- Email: [email protected]
Radical Prostatectomy, Sparing of the Seminal Vesicles, and Painful Orgasm
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Radical Prostatectomy, Sparing of the Seminal Vesicles, and Painful Orgasm Andrea Mogorovich, MD,*a Andreas E. Nilsson, MD,†a Stavros I. Tyritzis, MD, PhD, FEBU,†§a Stefan Carlsson, MD, PhD,† Martin Jonsson, MD,† Leif Haendler, MD,† Tommy Nyberg, MSc,‡ Gunnar Steineck, MD, PhD,‡a and N. Peter Wiklund, MD, PhD†a *Department of Surgery, Section of Urology, University of Pisa, Pisa, Italy; †Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden; ‡Department of Oncology and Pathology, Section of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden; §Department of Urology, Athens University Medical School, Laiko Hospital, Athens, Greece DOI: 10.1111/jsm.12086
ABSTRACT
Introduction. Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health. Aim. This study aims to investigate the prevalence of PO and to identify potential risk factors. Main Outcome Measures. A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire. Methods. Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency. Results. The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7–4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)sparing approach (RR 2.33, 95% CI 1.0–5.3, P = 0.045) and age <60 years were significantly related to the presence of PO (95% CI 0.5–0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO. Conclusions. We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population. Mogorovich A, Nilsson AE, Tyritzis SI, Carlsson S, Jonsson M, Haendler L, Nyberg T, Steineck G, and Wiklund NP. Radical prostatectomy, sparing of the seminal vesicles and painful orgasm. J Sex Med 2013;10:1417–1423. Key Words. Robot-Assisted; Radical Prostatectomy; Prostate Cancer; Sexual Dysfunction; Painful Orgasm; Dysorgasmia; Seminal Vesicles; Post-Prostatectomy Orgasmic Dysfunction
Introduction
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satisfying sexual life after radical prostatectomy (RP) requires not only adequate penile stiffness for vaginal penetration, but also requires being able to reach a satisfying orgasm. Orgasmic dysfunction post-RP consists of painful orgasm
a
Authors contributed equally.
© 2013 International Society for Sexual Medicine
(PO) (dysorgasmia), absence of orgasm (anorgasmia), and urine loss occurring during orgasm (climacturia) [1–3]. Deterioration in orgasmic function has been related to reduction in emotional and physical satisfaction which in turn may lead to sexually avoidant behavior and to the creation of a disharmony in a relationship [4–7]. To date, neither the etiologic mechanism, nor the predictive factors for PO after RP have been identified. In our department, seminal vesicle (SV) J Sex Med 2013;10:1417–1423
1418 sparing is normally performed in patients when a nerve-sparing procedure is planned and is oncologically feasible, because the motor and sensory components of the pelvic nerve are anatomically located 3–10 mm from the tip of the SV [8]. We postulate that the remaining SV tissue might induce PO. Thus, we studied this rationale in a large cohort of patients who underwent radical retropubic prostatectomy (RRP) and robotassisted laparoscopic radical prostatectomy (RALP), by using a study-specific questionnaire, to evaluate the prevalence of PO and analyze the association of SV-sparing along with other clinical and surgical factors potentially affecting orgasmic dysfunction. Patients and Methods
We attempted to include all men who had undergone RP between January 2002 and December 2006 at the Department of Urology at the Karolinska University Hospital. A total of 1,411 consecutive men were identified and invited to participate in the study. Of this total, 465 men had undergone RRP and 946 men had undergone RALP. A postal study-specific questionnaire was used to collect information from the patients included in the study. RRP and RALP were carried out according to the techniques previously described by Walsh et al. [9] and Nilsson et al. [10], respectively. The questionnaire was composed of 145 questions concerning quality of life (QoL) with emphasis on sexual life, erectile dysfunction, urinary incontinence, and self-assessed QoL. Questions were formulated addressing quality, frequency, and intensity of a symptom when appropriate. The questionnaire was also administered to a comparison group of 442 persons, derived from the Swedish Population Registry and matched for age and area of residency. Between February and December 2007, all patients in the study group received a letter explaining the study objectives and including an invitation to participate in the study. To those who agreed to participate, we sent a questionnaire, and 10 days later, we sent a combined thank you and reminding card. The study was approved by the research ethics committee at the Karolinska Institutet; informed consent was obtained during the telephone contact. This QoL questionnaire is based on questionnaires developed by previous investigations concerning QoL by the Clinical Cancer Epidemiology group at Karolinska Institutet and was refined after seven in-depth interJ Sex Med 2013;10:1417–1423
Mogorovich et al. views with patients who underwent RP [10–12]. Face validity was ensured with seven patients when an investigator accompanied them while they completed the questionnaire to make sure that no questions were misinterpreted. A pilot study was conducted with 20 participants where methods of data collection were tested. This led to minor modifications of the questionnaire. The orgasmic characteristics were evaluated by five relevant questions, while PO was measured by one question (Appendix 1). We analyzed patients having at least one episode of PO during the previous 6 months. Data on medication used by the patients that could impair their orgasmic function (mainly diuretics, a-methyl-DOPA, antidepressants) were also recorded. Erectile function was defined by the question: “During the previous 6 months, how stiff was your penis during sexual activity.” Good erectile function was assigned to men answering sufficient stiffness more than half of the occasions or more often. Intermediate erectile function was defined as sufficient stiffness in less than half of the occasions, whereas no function was defined by no sexual activity or never having sufficient stiffness. On a subset of 440 patients, a surgical questionnaire was completed by the surgeon at the end of the surgical procedure, when the surgeon was still in the operating theatre. This questionnaire