of 3,207 men who underwent RP were included in the analysis. The mean age was 61 ± 7 years. Most (97%) were heterosexual and 82% were Caucasian. Comorbidities included diabetes (11%), hypertension (45%), dyslipidemia (50%). 88% of men were in stable relationships with a mean duration of 27 ± 13 years. Mean partner age was 56 ± 9 years. The median time between RP and survey date was 203 days (interquartile range 85e428 days). 45% of men were less than 6 months post-op, 25% between 6e12 months post-op, and 30% were more than 12 months postoperatively. With regard to surgery type, 41% of men had a robotic-assisted laparoscopic prostatectomy, 35% had an open RP and 24% underwent a laparoscopic prostatectomy. 75% of men had bilateral nerve sparing procedures (with complete or partial nerve preservation) whereas 25% had complete nerve resection unilaterally or bilaterally. Men with climacturia were slightly younger (mean 60.3 years vs 61.6 years for men without climacturia, P < .001), had slightly younger partners (mean 55.7 years vs 56.6 years, P ¼ .03), and had higher erectile function grade (mean 2.90 vs 2.58, P ¼ .01), but did not differ significantly on other characteristics (Table 1).
Questionnaire
Climacturia
All patients received a proprietary intake questionnaire which addressed multiple domains of sexual function with structured questions on orgasmic dysfunction (presence, nature, dysorgasmia) and sexual incontinence. This was conducted during their first face-to-face post-RP evaluation by a sexual medicine clinician. With regard to sexual incontinence, they were specifically asked about the presence, quantity, and frequency of climacturia.
Overall, 745 men (23%) experienced climacturia after RP. Of these men, 70% reported a small volume of urine leakage (drops), whereas 24% reported moderate volume (<30 mL), and only 6% had large volume (30 mL). With regard to frequency, this was categorized as rare in 31%, occasional in 47%, and frequent in 22% of men. Men were separated into 3 groups based on time since RP: <6 months, 6e12 months, J Sex Med 2020;-:1e6
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Bother Associated With Climacturia
and >12 months. Neither frequency (P ¼ .36) nor quantity (P ¼ .89) differed by time since RP (Table 2).
Bother Of the men who experienced climacturia, 45% admitted to being bothered by their symptoms. 62% of men reported mild, 29% reported moderate, and 9% reported severe bother. When asked what they perceived their partner bother to be, only 15% of men believed that their partners were troubled by the climacturia. When evaluating predictors of bother, on univariable analysis, patient bother was associated with perceived partner bother (P < .001) and inversely correlated with relationship duration (P < .001). The overall frequency and quantity of climacturia (Table 3) were also predictive (P < .001 for both). Low- vs high-risk disease, nerve sparing status, RP type, erectile
grade, and patient or partner age were not predictive of patient bother. On multivariable analysis of patient bother, perceived partner bother (P < .001), shorter relationship duration (P ¼ .007), frequency (overall P < .001), and quantity (overall P ¼ .01) all remained significant (Table 4). Perceived partner bother was not significantly associated with relationship duration or quantity but was associated with patient bother (P < .001) and frequency (P < .001). In the adjusted model of perceived partner bother, both patient bother (P < .001) and frequency (overall P ¼ .004) were still significant (Table 5).
