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Penile length shortening after radical prostatectomy: Men's responses
European Journal of Oncology Nursing 14 (2010) 160–165
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European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Penile length shortening after radical prostatectomy: Men’s responses Wellam F. Yu Ko*, Lesley F. Degner, Thomas F. Hack, Garry Schroeder 627-110, Adamar Road, Winnipeg, Manitoba, R3T 3M3, Canada
a b s t r a c t Keywords: Penile length shortening Radical prostatectomy Masculinity Self image
Background: Prostate cancer (PC) is the most common type of male-specific cancer in North American men, and many men choose radical prostatectomy (RP) to remove their cancer. Although penile length shortening (PLS) occurs in a reported 68% to 71% of men undergoing RP, little is known about it. In an electronic journal search, only 9 medical articles (with no nursing publications) were published between 1980 and 2007. Purpose: To provide an account of patients’ perceptions and responses to living with PLS after RP. Methods and sample: Semi-structured interviews and a grounded theory approach were used to discover the basic social processes regarding men’s perceptions of a shortened penis and overall sense of self. A total of six men who underwent RP and consequently noticed PLS were recruited from a local PC support group for semi-structured interviews lasting between 40–60 min. Results: Based on subjects’ own definitions of masculinity, no significant changes in the constructs of masculinity and overall self-image perception were reported. Conclusions: Men undergoing RP may not be fully aware that PLS is a possible consequence related to treatment. In spite of this, subjects were not negatively affected by its occurrence. Ó 2009 Elsevier Ltd. All rights reserved.
Men’s responses Prostate cancer (PC) is the most prevalent male-specific malignancy in North America. An estimated 186,320 American men (American Cancer Society, 2008) and 24,700 Canadian men (Canadian Cancer Society, 2008) were diagnosed with it during 2008. Upon diagnosis of localized prostate cancer, many men will choose radical prostatectomy (RP) as a treatment method. Although erectile dysfunction (ED) and urinary incontinence are known side effects of RPs, penile length shortening (PLS) is often not associated with the procedure even thought it occurs in a reported 68% to 71% (Munding et al., 2001; Savoie et al., 2003). Preoccupation with the penis and its size has accompanied cultural evolution throughout the world. Often, figurines, paintings and phallic art depict greater than normal sized penises. Societies have often attributed the penis with powers symbolizing masculinity, strength, endurance, ability, courage, intelligence, knowledge, dominance over other men, and possession of women (Wylie and Eardley, 2007). However, being treated for cancer can produce various physical and psychological changes that threaten patients’ concept of sexuality and body image (Bertero, 2001; Cohen et al., 1998; Penson et al., 2003; Schag et al., 1994; Wilmoth, 2001). Thus,
* Corresponding author. Tel.: þ1 (204) 947 0802. E-mail address: [email protected] (W.F. Yu Ko). 1462-3889/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2009.09.001
a decrease in penile length after RP may negatively affect the psychological well being of prostate cancer survivors. The actual etiology of PLS is not known. What is known about PLS is that the greatest length reduction occurs during the first year post-operatively. Fraiman et al. (1999), Munding et al. (2001), and Gontero et al. (2007) noted that shortening occurred most markedly shortly after catheter removal and continued to diminish in length, albeit at a slower rate, for at least 12 months after surgery. Several theories exist regarding PLS. Munding et al. (2001) suggested that the removal of the section of urethra within the prostate shortened the total length of the urethra, resulting in a shortening of the penis. A second possible explanation by Munding et al. (2001) proposed that the decrease in penile length was the result of prepubic scarring resulting from RP, which shortened the suspensory ligaments of the penis, leading to a shortened penis. Ciancio and Kim (2000) suggested the formation of fibrotic tissue in the penis after RP as a cause of penile shortening, as they found that 41% of the patients who were referred to them for erectile dysfunction after RP also developed fibrotic changes. Causes of PLS at the histological level have also been pointed out. Klein et al. (1997) suggested that apoptosis of penile erectile tissue after cavernous neurotomy in the rat model caused neural damage that may explain the decreased penile size after RP. On the other hand, Moreland (1998) found that human penile smooth muscle cell culture tissues experienced changes when subject to hypoxic conditions. Consequently, it is assumed that circulatory
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deficiencies resulting from a radical prostatectomy may also affect penile length. Although these studies do not explain matter-offactly how penile shortening occurs, they keep the door open for possible explanations at a cellular level. Although studies by Perugia et al. (2005) and Savoie et al. (2003) suggested that bilateral nerve sparing radical retropubic prostatectomies (a surgical technique where the pudendal nerves that run posteriorly along the prostate are carefully separated from the prostate and left intact) do not prevent penile length shortening when compared to non-nerve sparing open prostatectomy (where the pudendal nerves are severed), Briganti et al. (2007) found that the former correlates positively with a decreased incidence of PLS. Clearly, the effect that each prostatectomy technique has on PLS needs to be studied further. Men seem to be more concerned about penile size than women. Francken et al. (2002) found in a survey study that women rated penile length as being ‘‘unimportant’’ and ‘‘totally unimportant’’ in 55% and 22% of the respondents, respectively. Whereas, Lee (1996) found in his sample of single male college students (n ¼ 128) that self-perception about penis size had a skewed distribution towards a small penis, even though these men felt that they had proportionately adequate body hair distribution and physique. These findings support a separate study performed in 2003, where 123 men had their penis measured while on a visit to a military hospital in Korea, finding that men had a tendency to underestimate the dimensions of their own penis (Son et al., 2003). Interestingly, results from studies conducted in Egypt and Italy found that almost all of the men seeking to enlarge their penile size had, as a matter of fact, normal penile dimensions (Mondaini et al., 2002; Shamloul, 2005). Mondaini et al. (2002) and Shamloul (2005) attribute the preoccupation about penile size in the Egyptian and Italian studies to men’s early exposure to more developed genitals from their peers and/or pornographic material during adolescence, leading to the belief that their own penises were inadequately small. In summary, current literature regarding lived experiences after RP focuses primarily on urinary and sexual effects of the procedure. And, although penile length is not thought to decrease with aging (Schneider et al., 2001), many men experience a noticeable decrease in penile length shortly after RP. The effects of a decrease in the length of the penis after RP and/or during adulthood have not been previously published. While several findings were made in this study, this paper will focus on the most salient results with the discussion of a resultant theory of masculinity in PC survivorship in a later paper. Purpose statement and definitions The goal of this study was to explore patients’ perceptions and responses of PLS after RP. To this end, penile length shortening was defined in this study as the subjects’ perceived loss of penile length after undergoing RP, irrespective of actual length changes. Methods Design Given that men’s perceptions of penis size is affected by social norms (Lee and Reiter, 2002), the design of this study was based on the grounded theory approach for its suitability in the exploration of social processes and social structures (Polit and Beck, 2004). Specifically, the current study was designed as a substantive theory type of grounded theory research. Usually, substantive theory research serves as the basis for more comprehensive studies that combine the results of several other related studies based on the
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substantive theory model that result in the formal grounded theory approach (Polit and Beck, 2004). Participants This qualitative study was undertaken in the city of Winnipeg, the capital of Manitoba, a Western Canadian province. Recruitment was conducted via open invitations at meetings held at the local prostate cancer support group, and by the posting of a recruitment advert in the group’s newsletter. The period of recruitment was of two months, in which time data saturation was achieved by the fifth subject. The main criteria for inclusion was the perception of penile length loss at least one year after undergoing RP, irrespective of stage of cancer at time of diagnosis or whether participants received other treatments for PC. A total of 11 men contacted the principal investigator demonstrating interest in participating, seven of whom met inclusion criteria, with one declining to participate before the scheduled interview. This resulted in a convenience sample of six participants (mean age 64.7, range 58–77), four of whom were retired and two worked full time. Five of them were married and lived with their spouses, whereas one of them was divorced and lived alone. Almost all (five) subjects stated being of Caucasian descent while one claimed Ukrainian heritage. Only one of the men declared high school as the highest level of education completed, whilst five had finished post secondary education. None of the participants reported to be able to achieve proper erections that allowed them to participate in penetrative sex. Only one participant declared having no urinary incontinence at all, while the remaining stated having only occasional or minor urinary symptoms such as urinary urge, stress incontinence, and nocturia. No bowel symptoms were reported by participants. Oneon-one interviews took place once participants agreed to, and signed the respective documents of consent. Participants were also met a second time by the principal investigator to confirm findings at a later date. The study was approved by the Education/Nursing Research Ethics Board, at the University of Manitoba in Winnipeg, Manitoba, Canada, and by the Manitoba Prostate Cancer Support Group. Data collection All subjects were offered a choice of venue for the interviews. These were conducted at participants’ homes, university interview room, and at a subject’s office. In a quiet environment, subjects completed a demographic information questionnaire before commencing the interview. The main author (a male nurse) conducted all of the interviews, which lasted between 40 to 60 min. All interviews were tape recorded and later transcribed verbatim, also by the main author. Numeric pseudonyms were assigned to all participants to guarantee anonymity. As with the grounded theory approach to qualitative research, data analysis occurred simultaneously with data collection. Semistructured interviews utilizing open-ended questions were used to probe issues starting from general well being to specific issues such as self image, importance of penile length/size, satisfaction of penile performance, and coping with situation (see Table 1). Follow-up questions aimed at gaining better understanding were used for areas where subjects expressed ambiguity, distress, and/or dissatisfaction. Data analysis Initial analysis of the data consisted with the familiarization of the content gathered from interviews. This involved reading and
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Table 1 Sample of interview questions. a) Tell me how you felt when you were first told you had prostate cancer. b) How did you decide to have your prostate removed? c) How did you fare out after surgery? d) Have you noticed any differences with your penis after radical prostatectomy? e) What was your reaction when you first noticed penile changes? f) How did radical prostatectomy affect your sexuality and sexual performance? g) How would you describe masculinity/manliness? Or: What characteristics make a man masculine/manly? h) How manly do you feel in relation to the size of your penis? i) How masculine do you think you are with respect to other men? j) How important was penile length/size to you before surgery? k) How important is penile length/size to you now? l) How does a shortened penis affect you? m) Is there anything that would improve your satisfaction with the way your penis works? n) How has the diagnosis of cancer changed your view of life? o) After all that has happened to you since learning that you had cancer, how are you faring out now?
