Assessing couples' preferences for postoperative sexual rehabilitation before radical prostatectomy
B. Joyce Davison, Room 310-1121 College Drive, College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada S7N 0W3. e-mail: email@example.com
Study Type – Therapy (patient's preference)
Level of Evidence 2b
What's known on the subject? and What does the study add?
Erectile dysfunction after radical prostatectomy (RP) continues to cause men significant levels of distress, but few report being satisfied with the erectile aids that are prescribed. Most couples who do seek treatment report difficulty in maintaining sexual activity and intimate relationships. Although inclusion of partners in sexual rehabilitation programmes may be beneficial, partners are usually not included as part of current treatment protocols.
Preoperative assessment of a couple's readiness to engage in a sexual rehabilitation programme is needed given that only 41% of patients scheduled for a radical prostatectomy during the study period agreed to be in the study. Results show that although patients have mild erectile function, their partners' overall levels of sexual function suggest a need for further medical evaluation. Patients want their partners to be included in the sexual rehabilitation process but few institutions currently offer couple-based rehabilitation programmes. Although intimacy levels of couples are high preoperatively, there is a need to prospectively determine how these levels are impacted by changes in sexual function postoperatively.
- • To evaluate the readiness of couples to engage in a sexual rehabilitation programme (SRP) before radical prostatectomy (RP) and to identify barriers to participation in an SRP after RP.
- • To identify couples' current levels of sexual function and intimacy.
PATIENTS AND METHODS
- • Patients completed the International Index of Erectile Function (IIEF) and their partners completed the Female Sexual Function Index (FSFI) to measure sexual function.
- • Couples completed the Miller Social Intimacy Scale (MSIS) to measure intimacy in relationships.
- • All participants were seen by a sexual health clinician after completing the measures to discuss barriers to participation in an SRP, and to receive an education session.
- • Study participants comprised 143 patients and 104 partners.
- • Patients <60 years old had significantly higher sexual function (P < 0.002) compared with those patients aged 60 years and older.
- • Partners' sexual function scores were suggestive of need for further medical evaluation.
- • Partners' participation was cited by patients as important to them enrolling in an SRP.
- • Couples' intimacy levels were strongly correlated (P < 0.0001).
- • Results suggest that less than 50% of patients are interested in receiving information about the impact of RP on sexual function before surgery.
- • Female sexual function should be assessed as part of any SRP because they may require medical treatment if they are to support rehabilitation efforts for their spouses.
- • Baseline assessment of a couple's sexual function and willingness to participate in an SRP should be performed preoperatively.
sexual rehabilitation programme
International Index of Erectile Function
Female Sexual Function Index
Miller Social Intimacy Scale.
Improved survival after prostate cancer treatment has resulted in clinicians focusing on methods to decrease treatment-related morbidity, but erectile dysfunction (ED) rates in the range of 25–75% continue to be reported after radical prostatectomy (RP) . Erectile difficulties after RP continue to cause men significant levels of distress [2–6], especially in younger men under the age of 65 years [2,7,8]. Approximately 60% of men seek medical help for ED after treatment for prostate cancer [9,10], but few report being satisfied with the erectile aid chosen  and 30–70% of patients discontinue the use of such aids within 1 year after RP [12–14]. For patients who undergo non-nerve sparing RP, 80% stop using any erectile aid because of the perceived lack of effectiveness in treating their ED 1-year after surgery . Almost 75% of patients using oral treatment for ED discontinue use after 18 months because of ‘effect below expectations’, and secondly because of partner's loss of sexual interest . The literature exploring this gap between effectiveness and use supports a broader sexual dysfunction perspective that encompasses factors such as performance anxiety, patient and partner depression, over-enthusiastic expectations, the partner's lack of readiness to resume lovemaking, hesitancy to use sexual aids; and the quality of the couple's non-sexual relationship [2,5]. Most couples who seek help after surgery, report facing long-term challenges in maintaining sexual activity and satisfactory relationships .