DISCUSSION Prostate cancer is the most common nonskin cancer in U.S. men, with an estimated 164,690 new cases and 29,430 deaths
Table 1. Patient (n ¼ 3,207) and partner (n ¼ 2,745) demographics Parameter
All
Climacturia
No climacturia
Patient age (years, mean ± SD) Partner age (years, mean ± SD) Percentage of men in stable relationships Relationship duration (years, mean ± SD) Sexual orientation, (%) Heterosexual Gay Bisexual Race, (%) Asian Black White Other Refused Comorbidities, (%) Hypertension Diabetes Hyperlipidemia Sleep apnea Coronary artery disease Smoking status, (%) Current Former Never Disease status, (%) High risk Low risk Nerve sparing status, (%) Preserved bilaterally Not preserved bilaterally Erectile grade, (mean ± SD) RP type, (%) LP RALP oRP
61 ± 7 56 ± 9 88% 27 ± 13
60 ± 7 56 ± 9 90% 26 ± 13
62 ± 7 57 ± 9 88% 27 ± 13
97% 3% 1%
97% 3% 1%
97% 3% 1%
2% 12% 82% 1% 3%
2% 12% 82% <1% 4%
2% 12% 82% 2% 2%
45% 11% 50% 11% 5%
44% 10% 50% 11% 4%
46% 11% 50% 11% 5%
9% 37% 54%
8% 38% 53%
9% 36% 55%
39% 61%
39% 61%
39% 61%
75% 25% 2.7 ± 2.7
74% 26% 2.9 ± 2.7
75% 25% 2.6 ± 2.7
24% 41% 35%
25% 42% 34%
24% 41% 36%
LP ¼ laparoscopic prostatectomy; oRP ¼ open radical prostatectomy; RALP ¼ robotic-assisted laparoscopic prostatectomy; RP ¼ radical prostatectomy. J Sex Med 2020;-:1e6
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Salter et al
Table 2. Comparison of the degree of climacturia across time points Characteristic
Group
<6 months (n ¼ 339)
6e12 months (n ¼ 199)
>12 months (n ¼ 209)
Quantity
Small (drops) Moderate (<30 mL) Large (30 mL) Rare (<25% orgasms) Occasional (25e50% orgasms) Frequent (>50% orgasms)
69% 26% 5% 31% 48% 21%
72% 21% 7% 34% 46% 20%
69% 24% 7% 28% 47% 26%
Frequency
P-value .89*
.36*
Time points are those after RP. *Chi-square analysis to compare the distribution of the quantity and frequency of climacturia across time.
from prostate cancer in the United States in 2018.1 Many men elect to undergo RP for getting their prostate cancer treated. A study using the Surveillance, Epidemiology and End Result (SEER) database from 2004 to 2014 found that RP was the single most common treatment modality chosen by men with prostate cancer and 37% of men elected this option.10 Thus, given the frequency of prostate cancer and RP, climacturia is a wide-spread issue. Interestingly, patients who undergo RP have a higher rate of climacturia than those undergoing radiation therapy. A study of 412 men undergoing RP or radiation found that those status post RP had a 28% rate of climacturia compared with only 5% in the radiation group (P < .001).5 Our climacturia rate (23%) is at the lower range of published literature. While Choi et al6 reported a 20% rate of climacturia in 475 men, they used a definition of 3 or more episodes, which Table 3. Unadjusted models of patient bother
Frequency of climacturia (frequent vs rare) Frequency of climacturia (occasional vs rare) Quantity of climacturia (large vs small) Quantity of climacturia (moderate vs small) Perceived partner bother (yes vs no) Patient age (per year) Disease, high risk vs low Nerve sparing status, preserved vs not RP type (LP vs RP) RP type (RALP vs RP) Erectile grade Partner age (per year) Relationship duration (per year)
OR (95% CI)
P-value
7.60 (4.67, 12.39)
<.001
2.82 (1.85, 4.30)
.89
3.60 (1.86, 7.01)
.03
3.01 (2.08, 4.36)
.05
5.26 (2.99, 9.25)
<.001
1.00 (0.98, 1.02) 0.87 (0.64, 1.19) 1.38 (0.96, 1.99)
.98 .38 .08
1.24 1.35 1.01 0.99 0.98
(0.84, 1.84) (0.96, 1.91) (0.95, 1.07) (0.97, 1.01) (0.97, 0.99)
.72 .21 .81 .24 <.001
LP ¼ laparoscopic prostatectomy; OR ¼ odds ratio; RALP ¼ roboticassisted laparoscopic prostatectomy; RP ¼ radical prostatectomy. Bolded P-values indicate statistical significance (P < .05).
