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Climacturia Following Radical Prostatectomy: Prevalence and Risk Factors
Climacturia Following Radical Prostatectomy: Prevalence and Risk Factors Jason Lee, Karen Hersey, Charlotte T. Lee and Neil Fleshner* From the University Health Network (Princess Margaret Hospital), University of Toronto, Toronto, Ontario
Purpose: Following radical prostatectomy urine leakage during orgasm is a poorly defined entity. We defined the prevalence, quantity, bother and coping mechanisms associated with this complication, called climacturia. Materials and Methods: A self-administered questionnaire was given to a cohort of sexually active men after radical prostatectomy. We inquired about the frequency, quantity, bother and coping mechanisms associated with climacturia. We also recorded uroflowmetry and an American Urological Association symptom score (International Prostate Symptom Score) in each patient. Results: Of the 42 patients enrolled with a mean age of 58.9 years and average time since radical prostatectomy of 23.6 months climacturia was reported in 19 (45%). Of the men 68% reported that it happened rarely or only occasionally, while 21% reported that it occurred most of the time or always. In terms of urine quantity 58% of respondents reported only a few drops but 16% reported a loss of more than 1 ounce. Of the patients 52% percent reported no or minimal bother but 48% reported that climacturia caused significant bother. Only 21% of respondents thought that it was of significant bother to their partners. Of the respondents 84% emptied the bladder before intercourse and 11% used condoms. Age, Gleason score and time since surgery were not predictors of climacturia. No association between peak urine flow on uroflowmetry or International Prostate Symptom Score and climacturia was found. Conclusions: Climacturia is a common clinical entity, occurring in almost half of all patients after radical prostatectomy. It can be a significant problem with respect to urine volume loss, associated bother and condom use. Patients must be informed about this complication before undergoing radical prostatectomy. Key Words: prostate, prostatectomy, questionnaires, urination disorders, orgasm
adical prostatectomy is associated with low perioperative morbidity and mortality.1–3 However, late complications continue to be an ongoing problem. Urinary incontinence is a well accepted complication following RP. Although the reported rates of incontinence varies, groups at most tertiary care centers report that 5% to 10% of patients are persistently incontinent after RP.3–5 Erectile dysfunction is another common complication following RP. However, with the advent of the nerve sparing method the rate of erectile dysfunction continues to improve.3–5 Although urinary incontinence and erectile dysfunction are well studied entities following RP, there is a relative paucity of research with regard to the quality of sexual life after RP, particularly concerning orgasm. In the last decade an increasing number of groups have examined the qualitative aspects of sexual functioning after RP, examining issues such as sexual desire, spousal satisfaction, psychological impact on relationships and other overall health related quality of life indexes.6 –9 Recently it came to our attention that some after patients who underwent RP and who were potent enough to participate in sexual activity noticed various amounts of urine leakage at the moment of climax. After a literature search we found only 2 studies specifically describing sexual climax associated uri-
R
Submitted for publication December 14, 2005. Study received review ethics board approval. * Financial interest and/or other relationship with AstraZeneca, BioRovantex, Merck and Abbott.
0022-5347/06/1766-2562/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
nary incontinence, although it is our belief that it is a much more prevalent problem.9,10 We describe the prevalence of urine leakage at the moment of climax, which we call climacturia. In addition, we describe its degree, associated impact on bother and patient related methods of coping.
METHODS Patients were enrolled from the outpatient clinic of one of the staff urological surgeons (NF). Patients were enrolled by consecutive recruitment. All patients seen in the clinic who had undergone RP were consecutively screened for suitability for study participation. In each suitable patient it was at least 12 months after RP and he was potent enough with and without phosphodiesterase-5 inhibitors to engage in sexual activity (intercourse or masturbation) within 6 months of assessment. Patients who had received other treatment modalities for prostate cancer, eg brachytherapy, radiation therapy or high intensity focused ultrasound, were excluded from study. Patients who had undergone any other lower urinary tract surgery, eg transurethral prostate resection, visual internal urethrotomy or urethroplasty, were also excluded. After patients met all inclusion criteria and consented to participate in the study they were given a self-administered questionnaire, which they completed and returned (see Appendix). The questionnaire examined aspects of climacturia, such as frequency, quantity of urine loss, coping mechanisms used
2562
Vol. 176, 2562-2565, December 2006 Printed in U.S.A. DOI:10.1016/j.juro.2006.07.158
CLIMACTURIA AFTER RADICAL PROSTATECTOMY
2563
TABLE 1. Baseline characteristics No. pts Mean age Mean time since RP (mos) Mean Gleason score* Mean peak urine flow on uroflowmetry (cc/sec) Mean I-PSS No. incontinence No. using aids No. with climacturia
42 58.9 23.6 6.6 16.6 7.4 3 22 19
* Unavailable in 8 patients.