It has been shown that RP has an impact on couples' levels of sexuality and sexual functioning [18–21]. Partners' involvement in the disease process has also been shown to have a positive influence on patients' ability to cope with and adapt to their illness and treatment [22–25]. A study conducted by Davison et al.  reported that most (60%) partners in their study were not interested in attending sexual health clinic appointments with their spouse after treatment of prostate cancer. The reasons why partners decline involvement in sexual rehabilitation programmes (SRPs) remains unclear. These findings suggest that although inclusion of partners in an SRP may be beneficial, many partners may decline through a lack of interest or because their spouses want to attend such appointments by themselves. To date, little is known about the factors that affect the partner's desire and willingness to be included in SRPs, and female partner's acceptance of the use of erectile aids .
The perceptions of patients and partners regarding the impact of surgical treatment for prostate cancer on erectile function (EF) vary in the literature. Some men believe that surgery will not affect their sexual function , whereas others are concerned that surgery will have an impact on their overall intimate relationship . Although men report being concerned about a loss of masculinity and sense of identity, female partners interpret this potential loss in terms of their long-term relationship and love being able to sustain them . Women report that ED is not as important to them as it is to their male counterparts, but the potential loss of their partner's sexual capacity is much more of a burden when the relationship is new or when the level of pretreatment sexual functioning was not satisfactory . Conversely, Sanders et al.  reported that female partners of patients who had been treated for prostate cancer, felt that their partners were less affectionate and as a result they felt unattractive and unwanted by their partners. Although couples have an expectation that erectile aids will allow them to continue sexual activity unaltered from what it was before treatment , this unrealistic expectation could potentially lead to disappointment and premature discontinuation of erectile aids .
This study was conducted to assist clinicians in identifying those patients who would be interested in participating in an SRP after surgery, and to assess levels of sexual function and relationship intimacy in couples before surgery. A secondary objective was to identify the perceived barriers of patients to enrolment in an SRP.
PARTICIPANTS AND METHODS
This descriptive study was approved by the local ethics committees before data collection. Between October 2009 and June 2011, all patients scheduled for an RP at one academic urology outpatient clinic in western Canada were invited to participate in this study along with their partners. Exclusion criteria for patients and partners were the inability to speak and read English. Partners were eligible if they were married to or living with the patient for a minimum of 6 months before surgery. Patients who had a partner and those men with partners who did not want to participate in this study were included in the sample. We also included men who were not in a long-term relationship.
Letters of invitation were given to patients by clinic staff when the RP was booked. Patients were contacted by a research assistant at least 1 month before surgery to determine if the patient (and his partner) wished to participate in the study. All patients and partners were invited to attend a 45-min education session with the sexual health clinician before surgery regardless of whether they wished to participate in the study. Patients were asked to bring their partners to this appointment. All participants provided signed informed consent in the clinic. Patients (and their partners) completed separate demographic questionnaires, and measures of current sexual function and intimacy independently. Couples, and men without a partner were then seen by a sexual health clinician in a private session to cover topics such as available treatment options for ED after surgery, setting realistic time frames for return of sexual function, desire to participate in an SRP after surgery, and primary motivation for doing so (including intimacy, regaining an erection).
The sexual health clinician provided participants with a detailed description of what such an SRP would comprise, including preoperative assessment and education, timing of follow-up appointments, erectile aid use, and ongoing evaluation of erectile status. Participants were also informed that they would be assessed at each of these appointments by both a physician and a sexual health clinician to determine how best to enhance their sexual function with the use of both sexual aids and psychotherapy.
She (S.G.) also used a semi-structured interview guide to identify barriers that patients perceived as having an impact on their decision about whether or not they would want to enrol in an SRP postoperatively (e.g. cost of medications, time and location of clinic appointments, patient's level of interest, partner's level of interest in being with spouse at SRP follow-up appointments, and level of concern regarding sexual function) if one was available. She also explored whether they would agree to attend preoperative group education sessions.