was composed of 37 questions concerning the surgical details of the operation, e.g., “Did you spare the tip of the seminal vesicle (SV)?” with response alternatives like bilateral, unilateral, and non SV-sparing. A total of 834 patients reported being able to have orgasms and all these patients were included in the statistical analysis. T-tests and chi-square tests were used for the comparison of patients having and not having orgasms. We calculated the proportions of patients reporting PO in each independent-variable category. Patient categories were compared using relative risk (RR; prevalence ratio), defined as the ratio of proportions and estimated according to the log-binomial regression model presented with 95% confidence intervals (CIs). The proportions of patients reporting PO in each category of the possible predictor variables were calculated. Outcome in different categories were compared using RR (prevalence ratio), defined as the ratio of proportions and estimated with log-binomial regression model. All RRs were adjusted for age and are presented with 95% CIs. The Cochran-Armitage trend test was also used to evaluate the significance of the variable SV sparing
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Painful Orgasm and Radical Prostatectomy Table 1
Cohort baseline characteristics
No. invited to participate No. returned questionnaires (%) Median age at follow-up (range) Median age at surgery (range) Median follow-up time, years (range) Clinical stage no. (%)* T1 T2 T3 Median PSA (range) No. robot-assisted No. open cases
Total number of patients
Patients having orgasm
Comparison group
1,411 1,288 (91%) 65 (41–79) 63 (37–77) 2.2 (0.3–5.2)
834 63 (41–79) 61 (37–77) 2.3 (0.3–5.2)
442 350 (79%) 63 (49–78) NA NA
702 (60) 422 (36) 55 (5) 6.9 (0.4–117) 864 (67%) 424 (33%)
510 (61.5) 285 (34) 35 (4) 7.7 (0.4–50) 613 (73.5%) 221 (26.5%)
NA NA NA NA NA NA
*Because of rounding percentages may not total 100.
on the occurrence of the PO. Testing was twotailed and at the 5% significance level. All calculations were performed using the SAS statistical software package (version 9.2, SAS Institute Inc., Cary, NC, USA). Results
Out of 1,411 patients eligible to participate, 1,288 (91%) returned the study-specific questionnaire and were included in the study. Table 1 shows the baseline characteristics of the included patients. Lymphadenectomy was performed in 15 patients. The standard criteria for lymphadenectomy were Gleason ⱖ 8 or PSA > 20 ng/mL. Fifty-five percent of the patients obtained an orgasm with a stiff penis. Forty-one percent achieved some type of orgasm without necessarily having an erection. Fifty-one patients out of a total of 788 (missing data on 43 patients) that did have an orgasm had also at least one event of climacturia as well. Among the non-participating men, 33 (2%) were lost to follow-up, 31 with no telephone number or address registered in population registers, and two dead (death unrelated to prostate cancer). Fortytwo (3%) declined to participate. Reasons for nonparticipation when stated were: did not speak Swedish (six men), dementia (five men), and blindness (one man). Of the posted questionnaires, 48 (3%) were not returned. Table 2 shows the distribution of the patients according to the frequency with which each experienced episodes of PO. In the study group, the rate of PO was significantly higher (18%) than in the comparison group (6%) (RR 2.8, 95% CI 1.7–4.5). Of the patients that reported at least one episode of PO, 36 patients were on antihypertensive medication, 6 patients on antidepressants, and 2 on drugs for neurological disorder.
When analyzing the independent value of the variables for PO (Table 3), we found that in the subgroup of 144 patients submitted to bilateral SV sparing, 30 (21%) reported PO. In comparison with this finding, 11 out of 91 (12%) of the subgroup of patients who underwent unilateral SV sparing, and 6 out of 67 (9%) who underwent bilateral complete removal of the SV, patients perceived pain. Using bilateral SV removal as the reference, bilateral SV sparing entailed a significantly higher RR of PO (RR 2.33, 95% CI 1.0–5.3, P = 0.045). When analyzing the different rates of dysorgasmic patients between unilateral and bilateral SV-sparing subgroup, we found the rates to be 12% and 21%, respectively; this difference was evident, but not statistically significant. However, in a comparison of the three subgroups using the Cochrane-Armitage test for trend, the difference was found to be statistically significant (P = 0.02). When analyzing age at surgery as an independent predictive factor for PO, we found that in the subgroup of 340 younger patients (<60 years old), 74 (22%) experienced PO, whereas 69 out of 460 (15%) older patients (ⱖ60 years old) were dysorgasmic. Older age was found to independently protect against PO with an RR of 0.7 (95% CI 0.5–0.9, P = 0.019) (Table 4). Table 2 Distribution of the patients according to their frequency of experienced painful orgasms (PO) No./total no. (%)
No orgasm in the last 6 months Never pain at orgasm Pain less than half of occasions Pain more than half of occasions Always pain at orgasm Not stated
Patients returning questionnaire
Patients having orgasm
454/1,288 (35) 657/1,288 (51) 72/1,288 (6) 45/1,288 (3) 26/1,288 (2) 34/1,288 (3)
NA 657/834 (79) 72/834 (9) 45/834 (5) 26/834 (3) 34/834 (4)
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Table 3 Surgical and clinical factors investigated for independently influencing the presence of PO after RRP and RALP in a subgroup of 422 patients with available detailed surgical data Variable SV-sparing
Nerve-sparing technique
Bladder neck dissection
Bilateral removal Unilateral sparing Bilateral sparing Interfascial Intrafascial Extrafascial Non-bladder neck sparing Bladder neck sparing
None of the other variables evaluated, inter/ intrafascial dissection, continence (defined as the need to use no more than 1 pad/day), pathological status, bladder neck sparing, definitive Gleason score, nerve sparing, surgical approach (open/ robot-assisted), time from surgery (as indicated by the respective follow-up time for each patient), use of phosphodiesterase type 5 inhibitors and postoperative erectile function showed any predictive value for independently causing PO after RP (Table 4). After adjustment for age, SV sparing was the only variable which showed statistically significant association with PO after surgery. Discussion
In this consecutive series of men who underwent RP at our center, we found that 11% of the 1,288
No. painful orgasm/total no.
