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Keywords:

  • orgasm;
  • radical prostatectomy;
  • pain

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Section Editor

Michael G. Wyllie

Panel of Advisors

Ian Eardley, UK

Jean Fourcroy, USA

Sidney Glina, Brazil

Julia Heiman, USA

Chris McMahon, Australia

Bob Millar, UK

Alvaro Morales, Canada

Michael Perelman, USA

OBJECTIVE

To define the type of orgasmic dysfunction in men after radical prostatectomy (RP), as absence of orgasm and orgasmic pain are recognized complaints, and changes in orgasm may lead to significant sexual dissatisfaction.

PATIENTS AND METHODS

Using an unvalidated questionnaire, demographic, erectile function and orgasmic function questions were answered by 239 patients who had previously undergone a retropubic RP.

RESULTS

Of the 239 patients, 22% had no change in orgasm intensity, 37% reported a complete absence of orgasm, 37% had decreased orgasm intensity and 4% reported a more intense orgasm after RP than before. Pain during orgasm (dysorgasmia) occurred in 14% of the patients; in these respondents the pain reportedly occurred always (with every orgasm) in 33%, frequently in 13%, occasionally in 35%, and rarely in 19%. Most patients (55%) had orgasm-associated pain for <1 min.

CONCLUSIONS

These results indicate that orgasmic functional changes are relatively common after RP and are worth considering by clinicians and researchers.


Abbreviations
RP

radical prostatectomy.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

In the USA alone, 195 000 men underwent prostatectomy in 2002 [1]. The mean age at the time of prostate cancer diagnosis has decreased from 72.3 years during 1980–85 to 70.6 years during 1990–95 [2]. Furthermore, the rate of RP in men aged <55 years has increased over the past decade [3]. Sexual dysfunction after RP is common, particularly in the early stages [4–7]. Given the incidence of the problem, the frequency of use of surgical intervention and the age at diagnosis, postoperative sexual function has assumed even greater importance for patients and their partners. There are many reports linking sexual dysfunction to decreased quality of life [6,8–10].

Most of the reports on sexual dysfunction after RP have focused specifically on erectile dysfunction [7,11,12]. However, changes in orgasm have been reported in patients after RP [13–15]. Orgasm, which is often considered to be a goal and reinforcer of sexual behaviour, remains the least understood phase of the sexual response cycle. Alterations in orgasm, and in particular its absence, are associated with significant reductions in emotional and physical satisfaction, which in turn may lead to sexual-avoidance behaviour and secondarily to discord in relationships [12,16]. To date there are few reports focusing on orgasmic dysfunction associated with RP. Thus we evaluated the incidence and extent of orgasmic dysfunction in patients after RP.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

After obtaining approval from the institution's ethics review board, a questionnaire was mailed to all patients who had had undergone RP at a one centre (Loyola University Medical Center) between 1995 and 1998. The questionnaire was returned confidentially, with no identifying information, in a stamped, pre-addressed envelope.

The questionnaire comprised 14 questions pertaining to: (i) the nerve-sparing nature and date of operation; (ii) erectile rigidity before and after RP; (iii) the presence or absence of orgasm; (iv) orgasm quality before and after RP; (v) the presence of orgasmic pain; (vi) the location of orgasmic pain; (vii) consistency and duration of orgasmic pain; (viii) continence level; and (ix) medical comorbidity profile. The results were assessed using standard statistical methods.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The questionnaire was returned by 239 of the 350 men (68%) to whom it was mailed; the mean (sd) age and duration since RP were 62 (13) years and 39.5 (20.8) months, respectively. Comorbidities in these men included hypertension (35%), diabetes (10%), dyslipidaemia (10%) and cigarette smoking (5%).

Using an erectile rigidity visual analogue scale of 0 (completely flaccid) to 100 (maximum rigidity), erectile rigidity decreased by 60 (30)% after RP in the entire group. While 22% of patients had no change in orgasm intensity, 37% reported a complete absence of orgasm, 37% had decreased orgasm intensity and 4% reported more intense orgasm after RP than before. Pain during orgasm (dysorgasmia) occurred in 14% of the patients. When given choices of penis, abdomen, rectum or ‘other’, patients reported that the primary location of pain at orgasm was in the penis (63%), abdomen (9%), rectum (24%) and other areas (4%). In those respondents who had dysorgasmia, pain was reported to occur always (with every orgasm) in 33%, frequently in 13%, occasionally in 35%, and rarely in 19%.

