- Email: [email protected]
EDITORIAL: ERECTILE FUNCTION AFTER TREATMENT FOR PROSTATE CANCER
0022-5347/01/1652-0440/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 440, February 2001 Printed in U.S.A.
EDITORIAL: ERECTILE FUNCTION AFTER TREATMENT FOR PROSTATE CANCER I encourage all urologists to pursue and promote research to understand better the effects of not only oncological urological treatment, but also of other urological conditions and their management on pediatric and adult male and female sexual function. This research is particularly relevant in such areas as pelvic trauma, pelvic surgery, genital reconstruction, urethral surgery, benign prostatic hyperplasia management and use of urological based medications, such as ␣-blockers, chemotherapy agents, vasoactive agents and androgen suppression agents. The fact is that urologists are not only the recognized medical experts for men’s health and sexual medicine, but they are among the leaders in the investigation of female sexual health issues. Urologists, in particular, need to understand better how the patient and partner will feel when provided urological treatment plans that may affect sexual performance. For the vast majority of patients and their partners sexual function remains a critical aspect of the perceived quality of life, and ramifications of management based changes in sexual function need to be discussed fully. It is only through further urological research of the effects of urological intervention on sexual medical issues that we will provide the most appropriate and realistic expectations to the couple, which deeply affect their lifestyle. I would encourage future urological investigations of sexual medical issues to take advantage of the more sophisticated and contemporary self-report measures of sexual medical outcome that have become commonplace in multiinstitutional vasoactive drug clinical trial design. These selfreport measures include the use of self-administered questionnaires in conjunction with daily diaries or event logs. Outcome measures, such as the International Index of Erectile Function and the Sexual Encounter Profile, have the enormous advantages of providing standardized and relatively cost efficient evaluation of multiple domains of pretreatment and posttreatment sexual function. Such data include a broader assessment of erectile function but also will provide information concerning orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. Such measures actually involve minimal patient (and partner) time and effort. In particular, studies have indicated a high degree of correlation of erection and intercourse satisfaction between Sexual Encounter Profile and International Index of Erectile Function measures. I would also encourage future urological investigations of sexual medical issues to obtain data, whenever possible, on the presence or absence of physiological and psychological variables recognized to predict sexual dysfunction. These well-known variables include vascular risk factor exposure, such as diabetes, hypertension, heart disease, low levels of high-density lipoprotein, cigarette smoking, use of medications for diabetes, heart disease and hypertension, and the presence of depression or anger. When sexual medical researchers are comparing 1 study population to another, knowledge of the important dimension of concomitant illnesses and medication will allow for enhanced data outcome interpretation, especially determination of the generalizability of the findings. Using methodology reported in the prospective research
investigations appearing in this issue of The Journal by Siegel (page 430) and Stock (page 436), et al the sexual outcome data were limited to erection quality with erections assessed by yes, no, partial or unknown in the study of Siegel et al and by 4 grades in the study of Stock et al. Siegel et al demonstrated that external beam radiation and radical prostatectomy shared high rates of postoperative erectile dysfunction. Stock et al showed a marked loss of erectile function with time after brachytherapy and a significant relationship between the radiation dose delivered and the prevalence of erectile dysfunction. These “first look” investigations on the sexual medical effects of prostate cancer treatments should expand to “second look” broader, more comprehensive investigations. For example, simply incorporating the International Index of Erectile Function and Sexual Encounter Profile will provide pertinent information on the effects of specific urological oncological treatments on ejaculation capability (likely maintained with radiation treatment), orgasm capability, libido, intercourse satisfaction, intercourse enjoyment and overall sex life satisfaction. Partner questionnaires are being widely used in vasoactive drug clinical trials and should also be incorporated in these urological treatment investigations. Women who report that their partner had sexual problems report their own sexual dysfunction significantly more often than those with erectile well functioning partners. Sexual disabilities and problems cannot be seen as isolated sexual phenomena that consist of a single symptom and involve only 1 member of the relationship. Emphasis on the broader context of sexual function and the importance of the couple must be addressed. There is growing expertise in the urological community of sexual medical research. The American Foundation for Urologic Disease Sexual Function Health Council and the Sexual Medical Society of North America (formerly Society for the Study of Impotence) are examples of contemporary organizations. I would strongly encourage more widespread collaboration among urological researchers, such as the Center for Prostate Disease Research, and these speciality sexual medical urological organizations. For example, 1 research project that I would like to see examined in more depth is the use of prophylactic “erectogenic” agents in the early postoperative period following radical prostatectomy. Preliminary data by Montorsi et al suggest that use of these treatments provides better long-term potency.1 It is through enhanced communication among all urological specialities that we will continue to remain the recognized medical experts in men’s health and male and female sexual medical issues.
440
Irwin S. Goldstein Department of Urology Boston University School of Medicine Boston, Massachusetts REFERENCE
1. Montorsi, F., Guazzoni, G., Strambi, L. F. et al: Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol, 158: 1408, 1997
Vol. 165, 440, February 2001 Printed in U.S.A.
