Erectile Dysfunction and Sexual Health After Radical Prostatectomy: Impact of Sexual Motivation

ORIGINAL ARTICLE Erectile dysfunction and sexual health after radical prostatectomy: impact of sexual motivation

R Messaoudi1, J Menard1, T Ripert1, H Parquet2 and F Staerman1

1Department of Urology and Andrology, Robert Debre´ Academic Hospital, Reims, France and 2Clinical Research Unit, Robert Debre´ Academic Hospital, Reims, France

The life expectancy of patients with localized prostate cancer at treatment initiation has increased, and post-treatment quality of life has become a key issue. The aim of this study is to assess the impact of Radical prostatectomy (RP) on patients’ sexual health and satisfaction according to sexual motivation using a self-administered questionnaire completed by two groups of RP patients, with high or lower levels of sexual motivation. A total of 63 consecutive patients were included (mean age, 63.9 years), of whom 74.6% were being treated for erectile dysfunction (ED). After RP, patients reported lower sexual desire (52.4%), reduced intercourse frequency (79.4%), anorgasmia (39.7%), less satisfying orgasm (38.1%), climacturia (25.4%), greater distress (68.3%) and/or lower partner satisfaction (56.5%). Among the most sexually motivated patients, 76.0% reported loss of masculine identity, 52% loss of self-esteem and 36.0% anxiety about performance. These rates were lower among less motivated patients (52.6, 28.9, and 18.4%, respectively). Mean overall satisfaction score was 4.8±2.9. The score was significantly lowered in motivated than less motivated patients (3.4 vs 5.8) (P ¼ 0.001). In conclusion, RP adversely affected erectile and orgasmic functions but also sexual desire, self-esteem and masculinity. The more motivated patients experienced greater distress and were less satisfied. International Journal of Impotence Research (2011) 23, 81–86; doi:10.1038/ijir.2011.8; published online 7 April 2011

Keywords: radical prostatectomy; sexuality; erectile dysfunction; satisfaction; questionnaire; psychological impact

Introduction the fear of relapse, especially in younger patients.2 So far, most studies have focussed on ED rather than Radical prostatectomy (RP) is a recommended on the broader issue of quality of sex life. The standard treatment for patients with low or inter- urologist tends to focus on the mechanical rigidity of mediate risk prostate cancer and a life expectancy of erections. Even so, according to a recent survey in more than 10 years. With increasingly early diag- France, only 38% of urologists routinely offer some nosis, life expectancy at treatment initiation has form of pharmacological penile rehabilitation after increased and post-treatment quality of life (QoL) RP, whereas 87% of the International Society for has become a key issue in the choice of treatment. Sexual Medicine practitioners do so, with those However, all treatments (RP, external beam radio- managing over 50 RP patients per year being the therapy, brachytherapy) adversely affect QoL.1 most proactive.3,4 In addition, even if erections are The main side effects of RP are urinary incon- restored after RP, with or without treatment, sexual tinence and erectile dysfunction (ED), with ED bother increases after RP and sexual health most having a possibly greater adverse impact on patients’ often does not return to its preoperative level.5 QoL in the longer term than urinary disorders and The aim of this study is to assess the impact of RP on patients’ sexual health and satisfaction according to sexual motivation.