The International Index of Erectile Function (IIEF)  is a 15-item self-report questionnaire that was used to measure patients' sexual function based on the preceding 4 weeks. This scale uses a Likert scale from 0 to 5 with higher scores indicating better sexual function. The scale consists of five separate domains of sexual function: EF, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction . Scoring on the IIEF allows differentiation between different degrees of severity of sexual dysfunction, and has been used in several clinical trials to assess sexual function. Based on the work by Rhoden et al.  scores on the EF domain range from 5 to 25, with ED classified into five categories based on the scores; severe (5–7), moderate (8–11), mild to moderate (12–16), mild (17–21), and no ED (22–25). The IIEF instrument has high internal consistency when used with patients with prostate cancer both before and after surgical treatment, as assessed by Cronbach's α (range 0.93–0.97) [26,33]. In this study, the IIEF was also shown to be reliable with this group of patients (0.95) as assessed by Cronbach's α.
The Female Sexual Function Index (FSFI)  is a 19-item self-report measure used to assess partners' levels of sexual function using the six domains of desire, subjective arousal, lubrication, orgasm, satisfaction and pain during sexual activity. Partners were asked to rate their own sexual function for the preceding 4 weeks using a Likert scale. Scores range from 0 (or 1) to 5, with higher scores indicating better sexual function. Based on the scoring guidelines suggested by Wiegel et al.  total scores less than 26.5 are suggestive of female sexual dysfunction, and scores less than 4.95 on the lubrication domain, 4.6 on the orgasm domain, and scores less than 3 on the sexual pain domain are suggestive of the need for further evaluation for sexual dysfunction. The FSFI has been validated as an appropriate tool to differentiate between women with and without sexual arousal disorder and has a high degree of internal consistency (Cronbach's α of 0.82 and higher), as well as a high test–retest reliability (r= 0.79 to r= 0.88) . In this study, internal consistency for the FSFI measure was 0.97 as assessed by Cronbach's α.
The Miller Social Intimacy Scale (MSIS) , a 17-item questionnaire, was used to measure patients' and their partners' intimacy. Participants responded to intimacy questions on a 10-point scale, with responses to six items selected in terms of frequency (1 = Very Rarely to 10 = Almost Always), and 11 items in terms of intensity (1 = Not Much to 10 = A Great Deal). Higher scores on the MSIS correspond to higher levels of intimacy. Internal consistency is high (Cronbach's α 0.91), as is test–retest reliability (r= 0.96) and convergent validity (r= 0.71) . The MSIS was also shown to be reliable with this group of patients (0.89) and partners (0.75) as assessed by Cronbach's α.
Two additional questions were added to both the IIEF and FSFI regarding frequency of sexual intercourse and activity over the past 6 months. In addition, a clinical scale was used to rate each patient's current erection rigidity from one (completely flaccid) to six (erection adequate for penetration) to 10 (fully rigid).
A short demographic questionnaire was used to solicit information on participant's age, previous medical conditions, marital or relationship status, ethnicity, education, employment and erectile aids currently being used. Date of diagnosis and other disease-relevant information were obtained from clinic records.
Descriptive statistics (frequency tables, means and sd, as appropriate) were used to describe the personal (age, education, marital status, employment status and ethnicity) and medical (PSA level, Gleason score, clinical stage of disease, previous use of erectile aids) variables of participants. Scores on the IIEF, FSFI and MSIS were calculated after the instruments scoring instructions. An anova was used to determine the impact of age on reported levels of sexual function of both patients and their partners. Correlations between patient's and partner's sexual activity over the past 6 months, and levels of intimacy in the relationship were conducted preoperatively using the Spearman's correlation coefficient. A P value of 0.05 was used to determine significance for all analyses.
In all, 143 men agreed to participate in this study, of whom 104 were couples. A total of 202 men refused to participate in this study for the following reasons: no interest (43.6%), too busy and timing was not convenient (27.7%), not currently sexually active so not a concern (8.4%), no need for further information at this time (7.4%), prefer to wait until after surgery to think about sexual function (6.4%), too anxious or stressed (3.4%), topic too sensitive (1.5%), and partner not interested (1.5%). Twenty-seven partners refused to participate in this study. Reasons that patients provided to explain why their partners did not participate included: no interest (20%), not discussed (15%), partner not available (15%), partner working (13%), not fluent in English (3%), and patient preference (3%).