FIG. 1. Climacturia frequency
by the patient and level of bother. The patient American Urological Association symptom score (I-PSS) was also determined. Because we were interested in the final caliber of the vesicourethral anastomosis and its association with climacturia, we also measured the peak flow rate via uroflowmetry. A minimum of 125 cc voided volume was considered useful for data analyses. Additional demographic and disease specific covariates were obtained from the patient chart. Review ethics board approval was secured for this study. Data were assembled in a Microsoft® Excel® spreadsheet. Men with and without climacturia were then compared using chi-square analysis and the t test for categorical and continuous covariates, respectively. All hypothesis testing was 2-sided with ⬍0.05 considered significant. RESULTS A total of 61 patients were screened and 42 were enrolled, of whom each fully completed the questionnaire and was able to provide an adequate urine volume for valid peak flow rate measurement. Table 1 lists patient demographics. Mean patient age at recruitment was 58.9 years (range 51 to 71) and mean time since surgery was 23.6 months (range 12 to 60). The mean peak flow rate was 16.6 cc per second (range 4.3 to 45.2). Of the 42 patients enrolled in the study 19 (45%) reported some degree of climacturia. Patients with climacturia were comparable in age, time since surgery and Gleason score to those without climacturia (table 2). Patients with climacturia had a trend toward a lower mean peak flow rate (14.6 vs 18.3 cc per second) and a higher mean I-PSS (9.1 vs 6.0). A higher percent of those with climacturia used aids to achieve erection (63.2% vs 43.5%) and experienced incontinence (10.5% vs 4.3%). No patient used any type of aid other than phosphodiesterase-5 inhibitors. None of these associations were statistically significant (table 2).
TABLE 2. Climacturia
No. pts Mean age ⫾ SD Mean time since RP in months (S.D.) Mean Gleason score* Mean I-PSS No. urinary incontinence† No. using aids to enhance erection‡ Mean peak urine flow on uroflowmetry (cc/sec)
Climacturia
No Climacturia
p Value
19 59.8 ⫾ 6.9 23.7 (17.0)
23 58.2 ⫾ 4.7 23.4 (13.9)
0.38 0.95
6.4 9.1 2 12
6.8 6 1 10
0.41 0.15 0.34 0.44
14.59
18.34
0.20
* Unavailable in 4 patients per group. † Greater than 1 pad daily. ‡ Oral medications or injection.
Four of the 19 patients (21%) who complained of climax associated incontinence stated that they experienced climacturia only rarely, 9 (47%) experienced it occasionally, 2 (11%) experienced it often, 3 (16%) experienced it most of the time and 1 (5%) stated that he experienced it all of the time (fig. 1). With regard to urine leakage volume 11 patients (58%) reported only a few drops. Five patients (26%) stated that they lost an ounce of urine each time, 2 (11%) stated that they lost between 1 and 5 ounces, and 1 (5%) reported more than 5 ounces of urine leakage (fig. 2). When asked about how much this bothered them, 10 patients (53%) stated that it was not a significant amount of bother. However, 9 patients (47%) believed that it was a significant bother to their quality of life. With regard to their partner or spouse 15 patients (79%) believed that it was no significant bother. However, 4 patients (21%) believed that it was of significant bother to their partners (fig. 3). When asked how they were coping, 3 patients (16%) said that they did nothing, while 14 (74%) stated that they emptied the bladder before sexual activity. Two patients (11%) stated that in addition to voiding, they also required a condom to cope with leakage (fig. 4). None of the identified and tested covariates were associated with climacturia (each p ⬎0.05). DISCUSSION Of the complex physiological processes associated with sexual activity orgasm is by far least understood. It involves physical stimulation as well as a cognitive component. On the other hand, the physiology of emission and ejaculation is understood to a greater degree and it involves involuntary autonomic and somatic action. Somatic input travels via the pudendal nerve to the upper lumbar sympathetic nuclei, causing a cascade of events that is signaled down the hypogastric nerve. Along with the transport of sperm to the prostatic urethra there is coordinated closure of the internal sphincter and relaxation of the external sphincter. This directs sperm into the bulbous ure-
FIG. 2. Quantity of urine loss
2564
CLIMACTURIA AFTER RADICAL PROSTATECTOMY
FIG. 4. Coping mechanisms FIG. 3. Degree of bother