re-reading of the transcripts, which formed the foundation for further analysis. Review of field notes and listening of the recorded interviews several times allowed the main author to evoke some of the contextual details from interviews. Analysis followed Glaser and Strauss (1973) description of substantive theory, within the grounded theory method. In this study, the processes of data collection, coding, and analysis occurred simultaneously. However, coding and analysis continued long after the last subject was interviewed, which occurred in three stages: a) The first stage of coding focused on scrutinizing the data line by line and identifying theoretical processes in the data by writing code words in the margins of the transcribed data. b) The second stage of coding required the main author to compare the data and its assigned codes in order to cluster them into categories according to obvious fit (Speziale & Carpenter, 2007). c) In the third coding stage, theoretical constructs were derived by identifying the central themes that emerged from the data. A selective sampling of the literature was carried out once emergent categories were identified. Stern (1980) suggested that a literature search before the study began was unnecessary as it may lead to prejudgments resulting in premature closure of ideas. The literature sampled was based on the categories that emerged from the data. As the main concepts or variables became apparent, the main author constantly compared them with the data to determine their importance and the conditions in which they occurred. Categories were reduced into one core variable which also symbolizes the basic social process found. Theoretical coding ensued after the identification of a core category, where the researcher selectively coded all the data related to the core variable. This allowed the author to focus on the data examination process in a theoretical rather than in a descriptive manner (Speziale and Carpenter, 2007). The abstraction of the data was put into different theoretical structures that allowed for the visualization of how the process of living with the perception of PLS occurs in men with PC.
shortening of the penis was a sizeable threat to men’s perceptions of self and masculinity; however, it was not given much significance by interviewees. Overall, at least for the participants of this study, men treated for PC seem to fare better than described in some of the qualitative publications. This study was conducted as part of a master’s in nursing thesis. As such, coding of data was initially conducted in consultation with the main author’s thesis supervisor (LD) in order to assure precision and soundness of the process. Findings While several themes emerged from this study, the central theme of ‘‘resignation’’ was present throughout the data collected. Although men did not state emphatically that they were in a state of resignation, they conveyed an awareness of their inability to return to a pre-cancerous lifestyle. As such, men adapted to the changes that PC brought them. Of note is that resignation was not seen by the men as a state of surrendering to the effects of PC, but as a situation of acceptance, and coexistence with the consequences of cancer. All of the men recognized that ‘‘focusing on the bigger picture’’ became an important tool in their lives that allowed them to coexist with the diagnosis of PC. As a sub-theme, the focus on the bigger picture allowed men to face the challenges of their condition as cancer survivors by attempting to obtain a grander view of their situation. This was done by taking into consideration past experiences, current state of affairs and hypothesizing how potential outcomes would affect them. Furthermore, men recognized a change in their life priorities stressing the importance of family relations, seeing the positive out of negative experiences, and improved in many cases, spousal communication. Although focusing on the bigger picture is a recurrent theme in a number of studies focusing on the lived experience of cancer survivors, we present three outstanding sub-themes that are specific to this study: unaltered masculinity, the unimportance of PLS, and, erectile dysfunction as a speed bump. Subjects’ definition of masculinity In an attempt to better understand the findings of this study, subjects’ definitions of masculinity were used as the foundation for data analysis. Most subjects defined masculinity as the ability to perform male gender roles, emphasizing the display of malespecific behaviors rather than the accentuation of male physical attributes. One subject described masculinity as: ‘‘. the way a man carries himself, [has] the responsibility and expectations to provide and protect his family. A man is expected to do certain things that give a sense of stability and make sure that the needs of the family are met.’’ Another subject said a masculine man should: ‘‘. just be a man. [displays] the basic qualities that a man would see. I’m not saying do the physical or being an athlete. I guess it’s how he carries himself as a person. you don’t have to really be manly to be strutting all of your stuff all the time.’’
Reflexivity
Unaltered masculinity
Reflexivity is a concept in qualitative studies, where the researcher examines how his or her thoughts, behaviors or preconceptions may have influenced the data collected (Polit and Beck, 2004). Initially, the primary author believed that the sudden
Given subjects’ definitions of masculinity, none of the men perceived changes in their own evaluation of masculinity after noticing PLS post-RP. One man compared how masculine he felt in relation to other men:
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‘‘. I feel about normal. I’d say I match up with most men, I’m not very athletic, but I can do a lot of things that other people do, and get along. I don’t feel unmanly or not a man.’’ There is some ambivalence in how men evaluate their own masculinity in light of the presence of ED. However, this has to do with the fact that men saw themselves as being unable to perform a ‘‘masculine’’ role in procuring coitus, which did not necessarily mean that they saw themselves as unmanly. One of the men compared how masculinity was affected by PLS and ED: ‘‘. I don’t think the size of my penis bothers me that much, whether I’m manly or not. I guess what bothers you is that you’re unable to perform with a woman.’’ Although these are just two examples of how men perceived their own masculinity after PC treatment, they illustrate a common theme: men are unlikely to associate changes in genitalia with masculinity. Unimportance of PLS None of the men in this study were concerned with what they perceived to be a shorter penis following RP. Due to the onset of ED men stripped the penis from any sexual significance, rendering its length and/or size irrelevant. As one man said: ‘‘. the size [of the penis]. doesn’t mean much if you’re not trying to get blood into it to get an erection. it’s just there to empty the bladder. As far as using it for sexual purposes. I just lost interest in that.’’ Neither did subjects believe that PLS was a cause of worry to their spouses, citing ED as having a greater impact in spousal satisfaction. However, men felt that the effects of RP were acknowledged and accepted by their significant others, further justifying their own perception that the shortening of their penis was unimportant: ‘‘We have discussed sex, of course. there is uh. accept[ance] of what has happened to me and the size of it now. I don’t think she’s thinking much about it per se. sex in her eyes has diminished and she’s accepted that. we just feel that the penis is not used for intercourse anymore. so the size doesn’t really matter to me or to my partner, I think.’’ The shortening of the penis was seen as only one item in a package of accepted side effects associated with treatment for prostate cancer. This acceptance is likely the result of men’s resignation to the unpreventable consequences of treatment. In spite of the several consequences brought forth by RP, men were able to reprioritize and shift focus on to issues they considered of greater importance. The following excerpt exemplifies such an acceptance: ‘‘You know, [the penis] shrank considerably. And I have to say I wasn’t somehow, terribly surprised. Uh. nobody told me that it would, I have to say that. nobody advised that at all. But I have to say that I wasn’t surprised that it did happen. I’m not sure why, it didn’t surprise me. Um. up until recently, as well, I have some problems. because of shrinkage, and because of what turned out to be a bit of scar tissue, you know post surgery. I had trouble sort of standing and peeing normally. if you combine the small penis with the fact that I didn’t have a very sort of normal stream. I simply could not stand and pee. I had to sit. But, for the most part, I have to say. I have much, more important things to worry about than the size of my penis.’’ Although none of the subjects thought the length of the penis was an issue to be concerned with, one of the participants explained
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that the return of some of its original length was desired along with the return of erectile function: ‘‘. even if you have an erection, [but] were so short that you couldn’t perform the act properly. that would be a concern. Sure. But, otherwise if I could get an erection, and I was on the shorter side, that would be okay too.’’
