Climacturia: a comprehensive review assessing pathophysiology, prevalence, impact, and treatment options regarding the "leak of pleasure"

Report of climacturia and orgasmic disorders after radical prostatectomy in a Brazilian tertiary hospital: shedding light on a neglected condition

PURPOSE

After radical prostatectomy (RP), it is rarely acknowledged that several sexual dysfunctions can arise. These include issues in the orgasmic domain (e.g., decreased orgasm intensity, dysorgasmia), problems with ejaculation (e.g., absence of ejaculation), the development of penile deformities, and low sexual desire. This article aims to report the occurrence of orgasmic and ejaculatory dysfunction when actively investigated, documenting those rates and characterizing specific features of these conditions following RP.

METHODS

This study has analyzed retrospective data from men who underwent RP and were experiencing erectile dysfunction. During a structured visit, patients were systematically questioned about dysorgasmia, altered orgasmic sensation, climacturia, and arousal incontinence. Continuous variables were analyzed using the Student T or ANOVA tests, while categorical variables were analyzed using Chi-squared or Fisher's exact tests. The associations were described as odds ratios with precise confidence intervals. All tests were two sided; a p value < 0.05 was considered statistically significant.

RESULTS

Sixty patients were included, out of which 3 (5%) reported dysorgasmia, while 33.3% presented a decrease in orgasm intensity. Climacturia was reported as the most common orgasmic disorder in 40 (66.6%) patients. However, only 14 patients (35%) reported that it frequently occurs, i.e., more than half of the time. Among the patients who reported climacturia, 72.5% classified it as mild losses. Additionally, arousal incontinence (AI) was noted in the study by 19 (26.3%) patients.

CONCLUSION

Our study highlights the importance of discussing orgasmic dysfunctions after RP, which can be frequent and bothersome but are often overlooked in preoperative counseling.

Relationship between post-prostatectomy urinary incontinence, sexual functions, and dyadic adjustment: A cross-sectional study

INTRODUCTION

Robot-assisted radical prostatectomy (RARP) is the treatment option for localized prostate cancer. It can lead to side effects like erectile dysfunction (ED) and post-prostatectomy urinary incontinence (PPUI). This study aimed to evaluate association between dyadic adjustment, PPUI and ED.

MATERIAL AND METHODS

Consecutive male patients who underwent RARP from January 2019 to December 2021, with at least 12 months of follow-up and preoperative International Index of Erectile Function (IIEF) 15 erectile domain questionnaire's score ⩾17 were enrolled. Demographic and surgical data were collected at baseline. Validated questionnaires were self-administered at 12-month follow-up: IIEF-15, Dyadic Adjustment scale (DAS), and Los Angeles-Prostate Cancer Index Urinary Function Score (UCLA-PCI-UFS). Univariable and multivariable analyses were performed to examine degree of association between different variables.

RESULTS

Out of 96 enrolled patients, 37 (38.5%) were socially incontinent (>1 pad per day) at 12 months from surgery. Statistically significant association was found between incontinence and lower DAS total score (p < 0.0001), DAS consensus domain (p < 0.0001), and DAS affectional expression domain (p = 0.002). DAS total score (p = 0.002) and DAS consensus domain score (p = 0.012) were lower in impotent group (IIEF-15 erectile domain score <17). On a multivariable analysis, PPUI (beta: -0.25; 95% CI: -4.42, -0.47; p = 0.016) and post-operative ED (beta: 0.19; 95% CI: 0.002, 0.57; p = 0.048) were independent predictors of low DAS score. Pelvic lymphadenectomy (PLND) (beta coefficient: 0.25; 95% CI: 0.1, 1.2; p = 0.022), bladder neck reconstruction (beta: 0.26; 95% CI: 0.19, 1.09; p = 0.006), and ED (beta coefficient: -0.3; 95% CI: -0.07, -0.018; p = 0.001) were independent predictors of continence status.

CONCLUSION

PPUI following RARP is associated with lower dyadic adjustment, independently from other factors, indicating significant impact of PPUI on marital relationships. Further research should be conducted to understand better the cross-effective relationship between PPUI, potency, dyadic adjustment, and the effect of surgical treatments on incontinence and sexual function.

The effect of puboperiurethral suspension stitch placement on climacturia after robot-assisted laparoscopic radical prostatectomy

BACKGROUND

Climacturia is defined as urine leakage associated with orgasm and can negatively affect patients' quality of life. The high prevalence of climacturia after radical prostatectomy (RP) has led to continued efforts to reduce climacturia rates. It has been shown that puboperiurethral suspension stitch placement during RP assists in the recovery of urinary continence.