tionnaire designed for this study did not undergo rigorous psychometric testing, although it clearly has face validity. Given that to our knowledge this condition has been an unrecognized entity to date, no validated questionnaire exists. Despite these limitations we believe that the results of the study may provide much relevant information for future studies regarding this entity. Two prior studies referred to climacturia, although not as a primary focus. In a study of orgasm quality after RP Koeman et al surprisingly found that 9 of 14 patients reported involuntary urine loss with orgasm.9 Although it was not a primary end point in their study, Koeman et al stated that this unexpected complication was likely more common than previously thought. In a more recent study from Madrid of the presence and quality of orgasm following RP MartinezSalamanca Garcia et al noted that 24 of 134 patients had urine leakage at orgasm.10 It is our opinion that, given the study findings, climacturia warrants mention to the patient before radical prostatectomy.
thra, where rhythmic contractions of the bulbocavernosus muscles propel sperm along with seminal fluid as ejaculate. It is generally believed that following RP the external urethral sphincter remains the dominant provider of continence. Thus, at the moment of climax with relaxation of the external urethral sphincter it is plausible that urine leakage would occur. What remains unclear with this hypothesis is that one would expect virtually all men to have climacturia following RP. It would also be common after transurethral prostatic resection, although to our knowledge this has not been described in men after transurethral prostate resection. We hypothesized that bladder neck stricture or a smaller caliber urethra would be less likely to leak urine, although our data do not support this. Indeed, although the associations were not statistically significant, the trend toward climacturia was higher in patients with a lower flow rate and lower I-PSS. These trends seem to demonstrate that bladder neck status and urethral caliber may not have a large role in determining the prevalence of climacturia and the physiology of this entity remains an enigma. This study has certain limitations that deserve mention. First is its relatively small sample size. Thus, it is possible that some tested covariates that are not significant in this study would be significant in a larger patient cohort. Also, the ques-
CONCLUSIONS We describe what is to our knowledge a previously unrecognized entity, that is the involuntary loss of urine at climax in men after RP. This condition is not uncommon and patients should be counseled about it as part of the preoperative discussion.
APPENDIX Prevalence and Risk Factors for Climax Associated Incontinence Post-Radical Prostatectomy Questionnaire Date (YYYY/MM/DD) PART A: please circle the one answer that best applies to you 1. Have you been sexually active in the last 6 months? Yes
Initials:
No
2. Do you use any aids to maintain an erection for sexual activity (e.g. Viagra®, Cialis®, Levitra®, MUSE®, vacuum device, etc)? Yes No 3. Have you experienced or noticed any leakage of urine during orgasm/climax? (If no, please proceed to question 9) Yes No 4. How often does this occur? Rarely Occasionally
Often
Most of the time
Always
5. How much urine leakage occurs? Few drops 1 Ounce
Greater than 1 ounce
5 Ounces
Greater than 5 ounces
6. How much of a bother is this urine leakage? None Small
Moderate
Large
Enormous
7. How much of a bother is this to your partner/spouse? None Small
Moderate
Large
Enormous
8. How are you coping? (circle one or more of the following) Do nothing Empty bladder prior to sexual activity
Use condom
Avoid intercourse
Other (appendix continued)
CLIMACTURIA AFTER RADICAL PROSTATECTOMY
2565
APPENDIX continued PART B: please circle the number that most appropriately applies to you 0 ⫽ Not at all 1 ⫽ Less than 1 time in 5 2 ⫽ Less than half the time
3 ⫽ About half the time
4 ⫽ More than half the time
5 ⫽ Almost always
9. Over the past month, how often have you had a sensation of not emptying your bladder completely after urination? 0 1 2 3 4
5
10. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4
5
11. Over the past month, how often have you found that you stopped and started again several times when you urinated? 0 1 2 3 4
5
12. Over the past month, how often have you found it difficult to postpone urination? 0 1 2
3
4
5
13. Over the past month, how often have you had a weak urinary stream? 0 1 2
3
4
5
14. Over the past month, how often have you had to push or strain to begin urinating? 0 1 2 3
4
5
15. Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? 0 1 2 3 4 5 Thank you for your time and cooperation.