Most patients were in a relationship, had greater than a high school education, and were working full-time. Most partners also had greater than a high school education, and were working outside the home (Table 1). Ninety per cent of participants in this sample were Caucasian.
Table 1. Demographic and clinical variables of study participants
|Age*|| || |
| Mean (sd)||61.5 (6.5)||57.3 (7.3)|
| <60 years, n (%)||52 (36.4)||60 (59.4)|
| 60–65 years, n (%)||52 (36.4)||28 (27.7)|
| >65 years, n (%)||39 (27.3)||13 (12.9)|
|Educational attainment†, n (%)|| || |
| <High school||10 (7.0)||3 (2.9)|
| High school||22 (15.4)||22 (21.6)|
| >High school||111 (77.6)||77 (75.5)|
|Relationship status, n (%)|| || |
| Married/cohabitating||124 (86.7)|| |
| Significant relationship||7 (4.9)|| |
| No relationship||12 (8.4)|| |
|Employment‡, n (%)|| || |
| Full-time||74 (51.7)||28 (27.5)|
| Part-time||18 (12.6)||29 (28.4)|
| Retired||48 (33.6)||3 (2.9)|
| Unemployed||3 (2.1)||42 (41.2)|
|Prostate-specific antigen (ng/mL), n (%)|| || |
| <10||115 (80.4)|| |
| ≥10||28 (19.6)|| |
|Gleason score, n (%)|| || |
| 6||51 (35.7)|| |
| 7||75 (52.4)|| |
| 8–9||17 (11.9)|| |
|Clinical stage§, n (%)|| || |
| T1||66 (46.8)|| |
| T2||68 (48.2)|| |
| T3||6 (4.3)|| |
| T4||1 (0.7)|| |
Twenty-nine (23%) patients stated that their current sexual function was a concern in the preoperative phase because of changes in firmness and ability to reach and maintain an erection. A total of 124 (87%) men reported having an erection that was adequate for penetration, as measured by the clinical assessment rating scale, and 36 (25%) of these men reported having fully rigid erections. However, 29 (23%) of these 124 patients reported using an oral erectile aid to enhance EF.
The total mean score on the IIEF was 52.31 (sd= 18.63) (Table 2). A comparison of the individual domain scores and total IIEF scores revealed significant differences based on the age of the patient. Patients <60 years of age had significantly higher scores on the EF, orgasmic function, intercourse satisfaction and overall satisfaction domains compared with patients in the 60–65, and >65-year age groups. Overall sexual function scores were also significantly (P < 0.002) higher for men <60 years of age compared with the other age groups.
Table 2. Measurements of the International Index of Erectile Function domains (N= 143); means (sd)
|Erectile function||21.52 (9.09)||25.10 (6.84)||19.69 (9.87)||19.18 (9.33)||6.90||0.001|
|Orgasmic function||8.10 (2.96)||9.13 (1.88)||7.54 (3.53)||7.46 (2.97)||5.34||0.006|
|Sexual desire||6.69 (1.84)||7.00 (1.76)||6.40 (2.08)||6.67 (1.56)||1.38||0.260|
|Intercourse satisfaction||8.62 (5.15)||10.25 (4.85)||7.77 (5.17)||7.59 (5.08)||4.29||0.016|
|Overall satisfaction||7.57 (2.40)||8.27 (2.18)||7.12 (2.68)||7.26 (2.10)||3.61||0.030|
|Overall score||52.31 (18.63)||59.60 (14.38)||48.33 (20.45)||47.90 (18.55)||6.77||0.002|
The total mean score on the FSFI was 24.30 (sd= 9.30). Group mean scores on the lubrication (4.01), orgasm (3.45) and sexual pain (4.31) were indicative of a need for further medical evaluation for sexual dysfunction. A comparison of the domains and total scores of the FSFI related to age group revealed no significant differences between the groups of women aged <60 years, 60–65 years, and >60–years (Table 3).