explains their lower prevalence. O'Neil et al5 had an overall prevalence of 23% in their population of 412 men. However, they included men who underwent radiation as a monotherapy as well as men who underwent RP and radiation. When evaluating men who underwent RP as a monotherapy, their climacturia rate was 28%.5 This rate is similar to the series of 256 men in a study by Frey et al,7 which demonstrated a 27% occurrence of climacturia after RP. Conversely, Barnas et al,9 noted a 93% rate of climacturia in 239 men post-RP, as defined as at least one episode of climacturia postoperatively. While this broad range can be explained in part by the definition of climacturia used (any episode vs 3 or more episodes) or the patient population (surgery and/or radiation), there is still a wide disparity that is not easily explained. Our study and that of Barnas et al9 both involved men who underwent RP and used the definition of any episode of climacturia. However, their study was a retrospective survey sent out to patients and had a 68% response rate.9 This could have introduced bias, as perhaps only the men with climacturia completed the survey. In our present study, we queried all patients who underwent RP in the sexual medicine clinic, which could explain our lower prevalence. In terms of bother, 45% of men experienced bother in our series. This is similar to the 48% of men with significant bother seen in the series of 42 men in a study by Lee et al4 In that study, patients perceived bother in 21% of their partners which is somewhat higher than the 15% seen in our series. Mitchell et al11 reported similar findings, with 44% of men endorsing bother from sexual incontinence at 3 months after the operation. To our knowledge, this is the largest study to evaluate predictors of bother. Intuitively, it makes sense that patients in shorter relationships or with higher perceived partner bother would be more bothered by climacturia. Similarly, it is unsurprising that worsening symptoms in terms of frequency and quantity are also predictive of bother. There are various management strategies for climacturia described in the literature. Patients report multiple strategies such as emptying their bladder before sexual activity, limiting fluid intake, or using condoms.12 The use of a variable tension penile loop in 124 men demonstrated cure of climacturia in 48% of men with improvement in the remaining patients who reported J Sex Med 2020;-:1e6
5
Bother Associated With Climacturia
Table 4. Predictors of patient bother on multivariable analysis
Frequency: frequent vs rare Frequency: occasional vs rare Perceived partner bother (yes vs no) Quantity: moderate vs small Quantity: large vs small Relationship duration (years) Patient age (years)
OR (CI)
P-value
5.61 (2.62, 12.01) 1.96 (1.06, 3.64) 3.41 (1.71, 6.80)
<.001 .033 .001
2.22 2.63 0.97 1.00
(1.25, 3.95) (0.78, 8.90) (0.95, 0.99) (0.97, 1.04)
.006 .12 .007 .90
OR ¼ odds ratio. Bolded P-values indicate statistical significance (P < .05).
only rare or occasional climacturia while using the device.13 Pelvic floor muscle training (PFMT) may also have a role in treating climacturia. In a tiny study, a 3-month program of PFMT in 7 men improved climacturia in 43% of patients compared with 0% improvement in controls who did not undergo PFMT.14 While surgery would not be recommended for men with sexual incontinence who were otherwise continent, a study on 11 men with stress urinary incontinence and sexual incontinence found that all men undergoing implant of an artificial urinary sphincter and 57% of men status post sling had improvement in their sexual quality of life.15 The strengths of this study include a much larger sample size for this specific patient population than those of other studies. In addition, to our knowledge, this is one of the first studies to assess patient bother secondary to climacturia and the first study assessing predictors of patient and perceived partner bother. This study has limitations in that it is a single-center study, and thus, the results may not be generalizable to the other centers. The study is also cross-sectional in nature; thus, we do not have timeto-event outcomes nor can all associations be assumed causal. Furthermore, the patients were all presenting to clinic for sexual dysfunction after RP which could introduce bias. The degree of climacturia was assessed subjectively by the patients. This introduces a limitation, as recall bias and subjective measurement are notoriously inaccurate. In addition, we did not use validated questionnaires as none exist for the evaluation of sexual incontinence. Finally, we were unable to assess partner bother directly and relied on patient perceptions.
being to query the partners themselves. In addition, we would like to assess the efficacy of preoperative climacturia counseling and postoperative management strategies on preventing patient bother.
CONCLUSIONS Climacturia occurs in more than one-fifth of men who underwent RP in this analysis. 45% of men reported bother related to their climacturia, while their perceived partner bother was relatively low, being reported by 15% of patients. Predictors of patient bother include worsening climacturia (frequency and quantity), perceived partner bother, and shorter relationship duration. Corresponding Author: John P. Mulhall, MD, MSc, FECSM, FACS, Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 16. East 60th Street, Suite 402, New York, NY 10022, USA. Tel: 646-888-6024; Fax: 646-888-6452; E-mail: [email protected] Conflict of Interest: The authors report no conflicts of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design John P. Mulhall; Christian J. Nelson (b) Acquisition of Data Carolyn A. Salter; Eduardo Miranda; Lawrence C. Jenkins; Phil Vu Bach; Nicole Benfante (c) Analysis and Interpretation of Data Christian J. Nelson; Elizabeth Schofield Category 2 (a) Drafting the Article Carolyn A. Salter; John P. Mulhall (b) Revising It for Intellectual Content Carolyn A. Salter; John P. Mulhall; Elizabeth Schofield Category 3
In terms of future directions for research, it would be ideal to obtain first-hand information on partner bother, the next step
(a) Final Approval of the Completed Article Christian J. Nelson; John P. Mulhall
Table 5. Predictors of perceived partner bother on multivariable
REFERENCES
analysis
Patient bother Frequency: frequent vs rare Frequency: occasional vs rare Age J Sex Med 2020;-:1e6
OR (95% CI)
P-value
1. Society AC. Facts & figures 2018. Atlanta, GA: American Cancer Society; 2018.
4.57 3.46 1.42 0.98
<.001 .005 .41 .39
2. Halpern JA, Shoag JE, Artis AS, et al. National trends in prostate biopsy and radical prostatectomy volumes following the US preventive services task force guidelines against prostate-specific antigen screening. JAMA Surg 2017; 152:192-198.