9.
Abbreviations and Acronyms I-PSS ⫽ International Prostate Symptom Score RP ⫽ radical prostatectomy REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
Ellison, L. M., Heaney, J. A. and Birkmeyer, J. D.: The effect of hospital volume on mortality and resource use after radical prostatectomy. J Urol, 163: 867, 2000 Yao, S. L. and Lu-Yao, G.: Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay. J Natl Cancer Inst, 91: 1950, 1999 Shekarriz, B., Upadhyay, J. and Wood, D. P.: Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am, 28: 639, 2001 Begg, C. B., Riedel, E. R., Bach, P. B., Kattan, M. W., Schrag, D., Warren, J. L. et al: Variations in morbidity after radical prostatectomy. N Engl J Med, 346: 1138, 2002 Koch, M. O., Smith, J. A., Jr., Hodge, E. M. and Brandell, R. A.: Prospective development of a cost-efficient program for radical retropubic prostatectomy. Urology, 44: 311, 1994 Hollenbeck, B. K., Dunn, R. L., Wei, J. T., Montie, J. E. and Sanda, M. G.: Determinants of long-term sexual health outcome after radical prostatectomy measured by a validated instrument. J Urol, 169: 1453, 2003 Kirschner-Hermanns, R. and Jakse, G.: Quality of life following radical prostatectomy. Crit Rev Oncol Hematol, 43: 141, 2002 Barnas, J. L., Pierpaoli, S., Ladd, P., Valenzuela, R., Aviv, N., Parker, M. et al: The prevalence and nature of orgasmic dysfunction after radical prostatectomy. BJU Int, 94: 603, 2004
Koeman, M., van Driel, M. F., Schultz, W. C. and Mensink, H. J.: Orgasm after radical prostatectomy. Br J Urol, 77: 861, 1996 10. Martinez-Salamanca Garcia, J. I., Jara Rascon, J., Moncada Iribarren, I., Garcia Burgos, J. and Hernandez Fernandez, C.: Orgasm sexual function after radical prostatectomy. Actas Urol Esp, 28: 756, 2004
EDITORIAL COMMENT These authors point out the presence and prevalence of a poorly described side effect of RP, that is climacturia. Using a well designed but nonvalidated questionnaire they observed that this side effect of surgery occurs in almost 50% of patients and it is generally mild (only a few drops in 58%) but it is significantly bothersome to 48% of the patients studied. This series suffers from the relatively small number of patients studied and from the lack of precise documentation of general continence in the group. Because the authors do not have quantitative measurements of continence in their patients, this should be an interesting avenue of future study in this patient population. In sum although this is not the first description of urinary loss associated with sexual climax after prostatectomy, this study provides us with further documentation of its existence and the relative effect that it may have in men who have undergone prostatectomy and their sexual partners (references 9 and 10 in article). Robert Flanigan Department of Urology Loyola University Chicago, Illinois
Purpose: Following radical prostatectomy urine leakage during orgasm is a poorly defined entity. We defined the prevalence, quantity, bother and coping mechanisms associated with this complication, called climacturia. Materials and Methods: A self-administered questionnaire was given to a cohort of sexually active men after radical prostatectomy. We inquired about the frequency, quantity, bother and coping mechanisms associated with climacturia. We also recorded uroflowmetry and an American Urological Association symptom score (International Prostate Symptom Score) in each patient. Results: Of the 42 patients enrolled with a mean age of 58.9 years and average time since radical prostatectomy of 23.6 months climacturia was reported in 19 (45%). Of the men 68% reported that it happened rarely or only occasionally, while 21% reported that it occurred most of the time or always. In terms of urine quantity 58% of respondents reported only a few drops but 16% reported a loss of more than 1 ounce. Of the patients 52% percent reported no or minimal bother but 48% reported that climacturia caused significant bother. Only 21% of respondents thought that it was of significant bother to their partners. Of the respondents 84% emptied the