Table 3. Measurements of the Female Sexual Function Index (N= 100); means (sd)
|Desire||3.45 (1.23)||3.61 (1.32)||3.30 (1.13)||3.00 (1.10)||1.55||0.22|
|Arousal||3.92 (1.80)||3.97 (1.78)||3.88 (1.82)||3.62 (2.12)||0.19||0.83|
|Lubrication||4.01 (2.06)||4.28 (23.14)||3.75 (2.06)||3.14 (2.27)||1.88||0.16|
|Orgasm||3.45 (2.31)||4.14 (1.95)||4.11 (1.91)||4.44 (1.91)||1.15||0.32|
|Satisfaction||4.63 (1.51)||4.70 (1.64)||4.33 (1.55)||4.92 (0.85)||0.83||0.44|
|Pain||4.31 (2.33)||4.33 (2.40)||4.23 (2.22)||4.09 (2.57)||0.06||0.94|
|Overall score||24.43 (9.20)||24.93 (9.61)||23.93 (8.89)||22.22 (9.05)||0.48||0.62|
Results from the two supplemental questions added to the IIEF identified that 15% of patients reported having sexual intercourse five to ten times in the previous 6 months, and 55% reported having intercourse 11 or more times. In addition, 22% of patients had some form of sexual activity other than intercourse five to ten times over the previous 6 months, and 56% had some form of sexual activity 11 or more times.
Similarly, results of the two supplemental questions added to the FSFI identified that 18 (18%) of the partners had had some form of sexual activity other than intercourse 5 to 10 times over the previous six months, and 52 (51%) had had some form of sexual activity 11 or more times. Sixteen (16%) reported having sexual intercourse five to ten times in the previous 6 months, and 59 (58%) reported having intercourse 11 or more times in the previous 6 months. The couple's responses to both of these supplemental questions were highly correlated (sexual intercourse r= 0.74, P < 0.001; sexual activity other than intercourse r= 0.28, P= 0.008).
Both patients and partners reported high levels of intimacy in their relationship (Table 4). In addition, the total scores on the subscales of frequency (r= 0.596, P < 0.0001) and intensity (r= 0.473, P < 0.0001) were highly correlated in the 104 couples.
Table 4. Scores on Miller Social Intimacy Scale
| Intensity (total score 0–110)||95.78 (10.83)|
| Frequency (total score 0–60)||48.54 (7.55)|
| Intensity (total score 0–110)||98.60 (9.31)|
| Frequency (total score 0–60)||50.06 (7.17)|
Most (99%) patients expressed an interest in being included in a comprehensive SRP if one was instituted at the clinic where they were being treated. Thirteen partners, who were in attendance, stated that they did not want to participate in such a comprehensive programme for the following reasons: five had health concerns, four were not interested, three had not discussed the issue with their partner before the session, and one did not live in this country on a continuous basis. For those patients with a sexual partner, 90% stated that their partner's interest would have an impact on whether or not they would participate in an SRP. Time and location of the appointments required to participate in such a programme was cited as a barrier by 27% of participants. Patients suggested that sexual rehabilitation appointments be made to coincide with follow-up appointments, especially those patients who lived further from the clinic. Patients living >100 km from the clinic still indicated that they would make the effort to attend the appointments at the sexual clinic. Approximately two-thirds (67%) of participants reported that they would be willing to attend preoperative group education sessions on sexual function and available treatments, 26% were not interested and 7% were unsure. The cost of erectile aid therapy was identified as a barrier by 12% of couples.
Urologists have identified the need for their patients to participate in some type of sexual rehabilitation activity after RP, but little is known about how many patients and their partners want to access such programmes. This study was conducted to help clinicians to identify those patients who would be interested in sexual rehabilitation activities after surgery, but we were not able to achieve this. One of the main reasons was that fewer than half of men scheduled for an RP were interested in learning more about the impact of surgery on EF and available treatments. Of the 345 men approached to be in this study, 143 (41%) consented. Of those patients who did agree to be in the study almost all (99%) wanted to participate in a comprehensive SRP at the clinic if one was available. This finding illustrates the need to determine if patients are interested in an SRP before they are enrolled in such a programme as part of a standardized preoperative clinic protocol.