Erectile dysfunction as a speed bump The return of erectile function was seen by all participants as the single event that would improve satisfaction with penile function. Yet, they acknowledged that sexual intimacy as they had known it was no longer possible. One man described the experience of ED as follows: ‘‘. as you get older, sex doesn’t mean as much, although it is important. there is no argue[ment] with that and it makes one feel good after having sexual intercourse. But after the surgery, well. that was gone and as time moved on, surprisingly, I kind of accepted it. it’s not easy, but I just accepted it. I guess my desire [for sex] too lessened and lessened I guess from the surgery. or not having sex and not being able to get an erection. well, it kind of fades away, the interest.’’ To these men, ED is a condition that deprived them of pleasures in the intimacy, but reasoned that there are also other issues in life that deserved greater attention than the grieving of such loss: ‘‘.I guess a guy always dreams or thinks about having sex again, but, you know, as time goes on. I have been involved in other things. It’s not as important as it was like five years ago. .But as far as my relationship with my wife, uh. I feel we’re just as close, for sure. In the relationship you know you don’t get the feelings of the sexual satisfaction of having intercourse, but that’s something you just live with.’’ Although unfortunate, participants agreed that the loss of erectile function was greatly missed, but it was compensated by the chance of ridding oneself of cancer. They also reasoned that men who underwent RP were not the only persons to suffer from ED and that in fact it affects more men than publicly acknowledged: ‘‘. erectile firmness would be one problem, but other than that it’s not a big thing to worry about. because that’s all you’ve lost, and I guess there’s been men around that probably lost erectile hardness maybe younger.’’ It seems that men tend to view ED from a perspective of resignation, taking into consideration other aspects of life that help strengthen the perception that the inconveniences derived from the treatment for PC are acceptable and, eventually normalized. Erectile dysfunction is therefore, seen as an incident that slows down men’s views on sexual satisfaction, and they move on by reevaluating life in a broader sense. Discussion Treatment of cancer may significantly alter a patient’s concept of self. This may be further complicated by the fact that men with prostate cancer tend not to disclose their illness-related concerns (Bailey et al., 2004). Although physiologic changes to the male genitalia occur in many men who undergo RP, these do not seem to affect their sense of masculinity. As a matter of fact, participants denied feeling less masculine than other men due to PLS and/or ED. It is clear that masculinity was not seen by our subjects as an exclusive physical trait that included the ability to attain erections.
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To these men, the concept of masculinity was emphasized by the expected behavioral qualities that men are to exhibit. Our results lend support to Stansbury and colleagues (2003) who investigated the gender schemas in veterans with PC. In their study, men prioritized fundamental ideals such as ‘‘responsibility’, ‘‘trust’’, ‘‘integrity’’, ‘‘dependability’’, ‘‘honor’’, and ‘‘protector’’ when describing masculinity; and marginalized terms such as ‘‘athletic’’, ‘‘tough’’, ‘‘testicles’’, among others as non-essential characteristics of masculinity (Stansbury et al., 2003). Such conceptualizations of masculinity may not be unique to men with PC. In a collaborative study conducted in the United States, United Kingdom, Germany, France, Italy, Spain, Mexico, and Brazil, 27,839, men (16% of whom reported ED) identified honor, self reliance and respect as more important values of masculinity than being physically attractive, sexually active and successful with women (Sand et al., 2008). Thus, there is room to speculate that the conceptualization of masculinity may lean towards the less physical aspects of manhood even before the diagnosis of cancer. Results presented here contrast several studies that have suggested that men who experience PC treatment side effects perceive decreases in their levels of masculinity (Bokhour et al., 2001; Clark et al., 2003a, 2003b; Davison et al., 2007). Although some men in this study believed that ED affected their own perception of masculinity, this was only limited to the inability to perform an expected ‘‘masculine’’ role during intimate heterosexual interactions. Otherwise, our findings point that there may be no relationship between PLS and/or ED and men’s constructs of masculinity. Because the men in this study saw masculinity as a behavioral trait rather than a physical characteristic, they were able to free the body from any significant role in their conceptualization of masculinity. The results of this study suggest that men view masculinity and the body as separate entities that are not necessarily associated. Under this framework, men were able to reason that their masculinities remained unchanged in spite of the appearance of PLS and ED. This contrasts previous findings by Oliffe (2005), Chapple and Ziebland (2002) and Fergus et al. (2002) who suggested that men with RP induced ED maintain the same level of masculinity by redefining their concept of masculinity to accommodate for the consequences of PC treatment. Yet masculinity may not be experienced equally in all men with cancer. Guverich et al., (2004) found that testicular cancer survivors experience both, a loss of masculinity and a justification to be exempt from the social definition of masculinity. The lack of somatic bother associated with PLS may be a reason why participants were not preoccupied by it. Another reason for the lack of importance attributed to PLS may lie within the very rationalization of accepting PC treatment side effects as consequences of prolonging life. This redefinition of concepts is explained in Korfage et al. (2006) findings that men adapt to the outcomes of prostate cancer treatment by accepting the side effects as unavoidable outcomes. In so doing, men reframed sexual, urinary and bowel dysfunctions as non-health related issues, normalizing the changes incurred with treatment for PC. Evidence suggests that very few men with PC regret undergoing RP (Clark and Talcott, 2006; Davison et al., 2007; Hu et al., 2003). Similarly, none of the interviewees expressed decisional regret with RP and its side effects. Only one of them expressed ambivalence due to ED and would have preferred knowing more about other options available to him at the time of diagnosis. None of the participants thought PLS was an issue important enough not to undergo RP. Of note is that these men already had RP at the time of interview. Whether men would see PLS as a condition to avoid RP remains to be explored.