(2.44, 8.55) (1.47, 8.15) (0.62, 3.23) (0.95, 1.02)
6 3. Koeman M, van Driel MF, Schultz WC, et al. Orgasm after radical prostatectomy. Br J Urol 1996;77:861-864. 4. Lee J, Hersey K, Lee CT, et al. Climacturia following radical prostatectomy: prevalence and risk factors. J Urol 2006; 176:2562-2565 [discussion: 65]. 5. O'Neil BB, Presson A, Gannon J, et al. Climacturia after definitive treatment of prostate cancer. J Urol 2014;191:159163. 6. Choi JM, Nelson CJ, Stasi J, et al. Orgasm associated incontinence (climacturia) following radical pelvic surgery: rates of occurrence and predictors. J Urol 2007;177:2223-2226. 7. Frey A, Sonksen J, Jakobsen H, et al. Prevalence and predicting factors for commonly neglected sexual side effects to radical prostatectomies: results from a cross-sectional questionnaire-based study. J Sex Med 2014;11:2318-2326. 8. Nilsson AE, Carlsson S, Johansson E, et al. Orgasm-associated urinary incontinence and sexual life after radical prostatectomy. J Sex Med 2011;8:2632-2639. 9. Barnas JL, Pierpaoli S, Ladd P, et al. The prevalence and nature of orgasmic dysfunction after radical prostatectomy. BJU Int 2004;94:603-605. 10. Burt LM, Shrieve DC, Tward JD. Factors influencing prostate cancer patterns of care: an analysis of treatment variation using the SEER database. Adv Radiat Oncol 2018;3:170-180.
Salter et al 11. Mitchell SA, Jain RK, Laze J, et al. Post-prostatectomy incontinence during sexual activity: a single center prevalence study. J Urol 2011;186:982-985. 12. Mendez MH, Sexton SJ, Lentz AC. Contemporary review of male and female climacturia and urinary leakage during sexual activities. Sex Med Rev 2018;6:16-28. 13. Mehta A, Deveci S, Mulhall JP. Efficacy of a penile variable tension loop for improving climacturia after radical prostatectomy. BJU Int 2013;111:500-504. 14. Geraerts I, Van Poppel H, Devoogdt N, et al. Pelvic floor muscle training for erectile dysfunction and climacturia 1 year after nerve sparing radical prostatectomy: a randomized controlled trial. Int J Impot Res 2016;28:9-13. 15. Jain R, Mitchell S, Laze J, et al. The effect of surgical intervention for stress urinary incontinence (UI) on postprostatectomy UI during sexual activity. BJU Int 2012; 109:1208-1212.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.jsxm.2019.12.016.
J Sex Med 2020;-:1e6
Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors Carolyn A. Salter, MD,1 Phil Vu Bach, MD,1,2 Eduardo Miranda, MD, PhD,1,3 Lawrence C. Jenkins, MD, MBA,1,4 Nicole Benfante, BS,1 Elizabeth Schofield, MPH,5 Christian J. Nelson, PhD,5 and John P. Mulhall, MD, MSc, FECSM, FACS1
ABSTRACT
Introduction: Orgasm-associated incontinence, climacturia, is one of the lesser studied radical prostatectomy (RP) complications. Little is known about patient bother related to this condition, specifically, its prevalence and predictors. Aim: To ascertain the prevalence and predictors of patient bother associated with climacturia. Methods: Patients presenting for the evaluation of sexual dysfunction after RP at a single center were queried on various domains of sexual dysfunction. This included orgasmic dysfunction and sexual incontinence (including climacturia and arousal incontinence). Patients were specifically asked about the frequency and amount of climacturia. In addition, questions addressed patient bother and the perceived bother of their partners. Descriptive statistics were used for patient characteristics. A t-test was used for comparing the frequency of patient and partner bother, and the Pearson correlation test compared relationships between bother and predictors. Multivariable analysis was conducted to define predictors of climacturia-associated bother. Main Outcome Measure: The main outcome measures was the prevalence and predictors of climacturiaassociated patient bother and perceived partner bother. Results: Climacturia was reported by 23% of 3,207 consecutive men analyzed. Bother of any degree was experienced by 45% of these patients, and 14% reported partner bother related to this condition. Patient bother was associated with perceived partner bother (P < .001) and inversely correlated with relationship duration (P < .001). The overall frequency and quantity of climacturia were also predictive (P < .001 for both). In the adjusted model, all of these factors remained significant. Clinical Implications: Given the prevalence of this condition and the bother associated with it, this complication should be discussed with patients preoperatively. Strength & Limitations: Strengths include a large study population and specific questions on climacturiaassociated bother. Limitations include the fact that it is a single-center study and no direct partner questioning occurred. Conclusion: Climacturia and its associated bother are common after RP. The predictors of patient bother include perceived partner bother, shorter relationship duration, and increasing frequency and quantity of climacturia. Salter CA, Bach PV, Miranda E, et al. Bother Associated With Climacturia After Radical Prostatectomy: Prevalence and Predictors. J Sex Med 2020;XX:XXXeXXX. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine.