RR (95% CI)
6/67 (9) 11/91 (12) 30/144 (21) 20/146 (14) 15/84 (18)
Reference 1.35 (0.5–3.5) 2.33 (1.0–5.3) 0.8 (0.4–1.4) Reference
11/72 (15) 39/234 (17)
0.9 (0.5–1.7) Reference
Age-adjusted RR (95% CI) 1.34 (0.5–3.5) 2.33 (1.0–5.3) 0.8 (0.4–1.4)
0.9 (0.5–1.7)
patients had experienced PO in the preceding 6 months. Our data indicate that bilateral, complete removal of the SV protects against PO after surgery. Sexual function, particularly erectile function, is decreased in most men after RP [13–16]; however, due to improvement in our understanding of prostatic anatomy and the standardization of the nerve-sparing technique, better functional outcomes have been reported [17]. Although orgasm is a component of sexual function important to QoL [18,19], it has been rarely investigated in patients who have undergone RP [20–22]. The relevance of orgasm for elderly men has already been demonstrated [23,24] and all efforts to preserve it may be considered, because its dysfunction seems to be associated with sexually avoidant behavior and relationship disharmony [4,5,25,26].
Table 4 Surgical and clinical factors investigated for independently influencing the presence of PO after RRP and RALP in the cohort of orgasm reporting patients Variable Nerve sparing
Age at surgery Continence Pathological Gleason score Pathological T-stage Surgical approach Follow-up (years)
Erectile function post-surgery
Use of phosphodiesterase type 5 inhibitor
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Non-nerve sparing Unilateral nerve sparing Bilateral nerve sparing Age ⱖ 60 Age ⱕ 59 Incontinent (pad use) Continent (no protective pads) Gleason ⱖ 4 + 3 Gleason ⱕ 3 + 4 PT3 PT2 Open Robot-assisted 0–1 1–2 2–3 3–4 4+ Good Intermediate No function Yes No
No. of painful orgasm/total no.
RR (95% CI)
20/118 (17) 40/227 (18) 44/235 (19) 69/460 (15) 74/340 (22) 30/152 (20) 113/642 (18) 22/129 (17) 120/665 (18) 42/225 (19) 96/562 (17) 38/212 (18) 105/588 (18) 9/80 (11) 59/348 (17) 40/178 (22) 20/94 (21) 15/100 (15) 43/254 (17) 29/154 (19) 69/382 (18) 101/539 (19) 42/259 (16)
0.9 (0.6–1.4) 0.9 (0.7–1.2) 1.0 (reference) 0.7 (0.5–0.9) 1.0 (reference) 1.1 (0.8–1.6) 1.0 (reference) 0.9 (0.6–1.4) 1.0 (reference) 1.1 (0.8–1.3) 1.0 (reference) 1.0 (0.7–1.4) 1.0 (reference) 0.8 (0.3–1.6) 1.1 (0.7–1.9) 1.5 (0.9–2.6) 1.4 (0.8–2.6) 1.0 (reference) 1.0 (reference) 1.1 (0.7–1.7) 1.1 (0.8–1.5) 1.2 (0.8–1.6) 1.0 (reference)
Age-adjusted RR (95% CI) 0.9 (0.6–1.4) 0.9 (0.6–1.5) 0.7 (0.4–1.2) 1.2 (0.8–1.7) 0.9 (0.6–1.4) 1.1 (0.8–1.3) 1.0 (0.7–1.4) 0.8 (0.3–1.6) 1.2 (0.7–2.0) 1.6 (0.9–2.7) 1.5 (0.8–2.7)
1.2 (0.8–1.8) 1.5 (0.8–1.6) 1.1 (0.8–1.6)
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Painful Orgasm and Radical Prostatectomy Barnas et al. [21] and Koeman et al. [20] reported prevalence of 14% and 11% of dysorgasmic patients, respectively; in our series, 11% of 1,288 patients experienced pain. The cause of dysorgasmia is not well understood; it has been postulated that bladder neck closure occurring during orgasm in patients after RP leads to spasm of the vesicourethral anastomosis or pelvic floor musculature dystonia leading to pain [21]. This hypothesis is supported by the experience of Barnas et al. [27] who administered the alpha-blocker tamsulosine, 0.4 mg once daily, to patients complaining about PO after surgery. This resulted in pain reduction in 75 out of 98 cases. Other mechanisms postulated are neuroapraxia of the cavernous nerves and even the psychological distress by men who have experienced major pelvic surgery. In our series, bilateral removal of the SV and older age seem to protect against PO. The statistical significance of age at the time of surgery as being protective may partially or entirely be due to the fact that bilateral SV sparing is generally attempted more in younger than in older patients in order to achieve better erectile outcomes in the younger patients. We postulate that the lateral portion of the SV that is left inside can continue to exert its physiological function secreting fluid and contracting during orgasm, because its neurovascular supply remains undamaged after a SV-sparing procedure. We believe that both fluid filling and contractions of the SV remnants can overstretch the wall of the vesicle and surrounding tissue thus causing pain. Interestingly, our hypothesis is not in conflict with the findings reported by Barnas et al. [21] who described the positive effects of tamsulosine in patients suffering from PO and postulated that intermittent bladder neck closure during the orgasm may be the possible causal mechanism. In fact, the presence of alpha-1a adrenoceptor mRNA in human SV tissue [28] has been demonstrated and the decreased capacity for contraction of the SV has been proposed as the cause of ejaculatory disorders induced by alpha-1 blockers [29]. Hence, we think that the benefit obtained by using tamsulosine in the series by Barnas could be attributable to the inhibition of the SV contraction instead of the relaxation of bladder neck as suggested by the authors. The rationale for using SV-sparing procedure is that the tip of the SV is close to the arterial supply of the bladder base and the proximal neurovascular bundles. Therefore, complete dissec-
