The effect of erectile dysfunction on the quality of life of men after radical prostatectomy

Authors


J.P. Meyer, Bristol Urological Institute, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK.
e-mail: jpmeyer@doctors.org.uk

Abstract

OBJECTIVE

To report on the first use of a quality-of-life (QoL) measure specific for erectile dysfunction (ED), the ‘ED effect on QoL’ (ED-EQoL), to assess the effect of ED on QoL after radical prostatectomy (RP).

PATIENTS AND METHODS

We retrospectively identified 89 patients who had undergone RP at one institution. Each was sent the ED-EQoL and a second questionnaire asking whether they had been counselled before RP about possible ED afterward.

RESULTS

The response rate was 91% and the median time since RP 92 months; 76% of those who were potent before RP were impotent afterward. The overall results showed that the QoL of 72% of patients was moderately or severely affected. For each question, on average a third of the patients reported that their QoL was affected either ‘quite a lot’ or ‘a great deal’.

CONCLUSIONS

This study shows that ED after RP has a profound effect on QoL; it is therefore important when assessing ED to use an ED-specific QoL questionnaire such as the ED-EQoL to measure the psychosocial effect of ED, in addition to using an instrument such as the International Index of Erectile Function to measure the functional aspects of ED.

Abbreviations
RP

radical prostatectomy

ED

erectile dysfunction

QoL

quality of life

ED-EQoL

ED effect on QoL (questionnaire)

EORTC

European Organization for the Research and Treatment of Cancer.

INTRODUCTION

With the increased rate of early detection of localized prostate cancer, more patients have been eligible for radical treatment in recent years. One such treatment is radical prostatectomy (RP), which may be by the retropubic or perineal route, or laparoscopic. Complications arising from RP include urinary incontinence and erectile dysfunction (ED). The incidence with which these complications occur vary among reported series. Catalona et al.[1] reported an impotence rate of only 32% after a bilateral nerve-sparing RP, whereas Stanford et al.[2] reported a 56–59% impotence rate with a nerve-sparing procedure and a 66% rate with standard RP.

Over the last decade there has been a general shift in the techniques used to make a clinical diagnosis of ED. This has changed from expensive, time-consuming and invasive techniques (e.g. dynamic infusion cavernosometry, penile duplex Doppler ultrasonography, and RigiScan studies) to simple, noninvasive, self-reporting questionnaires such as the International Index of Erectile Function [3]. Several studies have used questionnaires that are not specific for ED to determine the effect of ED on quality of life (QoL) [4]. Most of the self-reported questionnaires have focused on functional ability alone and have overlooked the emotional consequences and the possible profound effect that ED has on QoL. An ED-specific psychometrically validated QoL instrument was recently developed, the ‘ED effect on QoL’ (ED-EQoL) [5]. This is the only validated ED-specific measure available for use within the UK, and was developed using well-established principles of questionnaire design, with its reliability, validity and responsiveness verified in a multicentre study [6].

We used the ED-EQoL questionnaire to assess the effect of ED on the QoL of men after RP; this is the first reported use of this new instrument for quantifying the effect of ED on QoL.

PATIENTS AND METHODS

Patients who had undergone a retropubic RP for localized carcinoma of the prostate between 1 January 1991 and 31 December 1995 were identified by searching operative records at one centre. The search identified 89 patients (mean age 61 years, range 51–70); all 89 had their surgery undertaken by one surgeon. The medical records of each patient were available for review, from which the following information was obtained: demographic patient details, age, whether the prostatectomy was nerve-sparing or not, and whether the patient was potent before and after RP. This group of patients was sent the ED-EQoL and a second questionnaire enquiring as to whether they were counselled before RP about ED.

The ED-EQoL (Appendix) consists of 15 questions with each question having five possible responses, scored from 0 to 4. The 15 individual scores are then added to provide a total score of 0–60 (the higher the score, the poorer the QoL). The scores obtained from the ED-EQoL can be divided into three similar groups, i.e. those with a score of < 15 (mildly affected QoL), 15–29 (moderately affected) and ≥ 30 (severely affected) [5]. The second questionnaire comprised one question ‘Were you told before the operation that you may have difficulties getting an erection afterwards?’ and the patients were asked to tick ‘yes’ or ‘no’ in reply.