Key Words: Climacturia; Sexual Incontinence; Orgasm-Associated Incontinence; Orgasmic Dysfunction; Orgasm; Postprostatectomy Incontinence; Sexual Dysfunction
Received June 10, 2019. Accepted December 15, 2019.
4
1
5
Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA;
2
Division of Urology, Department of Surgery, University of Alberta Faculty of Medicine and Dentistry, Edmonton, AB, Canada;
3
Division of Urology, Federal University of Ceará, Ceará, Brazil;
J Sex Med 2020;-:1e6
Urology Service, Ohio State University, Columbus, OH, USA;
Departments of Psychiatry/Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine. https://doi.org/10.1016/j.jsxm.2019.12.016
1
2
INTRODUCTION Prostate cancer is a common malignancy in men, with a 1 in 9 lifetime risk of being diagnosed with prostate cancer in the United States.1 Treatment options for prostate cancer include active surveillance, watchful waiting, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy. RP is a commonly performed operation. A study evaluating inpatient discharges after RP in the United States from 2001 to 2013 found that this number could be as high as 88,381 annually.2 Sexual incontinence is a broad term encompassing both climacturia (orgasm-associated incontinence) and arousal (foreplay) incontinence. Climacturia refers to involuntary leakage of urine at the time of orgasm. Research on sexual incontinence in men is relatively new. The first study to address orgasm-associated incontinence after RP was by Koeman et al3 in 1996, and the term climacturia was first coined by Lee et al4 in 2006. The prevalence of climacturia varies in the literature based on the definition used, with prevalence rates ranging between 20% and 93%.3e9 While several series have evaluated climacturia prevalence, only 2 of these series have evaluated the prevalence of patient bother, with 44e48% of patients reporting significant bother and 21% perceived significant bother in their partners.3,4 The aim of this study was to evaluate the prevalence of patient bother, perceived partner bother, and the predictors of each. The prevalence and predictors of climacturia will not be addressed, as this has been extensively researched in the literature. Arousal incontinence will not be discussed, as this is the topic of another research project.
METHODS Study Population This was a retrospective analysis of data collected prospectively in our clinical practice which was approved by the Institutional Review Board (Protocol #16-469). Consecutive patients at a single center who presented for the management of postoperative sexual dysfunction between May 2006 and August 2018, who had previously undergone RP, constituted the study population. Only patients experiencing orgasm were included. Patients who underwent neoadjuvant, adjuvant, or salvage radiation therapy or androgen deprivation therapy were excluded. Patients who underwent salvage prostatectomy were also excluded. Comorbidity profile and demographics were recorded.
Salter et al
Self-reported subjective quantity was categorized as small (drops), moderate (<30 mL), or large amounts (30 mL). Frequency was categorized as never, rare (<25% orgasms), occasional (25e50% orgasms), and frequent (>50% orgasms). They were also asked about their degree of bother and the perceived bother in their partner, both of which were graded as mild, moderate, or severe.
Statistics Descriptive statistics were calculated for climacturia and bother characteristics. Baseline characteristics were compared between men who reported climacturia vs those who did not use a series of independent sample t-tests and chi-square tests. Analyses related to bother were limited to patients who reported climacturia. Unadjusted logistic regression models were used to assess associations between patient characteristics and the presence of bother, for either patients or partners. 2 final models were then fitted including all predictors found significant in the unadjusted models and an adjustment for age.