tion of the SV might damage these structures, raising the likelihood of postoperative urinary incontinence and erectile dysfunction. Thus, if resection of the tip of the SV is not oncologically necessary, it would seem wise to spare it. However, the benefits and the risks of SV tip preservation are subject to considerable uncertainty [30–35]. There are no good estimates of the degree to which SV sparing improves function and similarly we have no good estimates of the degree to which SV preservation increases the risk of recurrence. We employed epidemiological methods as adapted to this field by the hierarchical step model for study design and data interpretation [36]. Our setting that provides a consecutive series and high participation rate reduces the likelihood of selection-induced problems. Our preparatory process and the use of anonymous, self-administered questionnaires mimic the technique of blinding and thus prevent interviewerrelated bias and also decrease the risk of measurement errors. We realize that our study has several limitations. First, we did not exclude preoperatively dysorgasmic patients from the study; second, the operations were performed by different surgeons. However, surgeon experience might not insert bias, due to the fact that SV sparing was performed with a similar technique by all participating surgeons. Finally, we did not measure the severity of pain, using grading systems, such as the visual grading system (visual analog scale). Generalizability to other settings than ours may be compromised by culture-specific factors. Those factors could possibly lead to bias, but we believe that the large number of patients included and the use of a postal study-specific questionnaire makes this study valuable in aiding us in understanding predictive factors for orgasmic dysfunction after RP. Conclusion
We believe that attention should be paid to avoiding symptoms that can jeopardize the ability of the prostate cancer survivor to achieve a satisfactory sexual life after RP. In our study, the bilateral SV-sparing approach, which was performed in an effort to preserve better potency rates, was associated with a higher risk of experiencing PO. We advocated that when sparing the tip of the SVs, the patient should be informed for the potential adverse effect of PO. J Sex Med 2013;10:1417–1423
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Acknowledgments
Stavros I. Tyritzis is a European Urological Scholarship Program 2012 scholar, funded by the European Association of Urology. Other sources of funding: Stockholm City Council Research Foundry, National Institutes of Health and Swedish Cancer Society. Corresponding Author: Stavros I. Tyritzis, MD, PhD, FEBU, Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Solna 17176, Sweden. Tel: +46-8-517-745-41; Fax: +468-517-735-99; E-mail: [email protected]
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Conflict of Interest: The authors report no conflicts of interest. 12
Statement of Authorship
Category 1 (a) Conception and Design N. Peter Wiklund; Andreas E. Nilsson; Gunnar Steineck; Stavros I. Tyritzis (b) Acquisition of Data Andreas E. Nilsson; Andrea Mogorovich; Stavros I. Tyritzis; Martin Jonsson; Leif Haendler (c) Analysis and Interpretation of Data N. Peter Wiklund; Gunnar Steineck; Stefan Carlsson; Stavros I. Tyritzis; Tommy Nyberg
Category 2 (a) Drafting the Article Andrea Mogorovich; Andreas E. Nilsson; Stavros I. Tyritzis; Tommy Nyberg (b) Revising It for Intellectual Content N. Peter Wiklund; Gunnar Steineck
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Category 3 (a) Final Approval of the Completed Article N. Peter Wiklund; Gunnar Steineck References 1 Choi JM, Nelson CJ, Stasi J, Mulhall JP. Orgasm associated incontinence (climacturia) following radical pelvic surgery: Rates of occurrence and predictors. J Urol 2007;177:2223–6. 2 Lee J, Hersey K, Lee CT, Fleshner N. Climacturia following radical prostatectomy: Prevalence and risk factors. J Urol 2006;176:2562–5. 3 Nilsson AE, Carlsson S, Johansson E, Jonsson MN, Adding C, Nyberg T, Steineck G, Wiklund NP. Orgasm-associated urinary incontinence and sexual life after radical prostatectomy. J Sex Med 2011;8:2632–9. 4 Perez MA, Skinner EC, Meyerowitz BE. Sexuality and intimacy following radical prostatectomy: Patient and partner perspectives. Health Psychol 2002;21:288–93. 5 Snyder DK, Berg P. Determinants of sexual dissatisfaction in sexually distressed couples. Arch Sex Behav 1983;12:237–46. 6 Aroujo AB, Durante R, Feldman HA, Goldstein I, McKinlay JB. The relationship between depressive symptoms and male
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Radical Prostatectomy, Sparing of the Seminal Vesicles, and Painful Orgasm Andrea Mogorovich, MD,*a Andreas E. Nilsson, MD,†a Stavros I. Tyritzis, MD, PhD, FEBU,†§a Stefan Carlsson, MD, PhD,† Martin Jonsson, MD,† Leif Haendler, MD,† Tommy Nyberg, MSc,‡ Gunnar Steineck, MD, PhD,‡a and N. Peter Wiklund, MD, PhD†a *Department of Surgery, Section of Urology, University of Pisa, Pisa, Italy; †Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden; ‡Department of Oncology and Pathology, Section of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden; §Department of Urology, Athens University Medical School, Laiko Hospital, Athens, Greece DOI: 10.1111/jsm.12086