RESULTS

The ED-EQoL questionnaire was sent to all 89 patients; those who did not return the questionnaires were contacted by telephone and asked to forward their replies. Using this combined approach, 84 questionnaires were returned. Three were excluded as they were incomplete, leaving 81 completed questionnaires, giving a response rate of 91%. The median (range) time elapsed since RP was 92 (71–130) months and the median age of the patients 61 (51–70) years. The inpatient medical records of the 81 patients showed that two had a nerve-sparing RP, 79 did not, 74 were potent before RP and 56 of those who were potent before RP were impotent afterward. The primary interest was in this last group of patients; their ED-EQoL results are shown in Table 1.

Table 1.  ED-EQoL responses from the 56 preoperatively potent patients who were impotent after surgery
Question
(Appendix)
N (%) positive
Not at allA littleSomewhatQuite a lotA great deal
 116 (29) 11 (20) 9 (16) 8 (14)12 (21)
 210 (18)16 (29) 11 (20)12 (21) 7 (12)
 3 5 (9)14 (25)16 (29)15 (27) 6 (10)
 4 6 (11)22 (39)18 (32) 5 (9) 5 (9)
 5 2 (3.5)19 (34)17 (30) 7 (12.5) 11 (20)
 6 6 (11)23 (41)14 (25) 6 (11) 7 (12)
 715 (27)17 (30)12 (21) 6 (11) 6 (11)
 820 (36)12 (21)12 (21) 6 (11) 6 (11)
 916 (29)18 (32)10 (18) 8 (14) 4 (7)
1021 (38)14 (25)12 (21) 7 (12.5) 2 (3.5)
1126 (46)13 (23) 9 (16) 6 (11) 2 (4)
1222 (39)14 (25)12 (21) 7 (13) 1 (2)
1317 (30)21 (37.5) 11 (19.5) 6 (11) 1 (2)
14 9 (16)15 (26.5)19 (34) 7 (12.5) 6 (11)
1514 (25)20 (36)12 (21) 5 (9) 5 (9)

In response to the ED-EQoL questions, most patients felt that their QoL was affected in some way by their ED. Applying the three groups described by MacDonagh et al.[5] to the 56 men with ED after RP, 16 (28%) had a mildly affected QoL as a result of their ED, 29 (52%) were moderately affected and 11 (20%) severely affected. The responses from question 1 showed that 12 (21%) blamed themselves ‘a great deal’ for being unable to satisfy their partner because of their ED. Responses to question 2 showed that a third of men felt ‘quite a lot’ or ‘a great deal’ of guilt associated with their inability to produce an erection. In addition, 20% felt ‘a great deal’ less of a man because of their ED (question 5) and 38% of men felt either ‘quite a lot’ or ‘a great deal’ less desirable as a result of their ED (question 3). Even after a median of 92 months from RP, over two-thirds of men felt sad or tearful as a result of their erectile difficulties (question 13). In response to question 6, 89% of men felt some degree of anger or bitterness because of their ED; 84% felt that because of their ED ‘other people’, i.e. friends or colleagues, felt happier because they were sexually fulfilled (question 14). The responses to question 12 showed that 61% felt at least ‘a little’ preoccupied by their lack of erectile function, and 62% of men even reported that as a result of their ED they worried about how their life would develop in the future (question 10). Finally, most men (75%) felt that their self-esteem was to some degree damaged by their ED (question 15). In response to the second questionnaire, 9% stated that they were not informed about the risk of ED after RP.

DISCUSSION

This study showed that even a considerable time after RP, the resulting ED has a profound effect on QoL. Overall, 72% of men had a moderately or severely affected QoL because of their ED. The results from each question show that the many areas that constitute QoL are significantly affected by ED, including self-esteem, guilt, blame, happiness and anger. As this study did not include a control group we do not know what is ‘normal’ for men of a similar age not undergoing RP. Although most men inevitably have a deterioration in erectile function with age, we consider that despite the lack of a control group the profound effects on QoL from ED in the present study would be more than that expected in a control group of men of a similar age not undergoing RP.