This is one of the first studies exploring the extent to which partners wanted to be included in an SRP before surgical treatment. Partner's interest in participating in a comprehensive SRP was identified as a major factor having an influence on whether patients in our study would enrol in such a programme postoperatively. Partners have previously been reported as being less concerned about sexuality than patients [37,38], and less interested in attending sexual health appointments with their spouses after surgery . However, most (87%) of the partners in our study did want to participate in an SRP with their spouse. One explanation for this finding may be that partners in our study reported levels of sexual dysfunction requiring further therapeutic or medical evaluation, and they thought that participation in an SRP would be beneficial. Similarly, in a survey of sexual outcomes after prostate cancer treatment, Schover et al.  also reported that 66% of partners indicated having some degree of sexual dysfunction, suggesting that sexual dysfunction in partners may have a motivating impact on couples' readiness to engage in sexual rehabilitation activities after RP. However, a recent study by Moskovic et al.  reported that higher preoperative partner sexual function was associated with greater compliance of their spouses to sexual rehabilitation protocols. To date, there is no known published data exploring the effect of female partner's menopausal status and experience of sexual difficulties in relation to men's sexual recovery after prostatectomy, and partner's willingness to participate in the sexual rehabilitation process . Further study is required to determine the impact of partner's sexual function on the patient's willingness to participate in an SRP, and the influence this may have on patient compliance with postoperative medical protocols.
The reported incidence of ED after RP varies widely in the literature and a significant proportion of men will never be able to achieve pretreatment EF [40,41]. For example, much of the discrepancy in the literature on occurrence of sexual dysfunction after RP can be attributed to poor documentation of pretreatment EF and lack of using validated questionnaires to assess sexual function. A comparison of self-reported sexual function vs validated questionnaires shows that most men overstate their level of sexual function when asked by their physician . Preoperative EF is often a predictor of the ability to have an erection after RP, so it is important that patients' baseline sexual function is assessed preoperatively and that they are provided with reasonable expectations regarding postoperative EF and available treatments for ED.
Couples in our study reported having high levels of social intimacy preoperatively. However, the loss of EF poses a threat to a patient's masculine identity  and often has a devastating impact on the intimacy of the relationship . Furthermore, distress related to sexual dysfunction has also been shown to have the most negative and persistent impact on quality of life, and psychological and marital adjustment of both patients and their partners after RP [3,18]. The impact on intimacy also extends to apprehension at seeking intimate contact that may lead to an expectation of sexual performance, which in turn, results in disabled emotional and physical intimacy. Further prospective research studies are needed to measure how changes in sexual function impact on relationship intimacy after RP.
The major limitation to this study was the inability to conduct standardized measurements to make a comparison between those patients and partners who did not wish to participate in a postoperative SRP with those who did wish to enrol in such a programme. As 99% of participants in this study were interested in enrolling in such a programme if one was made available, we could not develop a predictive model of readiness to engage in an SRP. A second limitation was that we were not able to comment on the impact of current levels of sexual function and intimacy of those patients and partners who refused to be in the study. Perhaps these measures should be included as part of the preoperative assessment in clinics that offer SRPs. Third, we cannot conclude that all patients who refused to participate in this study were not interested in an SRP after RP. We also do not know if their current level of EF and sexual activity was having an influence on their refusal. However, fewer than 10 patients who refused to be in this study made an appointment with the sexual health clinician preoperatively to discuss the impact of surgery on sexual function and available erectile treatments. Lastly, it may be difficult to generalize our results to community-based urology clinics as the patients in our study were well educated and there was a lack of ethnic diversity. However, the sample was reflective of the patients seen at this clinic, which is a major referral centre in this Canadian province.
The era of early detection has resulted in many young, sexually active men and their partners expressing concern about preservation of EF after RP, a fact that is true for older men as well. There is also an emerging consumerist expectation that ED be treated as an essential component of ongoing cancer treatment. The results of this study support the need to ask couples if they wish to be enrolled in an SRP before surgical treatment, and to ensure that the sexual rehabilitation needs of both the patient and his sexual partner are addressed in SRP protocols.
We are grateful to the following urologists who provided access to their patients for this study: S. Larry Goldenberg, Martin Gleave, Peter Black and Alan So; and to Dr Jonathan Berkowitz for his statistical analysis.
CONFLICTS OF INTEREST