Most patients (55%) had orgasm-associated pain for <1 min, a third reported pain for 1–5 min and pain of >5 min was reported by 12%; only 2.5% of patients complained of pain lasting >1 h. Incontinence, of any degree, associated with orgasm at any time after RP was reported by 93% of the men. Orgasm-associated urine leakage occurred always (with every orgasm) in 16%, occasionally in 44%, rarely in 33% and never in 7% of the respondents.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Sexual dysfunction, including decreased orgasm intensity, lack of orgasm and pain during orgasm, may cause psychological distress that may in turn be associated with a reduction in quality of life, loss of self-esteem, self-confidence and discord in relationships [8]. In patients after RP this obstacle to resuming normal life comes during an already difficult period. A high incidence of erectile dysfunction after RP is a well recognized sequel of surgery and has been the focus of many reports on sexual function outcomes after RP [3,5,6,10]. To date, orgasmic dysfunction in this population has received little attention by clinicians and researchers alike

Orgasm is defined as the combined physiological changes and pleasure that occurs coincident with ejaculation in men. As the ejaculatory apparatus (prostate, seminal vesicles, ejaculatory ducts) is removed at RP the patient cannot subsequently ejaculate, and thus such patients have ‘dry orgasms’. While orgasm itself is a poorly understood event at the cerebral level, it is associated with well-documented and reproducible anatomical and physiological events, which include closure of the bladder neck, a rise in blood pressure, tachycardia and a sense of euphoria [17].

Sexual function is important to a person's quality of life [8,18,19]. The consistency, quality and satisfaction of orgasm are correlated with marital satisfaction, stability and happiness [20]. Therefore, alterations in orgasm may be associated with quality of life changes. Given the number of RPs in the USA annually, the decreasing age at the time of diagnosis compared with a decade ago, and the overall improved survival of men after RP, sexual function has assumed increasing importance.

There is no orgasm-specific questionnaire; there are numerous sexual function questionnaires, some of which, like the Derogaitis inventory which contains >200 questions [21], are burdensome for patients to complete and would probably result in a low return rate. The current ‘standard’ questionnaire, the International Index of Erectile Function, contains only two of 15 questions that pertain to orgasm, but this questionnaire was designed for assessing erectile function before and after pharmacotherapy, and is not considered robust for assessing orgasmic function.

Responses to the present questionnaire show that orgasmic dysfunction is a relatively prevalent problem in men after RP. These alterations include complete absence of orgasm, alterations in intensity, and orgasmic pain. Decreased intensity or the complete lack of orgasm was reported by three-quarters of the patients surveyed; 14% had orgasmic pain at some time after surgery. Goriunov et al.[14] reported on changes in orgasm in patients with BPH treated surgically. These author reported that 188 of 818 (23%) such patients had dysorgasmia after surgery. Koeman et al.[15] reported pain during orgasm in 11% of men after RP and 82% complained of diminished orgasmic intensity. A study of 43 men [13] who had had cystoprostatectomy for bladder cancer found that 25% of men sexually active after surgery were unable to attain orgasm and 17% of those able to achieve orgasm by masturbation found that the sensation was impaired. Steg et al.[22] reported that 36% of patients with BPH described their sensation of orgasm to be ‘different’ after prostatectomy.

The cause of dysorgasmia is not well understood; we postulate that the physiological bladder neck closure that occurs during orgasm in these men translates into spasm of the vesico-urethral anastomosis, or pelvic floor musculature dystonia, after RP. This phenomenon has been purported to be associated with penile and testicular pain in men with chronic pelvic pain disorder [23]. The latter group frequently report orgasmic pain and the similarity of the complaints with the present group is striking. The muscle spasm concept is supported by our experience with the amelioration of dysorgasmia using the α-blocker tamsulosin (JL Barnas, M Parker, P Guhring, JP Mulhall: unpublished data). Of 98 patients, 77% reported an improvement in pain and 8% complete resolution of their pain using oral tamsulosin at 0.4 mg/day. Using a visual analogue scale (0–10) for pain, tamsulosin therapy resulted in a statistically significant decrease in pain, with a mean decrease of 2.7 points after treatment. Anorgasmia and decreased intensity of orgasm are most probably psychological events, presumably related to the many issues that men with a diagnosis of prostate cancer and who have undergone major radical pelvic surgery experience.

As with all surveys involving sexual medicine, this study was subject to response and self-reporting bias, which may contribute to the error in calculating the precise magnitude of the incidence of orgasmic problems. The response rate was 68%, similar to the norm in such analyses. Another limitation is the potential for recall bias, as significantly many respondents completed the survey >18 months after RP. This is a routine problem for all retrospective questionnaire-based analyses. The questionnaire has not been validated and failed to adequately assess changes in pain and orgasm-associated urinary leak over time in these patients, readily apparent to us now but not at the time of designing the instrument. These shortcomings notwithstanding, the present findings stress the need for further research into the extent and cause of orgasmic changes in men after RP.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES
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