bladder before intercourse and 11% used condoms. Age, Gleason score and time since surgery were not predictors of climacturia. No association between peak urine flow on uroflowmetry or International Prostate Symptom Score and climacturia was found. Conclusions: Climacturia is a common clinical entity, occurring in almost half of all patients after radical prostatectomy. It can be a significant problem with respect to urine volume loss, associated bother and condom use. Patients must be informed about this complication before undergoing radical prostatectomy. Key Words: prostate, prostatectomy, questionnaires, urination disorders, orgasm
adical prostatectomy is associated with low perioperative morbidity and mortality.1–3 However, late complications continue to be an ongoing problem. Urinary incontinence is a well accepted complication following RP. Although the reported rates of incontinence varies, groups at most tertiary care centers report that 5% to 10% of patients are persistently incontinent after RP.3–5 Erectile dysfunction is another common complication following RP. However, with the advent of the nerve sparing method the rate of erectile dysfunction continues to improve.3–5 Although urinary incontinence and erectile dysfunction are well studied entities following RP, there is a relative paucity of research with regard to the quality of sexual life after RP, particularly concerning orgasm. In the last decade an increasing number of groups have examined the qualitative aspects of sexual functioning after RP, examining issues such as sexual desire, spousal satisfaction, psychological impact on relationships and other overall health related quality of life indexes.6 –9 Recently it came to our attention that some after patients who underwent RP and who were potent enough to participate in sexual activity noticed various amounts of urine leakage at the moment of climax. After a literature search we found only 2 studies specifically describing sexual climax associated uri-
R
Submitted for publication December 14, 2005. Study received review ethics board approval. * Financial interest and/or other relationship with AstraZeneca, BioRovantex, Merck and Abbott.
0022-5347/06/1766-2562/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
nary incontinence, although it is our belief that it is a much more prevalent problem.9,10 We describe the prevalence of urine leakage at the moment of climax, which we call climacturia. In addition, we describe its degree, associated impact on bother and patient related methods of coping.
METHODS Patients were enrolled from the outpatient clinic of one of the staff urological surgeons (NF). Patients were enrolled by consecutive recruitment. All patients seen in the clinic who had undergone RP were consecutively screened for suitability for study participation. In each suitable patient it was at least 12 months after RP and he was potent enough with and without phosphodiesterase-5 inhibitors to engage in sexual activity (intercourse or masturbation) within 6 months of assessment. Patients who had received other treatment modalities for prostate cancer, eg brachytherapy, radiation therapy or high intensity focused ultrasound, were excluded from study. Patients who had undergone any other lower urinary tract surgery, eg transurethral prostate resection, visual internal urethrotomy or urethroplasty, were also excluded. After patients met all inclusion criteria and consented to participate in the study they were given a self-administered questionnaire, which they completed and returned (see Appendix). The questionnaire examined aspects of climacturia, such as frequency, quantity of urine loss, coping mechanisms used
2562
Vol. 176, 2562-2565, December 2006 Printed in U.S.A. DOI:10.1016/j.juro.2006.07.158
CLIMACTURIA AFTER RADICAL PROSTATECTOMY
2563
TABLE 1. Baseline characteristics No. pts Mean age Mean time since RP (mos) Mean Gleason score* Mean peak urine flow on uroflowmetry (cc/sec) Mean I-PSS No. incontinence No. using aids No. with climacturia
42 58.9 23.6 6.6 16.6 7.4 3 22 19
* Unavailable in 8 patients.