EDITORIAL: ERECTILE FUNCTION AFTER TREATMENT FOR PROSTATE CANCER I encourage all urologists to pursue and promote research to understand better the effects of not only oncological urological treatment, but also of other urological conditions and their management on pediatric and adult male and female sexual function. This research is particularly relevant in such areas as pelvic trauma, pelvic surgery, genital reconstruction, urethral surgery, benign prostatic hyperplasia management and use of urological based medications, such as ␣-blockers, chemotherapy agents, vasoactive agents and androgen suppression agents. The fact is that urologists are not only the recognized medical experts for men’s health and sexual medicine, but they are among the leaders in the investigation of female sexual health issues. Urologists, in particular, need to understand better how the patient and partner will feel when provided urological treatment plans that may affect sexual performance. For the vast majority of patients and their partners sexual function remains a critical aspect of the perceived quality of life, and ramifications of management based changes in sexual function need to be discussed fully. It is only through further urological research of the effects of urological intervention on sexual medical issues that we will provide the most appropriate and realistic expectations to the couple, which deeply affect their lifestyle. I would encourage future urological investigations of sexual medical issues to take advantage of the more sophisticated and contemporary self-report measures of sexual medical outcome that have become commonplace in multiinstitutional vasoactive drug clinical trial design. These selfreport measures include the use of self-administered questionnaires in conjunction with daily diaries or event logs. Outcome measures, such as the International Index of Erectile Function and the Sexual Encounter Profile, have the enormous advantages of providing standardized and relatively cost efficient evaluation of multiple domains of pretreatment and posttreatment sexual function. Such data include a broader assessment of erectile function but also will provide information concerning orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. Such measures actually involve minimal patient (and partner) time and effort. In particular, studies have indicated a high degree of correlation of erection and intercourse satisfaction between Sexual Encounter Profile and International Index of Erectile Function measures. I would also encourage future urological investigations of sexual medical issues to obtain data, whenever possible, on the presence or absence of physiological and psychological variables recognized to predict sexual dysfunction. These well-known variables include vascular risk factor exposure, such as diabetes, hypertension, heart disease, low levels of high-density lipoprotein, cigarette smoking, use of medications for diabetes, heart disease and hypertension, and the presence of depression or anger. When sexual medical researchers are comparing 1 study population to another, knowledge of the important dimension of concomitant illnesses and medication will allow for enhanced data outcome interpretation, especially determination of the generalizability of the findings. Using methodology reported in the prospective research
investigations appearing in this issue of The Journal by Siegel (page 430) and Stock (page 436), et al the sexual outcome data were limited to erection quality with erections assessed by yes, no, partial or unknown in the study of Siegel et al and by 4 grades in the study of Stock et al. Siegel et al demonstrated that external beam radiation and radical prostatectomy shared high rates of postoperative erectile dysfunction. Stock et al showed a marked loss of erectile function with time after brachytherapy and a significant relationship between the radiation dose delivered and the prevalence of erectile dysfunction. These “first look” investigations on the sexual medical effects of prostate cancer treatments should expand to “second look” broader, more comprehensive investigations. For example, simply incorporating the International Index of Erectile Function and Sexual Encounter Profile will provide pertinent information on the effects of specific urological oncological treatments on ejaculation capability (likely maintained with radiation treatment), orgasm capability, libido, intercourse satisfaction, intercourse enjoyment and overall sex life satisfaction. Partner questionnaires are being widely used in vasoactive drug clinical trials and should also be incorporated in these urological treatment investigations. Women who report that their partner had sexual problems report their own sexual dysfunction significantly more often than those with erectile well functioning partners. Sexual disabilities and problems cannot be seen as isolated sexual phenomena that consist of a single symptom and involve only 1 member of the relationship. Emphasis on the broader context of sexual function and the importance of the couple must be addressed. There is growing expertise in the urological community of sexual medical research. The American Foundation for Urologic Disease Sexual Function Health Council and the Sexual Medical Society of North America (formerly Society for the Study of Impotence) are examples of contemporary organizations. I would strongly encourage more widespread collaboration among urological researchers, such as the Center for Prostate Disease Research, and these speciality sexual medical urological organizations. For example, 1 research project that I would like to see examined in more depth is the use of prophylactic “erectogenic” agents in the early postoperative period following radical prostatectomy. Preliminary data by Montorsi et al suggest that use of these treatments provides better long-term potency.1 It is through enhanced communication among all urological specialities that we will continue to remain the recognized medical experts in men’s health and male and female sexual medical issues.
440
Irwin S. Goldstein Department of Urology Boston University School of Medicine Boston, Massachusetts REFERENCE
1. Montorsi, F., Guazzoni, G., Strambi, L. F. et al: Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomized trial. J Urol, 158: 1408, 1997