Correspondence: R Messaoudi, De´partement d’Urologie- Andrologie, Robert Debre´ Academic Hospital, CHU Reims, Subjects and methods Avenue du Ge´ne´ral Koenig, Reims 51092, France. E-mail: [email protected] We performed a review of the literature to identify Received 10 December 2010; revised 1 February 2011; the different domains relevant to male sexuality in accepted 7 March 2011; published online 7 April 2011 order to devise a simple self-assessment sexual Sexual health after radical prostatectomy R Messaoudi et al 82 health questionnaire for patients who had under- Table 1 Patient characteristics gone RP. The questionnaire was comprised of 16 items assessing erectile function, ED treatments, Patients (n ¼ 63) sexual desire, orgasm and the psychological impact ± ± of ED. Overall sexual satisfaction was assessed by Mean age (years) s.d. 63.9 6.7 Mean preoperative prostate specific 8.01 (0.75–25.0) a visual analog scale from 0 to 10 (0 ¼ not at antigen (ng mlÀ1) (range) all satisfied; 10 ¼ highly satisfied) (Supplementary Appendix 1). Clinical stage, n (%) Between January 2008 and July 2008, the ques- T1a 4 (6.3) T1c 48 (76.2) tionnaire was administered to 64 consecutive pa- T2a 9 (14.3) tients during follow-up after RP. The patients T2b 2 (3.2) completed the questionnaire in the waiting room before the start of the consultation. Demographic Gleason score, n (%) 6 26 (41.3) and clinical data were collected from their medical 7 31 (49.2) records. Institutional Review Board approval was 8 3 (4.8) obtained for the retrospective chart review. Missing data 3 (4.8) We offer postoperative ED treatment to all RP patients who are sexually active preoperatively.6 Pathological stage, n (%) pT2 47 (74.6) The issue of ED treatment is raised after surgery, pT3 13 (20.6) once anxiety over surgery is over and patients have pT4 1 (1.6) received reassurance about their cancer treatment. Missing data 2 (3.2) Some patients request sexual management Pelvic lymph node dissection, n (%) 12 (19.1) promptly, others do not. Patients were thus arbi- Negative 12 trarily divided into two groups according to whether Positive 0 they had expressed a clear demand for sexual Positive margins,n(%) 11 (17.5) management (Group 1: sexually motivated) or not Adjuvant radiotherapy,n(%) 8 (12.7) (Group 2: less sexually motivated). The two groups Adjuvant hormonal therapy,n(%) 1 (1.6) Elevated PSA, n (%) 3 (4.7) were compared by Student’s t test or Wilcoxon’s test, as appropriate. To study the influence of duration of postoperative care, we compared results for three time frames specific antigen was detectable in only three (o12, 12–24 and 424 months). We used chi-square patients at the time of the study (0.1, 0.81 and statistics with or without Yate’s correction for sexual 0.21 ng mlÀ1). Patient and tumor characteristics are health variables (loss of masculine identity, loss of given in Table 1. self-esteem and anxiety over performance) and All 63 patients were heterosexual, with partners, ANOVA for the sexual satisfaction score (after and claimed to have had sexually satisfactory testing for the assumptions of normality and homo- intercourse before surgery. Six reported moderate geneity of variance (Bartlett’s test)). preoperative ED that had not, however, warranted pharmacological treatment. After surgery, 25 of the 63 patients had requested ED treatment before it was offered (Group 1—motivated to stay sexually active) Results (mean age, 65.3 years). The remaining 38 patients were in Group 2 (less motivated) (mean age, 63.0 Patient characteristics years). Data were available for 63 of the 64 patients as one patient refused to complete the questionnaire. The mean age of these 63 patients was 63.9±6.7 years. A ED treatment total of 50 patients had undergone laparoscopic RP, A total of 47 patients (74.6%) were being treated for 9 perineal RP, and 4 retropubic RP. No data were ED at the time of the survey: 39 (82%) with available for nerve sparing. The presence of cardi- intracavernous prostaglandin injections (ICI), 4 ovascular risk factors was the main comorbidity (29 (9%) with an oral type-5 phosphodiesterase inhibi- patients, 46%). The median interval between RP and tor (PDE5-I) and 4 (9%) with a penile prosthesis. administration of the questionnaire was 26.8 In Group 1 (motivated), 21/25 (84%) were under months (range, 6–67). Follow-up was less than 12 treatment. The four other patients had refused the months in 9 patients, between 12 and 24 months in offer of ICI but were not taking a PDEI-5 because it 24 patients and longer than 24 months in 30 was ineffective and/or too expensive. In Group 2 patients. Nine patients had received adjuvant (less motivated), 26/38 patients (68.4%) had taken therapy after a mean delay of 21 months (8 external up the offer of ED treatment, four had sufficiently beam radiotherapy and 1 anti-androgen treatment). adequate erections not to require treatment, and None had received neoadjuvant therapy. Prostate eight had come to terms with their ED and were