RESULTS Study Population A total of 3,207 men who underwent RP were included in the analysis. The mean age was 61 ± 7 years. Most (97%) were heterosexual and 82% were Caucasian. Comorbidities included diabetes (11%), hypertension (45%), dyslipidemia (50%). 88% of men were in stable relationships with a mean duration of 27 ± 13 years. Mean partner age was 56 ± 9 years. The median time between RP and survey date was 203 days (interquartile range 85e428 days). 45% of men were less than 6 months post-op, 25% between 6e12 months post-op, and 30% were more than 12 months postoperatively. With regard to surgery type, 41% of men had a robotic-assisted laparoscopic prostatectomy, 35% had an open RP and 24% underwent a laparoscopic prostatectomy. 75% of men had bilateral nerve sparing procedures (with complete or partial nerve preservation) whereas 25% had complete nerve resection unilaterally or bilaterally. Men with climacturia were slightly younger (mean 60.3 years vs 61.6 years for men without climacturia, P < .001), had slightly younger partners (mean 55.7 years vs 56.6 years, P ¼ .03), and had higher erectile function grade (mean 2.90 vs 2.58, P ¼ .01), but did not differ significantly on other characteristics (Table 1).
Questionnaire
Climacturia
All patients received a proprietary intake questionnaire which addressed multiple domains of sexual function with structured questions on orgasmic dysfunction (presence, nature, dysorgasmia) and sexual incontinence. This was conducted during their first face-to-face post-RP evaluation by a sexual medicine clinician. With regard to sexual incontinence, they were specifically asked about the presence, quantity, and frequency of climacturia.
Overall, 745 men (23%) experienced climacturia after RP. Of these men, 70% reported a small volume of urine leakage (drops), whereas 24% reported moderate volume (<30 mL), and only 6% had large volume (30 mL). With regard to frequency, this was categorized as rare in 31%, occasional in 47%, and frequent in 22% of men. Men were separated into 3 groups based on time since RP: <6 months, 6e12 months, J Sex Med 2020;-:1e6
3
Bother Associated With Climacturia
and >12 months. Neither frequency (P ¼ .36) nor quantity (P ¼ .89) differed by time since RP (Table 2).
Bother Of the men who experienced climacturia, 45% admitted to being bothered by their symptoms. 62% of men reported mild, 29% reported moderate, and 9% reported severe bother. When asked what they perceived their partner bother to be, only 15% of men believed that their partners were troubled by the climacturia. When evaluating predictors of bother, on univariable analysis, patient bother was associated with perceived partner bother (P < .001) and inversely correlated with relationship duration (P < .001). The overall frequency and quantity of climacturia (Table 3) were also predictive (P < .001 for both). Low- vs high-risk disease, nerve sparing status, RP type, erectile
grade, and patient or partner age were not predictive of patient bother. On multivariable analysis of patient bother, perceived partner bother (P < .001), shorter relationship duration (P ¼ .007), frequency (overall P < .001), and quantity (overall P ¼ .01) all remained significant (Table 4). Perceived partner bother was not significantly associated with relationship duration or quantity but was associated with patient bother (P < .001) and frequency (P < .001). In the adjusted model of perceived partner bother, both patient bother (P < .001) and frequency (overall P ¼ .004) were still significant (Table 5).