It is not known whether men who retain erectile function after RP would share the same views about PLS as the men in this study. It is possible that the retention of erectile function may be upset by a reduced penile length that that is inadequate for penetrative sex. Although anecdotal evidence exists suggesting those who can achieve erections after RP would likely see the return of original penile size during an erection, there is no concrete evidence to support such claims. Although it was not our intention to know whether subjects were informed about the possibility of PLS due to RP, four of the six subjects stated without prompting that they were unaware of such a consequence at the time of surgery. Similarly, Oliffe (2005) reported that of the men who suffered of PLS in his study, none was informed about it prior to RP. However, none of the men in this study were bothered by PLS at the time of the interview, attributing greater concern to the presence of ED. It is possible, nevertheless, that our subjects’ acceptance of PLS is the result of adaptation processes in place since RP, at least 12 months prior to interview. Limitations In qualitative studies, large numbers of participants are not necessarily beneficial to the investigation. Recruitment of subjects is guided by the achievement of data saturation, usually stopping at the time when no new information is being gathered from participants. In this study, saturation plus one subject was achieved. In spite of the efforts to obtain a diverse sample, however, no gay men, men with erectile function intact, nor representatives of ethnic minorities were included in this study. These are not intentional omissions, but rather, chance occurrences. Results presented here are not meant to characterize experiences of all men who have undergone a RP and noticed PLS. Subjects had lived with the consequences of RP for at least one year prior to interviews and had participated at the local PC support group meetings. Implications Many men often choose not to talk about issues regarding their health in order to conform to social norms. Health care providers need to be aware of these norms and not assume that men will fully disclose their health concerns during medical consultation. Respecting and honoring a man’s silence regarding uncomfortable topics should take place in an environment that provides them with ample opportunities to facilitate communication with health care providers. Better understanding of the concept of masculinity in men with PC will allow health care providers to maximize health outcomes with interventions that best suit the needs of convalescent men. Areas that the current sample identified as needing further improvement were around information seeking, compliance and reporting of health concerns. The perception of masculinity may also evolve over time. Knowing how different age groups define masculinity would be of great assistance in developing public health interventions that improve men’s health seeking behaviors. Health care providers should be aware that some men may be afflicted with self-image perception issues due to PLS. Nursing staff must acknowledge men’s concerns and demonstrate sympathy to those who suffer from PLS and/or ED. Nurses are in a position to provide support to men coming to terms with changes in their genitalia. Patients should be reassured that PLS is seen in many men who have undergone RP, and that its occurrence does not seem to bring pain or discomfort, nor does it affect the perception of gender and/or masculinity.
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Conclusions Diagnosis and treatment of PC can be a turning point in life for many men. Contrary to anecdotal statements encountered by the principal investigator about PLS by men without PC, PLS is not depicted as detrimental by the men who experience it. Rather, it is seen as an accepted occurrence resulting from treatment for PC. In such an acceptance, men did not perceive that their sense of self or masculinity was affected. The little concern men had related to PLS may be attributed to the lack of physical discomfort associated with it. Furthermore, none of the participants believed that the shortened penis affected them or their spouses. Without the ability to achieve proper erections, men saw no need to worry about penile length or size. However, there is a possibility that men may desire an increase of penile length or size if erections returned. Acknowledgements We would like to express our sincere gratitude to each man in this study for sharing his experiences, and to the men and women of the Manitoba Prostate Cancer Support Group, in Winnipeg, Manitoba. Wellam F. Yu Ko was supported by an Evidence-Based Practice Chair Award from the Canadian Health Services Research Foundation and the Canadian Institutes of Health Research. Conflict of interest There is no conflict of interest. References American Cancer Society, 2008. Overview: prostate cancer: how many men get prostate cancer?. Retrieved September 13th, 2008, from. http://www.cancer.org/ docroot/CRI/content/CRI_2_2_1X_How_many_men_get_prostate _cancer_36.asp. Bailey Jr., D.E., Mishel, M.H., Belyea, M., Stewart, J.L., Mohler, J., 2004. Uncertainty intervention for watchful waiting in prostate cancer. Cancer Nurs. 27 (5), 339–346. Bertero, C., 2001. Altered sexual patterns after treatment for prostate cancer. Cancer Pract. 9, 245–251. Bokhour, B.G., Clark, J.A., Inui, T.S., Silliman, R.A., Talcott, J.A., 2001. Sexuality after treatment for early prostate cancer: exploring the meanings of ‘‘erectile dysfunction’’ J. Gen. Int. Med. 16, 649–655. Briganti, A., Fabbri, F., Salonia, A., Chun, F.-H., Deho`, F., Zanni, G., Suardi, N., Karakiewicz, P.I., Rigatti, P., Montorsi, F., 2007. Preserved postoperative penile correlates well with maintained erectile function after bilateral nerve-sparing prostatectomy. Eur. Urol.. doi:10.1016/j.eurouro.2007.03.050. Canadian Cancer Society, 2008. Prostate cancer statistics. Retrieved June 17th, 2008, from. http://info.cancer.ca/E/CCE/cceexplorer.asp?tocid¼41. Clark, J.A., Bokhour, B.G., Inui, T.S., Silliman, R.A., Talcott, J.A., 2003a. ‘Measuring patients’ perceptions of the outcomes of treatment for early prostate cancer. Med. Care 41 (8), 923–936. Clark, J.A., Inui, T.S., Silliman, R.A., Bokhour, B.G., Krasnow, S.H., Robinson, R.A., Spaulding, M., Talcott, J.A., 2003b. Patients’ perceptions of quality of life after treatment for early prostate cancer. J. Clin. Onc. 21 (20), 3777–3784. Clark, J.A., Talcott, J.A., 2006. Confidence and uncertainty long after initial treatment for early prostate cancer: survivors’ views of cancer control and the treatment of decisions they made. J. Clin. Onc. 24, 4457–4463. Chapple, A., Ziebland, S., 2002. Prostate cancer: embodied experience and perceptions of masculinity. Soc. Health Illn. 24 (6), 820–841. Ciancio, S.J., Kim, E.D., 2000. Penile fibrotic changes after radical retropubic prostatectomy. BJU Int. 85, 101–106. Cohen, M.Z., Kahn, D.L., Steeves, R.H., 1998. Beyond body image: the experience of breast cancer. ONF 25, 835–841. Davison, B.J., So, A.I., Goldenberg, L., 2007. Quality of life, sexual function and decisional regret at 1 year after surgical treatment for localized prostate cancer. BJU 100, 780–785. Fergus, K.D., Gray, R.E., Fitch, M.I., Labreque, M., Phillips, C., 2002. Active consideration: conceptualizing patient-provided support for spouse caregivers in the context of prostate cancer. Qual. Health Res. 12 (4), 492–514.
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Fraiman, M.C., Lepor, H., McCullough, A.R., 1999. Changes in penile morphometrics in men with erectile dysfunction after nerve-sparing radical retropubic prostatectomy. Mol. Urol. 3 (2), 109–115. Francken, A.B., van de Wiel, H.B.M., van Driel, M.F., Weijmar Schultz, W.C.M., 2002. What importance do women attribute to the size of the penis? Eur. Urol. 42, 426–431. Glaser, B.G., Strauss, A.L., 1973. The Discovery of Grounded Theory: Strategies for Qualitative Research. Illinois: Aldine Publishing Company, Chicago. Gontero, P., Galzerano, M., Bartoletti, R., Magnani, C., Tizzani, A., Frea, B., Mondaini, N., 2007. New insights into the pathogenesis of penile shortening after radical prostatectomy and the role of postoperative sexual function. J. Urol. 178 (2), 602–607. Guverich, M., Bishop, S., Bower, J., Malka, M., Nyhof-Young, J., 2004. (Dis)embodying gender and sexuality in testicular cancer. Soc. Sci. Med. 58, 1597–1607. Hu, J.C., Kwan, L., Saigal, C.S., Litwin, M.S., 2003. Regret in men treated for localized prostate cancer. J. Urol. 169, 2279–2283. Klein, L.T., Miller, M.I., Buttyan, R., Raffo, A.J., Burchard, M., Devris, G., Cao, Y.C., Olsson, C., Shabsigh, R., 1997. Apoptosis in the rat penis after penile denervation. J. Urol. 158 (2), 626–630. Korfage, I.J., Hak, T., de Koning, H.J., Essink-Bot, M.-L., 2006. Patients’ perceptions of the side-effects of prostate cancer treatment–a qualitative interview study. Soc. Sci. Med 63, 911–919. Lee, P.A., 1996. Survey report: concept of penis size. J. Sex Marit. Thera. 22 (2), 131–135. Lee, A.P., Reiter, E.O., 2002. Genital size: a common adolescent male concern. Adolesc. Med. 13 (1), 171–180. Mondaini, N., Ponchietti, R., Gontero, P., Muir, G.H., Natali, A., Di Loro, F., Caldarera, E., Biscioni, S., Rizzo, M., 2002. Penile length is normal in most men seeking penile lengthening procedures. Int. J. Impot. Res. 14, 283–286. Moreland, R.B., 1998. Is there a role of hypoxemia in penile fibrosis: a viewpoint presented to the Society for study of Impotence. Int. J. Impot. Res. 10 (2), 113–120. Munding, M.D., Wessells, H.B., Dalkin, B.L., 2001. Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy. Urology 58 (4), 567–569. Oliffe, J., 2005. Constructions of masculinity following prostatectomy-induced impotence. Soc. Sci. Med. 60, 2249–2259. Penson, D.F., Feng, Z., Muniyuki, A., McClerran, D., Albertson, P.C., Deapen, D., Gilliland, F., Hoffman, R., Stephenson, R.A., Potosky, A.L., Stanford, J.L., 2003. General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study. J. Clin. Onc. 21 (6), 1147–1154. Perugia, G., Liberti, M., Vicini, P., Colistro, F., Gentile, V., 2005. Use of local hyperthermia as prophylaxis of fibrosis and modification in penile length following radical retropubic prostatectomy. Int. J. Hyperthermia 21 (4), 359–365. Polit, D.F., Beck, C.T., 2004. Nursing Research: Principles and Methods, seventh ed. Lippincott Williams & Wilkins, New York, NY. Sand, M.S., Fisher, W., Rosen, R., Heiman, J., Eardley, I., 2008. Erectile dysfunction and constructs of masculinity and quality of life in the Multinational Men’s Attitudes to Life Events and Sexuality (MALES) Study. Int. Soc. Sex. Med. 5, 583–594. Savoie, M., Kim, S.S., Soloway, M.S., 2003. A prospective study measuring penile length in men treated with radical prostatectomy for prostate cancer. J. Urol. 169, 1462–1464. Schag, C.A.C., Ganz, P.A., Wing, D.S., Lee, J.J., 1994. Quality of life in adult survivors of lung, colon, and prostate cancer. Qual. Life Res. 3, 127–141. Schneider, T., Sperling, H., Lummen, G., Syllwasschy, J., Rubben, H., 2001. Does penile size in younger men cause problems with condom use? A prospective measurement of penile dimensions in 111 young and 32 older men. Urology 57 (2), 314–318. Shamloul, R., 2005. Treatment of men complaining of short penis. Urology 65, 1183–1185. Son, H., Lee, H., Huh, J.S., Kim, S.W., Paick, J.S., 2003. Studies on self-esteem of penile size in young Korean military men. Asian J. Andro. 5, 185–189. Speziale, H.J., Carpenter, D., 2007. Qualitative Research in Nursing: Advancing the Humanistic Imperative, fourth ed. Lippincott Williams & Wilkins, New York, NY. Stansbury, J.P., Mathewson-Chapman, M., Grant, K.E., 2003. Gender schema and prostate cancer: veterans’ cultural model of masculinity. Med. Anthro. 22, 175–204. Stern, P.N., 1980. Grounded theory methodology: its uses and processes. Image 12 (7), 20–23. Wilmoth, M.C., 2001. The aftermath of breast cancer: an altered sexual self. Cancer Nurs. 24, 78–86. Wylie, K.R., Eardley, I., 2007. Penile size and the ‘‘small penis syndrome’’ BJU Int. 99, 1449–1455.
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Penile length shortening after radical prostatectomy: Men’s responses Wellam F. Yu Ko*, Lesley F. Degner, Thomas F. Hack, Garry Schroeder 627-110, Adamar Road, Winnipeg, Manitoba, R3T 3M3, Canada
a b s t r a c t Keywords: Penile length shortening Radical prostatectomy Masculinity Self image
Background: Prostate cancer (PC) is the most common type of male-specific cancer in North American men, and many men choose radical prostatectomy (RP) to remove their cancer. Although penile length shortening (PLS) occurs in a reported 68% to 71% of men undergoing RP, little is known about it. In an electronic journal search, only 9 medical articles (with no nursing publications) were published between 1980 and 2007. Purpose: To provide an account of patients’ perceptions and responses to living with PLS after RP. Methods and sample: Semi-structured interviews and a grounded theory approach were used to discover the basic social processes regarding men’s perceptions of a shortened penis and overall sense of self. A total of six men who underwent RP and consequently noticed PLS were recruited from a local PC support group for semi-structured interviews lasting between 40–60 min. Results: Based on subjects’ own definitions of masculinity, no significant changes in the constructs of masculinity and overall self-image perception were reported. Conclusions: Men undergoing RP may not be fully aware that PLS is a possible consequence related to treatment. In spite of this, subjects were not negatively affected by its occurrence. Ó 2009 Elsevier Ltd. All rights reserved.
Men’s responses Prostate cancer (PC) is the most prevalent male-specific malignancy in North America. An estimated 186,320 American men (American Cancer Society, 2008) and 24,700 Canadian men (Canadian Cancer Society, 2008) were diagnosed with it during 2008. Upon diagnosis of localized prostate cancer, many men will choose radical prostatectomy (RP) as a treatment method. Although erectile dysfunction (ED) and urinary incontinence are known side effects of RPs, penile length shortening (PLS) is often not associated with the procedure even thought it occurs in a reported 68% to 71% (Munding et al., 2001; Savoie et al., 2003). Preoccupation with the penis and its size has accompanied cultural evolution throughout the world. Often, figurines, paintings and phallic art depict greater than normal sized penises. Societies have often attributed the penis with powers symbolizing masculinity, strength, endurance, ability, courage, intelligence, knowledge, dominance over other men, and possession of women (Wylie and Eardley, 2007). However, being treated for cancer can produce various physical and psychological changes that threaten patients’ concept of sexuality and body image (Bertero, 2001; Cohen et al., 1998; Penson et al., 2003; Schag et al., 1994; Wilmoth, 2001). Thus,
* Corresponding author. Tel.: þ1 (204) 947 0802. E-mail address: [email protected] (W.F. Yu Ko). 1462-3889/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2009.09.001
a decrease in penile length after RP may negatively affect the psychological well being of prostate cancer survivors. The actual etiology of PLS is not known. What is known about PLS is that the greatest length reduction occurs during the first year post-operatively. Fraiman et al. (1999), Munding et al. (2001), and Gontero et al. (2007) noted that shortening occurred most markedly shortly after catheter removal and continued to diminish in length, albeit at a slower rate, for at least 12 months after surgery. Several theories exist regarding PLS. Munding et al. (2001) suggested that the removal of the section of urethra within the prostate shortened the total length of the urethra, resulting in a shortening of the penis. A second possible explanation by Munding et al. (2001) proposed that the decrease in penile length was the result of prepubic scarring resulting from RP, which shortened the suspensory ligaments of the penis, leading to a shortened penis. Ciancio and Kim (2000) suggested the formation of fibrotic tissue in the penis after RP as a cause of penile shortening, as they found that 41% of the patients who were referred to them for erectile dysfunction after RP also developed fibrotic changes. Causes of PLS at the histological level have also been pointed out. Klein et al. (1997) suggested that apoptosis of penile erectile tissue after cavernous neurotomy in the rat model caused neural damage that may explain the decreased penile size after RP. On the other hand, Moreland (1998) found that human penile smooth muscle cell culture tissues experienced changes when subject to hypoxic conditions. Consequently, it is assumed that circulatory
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deficiencies resulting from a radical prostatectomy may also affect penile length. Although these studies do not explain matter-offactly how penile shortening occurs, they keep the door open for possible explanations at a cellular level. Although studies by Perugia et al. (2005) and Savoie et al. (2003) suggested that bilateral nerve sparing radical retropubic prostatectomies (a surgical technique where the pudendal nerves that run posteriorly along the prostate are carefully separated from the prostate and left intact) do not prevent penile length shortening when compared to non-nerve sparing open prostatectomy (where the pudendal nerves are severed), Briganti et al. (2007) found that the former correlates positively with a decreased incidence of PLS. Clearly, the effect that each prostatectomy technique has on PLS needs to be studied further. Men seem to be more concerned about penile size than women. Francken et al. (2002) found in a survey study that women rated penile length as being ‘‘unimportant’’ and ‘‘totally unimportant’’ in 55% and 22% of the respondents, respectively. Whereas, Lee (1996) found in his sample of single male college students (n ¼ 128) that self-perception about penis size had a skewed distribution towards a small penis, even though these men felt that they had proportionately adequate body hair distribution and physique. These findings support a separate study performed in 2003, where 123 men had their penis measured while on a visit to a military hospital in Korea, finding that men had a tendency to underestimate the dimensions of their own penis (Son et al., 2003). Interestingly, results from studies conducted in Egypt and Italy found that almost all of the men seeking to enlarge their penile size had, as a matter of fact, normal penile dimensions (Mondaini et al., 2002; Shamloul, 2005). Mondaini et al. (2002) and Shamloul (2005) attribute the preoccupation about penile size in the Egyptian and Italian studies to men’s early exposure to more developed genitals from their peers and/or pornographic material during adolescence, leading to the belief that their own penises were inadequately small. In summary, current literature regarding lived experiences after RP focuses primarily on urinary and sexual effects of the procedure. And, although penile length is not thought to decrease with aging (Schneider et al., 2001), many men experience a noticeable decrease in penile length shortly after RP. The effects of a decrease in the length of the penis after RP and/or during adulthood have not been previously published. While several findings were made in this study, this paper will focus on the most salient results with the discussion of a resultant theory of masculinity in PC survivorship in a later paper. Purpose statement and definitions The goal of this study was to explore patients’ perceptions and responses of PLS after RP. To this end, penile length shortening was defined in this study as the subjects’ perceived loss of penile length after undergoing RP, irrespective of actual length changes. Methods Design Given that men’s perceptions of penis size is affected by social norms (Lee and Reiter, 2002), the design of this study was based on the grounded theory approach for its suitability in the exploration of social processes and social structures (Polit and Beck, 2004). Specifically, the current study was designed as a substantive theory type of grounded theory research. Usually, substantive theory research serves as the basis for more comprehensive studies that combine the results of several other related studies based on the