International Journal of Impotence Research Sexual health after radical prostatectomy R Messaoudi et al 83 Table 2 Changes in sexual health after RP Table 3 Psychological impact and satisfaction

Decrease No change Increase Group 1 Group 2 (motivated) (less motivated) Sexual desire, n (%) 33 (52.4) 27 (42.9) 3 (4.7) N ¼ 25 N ¼ 38 Frequency of intercourse, n (%) 50 (79.4) 13 (20.6) 0 (0) Orgasm, n (%) 49 (77.8)a 9 (14.3) 5 (7.9) Psychological impact, n (%) Loss of masculinity 19 (76) 20 (52.6) Abbreviation: RP, radical prostatectomy. Loss of self-esteem 13 (52) 11 (28.9) a Anorgasmia, n (%): 25 (39.7). Anxiety about performance 9 (36) 7 (18.4) Mean satisfaction score (VAS) All patients 3.4 (n ¼ 25) 5.8a (n ¼ 38) uninterested in treatment. Overall, 16/63 patients ED treated 3.9 (n ¼ 21) 5.3 (n ¼ 26) (25.4%) were not receiving ED treatment and 51/63 ICI 2.9 (n ¼ 14) 5.4 (n ¼ 25) (81%) had erections firm enough for intercourse. PDEI-5 3.2 (n ¼ 3) 3 (n ¼ 1) Penile prosthesis 8.1 (n ¼ 4) n ¼ 0 Most patients (33/47, 70.2%) reported that they were Untreated 0.5b (n ¼ 4) 6.9b (n ¼ 12) satisfied with their treatment for ED. a Group 1 vs Group 2: P ¼ 0.001. b Untreated vs treated: Group 1: P ¼ 0.0117; Group 2: P ¼ 0.0884. Sexual desire, frequency of intercourse and orgasm after RP Results are summarized in Table 2. After RP, half of the patients reported a decrease in sexual desire and score did not depend on length of follow-up three quarters reported decreased frequency of (Table 4), patient age and tumor characteristics intercourse, anorgasmia or a less satisfying orgasm. (Table 5). Overall, 56.5% of patients claimed that Before RP, all 63 patients had achieved orgasm their partner felt less sexual satisfaction since the (77.8% at each intercourse). operation had taken place. Inadvertent urine leakage at orgasm (climacturia) was reported by 16 patients (25.4%) and considered to be bothersome by 9/16 patients (56.3%), but not to Discussion the extent of precluding intercourse. Four of the 16 patients who experienced climacturia were incon- When advocating RP in young men with prostate tinent. cancer, simply focusing on ED, especially in those The absence of ejaculation was considered bother- patients who most value their sexual activity, is not some by 33/61 patients (54.1%) and bothersome enough. Other important QoL sexual domains such enough to avoid intercourse by 5/61 patients (8.2%). as libido and orgasm need to be considered. Two patients did not answer this question. For a satisfactory sexual relationship, maintaining a sufficiently rigid erection is important. Early penile rehabilitation can significantly improve the rate of postoperative spontaneous erections and Psychological impact sexual QoL, and administration of a PDEI-5 such Overall, 43 patients (68.3%) experienced at least as sildenafil can help to enhance rigidity.7–9 Accord- one of the following: loss of masculine identity ing to a literature review, the efficacy of sildenafil (n ¼ 39, 61.9% of patients), loss of self-esteem ranges from 14 to 53%, but this range can be (n ¼ 24, 38.1%) and anxiety over performance extended to 14–85% on switching to ICI.10,11 Penile (n ¼ 16, 25.4%). The feeling of loss of masculine rehabilitation should be discussed with all patients, identity could be either overwhelming (10/39, regardless of their sexual motivation, and initiated 25.6%) or partial (29/39, 74.4%). The adverse promptly after RP.9,12,13 Among our 63 RP patients, psychological impact was greatest in Group 1 74.6% were regularly using ED treatment and 81% patients (Table 3) and did not depend on length of had erections adequate for intercourse with or follow-up (Table 4). without pharmacological assistance. Most treated patients were using ICI (82%) for reasons of efficacy and cost despite a preference for less invasive Overall sexual satisfaction treatment (French national health insurance reim- Mean sexual satisfaction score on the visual analog burses ICI but not PDEI-5s). Most patients (70.2%) scale was 4.8±2.9 (out of 10). Group 2 patients had a reported that they were satisfied with their ED higher mean score than Group 1 patients; untreated treatment. Group 1 patients were less satisfied than treated Despite their ED treatment, half of our patients patients; treated and untreated Group 2 patients had experienced diminished sexual desire and three similar scores (Table 2). Patients with a penile quarters less frequent intercourse after a median prosthesis had the highest mean score (8.1). The follow-up of 2 years. This agrees with published

