Postprostatectomy Sexual Dysfunction: Is restoring erections enough? This document discusses several important points: 1. While erectile dysfunction is the most commonly addressed sexual side effect after radical prostatectomy, other issues like loss of libido, anejaculation, orgasmic dysfunction, penile shortening and Peyronie's disease are gaining recognition. 2. Restoring erections through penile rehabilitation may not be enough, as other sexual dysfunctions can negatively impact quality of life. 3. A multidisciplinary approach is needed to address the range of potential sexual issues after prostatectomy, including psychological factors and partner considerations.

1. Postprostatectomy Sexual Dysfunction:
Is restoring erections enough?
Ege Can Serefoglu, MD, FECSM.
Bahceci Health Group, Istanbul, Turkey
1

2. Postprostatectomy Sexual Dysfunction:
Is restoring erections enough?
NO..!
2

3. Introduction
 Pca is the most common none-skin cancer of
men in the developed countries
• with an estimated global incidence of 1.1 million cases in 2012
• incidence is increasing
 RP is considered standard treatment with
curative potential for localized PCa
 RP may result in functional problems
• most notably, UI and SDs
• disruption of local nerves, blood vessels, and muscular tissues
3
Ferlay J et al. Int J Cancer. 2015
Bill-Axelson A et al. N Engl J Med 2011

4. Introduction
 Traditionally, the sexual problem that has
received the most focus was ED
– “penile-rehabilitation” programs have been developed
 In recent years, there has been an increased
focus on previously neglected sexual side
effects
– loss of libido, EjD, orgasmic dys, penile shortening and PD
 The importance of psychological issues and
partner considerations are gaining recognition
as factors in sexuality after RP
4
Frey et al. J Sex Med 2014
Tal R et al. J Sex Med 2009
Ficarra V et al. Eur Urol 2012

5. Post Radical Prostatectomy Sexual
Dysfunctions
 Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia / Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction

6.  Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia / Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction
Post Radical Prostatectomy Sexual
Dysfunctions

7. The incidence of post-
RP ED ranges between
15-95%1
Meta-analysis of RARP
trials2
• 12 month – 10-46% ED
• 24 month – 6-37% ED
Post-op EF recovery:
• Majority within 2 yr
• Fails to achieve baseline
1. Mulhall JP. J Urol 2009
2. Ficarra V, et al: 2012, Eur Urol.
Incidence of Post-RP ED

8. Predictors of Post-RP ED
 Factors which influence postoperative EF:
• nerve-sparing status
• patient age
• preoperative EF
• comorbidities
___________________________________________
• surgical technique (RARP?)
• surgical tools (Cautery?)
• surgeon experience
Alemozaffar M, et al. JAMA. 2011

9. Pathophysiology of post-RP ED

10. Pathophysiology of post-RP ED
Hatzimouratidis et al Eur Urol 2009

11. Post-RP Penile Histologic Changes
Iacono F et al. J Urol. 2005
Pre-RP Post-RP
decrease in cavernosal
SM cells
(2nd postop mo)

12. Penile rehabilitation
Hatzimouratidis et al Eur Urol 2009
- During erections the
penis oxygenation rises
from 35-40  75-100
mmHg
- Thus, oxygenation is
preserved as long as
men obtain erections
regularly.

13. Penile rehabilitation
 Available Tx
• On-demand / Daily PDE-5 inhibitors
• Intracavernosal Injections
• Vacuum Erection Devices (VED)
 No clear benefit in restoring erections
• PDE5Is improve erections while taking..!
– Lack of evidence for prevention of permanent loss of EF / restoration of EF
• Injection therapies may often be required
• VED or penile traction helps maintain / improve length

14. Tadalafil - Montorsi 2014
Washout
Montorsi F, et al. Eur Urol.
2014

15. Post Radical Prostatectomy Sexual
Dysfunctions
 Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia/Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction

16. Normal Ejaculation

17. Post RP Anejaculation

18. Post RP Anejaculation
 Anejaculation may be bothersome for half of post RP
pts (and their partners)
 Anejaculation adversely affects orgasm in 1/3 of pts
 Pts may avoid intercourse because of anejaculation
Messaoudi et al. Int J Impot Res 2011
Tsivian M et al. Int Braz J Urol. 2009

19. Anejaculation
 Ejaculation is important for
• Sexual pleasure & satisfaction
• Sense of manhood
• Fertility (20% PCa pts would bank sperm before RP)
 The patients must be informed about the risk of
anejaculation and infertility
• possible fertility preservation interventions must be offered to
men with PCa who desires to become father
Salonia et al. Fertil Steril 2013

20.  Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia / Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction
Post Radical Prostatectomy Sexual
Dysfunctions

21. Orgasm
 Orgasm is the least understood phase of the
sexual response cycle
 Orgasm is associated with striated muscle
contractions, resulting in semen expulsion
during ejaculation
• involves the sympathetic, parasympathetic and somatic
nervous systems
• via the pelvic plexus, pudendal nerve and hypogastric nerve
Mah et al. Clin Psychol Rev 2001