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substantive theory model that result in the formal grounded theory approach (Polit and Beck, 2004). Participants This qualitative study was undertaken in the city of Winnipeg, the capital of Manitoba, a Western Canadian province. Recruitment was conducted via open invitations at meetings held at the local prostate cancer support group, and by the posting of a recruitment advert in the group’s newsletter. The period of recruitment was of two months, in which time data saturation was achieved by the fifth subject. The main criteria for inclusion was the perception of penile length loss at least one year after undergoing RP, irrespective of stage of cancer at time of diagnosis or whether participants received other treatments for PC. A total of 11 men contacted the principal investigator demonstrating interest in participating, seven of whom met inclusion criteria, with one declining to participate before the scheduled interview. This resulted in a convenience sample of six participants (mean age 64.7, range 58–77), four of whom were retired and two worked full time. Five of them were married and lived with their spouses, whereas one of them was divorced and lived alone. Almost all (five) subjects stated being of Caucasian descent while one claimed Ukrainian heritage. Only one of the men declared high school as the highest level of education completed, whilst five had finished post secondary education. None of the participants reported to be able to achieve proper erections that allowed them to participate in penetrative sex. Only one participant declared having no urinary incontinence at all, while the remaining stated having only occasional or minor urinary symptoms such as urinary urge, stress incontinence, and nocturia. No bowel symptoms were reported by participants. Oneon-one interviews took place once participants agreed to, and signed the respective documents of consent. Participants were also met a second time by the principal investigator to confirm findings at a later date. The study was approved by the Education/Nursing Research Ethics Board, at the University of Manitoba in Winnipeg, Manitoba, Canada, and by the Manitoba Prostate Cancer Support Group. Data collection All subjects were offered a choice of venue for the interviews. These were conducted at participants’ homes, university interview room, and at a subject’s office. In a quiet environment, subjects completed a demographic information questionnaire before commencing the interview. The main author (a male nurse) conducted all of the interviews, which lasted between 40 to 60 min. All interviews were tape recorded and later transcribed verbatim, also by the main author. Numeric pseudonyms were assigned to all participants to guarantee anonymity. As with the grounded theory approach to qualitative research, data analysis occurred simultaneously with data collection. Semistructured interviews utilizing open-ended questions were used to probe issues starting from general well being to specific issues such as self image, importance of penile length/size, satisfaction of penile performance, and coping with situation (see Table 1). Follow-up questions aimed at gaining better understanding were used for areas where subjects expressed ambiguity, distress, and/or dissatisfaction. Data analysis Initial analysis of the data consisted with the familiarization of the content gathered from interviews. This involved reading and
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Table 1 Sample of interview questions. a) Tell me how you felt when you were first told you had prostate cancer. b) How did you decide to have your prostate removed? c) How did you fare out after surgery? d) Have you noticed any differences with your penis after radical prostatectomy? e) What was your reaction when you first noticed penile changes? f) How did radical prostatectomy affect your sexuality and sexual performance? g) How would you describe masculinity/manliness? Or: What characteristics make a man masculine/manly? h) How manly do you feel in relation to the size of your penis? i) How masculine do you think you are with respect to other men? j) How important was penile length/size to you before surgery? k) How important is penile length/size to you now? l) How does a shortened penis affect you? m) Is there anything that would improve your satisfaction with the way your penis works? n) How has the diagnosis of cancer changed your view of life? o) After all that has happened to you since learning that you had cancer, how are you faring out now?
re-reading of the transcripts, which formed the foundation for further analysis. Review of field notes and listening of the recorded interviews several times allowed the main author to evoke some of the contextual details from interviews. Analysis followed Glaser and Strauss (1973) description of substantive theory, within the grounded theory method. In this study, the processes of data collection, coding, and analysis occurred simultaneously. However, coding and analysis continued long after the last subject was interviewed, which occurred in three stages: a) The first stage of coding focused on scrutinizing the data line by line and identifying theoretical processes in the data by writing code words in the margins of the transcribed data. b) The second stage of coding required the main author to compare the data and its assigned codes in order to cluster them into categories according to obvious fit (Speziale & Carpenter, 2007). c) In the third coding stage, theoretical constructs were derived by identifying the central themes that emerged from the data. A selective sampling of the literature was carried out once emergent categories were identified. Stern (1980) suggested that a literature search before the study began was unnecessary as it may lead to prejudgments resulting in premature closure of ideas. The literature sampled was based on the categories that emerged from the data. As the main concepts or variables became apparent, the main author constantly compared them with the data to determine their importance and the conditions in which they occurred. Categories were reduced into one core variable which also symbolizes the basic social process found. Theoretical coding ensued after the identification of a core category, where the researcher selectively coded all the data related to the core variable. This allowed the author to focus on the data examination process in a theoretical rather than in a descriptive manner (Speziale and Carpenter, 2007). The abstraction of the data was put into different theoretical structures that allowed for the visualization of how the process of living with the perception of PLS occurs in men with PC.
shortening of the penis was a sizeable threat to men’s perceptions of self and masculinity; however, it was not given much significance by interviewees. Overall, at least for the participants of this study, men treated for PC seem to fare better than described in some of the qualitative publications. This study was conducted as part of a master’s in nursing thesis. As such, coding of data was initially conducted in consultation with the main author’s thesis supervisor (LD) in order to assure precision and soundness of the process. Findings While several themes emerged from this study, the central theme of ‘‘resignation’’ was present throughout the data collected. Although men did not state emphatically that they were in a state of resignation, they conveyed an awareness of their inability to return to a pre-cancerous lifestyle. As such, men adapted to the changes that PC brought them. Of note is that resignation was not seen by the men as a state of surrendering to the effects of PC, but as a situation of acceptance, and coexistence with the consequences of cancer. All of the men recognized that ‘‘focusing on the bigger picture’’ became an important tool in their lives that allowed them to coexist with the diagnosis of PC. As a sub-theme, the focus on the bigger picture allowed men to face the challenges of their condition as cancer survivors by attempting to obtain a grander view of their situation. This was done by taking into consideration past experiences, current state of affairs and hypothesizing how potential outcomes would affect them. Furthermore, men recognized a change in their life priorities stressing the importance of family relations, seeing the positive out of negative experiences, and improved in many cases, spousal communication. Although focusing on the bigger picture is a recurrent theme in a number of studies focusing on the lived experience of cancer survivors, we present three outstanding sub-themes that are specific to this study: unaltered masculinity, the unimportance of PLS, and, erectile dysfunction as a speed bump. Subjects’ definition of masculinity In an attempt to better understand the findings of this study, subjects’ definitions of masculinity were used as the foundation for data analysis. Most subjects defined masculinity as the ability to perform male gender roles, emphasizing the display of malespecific behaviors rather than the accentuation of male physical attributes. One subject described masculinity as: ‘‘. the way a man carries himself, [has] the responsibility and expectations to provide and protect his family. A man is expected to do certain things that give a sense of stability and make sure that the needs of the family are met.’’ Another subject said a masculine man should: ‘‘. just be a man. [displays] the basic qualities that a man would see. I’m not saying do the physical or being an athlete. I guess it’s how he carries himself as a person. you don’t have to really be manly to be strutting all of your stuff all the time.’’