FIG. 1. Climacturia frequency
by the patient and level of bother. The patient American Urological Association symptom score (I-PSS) was also determined. Because we were interested in the final caliber of the vesicourethral anastomosis and its association with climacturia, we also measured the peak flow rate via uroflowmetry. A minimum of 125 cc voided volume was considered useful for data analyses. Additional demographic and disease specific covariates were obtained from the patient chart. Review ethics board approval was secured for this study. Data were assembled in a Microsoft® Excel® spreadsheet. Men with and without climacturia were then compared using chi-square analysis and the t test for categorical and continuous covariates, respectively. All hypothesis testing was 2-sided with ⬍0.05 considered significant. RESULTS A total of 61 patients were screened and 42 were enrolled, of whom each fully completed the questionnaire and was able to provide an adequate urine volume for valid peak flow rate measurement. Table 1 lists patient demographics. Mean patient age at recruitment was 58.9 years (range 51 to 71) and mean time since surgery was 23.6 months (range 12 to 60). The mean peak flow rate was 16.6 cc per second (range 4.3 to 45.2). Of the 42 patients enrolled in the study 19 (45%) reported some degree of climacturia. Patients with climacturia were comparable in age, time since surgery and Gleason score to those without climacturia (table 2). Patients with climacturia had a trend toward a lower mean peak flow rate (14.6 vs 18.3 cc per second) and a higher mean I-PSS (9.1 vs 6.0). A higher percent of those with climacturia used aids to achieve erection (63.2% vs 43.5%) and experienced incontinence (10.5% vs 4.3%). No patient used any type of aid other than phosphodiesterase-5 inhibitors. None of these associations were statistically significant (table 2).
TABLE 2. Climacturia
No. pts Mean age ⫾ SD Mean time since RP in months (S.D.) Mean Gleason score* Mean I-PSS No. urinary incontinence† No. using aids to enhance erection‡ Mean peak urine flow on uroflowmetry (cc/sec)
Climacturia
No Climacturia
p Value
19 59.8 ⫾ 6.9 23.7 (17.0)
23 58.2 ⫾ 4.7 23.4 (13.9)
0.38 0.95
6.4 9.1 2 12
6.8 6 1 10
0.41 0.15 0.34 0.44
14.59
18.34
0.20
* Unavailable in 4 patients per group. † Greater than 1 pad daily. ‡ Oral medications or injection.
Four of the 19 patients (21%) who complained of climax associated incontinence stated that they experienced climacturia only rarely, 9 (47%) experienced it occasionally, 2 (11%) experienced it often, 3 (16%) experienced it most of the time and 1 (5%) stated that he experienced it all of the time (fig. 1). With regard to urine leakage volume 11 patients (58%) reported only a few drops. Five patients (26%) stated that they lost an ounce of urine each time, 2 (11%) stated that they lost between 1 and 5 ounces, and 1 (5%) reported more than 5 ounces of urine leakage (fig. 2). When asked about how much this bothered them, 10 patients (53%) stated that it was not a significant amount of bother. However, 9 patients (47%) believed that it was a significant bother to their quality of life. With regard to their partner or spouse 15 patients (79%) believed that it was no significant bother. However, 4 patients (21%) believed that it was of significant bother to their partners (fig. 3). When asked how they were coping, 3 patients (16%) said that they did nothing, while 14 (74%) stated that they emptied the bladder before sexual activity. Two patients (11%) stated that in addition to voiding, they also required a condom to cope with leakage (fig. 4). None of the identified and tested covariates were associated with climacturia (each p ⬎0.05). DISCUSSION Of the complex physiological processes associated with sexual activity orgasm is by far least understood. It involves physical stimulation as well as a cognitive component. On the other hand, the physiology of emission and ejaculation is understood to a greater degree and it involves involuntary autonomic and somatic action. Somatic input travels via the pudendal nerve to the upper lumbar sympathetic nuclei, causing a cascade of events that is signaled down the hypogastric nerve. Along with the transport of sperm to the prostatic urethra there is coordinated closure of the internal sphincter and relaxation of the external sphincter. This directs sperm into the bulbous ure-
FIG. 2. Quantity of urine loss
2564
CLIMACTURIA AFTER RADICAL PROSTATECTOMY
FIG. 4. Coping mechanisms FIG. 3. Degree of bother
tionnaire designed for this study did not undergo rigorous psychometric testing, although it clearly has face validity. Given that to our knowledge this condition has been an unrecognized entity to date, no validated questionnaire exists. Despite these limitations we believe that the results of the study may provide much relevant information for future studies regarding this entity. Two prior studies referred to climacturia, although not as a primary focus. In a study of orgasm quality after RP Koeman et al surprisingly found that 9 of 14 patients reported involuntary urine loss with orgasm.9 Although it was not a primary end point in their study, Koeman et al stated that this unexpected complication was likely more common than previously thought. In a more recent study from Madrid of the presence and quality of orgasm following RP MartinezSalamanca Garcia et al noted that 24 of 134 patients had urine leakage at orgasm.10 It is our opinion that, given the study findings, climacturia warrants mention to the patient before radical prostatectomy.