22. Normal Orgasm
 There are 3 components of orgasm
1. CNS stimulation
2. Pelvic muscle activity
3. Semen ejaculation
Mah et al. Clin Psychol Rev 2001

23. Post RP Orgasm
 All 3 components of orgasm are affected
1. CNS stimulation  depression / anxiety due to PCa
2. Pelvic muscle activity  local nerve damage
3. Semen ejaculation  not exists
Mah et al. Clin Psychol Rev 2001

24. Post RP Orgasmic Dysfunctions
1. Change in orgasmic nature
• Decrease in Intensity
• Change in Timing (premature, retarded)
2. Anorgasmia
3. Orgasmic pain (Dysorgasmia)
Helgason et al. Br J Cancer 1996
Koeman et al. Br J Urol 1996

25. Author Year No. of
patients
Orgasmic dysfunction type and rate
Capogrosso 2016 749 9.5% orgasmic pain (more common after ORP)
Frey 2014 256 5% anorgasmia
60% decreased orgasm intensity
6% increased orgasm intensity
9% orgasmic pain (dysorgasmia)
Matsushiata 2012 702 12% orgasmic pain (primarily in the penis)
Tewari 2012 408 15% anorgasmia (age and NS status influence
orgasm recovery)
Dubbleman 2010 458 33.2% decreased orgasm intensity orgasm (age,
NS status, UI influence orgasm recovery)
Barnas 2004 239 37% complete absence of orgasm
37% decreased orgasm intensity
4% increased orgasm intensity
14% orgasmic pain (dysorgasmia)
Koheman 1996 17 82% decreased orgasmic intensity
14% orgasmic pain (dysorgasmia)

26. 49
Du et al. J Urol. 2017

27. Post RP Orgasmic Dysfunctions
 Between 20-74% report decreased or absent ability
to achieve orgasm
• More common among older men, after non-NS RP
• Preop orgasmic function, EF, sexual desire and UI are important RFs
 Between 3-19% report dysorgasmia
• pain lasts for less than 1 minute
• can be felt in penis/testis/rectum
• more common after ORP (compared with RARP)
• intensity and frequency of pain decrease during follow-up
 Only 15% are aware of the risk of change in the
nature of orgasm
• Uro-oncologists are very busy..!
Du et al. J Urol. 2017
Fode et al. Nat Rev Urol 2016
Wittmann et al. J Sex Med 2015
Deveci et al. BJU Int 2016

28. Treatment of Orgasmic Dysfunctions
 The patient must be informed that orgasmic
dysfucntions (esp. dysorgasmia) may resolve with
time
 Tamsulosin 0.4 mg may be effective in dysorgasmia
 PDE5Is (vardenafil) may improve orgasmic functions
Fode et al. Nat Rev Urol 2016
Barnas et al. Eur Urol 2005
Nehra et al. J Urol 2005

29.  Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia / Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction
Post Radical Prostatectomy Sexual
Dysfunctions

30.  UI at the time of orgasm is a common problem
after RP
• avoidance of sexual activity
• depressed mood, anxiety
• Worse QoL
Climacturia
Nilsson et al. J Sex Med 2011

31. Author Year No. of
patients
Orgasmic incontinence (climacturia) rate
Capogrosso 2016 749 29.5% (better recovery after RARP vs. ORP)
Frey 2014 256 29% incontinence during foreplay
27% climacturia
Mitchell 2011 1,358 44.4% at 3 mo ; 36.1% at 24 mo
Strongly correlated with UI
Nilsson 2011 691 38.8%
Choi 2007 475 20%
Lee 2006 42 45% (more common among men with
dysorgasmia and penile shortening)
Barnas 2004 239 93% at any time after RP
- 16% always
- 44% occasionally
- 33% rarely
Koheman 1996 17 64%

32.  The exact pathophysiology behind the problem
remains unknown
• anatomic alterations to the urinary tract
• nerve damage during surgery
 Among pts with post RP climacturia
• Functional urethral length is shorter (1.5 cm, p=0.02)
• Time to continence recovery is longer (p=0.05)
 Time from surgery might be important
• 24% within the first 12 mo
• 12% after 1 year
Climacturia
Fode et al. Sex Med Rev. 2016
Manassero et al. J Sex Med. 2012

33. Possible Consequences of Climacturia
 Sense of loss of control
 “Leaking anxiety”  Psychogenic ED
 Difficulty with oral sex
 Avoidance of sexual activity

34. Climacturia Treatment
 Inform the pts about climacturia before RP
• patients might feel abnormal and more ashamed w/o info
 Pragmatic measures
• emptying the bladder before sexual activity
• use of condoms
 Adjustable Constriction loop (penile constriction ring)
 Pelvic Floor Rehabilitation
 Post-RP UI surgeries
• artificial urinary sphincters
• urethral slings
Jain et al BJU Int 2012
Mehta et al. BJU Int. 2012
Sighinolfi et al. J Sex Med 2009

35.  Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia/Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction
Post Radical Prostatectomy Sexual
Dysfunctions

