Editor's Commentary - Patient expectations on sexual function following prostate cancer treatment

BERKELEY, CA (UroToday.com) - There have been three recent research publications addressing sexual and erectile function in men following prostate cancer treatments. All three have significant implications for clinicians treating patients with prostate cancer.

The first, by Alemozaffar and colleagues (2011), reported on results of men in the Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment (from 2003-2006) prospective, longitudinal, multicenter (9 US university-affiliated hospitals) study. These men had untreated clinical stage T1 to T2 prostate cancer who went on to have prostatectomy (n=524), external beam radiotherapy (n-241), or brachytherapy (n=262). This report is on the 1,027 men who completed the 24-month interview. The authors defined functional erections as an answer of “firm enough for intercourse.” The outcomes for erectile function were somewhat dismal as only 33% (177/511) of men who underwent a prostatectomy had functional erections at 2 years. Men who were younger and had nerve-sparing technique had an increased chance of having functional erections after the surgery. The ability to attain functional erections at 2 years following external radiotherapy was 37%, (84/229) and with brachytherapy it was 43% (107/247). The authors provide information about pretreatment erectile function. Of men who were potent prior to treatment, most were using oral drug therapy (60%), and 74% of the men had tried all treatments (PDE5 inhibitors, vacuum erection devices, penile injections) reporting that penile injections were the most effective. But the authors note that the men who had undergone prostatectomy surgery were most likely to use these ED treatments. This study shows the importance of the need for clinicians to assist men prior to surgery in setting realistic sexual function expectations.

The second article by Whittmann, Foley and Balon (2011) is an interesting article on the biopsychosocial aspect of sexual recovery following prostatectomy. As seen in clinical practice, men report the loss of spontaneity of sexual intimacy and the disappointment they experience. But most are not willing to discuss their problems with a wife or partner. The authors note that a lack of actual penetrative intercourse may not have as much of an impact on wives, who may not value that part of sexual activity as much as the man. Female partners may not be as accepting of erectile aids, which may also negatively impact sexual activity. The authors feel that men who have lost erectile function following prostatectomy may actually experience grief and mourning psychologically and physiologically.

The third article in this review also has clinical implications. It is by Whittman and colleagues (2011) and it discusses the fact that preoperative expectations of urinary, bowel, hormonal, and sexual function by men undergoing radical prostatectomy do not match outcomes at one year post procedure. This was a study at one site, University of Michigan, and involved preoperative counseling about expected outcomes after radical prostatectomy. Counseling was provided by a trained urological oncologist, a nurse practitioner, and in some cases, a social worker. Participants were asked to completed the EPIC-SF preoperatively and at one year post surgery. The EPIC-SG is a validated 13-item questionnaire that uses a 5-point Lickert scale to assess 5 functional domains:

  1. urinary incontinence,
  2. urinary irritative symptoms,
  3. bowel function,
  4. hormonal function and,
  5. sexual function.

The EPIC-Exp was given at baseline to determine how participants expected to be functioning post-operatively in these domains at one year. Of the 526 men who consented, only 152 completed the questionnaires both pre-operatively and one year post-operatively. Results indicated that a significant portion of the men (61% had same or better function) had overly optimistic expectations regarding UI and sexual function, despite counseling. A disturbing finding was that 17% expected improved erections following surgery and 70% expected the same bladder control, with 17% expecting better control. The authors' conclusion was that men who undergo prostatectomy have unrealistic expectations, despite intensive counseling. As a clinician who routinely sees men with urinary incontinence following surgery, these findings were not surprising.


  1. Alemozaffar M, Regan MM, Cooperberg MR, Wei JT, Michalski JM, Sandler HM, Hembroff L, Sadetsky N, Saigal CS, Litwin MS, Klein E, Kibel AS, Hamstra DA, Pisters LL, Kuban DA, Kaplan ID, Wood DP, Ciezki J, Dunn RL, Carroll PR, Sanda MG. Prediction of erectile function following treatment for prostate cancer. JAMA. 2011;306(11):1205-14
  2. Wittmann D, Foley S, Balon R. A biopsychosocial approach to sexual recovery after prostate cancer surgery: The role of grief and mourning, J Sex Marital Ther. 2011;37(2):130-44. http://dx.doi.org/10.1080/0092623X.2011.560538
  3. Wittmann D, He C, Coelho M, Hollenbeck B, Montie JE, Wood DP Jr. Patient preoperative expectations of urinary, bowel, hormonal and sexual functioning do not match actual outcomes 1 year after radical prostatectomy. J Urol. 2011;186(2),494-9.


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