ABSTRACT
Introduction. Erectile dysfunction has been widely investigated as the major factor responsible for sexual bother in patients after radical prostatectomy (RP); painful orgasm (PO) is one element of this bother, but little is known about its prevalence and its effects on sexual health. Aim. This study aims to investigate the prevalence of PO and to identify potential risk factors. Main Outcome Measures. A total of 1,411 consecutive patients underwent open (radical retropubic prostatectomy) or robot-assisted laparoscopic RP between 2002 and 2006. The patients were asked to complete a study-specific questionnaire. Methods. Of a total of 145 questions, 5 dealt with the orgasmic characteristics. The questionnaire was also administered to a comparison group of 442 persons, matched for age and area of residency. Results. The response rate was 91% (1,288 patients). A total of 143 (11%) patients reported PO. Among the 834 men being able to have an orgasm, the prevalence was 18% vs. 6% in the comparison group (relative risk [RR] 2.8, 95% confidence interval [CI] 1.7–4.5). When analyzed as independent variables, bilateral seminal vesicle (SV)sparing approach (RR 2.33, 95% CI 1.0–5.3, P = 0.045) and age <60 years were significantly related to the presence of PO (95% CI 0.5–0.9, P = 0.019). After adjustment for age, bilateral SV-sparing still remained a significant predictor for occurrence of PO. Conclusions. We found that PO occurs significantly more often in patients undergoing bilateral SV-sparing RP when compared with age-matched comparison population. Mogorovich A, Nilsson AE, Tyritzis SI, Carlsson S, Jonsson M, Haendler L, Nyberg T, Steineck G, and Wiklund NP. Radical prostatectomy, sparing of the seminal vesicles and painful orgasm. J Sex Med 2013;10:1417–1423. Key Words. Robot-Assisted; Radical Prostatectomy; Prostate Cancer; Sexual Dysfunction; Painful Orgasm; Dysorgasmia; Seminal Vesicles; Post-Prostatectomy Orgasmic Dysfunction
Introduction
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satisfying sexual life after radical prostatectomy (RP) requires not only adequate penile stiffness for vaginal penetration, but also requires being able to reach a satisfying orgasm. Orgasmic dysfunction post-RP consists of painful orgasm
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Authors contributed equally.
© 2013 International Society for Sexual Medicine
(PO) (dysorgasmia), absence of orgasm (anorgasmia), and urine loss occurring during orgasm (climacturia) [1–3]. Deterioration in orgasmic function has been related to reduction in emotional and physical satisfaction which in turn may lead to sexually avoidant behavior and to the creation of a disharmony in a relationship [4–7]. To date, neither the etiologic mechanism, nor the predictive factors for PO after RP have been identified. In our department, seminal vesicle (SV) J Sex Med 2013;10:1417–1423
1418 sparing is normally performed in patients when a nerve-sparing procedure is planned and is oncologically feasible, because the motor and sensory components of the pelvic nerve are anatomically located 3–10 mm from the tip of the SV [8]. We postulate that the remaining SV tissue might induce PO. Thus, we studied this rationale in a large cohort of patients who underwent radical retropubic prostatectomy (RRP) and robotassisted laparoscopic radical prostatectomy (RALP), by using a study-specific questionnaire, to evaluate the prevalence of PO and analyze the association of SV-sparing along with other clinical and surgical factors potentially affecting orgasmic dysfunction. Patients and Methods
We attempted to include all men who had undergone RP between January 2002 and December 2006 at the Department of Urology at the Karolinska University Hospital. A total of 1,411 consecutive men were identified and invited to participate in the study. Of this total, 465 men had undergone RRP and 946 men had undergone RALP. A postal study-specific questionnaire was used to collect information from the patients included in the study. RRP and RALP were carried out according to the techniques previously described by Walsh et al. [9] and Nilsson et al. [10], respectively. The questionnaire was composed of 145 questions concerning quality of life (QoL) with emphasis on sexual life, erectile dysfunction, urinary incontinence, and self-assessed QoL. Questions were formulated addressing quality, frequency, and intensity of a symptom when appropriate. The questionnaire was also administered to a comparison group of 442 persons, derived from the Swedish Population Registry and matched for age and area of residency. Between February and December 2007, all patients in the study group received a letter explaining the study objectives and including an invitation to participate in the study. To those who agreed to participate, we sent a questionnaire, and 10 days later, we sent a combined thank you and reminding card. The study was approved by the research ethics committee at the Karolinska Institutet; informed consent was obtained during the telephone contact. This QoL questionnaire is based on questionnaires developed by previous investigations concerning QoL by the Clinical Cancer Epidemiology group at Karolinska Institutet and was refined after seven in-depth interJ Sex Med 2013;10:1417–1423