DISCUSSION Prostate cancer is the most common nonskin cancer in U.S. men, with an estimated 164,690 new cases and 29,430 deaths
Table 1. Patient (n ¼ 3,207) and partner (n ¼ 2,745) demographics Parameter
All
Climacturia
No climacturia
Patient age (years, mean ± SD) Partner age (years, mean ± SD) Percentage of men in stable relationships Relationship duration (years, mean ± SD) Sexual orientation, (%) Heterosexual Gay Bisexual Race, (%) Asian Black White Other Refused Comorbidities, (%) Hypertension Diabetes Hyperlipidemia Sleep apnea Coronary artery disease Smoking status, (%) Current Former Never Disease status, (%) High risk Low risk Nerve sparing status, (%) Preserved bilaterally Not preserved bilaterally Erectile grade, (mean ± SD) RP type, (%) LP RALP oRP
61 ± 7 56 ± 9 88% 27 ± 13
60 ± 7 56 ± 9 90% 26 ± 13
62 ± 7 57 ± 9 88% 27 ± 13
97% 3% 1%
97% 3% 1%
97% 3% 1%
2% 12% 82% 1% 3%
2% 12% 82% <1% 4%
2% 12% 82% 2% 2%
45% 11% 50% 11% 5%
44% 10% 50% 11% 4%
46% 11% 50% 11% 5%
9% 37% 54%
8% 38% 53%
9% 36% 55%
39% 61%
39% 61%
39% 61%
75% 25% 2.7 ± 2.7
74% 26% 2.9 ± 2.7
75% 25% 2.6 ± 2.7
24% 41% 35%
25% 42% 34%
24% 41% 36%
LP ¼ laparoscopic prostatectomy; oRP ¼ open radical prostatectomy; RALP ¼ robotic-assisted laparoscopic prostatectomy; RP ¼ radical prostatectomy. J Sex Med 2020;-:1e6
4
Salter et al
Table 2. Comparison of the degree of climacturia across time points Characteristic
Group
<6 months (n ¼ 339)
6e12 months (n ¼ 199)
>12 months (n ¼ 209)
Quantity
Small (drops) Moderate (<30 mL) Large (30 mL) Rare (<25% orgasms) Occasional (25e50% orgasms) Frequent (>50% orgasms)
69% 26% 5% 31% 48% 21%
72% 21% 7% 34% 46% 20%
69% 24% 7% 28% 47% 26%
Frequency
P-value .89*
.36*
Time points are those after RP. *Chi-square analysis to compare the distribution of the quantity and frequency of climacturia across time.
from prostate cancer in the United States in 2018.1 Many men elect to undergo RP for getting their prostate cancer treated. A study using the Surveillance, Epidemiology and End Result (SEER) database from 2004 to 2014 found that RP was the single most common treatment modality chosen by men with prostate cancer and 37% of men elected this option.10 Thus, given the frequency of prostate cancer and RP, climacturia is a wide-spread issue. Interestingly, patients who undergo RP have a higher rate of climacturia than those undergoing radiation therapy. A study of 412 men undergoing RP or radiation found that those status post RP had a 28% rate of climacturia compared with only 5% in the radiation group (P < .001).5 Our climacturia rate (23%) is at the lower range of published literature. While Choi et al6 reported a 20% rate of climacturia in 475 men, they used a definition of 3 or more episodes, which Table 3. Unadjusted models of patient bother
Frequency of climacturia (frequent vs rare) Frequency of climacturia (occasional vs rare) Quantity of climacturia (large vs small) Quantity of climacturia (moderate vs small) Perceived partner bother (yes vs no) Patient age (per year) Disease, high risk vs low Nerve sparing status, preserved vs not RP type (LP vs RP) RP type (RALP vs RP) Erectile grade Partner age (per year) Relationship duration (per year)
OR (95% CI)
P-value
7.60 (4.67, 12.39)
<.001
2.82 (1.85, 4.30)
.89
3.60 (1.86, 7.01)
.03
3.01 (2.08, 4.36)
.05
5.26 (2.99, 9.25)
<.001
1.00 (0.98, 1.02) 0.87 (0.64, 1.19) 1.38 (0.96, 1.99)
.98 .38 .08
1.24 1.35 1.01 0.99 0.98
(0.84, 1.84) (0.96, 1.91) (0.95, 1.07) (0.97, 1.01) (0.97, 0.99)
.72 .21 .81 .24 <.001
LP ¼ laparoscopic prostatectomy; OR ¼ odds ratio; RALP ¼ roboticassisted laparoscopic prostatectomy; RP ¼ radical prostatectomy. Bolded P-values indicate statistical significance (P < .05).