International Journal of Impotence Research Sexual health after radical prostatectomy R Messaoudi et al 84 Table 4 Psychological impact according to time frame of follow-up

Follow-up (months) P

o12 12–24 424

Patients, n (%) 25 (39.7) 13 (20.6) 25 (39.7) Overall psychological impact, n (%) 16 (64.0) 10 (76.9) 17 (68.0) 0.72a Loss of masculinity 15 (60.0) 9 (69.2) 15 (60.0) 0.83b Loss of self-esteem 8 (32.0) 6 (46.2) 10 (40.0) 0.67b Anxiety over performance 8 (32.0) 2 (15.4) 6 (24.0) 0.53b Mean satisfaction score±s.d. 4.7±2.9 5.2±2.8 4.8±3.0 0.87c

a Chi-square test. b Chi-square test with Yate’s correction (only one expected frequency o5 and 43). c ANOVA (test of normality and equal variances (Bartlett’s test, P ¼ 0.96)).

Table 5 Age, pathological stage and Gleason score according to of a feeling of seminal vesicle and prostate contrac- satisfaction score tion may account for less satisfying orgasms. In addition, some patients may be bothered by the Satisfaction Satisfaction P scoreX5 scoreo5 absence of ejaculation (54.1% in our study). Among (N ¼ 38) (N ¼ 24) our patients, 8.2% avoided intercourse for this reason. It is therefore important to inform patients Age, n (%) 0.91a that the prostate and seminal vesicles are not p65 years 20 (60.6) 13 (39.4) required for orgasm, which can occur without 465 years 18 (62.1) 11 (37.9) ejaculation and/or with a flaccid penis. Patients Pathological stage, n (%) 0.69b should be counseled to persevere and prolong pT2 28 (59.6) 19 (40.4) intercourse. PT3 9 (75.0) 3 (25.0) Urine leakage at orgasm might also explain less PT4 1 (100.0) 0 (0) satisfying orgasms. This surgical complication has received little attention. A quarter of our patients Gleason score, n (%) 0.87a o7 16 (61.5) 10 (38.5) suffered from climacturia and over half of these X7 21 (63.6) 12 (36.4) found it bothersome. Climacturia was first reported by Koeman et al.15 who recorded a high 64% a Pearson’s Chi-square test. incidence among 20 sexually active RP patients. b Fisher’s Exact Test. Later studies give lower rates, namely, 20.2% among 475 RP or cystectomy patients (with a lower rate for cystectomy) and 45% among 42 RP patients.21,22 Of decreased libido rates (45–55%) after RP.14,15 The these patients, 48% found it bothersome.22 Climac- decrease may be related to hypogonadonism and turia can often be associated with moderate stress may be amenable to androgen replacement therapy incontinence23 but this was the case in only 4 of our in patients whose prostate cancer is under con- 16 patients. Impaired sphincter function was there- trol.16,17 A prospective study found a high serum fore not the cause of the climacturia in most of our luteinizing hormone level and a decrease in serum patients. A possible cause might be lack of sphincter dihydrotestosterone but none in total or free testos- smooth muscle tissue associated with normal re- terone.18 We did not perform any hormone assays to laxation of the external sphincter at orgasm.15 But assess hypogonadism in our study. data on climacturia as a function of bladder neck Most of our patients experienced compromised preservation during RP are lacking. Recommended orgasm (anorgasmia, 39.7%; less satisfying orgasm, management is emptying the bladder before inter- 38.1%). This observation supports the results of a course and/or use of a condom, or possibly pelvic study in 239 RP patients showing a 37% prevalence floor rehabilitation treatment.24 Studies of tricyclic of complete absence of orgasm, as well as of antidepressant administration and penis rings are decreased orgasm intensity.19 Orgasmic function anecdotal. improves linearly over the 48 months after RP but Compromised sexual function had a strong psy- is not improved by IPDE-5 administration.20 The chological and emotional impact on our patient. physiology of orgasm has not yet been fully This impact was greater in the more sexually elucidated. Orgasm includes involuntary muscle motivated patients. Two-thirds of patients experi- contractions, contraction of the seminal vesicles enced at least one of the following: loss of masculine and prostate, changes in heart and respiratory rates, identity, loss of self-esteem and anxiety over and modified consciousness. After RP, the absence performance. Loss of masculine identity affected