Mogorovich et al. views with patients who underwent RP [10–12]. Face validity was ensured with seven patients when an investigator accompanied them while they completed the questionnaire to make sure that no questions were misinterpreted. A pilot study was conducted with 20 participants where methods of data collection were tested. This led to minor modifications of the questionnaire. The orgasmic characteristics were evaluated by five relevant questions, while PO was measured by one question (Appendix 1). We analyzed patients having at least one episode of PO during the previous 6 months. Data on medication used by the patients that could impair their orgasmic function (mainly diuretics, a-methyl-DOPA, antidepressants) were also recorded. Erectile function was defined by the question: “During the previous 6 months, how stiff was your penis during sexual activity.” Good erectile function was assigned to men answering sufficient stiffness more than half of the occasions or more often. Intermediate erectile function was defined as sufficient stiffness in less than half of the occasions, whereas no function was defined by no sexual activity or never having sufficient stiffness. On a subset of 440 patients, a surgical questionnaire was completed by the surgeon at the end of the surgical procedure, when the surgeon was still in the operating theatre. This questionnaire was composed of 37 questions concerning the surgical details of the operation, e.g., “Did you spare the tip of the seminal vesicle (SV)?” with response alternatives like bilateral, unilateral, and non SV-sparing. A total of 834 patients reported being able to have orgasms and all these patients were included in the statistical analysis. T-tests and chi-square tests were used for the comparison of patients having and not having orgasms. We calculated the proportions of patients reporting PO in each independent-variable category. Patient categories were compared using relative risk (RR; prevalence ratio), defined as the ratio of proportions and estimated according to the log-binomial regression model presented with 95% confidence intervals (CIs). The proportions of patients reporting PO in each category of the possible predictor variables were calculated. Outcome in different categories were compared using RR (prevalence ratio), defined as the ratio of proportions and estimated with log-binomial regression model. All RRs were adjusted for age and are presented with 95% CIs. The Cochran-Armitage trend test was also used to evaluate the significance of the variable SV sparing
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Painful Orgasm and Radical Prostatectomy Table 1
Cohort baseline characteristics
No. invited to participate No. returned questionnaires (%) Median age at follow-up (range) Median age at surgery (range) Median follow-up time, years (range) Clinical stage no. (%)* T1 T2 T3 Median PSA (range) No. robot-assisted No. open cases
Total number of patients
Patients having orgasm
Comparison group
1,411 1,288 (91%) 65 (41–79) 63 (37–77) 2.2 (0.3–5.2)
834 63 (41–79) 61 (37–77) 2.3 (0.3–5.2)
442 350 (79%) 63 (49–78) NA NA
702 (60) 422 (36) 55 (5) 6.9 (0.4–117) 864 (67%) 424 (33%)
510 (61.5) 285 (34) 35 (4) 7.7 (0.4–50) 613 (73.5%) 221 (26.5%)
NA NA NA NA NA NA
*Because of rounding percentages may not total 100.
on the occurrence of the PO. Testing was twotailed and at the 5% significance level. All calculations were performed using the SAS statistical software package (version 9.2, SAS Institute Inc., Cary, NC, USA). Results
Out of 1,411 patients eligible to participate, 1,288 (91%) returned the study-specific questionnaire and were included in the study. Table 1 shows the baseline characteristics of the included patients. Lymphadenectomy was performed in 15 patients. The standard criteria for lymphadenectomy were Gleason ⱖ 8 or PSA > 20 ng/mL. Fifty-five percent of the patients obtained an orgasm with a stiff penis. Forty-one percent achieved some type of orgasm without necessarily having an erection. Fifty-one patients out of a total of 788 (missing data on 43 patients) that did have an orgasm had also at least one event of climacturia as well. Among the non-participating men, 33 (2%) were lost to follow-up, 31 with no telephone number or address registered in population registers, and two dead (death unrelated to prostate cancer). Fortytwo (3%) declined to participate. Reasons for nonparticipation when stated were: did not speak Swedish (six men), dementia (five men), and blindness (one man). Of the posted questionnaires, 48 (3%) were not returned. Table 2 shows the distribution of the patients according to the frequency with which each experienced episodes of PO. In the study group, the rate of PO was significantly higher (18%) than in the comparison group (6%) (RR 2.8, 95% CI 1.7–4.5). Of the patients that reported at least one episode of PO, 36 patients were on antihypertensive medication, 6 patients on antidepressants, and 2 on drugs for neurological disorder.