explains their lower prevalence. O'Neil et al5 had an overall prevalence of 23% in their population of 412 men. However, they included men who underwent radiation as a monotherapy as well as men who underwent RP and radiation. When evaluating men who underwent RP as a monotherapy, their climacturia rate was 28%.5 This rate is similar to the series of 256 men in a study by Frey et al,7 which demonstrated a 27% occurrence of climacturia after RP. Conversely, Barnas et al,9 noted a 93% rate of climacturia in 239 men post-RP, as defined as at least one episode of climacturia postoperatively. While this broad range can be explained in part by the definition of climacturia used (any episode vs 3 or more episodes) or the patient population (surgery and/or radiation), there is still a wide disparity that is not easily explained. Our study and that of Barnas et al9 both involved men who underwent RP and used the definition of any episode of climacturia. However, their study was a retrospective survey sent out to patients and had a 68% response rate.9 This could have introduced bias, as perhaps only the men with climacturia completed the survey. In our present study, we queried all patients who underwent RP in the sexual medicine clinic, which could explain our lower prevalence. In terms of bother, 45% of men experienced bother in our series. This is similar to the 48% of men with significant bother seen in the series of 42 men in a study by Lee et al4 In that study, patients perceived bother in 21% of their partners which is somewhat higher than the 15% seen in our series. Mitchell et al11 reported similar findings, with 44% of men endorsing bother from sexual incontinence at 3 months after the operation. To our knowledge, this is the largest study to evaluate predictors of bother. Intuitively, it makes sense that patients in shorter relationships or with higher perceived partner bother would be more bothered by climacturia. Similarly, it is unsurprising that worsening symptoms in terms of frequency and quantity are also predictive of bother. There are various management strategies for climacturia described in the literature. Patients report multiple strategies such as emptying their bladder before sexual activity, limiting fluid intake, or using condoms.12 The use of a variable tension penile loop in 124 men demonstrated cure of climacturia in 48% of men with improvement in the remaining patients who reported J Sex Med 2020;-:1e6
5
Bother Associated With Climacturia
Table 4. Predictors of patient bother on multivariable analysis
Frequency: frequent vs rare Frequency: occasional vs rare Perceived partner bother (yes vs no) Quantity: moderate vs small Quantity: large vs small Relationship duration (years) Patient age (years)
OR (CI)
P-value
5.61 (2.62, 12.01) 1.96 (1.06, 3.64) 3.41 (1.71, 6.80)
<.001 .033 .001
2.22 2.63 0.97 1.00
(1.25, 3.95) (0.78, 8.90) (0.95, 0.99) (0.97, 1.04)
.006 .12 .007 .90
OR ¼ odds ratio. Bolded P-values indicate statistical significance (P < .05).
only rare or occasional climacturia while using the device.13 Pelvic floor muscle training (PFMT) may also have a role in treating climacturia. In a tiny study, a 3-month program of PFMT in 7 men improved climacturia in 43% of patients compared with 0% improvement in controls who did not undergo PFMT.14 While surgery would not be recommended for men with sexual incontinence who were otherwise continent, a study on 11 men with stress urinary incontinence and sexual incontinence found that all men undergoing implant of an artificial urinary sphincter and 57% of men status post sling had improvement in their sexual quality of life.15 The strengths of this study include a much larger sample size for this specific patient population than those of other studies. In addition, to our knowledge, this is one of the first studies to assess patient bother secondary to climacturia and the first study assessing predictors of patient and perceived partner bother. This study has limitations in that it is a single-center study, and thus, the results may not be generalizable to the other centers. The study is also cross-sectional in nature; thus, we do not have timeto-event outcomes nor can all associations be assumed causal. Furthermore, the patients were all presenting to clinic for sexual dysfunction after RP which could introduce bias. The degree of climacturia was assessed subjectively by the patients. This introduces a limitation, as recall bias and subjective measurement are notoriously inaccurate. In addition, we did not use validated questionnaires as none exist for the evaluation of sexual incontinence. Finally, we were unable to assess partner bother directly and relied on patient perceptions.
being to query the partners themselves. In addition, we would like to assess the efficacy of preoperative climacturia counseling and postoperative management strategies on preventing patient bother.
CONCLUSIONS Climacturia occurs in more than one-fifth of men who underwent RP in this analysis. 45% of men reported bother related to their climacturia, while their perceived partner bother was relatively low, being reported by 15% of patients. Predictors of patient bother include worsening climacturia (frequency and quantity), perceived partner bother, and shorter relationship duration. Corresponding Author: John P. Mulhall, MD, MSc, FECSM, FACS, Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 16. East 60th Street, Suite 402, New York, NY 10022, USA. Tel: 646-888-6024; Fax: 646-888-6452; E-mail: [email protected] Conflict of Interest: The authors report no conflicts of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design John P. Mulhall; Christian J. Nelson (b) Acquisition of Data Carolyn A. Salter; Eduardo Miranda; Lawrence C. Jenkins; Phil Vu Bach; Nicole Benfante (c) Analysis and Interpretation of Data Christian J. Nelson; Elizabeth Schofield Category 2 (a) Drafting the Article Carolyn A. Salter; John P. Mulhall (b) Revising It for Intellectual Content Carolyn A. Salter; John P. Mulhall; Elizabeth Schofield Category 3
In terms of future directions for research, it would be ideal to obtain first-hand information on partner bother, the next step
(a) Final Approval of the Completed Article Christian J. Nelson; John P. Mulhall
Table 5. Predictors of perceived partner bother on multivariable
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SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.jsxm.2019.12.016.
J Sex Med 2020;-:1e6