A deficiency of this study is that it retrospectively assessed the effect of ED on QoL. There can be no doubt that a prospective analysis with more patients would have produced more interpretable results, but the magnitude of the deterioration in QoL in this study suggests that it would still be reasonable to conclude that RP adversely affects ED.

Before developing the ED-EQoL there was no suitable instrument to assess the psychosocial impact of ED on QoL. The European Organization for the Research and Treatment of Cancer (EORTC) developed a questionnaire to assess QoL in patients with cancer (QLQ-C30), but this is not specific for ED [7]. The EORTC designed several disease-specific modules to be administered in addition to the core questionnaire. There is a module for use in patients with prostate cancer, and this is presently a phase IV module (QLQ-PR25). The topics addressed by the QLQ-PR25 include the common side-effects of prostate surgery, radiation therapy and hormonal treatment, together with problems of micturition, bowel function and sexuality. We did not use the QLQ-C30 or QLQ-PR25, as unlike the ED-EQoL, neither is specific for ED and the aim of the present study was to address QoL issues that result from ED rather than prostate cancer itself, and its effects on other systems.

The psychosocial impact of ED can, and often is, neglected after RP as the functional and physical variables invariably take precedence. The psychosocial impact on the patient is significant; a third of the present men felt that other people are ‘quite a lot’ or ‘a great deal’ happier because they are sexually fulfilled, and 38% felt ‘quite a lot’ or ‘a great deal’ less desirable as a result of their erectile difficulties. Indeed, even after a median of 92 months from RP the psychosocial effects of ED on QoL remain profound, i.e. 71% of men continue to feel ‘a little’ or ‘somewhat’ hurt by their partner's response to their erectile difficulties, and 73% of men feel to some extent a failure because of their ED.

In the second questionnaire 9% reported not being informed about the risk of ED; given the median of 92 months from RP, there may be an element of recall bias associated with this result. Despite this, it is vital that all patients undergoing RP are counselled particularly about the possibility of ED. To ensure that this is so all patients undergoing RP at our institution are now provided with written information leaflets and are counselled before RP by a specialist uro-oncology nurse.

The higher than average impotence rate of 76% after RP can be explained as 98% of the men did not have a nerve-sparing RP, as was the usual practice within our institution during the early 1990s. With the adoption of a bilateral nerve-sparing approach, in a later series at our institution, the impotency rate was much lower (33%).

The results of the present study have implications for current practice; the large effect of ED on QoL even many years after surgery shows the importance of careful counselling before and after RP, and suggests that ED should be formally assessed using a measure such as the ED-EQoL, to identify those patients affected by ED, thus enabling the clinician to target treatment and provide counselling when necessary.

In conclusion, there is a significant and sustained effect of ED on QoL after RP; to document this effect and to identify those patients suitable for appropriate therapy and counselling, we suggest that both psychosocial and functional aspects of ED should be routinely assessed before and after RP using measures such as the International Index of Erectile Function and the ED-EQoL.

Appendix

APPENDIX 1

The ED-EQoL

Please tick appropriate box:

[Not at all/A little/Somewhat/Quite a lot/A great deal]

  • 1As a result of your erectile dysfunction, do you blame yourself for being unable to satisfy your partner?
  • 2Does your inability to produce an erection with your partner make you feel guilty?
  • 3Do you feel less desirable as a result of your erectile difficulties?
  • 4Do you feel hurt by your partner's response to your erectile difficulties?
  • 5Does the fact that you are unable to produce an erection make you feel less of a man?
  • 6Do you feel angry or bitter that you cannot produce an erection?
  • 7Do you feel a failure because of your erectile difficulties?
  • 8Does your partner feel let down by your inability to produce an erection?
  • 9Are you worried that your erectile problems have affected the closeness between you and your partner?
  • 10Does your erectile problem make you worry about how your life will develop in the future?
  • 11Is your sense of identity altered by your lack of erectile function?
  • 12Are you preoccupied by your erection problems?
  • 13Do you feel sad or tearful as a result of your erectile difficulties?
  • 14Do you feel that other people are happier than you because they are sexually fulfilled?
  • 15Is your self-esteem damaged by your erectile problems?

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