When analyzing the independent value of the variables for PO (Table 3), we found that in the subgroup of 144 patients submitted to bilateral SV sparing, 30 (21%) reported PO. In comparison with this finding, 11 out of 91 (12%) of the subgroup of patients who underwent unilateral SV sparing, and 6 out of 67 (9%) who underwent bilateral complete removal of the SV, patients perceived pain. Using bilateral SV removal as the reference, bilateral SV sparing entailed a significantly higher RR of PO (RR 2.33, 95% CI 1.0–5.3, P = 0.045). When analyzing the different rates of dysorgasmic patients between unilateral and bilateral SV-sparing subgroup, we found the rates to be 12% and 21%, respectively; this difference was evident, but not statistically significant. However, in a comparison of the three subgroups using the Cochrane-Armitage test for trend, the difference was found to be statistically significant (P = 0.02). When analyzing age at surgery as an independent predictive factor for PO, we found that in the subgroup of 340 younger patients (<60 years old), 74 (22%) experienced PO, whereas 69 out of 460 (15%) older patients (ⱖ60 years old) were dysorgasmic. Older age was found to independently protect against PO with an RR of 0.7 (95% CI 0.5–0.9, P = 0.019) (Table 4). Table 2 Distribution of the patients according to their frequency of experienced painful orgasms (PO) No./total no. (%)
No orgasm in the last 6 months Never pain at orgasm Pain less than half of occasions Pain more than half of occasions Always pain at orgasm Not stated
Patients returning questionnaire
Patients having orgasm
454/1,288 (35) 657/1,288 (51) 72/1,288 (6) 45/1,288 (3) 26/1,288 (2) 34/1,288 (3)
NA 657/834 (79) 72/834 (9) 45/834 (5) 26/834 (3) 34/834 (4)
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Table 3 Surgical and clinical factors investigated for independently influencing the presence of PO after RRP and RALP in a subgroup of 422 patients with available detailed surgical data Variable SV-sparing
Nerve-sparing technique
Bladder neck dissection
Bilateral removal Unilateral sparing Bilateral sparing Interfascial Intrafascial Extrafascial Non-bladder neck sparing Bladder neck sparing
None of the other variables evaluated, inter/ intrafascial dissection, continence (defined as the need to use no more than 1 pad/day), pathological status, bladder neck sparing, definitive Gleason score, nerve sparing, surgical approach (open/ robot-assisted), time from surgery (as indicated by the respective follow-up time for each patient), use of phosphodiesterase type 5 inhibitors and postoperative erectile function showed any predictive value for independently causing PO after RP (Table 4). After adjustment for age, SV sparing was the only variable which showed statistically significant association with PO after surgery. Discussion
In this consecutive series of men who underwent RP at our center, we found that 11% of the 1,288
No. painful orgasm/total no.
RR (95% CI)
6/67 (9) 11/91 (12) 30/144 (21) 20/146 (14) 15/84 (18)
Reference 1.35 (0.5–3.5) 2.33 (1.0–5.3) 0.8 (0.4–1.4) Reference
11/72 (15) 39/234 (17)
0.9 (0.5–1.7) Reference
Age-adjusted RR (95% CI) 1.34 (0.5–3.5) 2.33 (1.0–5.3) 0.8 (0.4–1.4)
0.9 (0.5–1.7)
patients had experienced PO in the preceding 6 months. Our data indicate that bilateral, complete removal of the SV protects against PO after surgery. Sexual function, particularly erectile function, is decreased in most men after RP [13–16]; however, due to improvement in our understanding of prostatic anatomy and the standardization of the nerve-sparing technique, better functional outcomes have been reported [17]. Although orgasm is a component of sexual function important to QoL [18,19], it has been rarely investigated in patients who have undergone RP [20–22]. The relevance of orgasm for elderly men has already been demonstrated [23,24] and all efforts to preserve it may be considered, because its dysfunction seems to be associated with sexually avoidant behavior and relationship disharmony [4,5,25,26].
Table 4 Surgical and clinical factors investigated for independently influencing the presence of PO after RRP and RALP in the cohort of orgasm reporting patients Variable Nerve sparing
Age at surgery Continence Pathological Gleason score Pathological T-stage Surgical approach Follow-up (years)
Erectile function post-surgery
Use of phosphodiesterase type 5 inhibitor
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Non-nerve sparing Unilateral nerve sparing Bilateral nerve sparing Age ⱖ 60 Age ⱕ 59 Incontinent (pad use) Continent (no protective pads) Gleason ⱖ 4 + 3 Gleason ⱕ 3 + 4 PT3 PT2 Open Robot-assisted 0–1 1–2 2–3 3–4 4+ Good Intermediate No function Yes No
No. of painful orgasm/total no.