36. Penile Length Loss
 Penile shortening and penile deformities are
common after RP (2.4-12 mm)
 The underlying mechanisms may be:
1. Increased sympathetic tone
• RP damages parasympathetic nerves only
(Sympathetic is intact and unopposed)
2. Penile hypoxia (SM apoptosis  fibrosis)
3. Tunical changes
• Thickening of TA
• Loss of elasticity
• Peyronie’s disease

37. Author Year No. of
patients
Time
interval
Main outcomes
Gontero 2007 126 1 year 1.34cm shortening – flaccid length
2.30cm shortening – stretched length
Briganti 2007 33 6 months No statistically significant length changes, both
flaccid and erect states
Savoie 2003 124 3 months 19% had ≥15% shortening, stretched length
1.2cm shortening – flaccid length
1.1cm shortening – stretched length
Munding 2001 31 3 months 13% increased stretched length
16% no change in stretched length
71% had decreased stretched length:
23% - up to 0.5cm
35% - 1.0-2.0cm
13% - more than 2.0cm
Fraiman 1999 100 1.7-27.6
months
8% decrease in flaccid length
9% decrease in erect length
Greatest change at 4-8 months
Penile Length Loss

38. Vasconcelos et al. Urology. 2012

39. Penile Length Loss
 Possible protective factors for postoperative
penile size:
• Nerve-sparing surgery
• recovery of EF
• use of PDE5Is
 Possible consequences of penile shortening
• Body image deterioration
• Self-esteem decrease
• Partner distress
• Penetration failure (obese couples)
Gontero et al. J Urol 2007
Engel et al. J Endourol 2011
Berookhim et al. BJU Int 2014
Briganti et al. Eur Urol 2007

40.  Patients should be informed of the potential side
effects of RP on penile length
 Daily PDE5Is (tadalafil) may preserve penile length
• (4.1 mm better than placebo)
 Vacuum erection device
Treatment of Penile Length Loss
Brock et al. Urology. 2015
Kohler et al. BJU Int. 2007
Raina et al. Int J Impot Res. 2006

41.  Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia/Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction
Post Radical Prostatectomy Sexual
Dysfunctions

42.  Penile fibrotic changes are common after RP
 A large study (n=1,011) reported de novo
curvatures are observed in 15.9% of patients
• developing at a mean of 13.9 months after RP
• younger age and white race are significant risk factors
Peyronie’s Disease
Ciancio and Kim. BJU Int. 2000
Tal et al. J Sex Med 2010

43.  Erectile Dysfunction
 Anejaculation
 Orgasmic Dysfunction
 Climacturia/Foreplay Incontinence
 Penile Length Alterations
 Peyronie’s Disease
 Low Libido
 Psychogenic sexual dysfunction
Post Radical Prostatectomy Sexual
Dysfunctions

44.  PCa diagnosis might be enough to impair
sexual function
• 14% reported no sexual activity
Psychogenic Sexual Dysfunctions
Saitz et al. Andrology 2013

45. Psychogenic Sexual Dysfunctions
Decreased sexual activity 20%
Decreased sexual interest 15%
Decreased sexual pleasure 12%
Problems obtaining erection 10%
Incrocci et al. J Sex Marital Ther. 2001
Before PCa treatment

46. Psychogenic Sexual Dysfunctions
Zaider et al. J Sex Med. 2012
After PCa treatment

47.  Depression, anxiety and relationship problems
play an important role in overall sexual
satisfaction after RP
 Discussions with physicians (or psychologists)
could help them express their feelings
 Ideally, such discussions should start before
the initiation of cancer treatment to prepare the
patient and his partner for potential side effects.
Psychogenic Sexual Dysfunctions
Nelson et al. J Sex Med 2007
Canada et al. Cancer 2005
Titta et al. J Sex Med 2006
Molton et al. J Psychosom Res 2008

48.  Aim: To validate the Female
Sexual Distress Scale (SDS) in samples of men
with PCa.
• Internal consistency > 0.93; test-retest reliabilities > 0.82
 SDS can be used in samples of men with PCa for
the assessment of distress
73

49. 74

50. Conclusions-1
 Sexual function after RP is definitely NOT only
ED
• Therefore, restoration of EF alone is not enough.
 Clinicians must start considering “full sexual
rehabilitation”, instead of of simple “penile
rehabilitation”
• Penile rehabilitation does not seem to work anyway
 Although our knowledge of the pathophysiology
is limited and our treatment options are few,
information about sexual side effects may help
patients to cope with these problems

51. Conclusions-2
 Anejaculation may be bothersome for half of
post RP pts (and their partners)
 The patients must be informed about
anejaculation and the risk of infertility
• 20% consider sperm preservation
 The patients must be informed about orgasmic
dysfucntions
 Orgasmic problems may resolve with time
• Tamsulosin and/or PDE5Is may help

52. Conclusions-3
 One thirds of pts suffer from climacturia
• Pragmatic measures, penile constriction rings, PFM rehab may help
 Patients should be informed of the potential side
effects of RP on penile length (up to 2.3 cm)
– Daily PDE5Is (tadalafil) or VED may preserve penile length
 Psychological issues must be recognized and
appropriately dealt with.
• SDS questionnaire may help
 Partners should be included in the management
whenever possible.

53. Thank you…
egecanserefoglu@hotmail.com