BERKELEY, CA (UroToday.com) - Successful surgical treatment of prostate cancer, radical prostatectomy, includes a “trifecta” outcome: cancer cure, urinary continence and preservation of sexual function.Discussion on sexual function after prostate cancer treatments has been traditionally limited to erectile function only. Providing sexual medicine care for men after radical prostatectomy, we witness a wider spectrum of alterations in the structure and function of the male genital system following radical prostatectomy, including penile length alterations, climacturia (urine incontinence during orgasm), urine incontinence during sexual activity before orgasm occurs, a negative impact of anejaculation on satisfaction from sexual activity, dysorgasmia (painful orgasm) and changes in orgasm intensity and in orgasmic pleasure. Indeed, in the past decade, there is a growing interest in clinical research to depict the full picture of sexual dysfunction after radical prostatectomy and to seek interventions to alleviate these consequences of radical prostatectomy.
Peyronie’s disease is a medical condition with significant impact on sexual function. It was our impression that there is a larger than expected proportion of men in our post radical prostatectomy population who had manifestations of Peyronie’s disease. Peyronie’s disease is commonly underdiagnosed, especially in cases of erectile dysfunction, as the manifestations of the disease are best noticed during a full erection. Men who had radical prostatectomy may be at increased risk for Peyronie’s disease due a possible role of extensive pelvic surgery as a risk factor, but they commonly struggle to achieve erections and Peyronie’s disease may easily be missed. Not uncommonly, the deformity associated with Peyronie’s disease is first seen after achieving a rigid erection for the first time using intracavernosal injection therapy.
In our study, we looked at men who sought sexual medicine care and found a remarkably high overall Peyronie’s disease incidence of 15.9%. Unfortunately, we did not have an evaluation of men who had surgery in our institution and did not attend our sexual medicine program, thus we cannot elucidate the exact incidence of Peyronie’s disease nor its time-dependent occurrence. Despite this important limitation, a major clinical implication of our study is that, among men who do seek sexual health care after radical prostatectomy, Peyronie’s disease incidence is high and an effort should be made to actively diagnose this condition. In our study, Peyronie’s disease evaluation included careful history taking with direct questioning regarding the presence of a curvature or other deformities and indurations, penile physical examination looking for plaques and sonographic evaluation in cases, clinically suspected for Peyronie’s disease.
An argument may be made regarding the value of actively evaluating Peyronie’s disease in patients who are not complaining of penile curvature or other Peyronie’s disease related complaints, but we strongly believe that early diagnosis of Peyronie’s disease is clinically meaningful for the following considerations:
- As with other sexual dysfunctions (e.g. erectile dysfunction), men may not raise sexual health issues, even when there is significant associated bother. In cancer patients, it has been suggested that men may be even more hesitant to discuss these issues, as they may feel that it is inappropriate when confronting cancer is the main issue.
- Although there is no universally effective medical treatment for Peyronie’s disease, it has been demonstrated that medical treatment may be more effective in the initial stage of Peyronie’s disease. Thus, delaying the diagnosis of Peyronie’s disease may lower the chances of successful non-surgical treatment.
- Men after radical prostatectomy often use intracavernosal injections as a treatment for their erectile dysfunction. Not uncommonly, it takes several attempts and dose increments to elucidate the right dose to achieve a fully rigid erection. Noticing a curvature or other deformity after several intracavernosal injections may be alarming to the patient. It is also our experience that patients tend to associate the curvature with injection use, although there is no solid scientific basis showing a causative association between intracavernosal injections and the occurrence of Peyronie’s disease. Early diagnosis of Peyronie’s disease, before the use of intracavernosal injections, may reassure men after radical prostatectomy regarding the lack of association between this treatment and the occurrence of the deformity and lead to better acceptance of intracavernosal injections therapy.
- Men with existing Peyronie’s plaques may encounter difficulties inserting the needle while using intracavernosal injections due to inadvertent insertion of the needle into the plaque. Knowing the location and extent of penile plaques allows for better injection training with individual education to avoid needle insertion into the plaques.
- Men after radical prostatectomy are anticipating nerve recovery and return of pre-operative erectile function. Early diagnosis of Peyronie’s disease allows for providing more accurate prognostic information regarding the recovery of sexual function after radical prostatectomy, including possible difficulties to penetrate - not only due to erectile dysfunction but also due to penile angulation and penile shaft instability and possible progression of Peyronie’s disease.
- The diagnosis of Peyronie’s disease may impact on treatment decision for erectile dysfunction for men after radical prostatectomy, e.g. a greater tendency to opt for penile implant surgery in cases of erectile dysfunction and concomitant clinically significant curvature rather than struggling with penile injections with unsatisfactory results.
In summary, although the full epidemiologic incidence of Peyronie’s disease following radical prostatectomy as well as the linking causative mechanism is far from being fully elucidated, our study clearly defines a high incidence of Peyronie’s disease in the studied population of men after radical prostatectomy seeking sexual health care. Therefore we concluded that it is imperative for sexual health care providers to make an effort to diagnose Peyronie’s disease in these men early, as this diagnosis carries significant prognostic and treatment related implications.
Written by:
Raanan Tal and John P. Mulhall as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Peyronie's disease following radical prostatectomy: Incidence and predictors - Abstract