Reflexivity
Unaltered masculinity
Reflexivity is a concept in qualitative studies, where the researcher examines how his or her thoughts, behaviors or preconceptions may have influenced the data collected (Polit and Beck, 2004). Initially, the primary author believed that the sudden
Given subjects’ definitions of masculinity, none of the men perceived changes in their own evaluation of masculinity after noticing PLS post-RP. One man compared how masculine he felt in relation to other men:
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‘‘. I feel about normal. I’d say I match up with most men, I’m not very athletic, but I can do a lot of things that other people do, and get along. I don’t feel unmanly or not a man.’’ There is some ambivalence in how men evaluate their own masculinity in light of the presence of ED. However, this has to do with the fact that men saw themselves as being unable to perform a ‘‘masculine’’ role in procuring coitus, which did not necessarily mean that they saw themselves as unmanly. One of the men compared how masculinity was affected by PLS and ED: ‘‘. I don’t think the size of my penis bothers me that much, whether I’m manly or not. I guess what bothers you is that you’re unable to perform with a woman.’’ Although these are just two examples of how men perceived their own masculinity after PC treatment, they illustrate a common theme: men are unlikely to associate changes in genitalia with masculinity. Unimportance of PLS None of the men in this study were concerned with what they perceived to be a shorter penis following RP. Due to the onset of ED men stripped the penis from any sexual significance, rendering its length and/or size irrelevant. As one man said: ‘‘. the size [of the penis]. doesn’t mean much if you’re not trying to get blood into it to get an erection. it’s just there to empty the bladder. As far as using it for sexual purposes. I just lost interest in that.’’ Neither did subjects believe that PLS was a cause of worry to their spouses, citing ED as having a greater impact in spousal satisfaction. However, men felt that the effects of RP were acknowledged and accepted by their significant others, further justifying their own perception that the shortening of their penis was unimportant: ‘‘We have discussed sex, of course. there is uh. accept[ance] of what has happened to me and the size of it now. I don’t think she’s thinking much about it per se. sex in her eyes has diminished and she’s accepted that. we just feel that the penis is not used for intercourse anymore. so the size doesn’t really matter to me or to my partner, I think.’’ The shortening of the penis was seen as only one item in a package of accepted side effects associated with treatment for prostate cancer. This acceptance is likely the result of men’s resignation to the unpreventable consequences of treatment. In spite of the several consequences brought forth by RP, men were able to reprioritize and shift focus on to issues they considered of greater importance. The following excerpt exemplifies such an acceptance: ‘‘You know, [the penis] shrank considerably. And I have to say I wasn’t somehow, terribly surprised. Uh. nobody told me that it would, I have to say that. nobody advised that at all. But I have to say that I wasn’t surprised that it did happen. I’m not sure why, it didn’t surprise me. Um. up until recently, as well, I have some problems. because of shrinkage, and because of what turned out to be a bit of scar tissue, you know post surgery. I had trouble sort of standing and peeing normally. if you combine the small penis with the fact that I didn’t have a very sort of normal stream. I simply could not stand and pee. I had to sit. But, for the most part, I have to say. I have much, more important things to worry about than the size of my penis.’’ Although none of the subjects thought the length of the penis was an issue to be concerned with, one of the participants explained
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that the return of some of its original length was desired along with the return of erectile function: ‘‘. even if you have an erection, [but] were so short that you couldn’t perform the act properly. that would be a concern. Sure. But, otherwise if I could get an erection, and I was on the shorter side, that would be okay too.’’
Erectile dysfunction as a speed bump The return of erectile function was seen by all participants as the single event that would improve satisfaction with penile function. Yet, they acknowledged that sexual intimacy as they had known it was no longer possible. One man described the experience of ED as follows: ‘‘. as you get older, sex doesn’t mean as much, although it is important. there is no argue[ment] with that and it makes one feel good after having sexual intercourse. But after the surgery, well. that was gone and as time moved on, surprisingly, I kind of accepted it. it’s not easy, but I just accepted it. I guess my desire [for sex] too lessened and lessened I guess from the surgery. or not having sex and not being able to get an erection. well, it kind of fades away, the interest.’’ To these men, ED is a condition that deprived them of pleasures in the intimacy, but reasoned that there are also other issues in life that deserved greater attention than the grieving of such loss: ‘‘.I guess a guy always dreams or thinks about having sex again, but, you know, as time goes on. I have been involved in other things. It’s not as important as it was like five years ago. .But as far as my relationship with my wife, uh. I feel we’re just as close, for sure. In the relationship you know you don’t get the feelings of the sexual satisfaction of having intercourse, but that’s something you just live with.’’ Although unfortunate, participants agreed that the loss of erectile function was greatly missed, but it was compensated by the chance of ridding oneself of cancer. They also reasoned that men who underwent RP were not the only persons to suffer from ED and that in fact it affects more men than publicly acknowledged: ‘‘. erectile firmness would be one problem, but other than that it’s not a big thing to worry about. because that’s all you’ve lost, and I guess there’s been men around that probably lost erectile hardness maybe younger.’’ It seems that men tend to view ED from a perspective of resignation, taking into consideration other aspects of life that help strengthen the perception that the inconveniences derived from the treatment for PC are acceptable and, eventually normalized. Erectile dysfunction is therefore, seen as an incident that slows down men’s views on sexual satisfaction, and they move on by reevaluating life in a broader sense. Discussion Treatment of cancer may significantly alter a patient’s concept of self. This may be further complicated by the fact that men with prostate cancer tend not to disclose their illness-related concerns (Bailey et al., 2004). Although physiologic changes to the male genitalia occur in many men who undergo RP, these do not seem to affect their sense of masculinity. As a matter of fact, participants denied feeling less masculine than other men due to PLS and/or ED. It is clear that masculinity was not seen by our subjects as an exclusive physical trait that included the ability to attain erections.
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To these men, the concept of masculinity was emphasized by the expected behavioral qualities that men are to exhibit. Our results lend support to Stansbury and colleagues (2003) who investigated the gender schemas in veterans with PC. In their study, men prioritized fundamental ideals such as ‘‘responsibility’, ‘‘trust’’, ‘‘integrity’’, ‘‘dependability’’, ‘‘honor’’, and ‘‘protector’’ when describing masculinity; and marginalized terms such as ‘‘athletic’’, ‘‘tough’’, ‘‘testicles’’, among others as non-essential characteristics of masculinity (Stansbury et al., 2003). Such conceptualizations of masculinity may not be unique to men with PC. In a collaborative study conducted in the United States, United Kingdom, Germany, France, Italy, Spain, Mexico, and Brazil, 27,839, men (16% of whom reported ED) identified honor, self reliance and respect as more important values of masculinity than being physically attractive, sexually active and successful with women (Sand et al., 2008). Thus, there is room to speculate that the conceptualization of masculinity may lean towards the less physical aspects of manhood even before the diagnosis of cancer. Results presented here contrast several studies that have suggested that men who experience PC treatment side effects perceive decreases in their levels of masculinity (Bokhour et al., 2001; Clark et al., 2003a, 2003b; Davison et al., 2007). Although some men in this study believed that ED affected their own perception of masculinity, this was only limited to the inability to perform an expected ‘‘masculine’’ role during intimate heterosexual interactions. Otherwise, our findings point that there may be no relationship between PLS and/or ED and men’s constructs of masculinity. Because the men in this study saw masculinity as a behavioral trait rather than a physical characteristic, they were able to free the body from any significant role in their conceptualization of masculinity. The results of this study suggest that men view masculinity and the body as separate entities that are not necessarily associated. Under this framework, men were able to reason that their masculinities remained unchanged in spite of the appearance of PLS and ED. This contrasts previous findings by Oliffe (2005), Chapple and Ziebland (2002) and Fergus et al. (2002) who suggested that men with RP induced ED maintain the same level of masculinity by redefining their concept of masculinity to accommodate for the consequences of PC treatment. Yet masculinity may not be experienced equally in all men with cancer. Guverich et al., (2004) found that testicular cancer survivors experience both, a loss of masculinity and a justification to be exempt from the social definition of masculinity. The lack of somatic bother associated with PLS may be a reason why participants were not preoccupied by it. Another reason for the lack of importance attributed to PLS may lie within the very rationalization of accepting PC treatment side effects as consequences of prolonging life. This redefinition of concepts is explained in Korfage et al. (2006) findings that men adapt to the outcomes of prostate cancer treatment by accepting the side effects as unavoidable outcomes. In so doing, men reframed sexual, urinary and bowel dysfunctions as non-health related issues, normalizing the changes incurred with treatment for PC. Evidence suggests that very few men with PC regret undergoing RP (Clark and Talcott, 2006; Davison et al., 2007; Hu et al., 2003). Similarly, none of the interviewees expressed decisional regret with RP and its side effects. Only one of them expressed ambivalence due to ED and would have preferred knowing more about other options available to him at the time of diagnosis. None of the participants thought PLS was an issue important enough not to undergo RP. Of note is that these men already had RP at the time of interview. Whether men would see PLS as a condition to avoid RP remains to be explored.