RR (95% CI)
20/118 (17) 40/227 (18) 44/235 (19) 69/460 (15) 74/340 (22) 30/152 (20) 113/642 (18) 22/129 (17) 120/665 (18) 42/225 (19) 96/562 (17) 38/212 (18) 105/588 (18) 9/80 (11) 59/348 (17) 40/178 (22) 20/94 (21) 15/100 (15) 43/254 (17) 29/154 (19) 69/382 (18) 101/539 (19) 42/259 (16)
0.9 (0.6–1.4) 0.9 (0.7–1.2) 1.0 (reference) 0.7 (0.5–0.9) 1.0 (reference) 1.1 (0.8–1.6) 1.0 (reference) 0.9 (0.6–1.4) 1.0 (reference) 1.1 (0.8–1.3) 1.0 (reference) 1.0 (0.7–1.4) 1.0 (reference) 0.8 (0.3–1.6) 1.1 (0.7–1.9) 1.5 (0.9–2.6) 1.4 (0.8–2.6) 1.0 (reference) 1.0 (reference) 1.1 (0.7–1.7) 1.1 (0.8–1.5) 1.2 (0.8–1.6) 1.0 (reference)
Age-adjusted RR (95% CI) 0.9 (0.6–1.4) 0.9 (0.6–1.5) 0.7 (0.4–1.2) 1.2 (0.8–1.7) 0.9 (0.6–1.4) 1.1 (0.8–1.3) 1.0 (0.7–1.4) 0.8 (0.3–1.6) 1.2 (0.7–2.0) 1.6 (0.9–2.7) 1.5 (0.8–2.7)
1.2 (0.8–1.8) 1.5 (0.8–1.6) 1.1 (0.8–1.6)
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Painful Orgasm and Radical Prostatectomy Barnas et al. [21] and Koeman et al. [20] reported prevalence of 14% and 11% of dysorgasmic patients, respectively; in our series, 11% of 1,288 patients experienced pain. The cause of dysorgasmia is not well understood; it has been postulated that bladder neck closure occurring during orgasm in patients after RP leads to spasm of the vesicourethral anastomosis or pelvic floor musculature dystonia leading to pain [21]. This hypothesis is supported by the experience of Barnas et al. [27] who administered the alpha-blocker tamsulosine, 0.4 mg once daily, to patients complaining about PO after surgery. This resulted in pain reduction in 75 out of 98 cases. Other mechanisms postulated are neuroapraxia of the cavernous nerves and even the psychological distress by men who have experienced major pelvic surgery. In our series, bilateral removal of the SV and older age seem to protect against PO. The statistical significance of age at the time of surgery as being protective may partially or entirely be due to the fact that bilateral SV sparing is generally attempted more in younger than in older patients in order to achieve better erectile outcomes in the younger patients. We postulate that the lateral portion of the SV that is left inside can continue to exert its physiological function secreting fluid and contracting during orgasm, because its neurovascular supply remains undamaged after a SV-sparing procedure. We believe that both fluid filling and contractions of the SV remnants can overstretch the wall of the vesicle and surrounding tissue thus causing pain. Interestingly, our hypothesis is not in conflict with the findings reported by Barnas et al. [21] who described the positive effects of tamsulosine in patients suffering from PO and postulated that intermittent bladder neck closure during the orgasm may be the possible causal mechanism. In fact, the presence of alpha-1a adrenoceptor mRNA in human SV tissue [28] has been demonstrated and the decreased capacity for contraction of the SV has been proposed as the cause of ejaculatory disorders induced by alpha-1 blockers [29]. Hence, we think that the benefit obtained by using tamsulosine in the series by Barnas could be attributable to the inhibition of the SV contraction instead of the relaxation of bladder neck as suggested by the authors. The rationale for using SV-sparing procedure is that the tip of the SV is close to the arterial supply of the bladder base and the proximal neurovascular bundles. Therefore, complete dissec-
tion of the SV might damage these structures, raising the likelihood of postoperative urinary incontinence and erectile dysfunction. Thus, if resection of the tip of the SV is not oncologically necessary, it would seem wise to spare it. However, the benefits and the risks of SV tip preservation are subject to considerable uncertainty [30–35]. There are no good estimates of the degree to which SV sparing improves function and similarly we have no good estimates of the degree to which SV preservation increases the risk of recurrence. We employed epidemiological methods as adapted to this field by the hierarchical step model for study design and data interpretation [36]. Our setting that provides a consecutive series and high participation rate reduces the likelihood of selection-induced problems. Our preparatory process and the use of anonymous, self-administered questionnaires mimic the technique of blinding and thus prevent interviewerrelated bias and also decrease the risk of measurement errors. We realize that our study has several limitations. First, we did not exclude preoperatively dysorgasmic patients from the study; second, the operations were performed by different surgeons. However, surgeon experience might not insert bias, due to the fact that SV sparing was performed with a similar technique by all participating surgeons. Finally, we did not measure the severity of pain, using grading systems, such as the visual grading system (visual analog scale). Generalizability to other settings than ours may be compromised by culture-specific factors. Those factors could possibly lead to bias, but we believe that the large number of patients included and the use of a postal study-specific questionnaire makes this study valuable in aiding us in understanding predictive factors for orgasmic dysfunction after RP. Conclusion
We believe that attention should be paid to avoiding symptoms that can jeopardize the ability of the prostate cancer survivor to achieve a satisfactory sexual life after RP. In our study, the bilateral SV-sparing approach, which was performed in an effort to preserve better potency rates, was associated with a higher risk of experiencing PO. We advocated that when sparing the tip of the SVs, the patient should be informed for the potential adverse effect of PO. J Sex Med 2013;10:1417–1423
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Acknowledgments
Stavros I. Tyritzis is a European Urological Scholarship Program 2012 scholar, funded by the European Association of Urology. Other sources of funding: Stockholm City Council Research Foundry, National Institutes of Health and Swedish Cancer Society. Corresponding Author: Stavros I. Tyritzis, MD, PhD, FEBU, Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Solna 17176, Sweden. Tel: +46-8-517-745-41; Fax: +468-517-735-99; E-mail: [email protected]
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Conflict of Interest: The authors report no conflicts of interest. 12
Statement of Authorship
Category 1 (a) Conception and Design N. Peter Wiklund; Andreas E. Nilsson; Gunnar Steineck; Stavros I. Tyritzis (b) Acquisition of Data Andreas E. Nilsson; Andrea Mogorovich; Stavros I. Tyritzis; Martin Jonsson; Leif Haendler (c) Analysis and Interpretation of Data N. Peter Wiklund; Gunnar Steineck; Stefan Carlsson; Stavros I. Tyritzis; Tommy Nyberg
Category 2 (a) Drafting the Article Andrea Mogorovich; Andreas E. Nilsson; Stavros I. Tyritzis; Tommy Nyberg (b) Revising It for Intellectual Content N. Peter Wiklund; Gunnar Steineck
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