International Journal of Impotence Research Sexual health after radical prostatectomy R Messaoudi et al 85 the most patients (61.9%) and has been frequently these items, they are too complex for daily clinical reported in the literature.25 It can affect everyday use. Our questionnaire also had the advantage of relationships with women, sexual intimacy and enabling comparison between two groups of pa- fantasy life.26 Loss of self-esteem was experienced tients with different expectations with regard to by 28.9% of the less motivated patients and 52% of their sexuality. the motivated patients, and anxiety over performance before intercourse by 25.4% of all patients. These rates are somewhat lower than published Conclusion rates (75% for self-esteem,25 28–70% for anxiety 27 Postoperative management of the sexual health of over performance ). RP patients should consider not only the mechanics The psychological impact of compromised sexual of erections but also aspects such as sexual desire, function did not depend on the time-frame of orgasm, climacturia and the psychological impact of follow-up after RP (o12, 12–24, 424 months), compromised sexuality (loss of masculine identity, confirming the difficulty patients have in coping loss of self-esteem and anxiety about performance). psychologically with continued compromised sex- Adverse repercussions engendered greater distress ual function. Erections may improve, but sexual in sexually more motivated patients, even if their ED bother tends to worsen or remain stable during the 5 treatment was seen to be satisfactory, than in less 24 months after RP. To improve patients’ and their motivated patients whose sex-life proved to be more partners’ sex-lives, it is thus necessary not only to satisfying despite ED. The urologist should bring up treat the mechanics (ED treatment), but also to the issues of ED and other aspects of sexual provide appropriate psychological or sexual coun- dysfunction when treatment options for localized seling to help cope with the impact of RP on sexual 6,28 prostate cancer are being reviewed with the patient. desire and orgasm. Further studies on a larger population are needed to In our study, the patients who were most confirm our results. motivated to remain sexually active after RP (Group 1) experienced a greater degree of bother and had a lower overall sexual satisfaction score than the less motivated patients. Their satisfaction score was very Conflict of interest low (0.5/10) when they were not receiving ED treatment but higher on treatment (3.9/10), thus The authors declare no conflict of interest. confirming the benefit of treatment in motivated patients.29 The benefit of ED treatment on satisfaction was not apparent in the less motivated patients. Acknowledgments These patients had a higher satisfaction score than motivated patients and their score did not depend We disclose the sources of any support for the work, on treatment (6.9 vs 5.3; P ¼ 0.088). Untreated less received in the form of grants and/or equipment motivated patients (12.7%) did not find the absence and drugs. of an erection as bothersome. Despite the lack of ED treatment, they had a satisfying sex-life with physical intimacy not involving intercourse. A 50% References rate of indifference to ED has been reported among 30 prostate cancer survivors. 1 Huang GJ, Sadetsky N, Penson DF. Health related quality of Patients’ attitude to their sex-life is thus a key life for men treated for localised prostate cancer with long- factor to be taken into account when choosing term followup. J Urol 2010; 183: 2206–2212. 2 Crowe H, Costello AJ. Prostate cancer: perspectives on quality treatment for localized prostate cancer. The most of life and impact of treatments on patients and their partners. motivated to maintain erections are the most Urol Nurs 2003; 23: 279–285. difficult to satisfy. If RP is indicated, patients should 3 Giuliano F, Amar E, Chevallier D, Montaigne O, Joubert JM, be provided with full information on repercussions Chartier-Kastler E. How urologists manage erectile dysfunction after radical prostatectomy: a national survey (REPAIR) by on sexual health and undergo close postoperative the French urological association. J Sex Med 2008; 5: 448–457. follow up to reduce distress and improve QoL. 4 Teloken P, Mesquita G, Montorsi F, Mulhall J. Post-radical Our prospective study has several limitations: a prostatectomy pharmacological penile rehabilitation: practice small sample size, a cross-sectional and not long- patterns among the international society for sexual medicine itudinal design, no preoperative baseline (we had to practitioners. J Sex Med 2009; 6: 2032–2038. 5 Nelson CJ, Devesi S, Stasi J, Scardino PT, Mulhall J. Sexual rely on patients’ recall of their earlier sexuality), bother following radical prostatectomy. J Sex Med 2010; 7: lack of data on nerve-sparing surgery and use of 129–135. unvalidated psychometric instruments. We devised 6 Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, our own questionnaire for sexual health because Zippe C et al. The use of treatments for erectile dysfunction among survivors of prostate carcinoma. Cancer 2002; 95: available validated questionnaires omit key items in 2397–2407. our study (eg, climacturia and lack of ejaculation), if 7 Claes HI, Goldstein I, Althof SE, Berner MM, Cappelleri JC, they are simple and easy-to-use, or if they do contain Bushmakin AG et al. Understanding the effects of sildenafil