It is not known whether men who retain erectile function after RP would share the same views about PLS as the men in this study. It is possible that the retention of erectile function may be upset by a reduced penile length that that is inadequate for penetrative sex. Although anecdotal evidence exists suggesting those who can achieve erections after RP would likely see the return of original penile size during an erection, there is no concrete evidence to support such claims. Although it was not our intention to know whether subjects were informed about the possibility of PLS due to RP, four of the six subjects stated without prompting that they were unaware of such a consequence at the time of surgery. Similarly, Oliffe (2005) reported that of the men who suffered of PLS in his study, none was informed about it prior to RP. However, none of the men in this study were bothered by PLS at the time of the interview, attributing greater concern to the presence of ED. It is possible, nevertheless, that our subjects’ acceptance of PLS is the result of adaptation processes in place since RP, at least 12 months prior to interview. Limitations In qualitative studies, large numbers of participants are not necessarily beneficial to the investigation. Recruitment of subjects is guided by the achievement of data saturation, usually stopping at the time when no new information is being gathered from participants. In this study, saturation plus one subject was achieved. In spite of the efforts to obtain a diverse sample, however, no gay men, men with erectile function intact, nor representatives of ethnic minorities were included in this study. These are not intentional omissions, but rather, chance occurrences. Results presented here are not meant to characterize experiences of all men who have undergone a RP and noticed PLS. Subjects had lived with the consequences of RP for at least one year prior to interviews and had participated at the local PC support group meetings. Implications Many men often choose not to talk about issues regarding their health in order to conform to social norms. Health care providers need to be aware of these norms and not assume that men will fully disclose their health concerns during medical consultation. Respecting and honoring a man’s silence regarding uncomfortable topics should take place in an environment that provides them with ample opportunities to facilitate communication with health care providers. Better understanding of the concept of masculinity in men with PC will allow health care providers to maximize health outcomes with interventions that best suit the needs of convalescent men. Areas that the current sample identified as needing further improvement were around information seeking, compliance and reporting of health concerns. The perception of masculinity may also evolve over time. Knowing how different age groups define masculinity would be of great assistance in developing public health interventions that improve men’s health seeking behaviors. Health care providers should be aware that some men may be afflicted with self-image perception issues due to PLS. Nursing staff must acknowledge men’s concerns and demonstrate sympathy to those who suffer from PLS and/or ED. Nurses are in a position to provide support to men coming to terms with changes in their genitalia. Patients should be reassured that PLS is seen in many men who have undergone RP, and that its occurrence does not seem to bring pain or discomfort, nor does it affect the perception of gender and/or masculinity.
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Conclusions Diagnosis and treatment of PC can be a turning point in life for many men. Contrary to anecdotal statements encountered by the principal investigator about PLS by men without PC, PLS is not depicted as detrimental by the men who experience it. Rather, it is seen as an accepted occurrence resulting from treatment for PC. In such an acceptance, men did not perceive that their sense of self or masculinity was affected. The little concern men had related to PLS may be attributed to the lack of physical discomfort associated with it. Furthermore, none of the participants believed that the shortened penis affected them or their spouses. Without the ability to achieve proper erections, men saw no need to worry about penile length or size. However, there is a possibility that men may desire an increase of penile length or size if erections returned. Acknowledgements We would like to express our sincere gratitude to each man in this study for sharing his experiences, and to the men and women of the Manitoba Prostate Cancer Support Group, in Winnipeg, Manitoba. Wellam F. Yu Ko was supported by an Evidence-Based Practice Chair Award from the Canadian Health Services Research Foundation and the Canadian Institutes of Health Research. Conflict of interest There is no conflict of interest. References American Cancer Society, 2008. Overview: prostate cancer: how many men get prostate cancer?. Retrieved September 13th, 2008, from. http://www.cancer.org/ docroot/CRI/content/CRI_2_2_1X_How_many_men_get_prostate _cancer_36.asp. Bailey Jr., D.E., Mishel, M.H., Belyea, M., Stewart, J.L., Mohler, J., 2004. Uncertainty intervention for watchful waiting in prostate cancer. Cancer Nurs. 27 (5), 339–346. Bertero, C., 2001. Altered sexual patterns after treatment for prostate cancer. Cancer Pract. 9, 245–251. Bokhour, B.G., Clark, J.A., Inui, T.S., Silliman, R.A., Talcott, J.A., 2001. Sexuality after treatment for early prostate cancer: exploring the meanings of ‘‘erectile dysfunction’’ J. Gen. Int. Med. 16, 649–655. Briganti, A., Fabbri, F., Salonia, A., Chun, F.-H., Deho`, F., Zanni, G., Suardi, N., Karakiewicz, P.I., Rigatti, P., Montorsi, F., 2007. Preserved postoperative penile correlates well with maintained erectile function after bilateral nerve-sparing prostatectomy. Eur. Urol.. doi:10.1016/j.eurouro.2007.03.050. Canadian Cancer Society, 2008. Prostate cancer statistics. Retrieved June 17th, 2008, from. http://info.cancer.ca/E/CCE/cceexplorer.asp?tocid¼41. Clark, J.A., Bokhour, B.G., Inui, T.S., Silliman, R.A., Talcott, J.A., 2003a. ‘Measuring patients’ perceptions of the outcomes of treatment for early prostate cancer. Med. Care 41 (8), 923–936. Clark, J.A., Inui, T.S., Silliman, R.A., Bokhour, B.G., Krasnow, S.H., Robinson, R.A., Spaulding, M., Talcott, J.A., 2003b. Patients’ perceptions of quality of life after treatment for early prostate cancer. J. Clin. Onc. 21 (20), 3777–3784. Clark, J.A., Talcott, J.A., 2006. Confidence and uncertainty long after initial treatment for early prostate cancer: survivors’ views of cancer control and the treatment of decisions they made. J. Clin. Onc. 24, 4457–4463. Chapple, A., Ziebland, S., 2002. Prostate cancer: embodied experience and perceptions of masculinity. Soc. Health Illn. 24 (6), 820–841. Ciancio, S.J., Kim, E.D., 2000. Penile fibrotic changes after radical retropubic prostatectomy. BJU Int. 85, 101–106. Cohen, M.Z., Kahn, D.L., Steeves, R.H., 1998. Beyond body image: the experience of breast cancer. ONF 25, 835–841. Davison, B.J., So, A.I., Goldenberg, L., 2007. Quality of life, sexual function and decisional regret at 1 year after surgical treatment for localized prostate cancer. BJU 100, 780–785. Fergus, K.D., Gray, R.E., Fitch, M.I., Labreque, M., Phillips, C., 2002. Active consideration: conceptualizing patient-provided support for spouse caregivers in the context of prostate cancer. Qual. Health Res. 12 (4), 492–514.
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