thra, where rhythmic contractions of the bulbocavernosus muscles propel sperm along with seminal fluid as ejaculate. It is generally believed that following RP the external urethral sphincter remains the dominant provider of continence. Thus, at the moment of climax with relaxation of the external urethral sphincter it is plausible that urine leakage would occur. What remains unclear with this hypothesis is that one would expect virtually all men to have climacturia following RP. It would also be common after transurethral prostatic resection, although to our knowledge this has not been described in men after transurethral prostate resection. We hypothesized that bladder neck stricture or a smaller caliber urethra would be less likely to leak urine, although our data do not support this. Indeed, although the associations were not statistically significant, the trend toward climacturia was higher in patients with a lower flow rate and lower I-PSS. These trends seem to demonstrate that bladder neck status and urethral caliber may not have a large role in determining the prevalence of climacturia and the physiology of this entity remains an enigma. This study has certain limitations that deserve mention. First is its relatively small sample size. Thus, it is possible that some tested covariates that are not significant in this study would be significant in a larger patient cohort. Also, the ques-
CONCLUSIONS We describe what is to our knowledge a previously unrecognized entity, that is the involuntary loss of urine at climax in men after RP. This condition is not uncommon and patients should be counseled about it as part of the preoperative discussion.
APPENDIX Prevalence and Risk Factors for Climax Associated Incontinence Post-Radical Prostatectomy Questionnaire Date (YYYY/MM/DD) PART A: please circle the one answer that best applies to you 1. Have you been sexually active in the last 6 months? Yes
Initials:
No
2. Do you use any aids to maintain an erection for sexual activity (e.g. Viagra®, Cialis®, Levitra®, MUSE®, vacuum device, etc)? Yes No 3. Have you experienced or noticed any leakage of urine during orgasm/climax? (If no, please proceed to question 9) Yes No 4. How often does this occur? Rarely Occasionally
Often
Most of the time
Always
5. How much urine leakage occurs? Few drops 1 Ounce
Greater than 1 ounce
5 Ounces
Greater than 5 ounces
6. How much of a bother is this urine leakage? None Small
Moderate
Large
Enormous
7. How much of a bother is this to your partner/spouse? None Small
Moderate
Large
Enormous
8. How are you coping? (circle one or more of the following) Do nothing Empty bladder prior to sexual activity
Use condom
Avoid intercourse
Other (appendix continued)
CLIMACTURIA AFTER RADICAL PROSTATECTOMY
2565
APPENDIX continued PART B: please circle the number that most appropriately applies to you 0 ⫽ Not at all 1 ⫽ Less than 1 time in 5 2 ⫽ Less than half the time
3 ⫽ About half the time
4 ⫽ More than half the time
5 ⫽ Almost always
9. Over the past month, how often have you had a sensation of not emptying your bladder completely after urination? 0 1 2 3 4
5
10. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0 1 2 3 4
5
11. Over the past month, how often have you found that you stopped and started again several times when you urinated? 0 1 2 3 4
5
12. Over the past month, how often have you found it difficult to postpone urination? 0 1 2
3
4
5
13. Over the past month, how often have you had a weak urinary stream? 0 1 2
3
4
5
14. Over the past month, how often have you had to push or strain to begin urinating? 0 1 2 3
4
5
15. Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? 0 1 2 3 4 5 Thank you for your time and cooperation.
9.
Abbreviations and Acronyms I-PSS ⫽ International Prostate Symptom Score RP ⫽ radical prostatectomy REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
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EDITORIAL COMMENT These authors point out the presence and prevalence of a poorly described side effect of RP, that is climacturia. Using a well designed but nonvalidated questionnaire they observed that this side effect of surgery occurs in almost 50% of patients and it is generally mild (only a few drops in 58%) but it is significantly bothersome to 48% of the patients studied. This series suffers from the relatively small number of patients studied and from the lack of precise documentation of general continence in the group. Because the authors do not have quantitative measurements of continence in their patients, this should be an interesting avenue of future study in this patient population. In sum although this is not the first description of urinary loss associated with sexual climax after prostatectomy, this study provides us with further documentation of its existence and the relative effect that it may have in men who have undergone prostatectomy and their sexual partners (references 9 and 10 in article). Robert Flanigan Department of Urology Loyola University Chicago, Illinois