International Journal of Impotence Research Sexual health after radical prostatectomy R Messaoudi et al 86 treatment on erection maintenance and erection hardness. 20 Salonia A, Gallina A, Briganti A, Colombo R, Bertini R, Da J Sex Med 2010; 7: 2184–2191. Pozzo LF et al. Postoperative orgasmic function increases over 8 Mulhall JP, Land S, Parker M, Waters B, Flanigan RC. The use time in patients undergoing nerve-sparing radical prostatect- of erectogenic pharmacotherapy regimen following radical omy. J Sex Med 2010; 7: 149–155. prostatectomy improves recovery of spontaneous erectile 21 Choi JM, Nelson CJ, Stasi J, Mulhall JP. Orgasm associated function. J Sex Med 2005; 2: 532–542. incontinence (climacturia) following radical pelvic 9 Muller A, Parker M, Waters BW Flanigan RC, Mulhall JP. surgery: rates of occurrence and predictors. J Urol 2007; 177: Penile rehabilitation following radical prostatectomy: predict- 2223–2226. ing success. J Sex Med 2009; 6: 2806–2812. 22 Lee J, Hersey K, Lee CT, Fleshner N. Climacturia following 10 Montorsi F, McCullough A. Efficacy of sildenafil citrate in radical prostatectomy: prevalence and risk factors. J Urol 2006; men with erectile dysfunction following radical prostatect- 176: 2562–2565. omy: a systematic review of clinical data. J Sex Med 2005; 2: 23 Abouassaly R, Lane BR, Lakin MM, Klein EA, Gill IS. 658–667. Ejaculatory urine incontinence after radical prostatectomy. 11 Baniel J, Israilov S, Segenreich E, Livne PM. Comparative Urology 2006; 68: 1248–1252. evaluation of treatment for erectile dysfunction in patients 24 Sighinolfi MC, Rivalta M, Mofferdin A, Micali S, De Stefani S, with prostate cancer after radical retropubic prostatectomy. Bianchi G. Potential effectiveness of pelvic floor rehabilitation BJU Int 2001; 88: 58–62. treatment for postradical prostatectomy incontinence, climac- 12 Mulhall JP, Bella AJ, Briganti A, McCullough A, Brock G. turia, and erectile dysfunction: a case series. J Sex Med 2009; Erectile function rehabilitation in the radical prostatectomy 6: 3496–3499. patient. J Sex Med 2010; 7: 1687–1698. 25 Meyer JP, Gillatt DA, Lockyer R, Macdonagh R. The effect of 13 Mulhall JP, Parker M, Waters BW, Flanigan R. The timing of erectile dysfunction on the quality of life of men after radical penile rehabilitation after bilateral nerve-sparing radical prostatectomy. BJU Int 2003; 92: 929–931. prostatectomy affects the recovery of erectile function. BJU 26 Bokhour BG, Clark JA, Inui TS, Silliman RA, Talcott JA. Int 2010; 105: 37–41. Sexuality after treatment for early prostate cancer: exploring 14 Schover LR, Fouladi RT, Warneke CL, Neese L, the meanings of ‘erectile dysfunction’. J Gen Intern Med 2001; Klein EA, Zippe C et al. Defining sexual outcomes after 16: 649–655. treatment for localized prostate carcinoma. Cancer 2002; 95: 27 Matthew AG, Goldman A, Trachtenberg J, Robinson J, 1773–1785. Horsburgh S, Currie K et al. Sexual dysfunction after radical 15 Koeman M, van Driel MF, Schultz WC, Mensink HJ. Orgasm prostatectomy: prevalence, treatment, restricted use of treat- after radical prostatectomy. BJU Int 1996; 77: 861–864. ments and distress. J Urol 2005; 174: 2105–2110. 16 Kauffman JM, Graydon RJ. Androgen replacement after 28 Nelson CJ, Choi JM, Mulhall JP, Roth AJ. Determinants of curative radical prostatectomy for prostate cancer in hypogo- sexual satisfaction in men with prostate cancer. J Sex Med nadal men. J Urol 2004; 172: 827–828. 2007; 4: 1422–1427. 17 Rhoden EL, Averbeck MA, Teloken PE. Androgen replacement 29 Perez MA, Meyerowitz BE, Lieskovsky G, Skinner DG, in men undergoing treatment for prostate cancer. J Sex Med Reynolds B, Skinner EC. Quality of life and sexuality following 2008; 5: 2202–2208. radical prostatectomy in patients with prostate cancer who use 18 Miller LR, Partin AW, Chan DW, Bruzek DJ, Dobs AS, Epstein or do not use erectile aids. Urology 1997; 50: 40–46. JI et al. Influence of radical prostatectomy on serum hormone 30 Miller DC, Wei JT, Dunn RL, Montie JE, Pimentel H, Sandler levels. J Urol 1998; 160: 449–453. HM et al. Use of medications or devices for erectile 19 Barnas JL, Pierpaoli S, Ladd P, Valenzuela R, Aviv N, Parker M dysfunction among long-term prostate cancer treatment et al. The prevalence and nature of orgasmic dysfunction after survivors: potential influence of sexual motivation and/or radical prostatectomy. BJU Int 2004; 94: 603–605. indifference. Urology 2006; 68: 166–171.

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