AIM

To evaluate the impact of puboperiurethral suspension stitch placement during RP on post-RP climacturia.

METHODS

We conducted a retrospective study of patients who underwent nerve-sparing robot-assisted laparoscopic RP (RALP) at our institution between 2016 and 2023. The patients were categorized into 2 groups: Group 1 (n = 32) that underwent nerve-sparing RALP with puboperiurethral suspension stitch placement and Group 2 (n = 62) that underwent nerve-sparing RALP alone. Patients who were not able to achieve penetration at the last follow-up visit were excluded from the study. The clinical history, parameters of prostate cancer, details of medical and surgical treatments, and follow-up data were evaluated.

OUTCOMES

Differences in sexual and urinary function, climacturia rates, and complications between nerve-sparing RP with and without puboperiurethral suspension stitch placement.

RESULTS

There were no significant differences between the groups in terms of surgical complications. The mean follow-up time was 14.62 ± 3.55 months in Group 1 and 14.43 ± 4.44 months in Group 2 (P = .42). Postoperative erectile functions were similar between the groups. At the last follow-up visit, climacturia was present in 4 patients (12.5%) in Group 1 and 24 patients (38.7%) in Group 2 (P = .016). The long-term stress urinary incontinence rates were similar between the groups.

CLINICAL IMPLICATIONS

This study provides comparative results on postoperative climacturia rates between nerve-sparing RALP groups with and without puboperiurethral suspension stitch placement. These results show that puboperiurethral suspension stitch can help to prevent postoperative climacturia after RP.

STRENGTH AND LIMITATIONS

This is the first study in the literature that evaluates the effect of puboperiurethral suspension stitch on climacturia. The limitations include the single-center, retrospective design with potential selection bias, possible inaccuracies in the recorded medical data, and challenges in controlling confounding variables.

CONCLUSION

Our study demonstrated that puboperiurethral suspension stitch was a feasible option for the prevention of climacturia after RALP without an increased risk of complications.

Shorter prostatic urethral length in preoperative Magnetic Resonance Imaging is associated with higher risk of climacturia following robot-assisted laparoscopic radical prostatectomy

Climacturia is defined as the leakage of urine during orgasm and it is an adverse effect of radical prostatectomy. Our goal was to determine if various preoperative MRI pelvic floor measurements were associated with the risk of climacturia following robot-assisted laparoscopic radical prostatectomy. For this purpose, we conducted a prospective study involving 57 patients who underwent robot-assisted laparoscopic radical prostatectomy. MRI measurements were analysed by 2 urologists and 2 radiologists. Follow-up was carried out at 3, 6, and 12 months using the Parra orgasmic function questionnaire. We analysed all measurements, along with other patient, surgery, and tumour characteristics, classifying patients into two groups based on the presence or absence of climacturia. A logistic regression model was applied among statistically significant variables. STROBE recommendations were taken into consideration. Shorter prostatic urethral length was associated with higher risk of climacturia at 3 months, OR = 0.83 (95%CI 0.688-0.98) (p = 0.024). Patients with climacturia at 6 months had greater median urethral width [12.66 mm, interquartile range (IQR): 11.77-13.55 vs 12.13 mm, IQR 11.08-13.18] (p = 0.02). Patients with climacturia at 12 months had a higher proportion of preoperative lower urinary tract symptoms (57.14% vs. 20%) (p = 0.026). In the logistic regression, the history of lower urinary tract symptoms was associated with a higher risk of climacturia, OR = 6.07 (95% CI 1.342-26.03) (p = 0.023). In conclusion, shorter prostatic urethral length in preoperative MRI and a history of lower urinary tract symptoms were associated with a higher risk of climacturia following robot-assisted laparoscopic radical prostatectomy.

Sexual function and rehabilitation after radiation therapy for prostate cancer: a review

The treatment of prostate cancer is partly guided by patient preferences. Radical prostatectomy and radiation therapy are the standard radical therapies for localized disease and render comparable oncologic outcomes. Considering that survival is high regardless of the chosen treatment, factors such as treatment-related toxicities affecting the patients' quality of life play an important role in their decision. Notably, post-treatment sexual dysfunction, which includes decreased libido, erectile dysfunction, and ejaculatory dysfunction has been shown to be an important and prevalent concern of prostate cancer survivors. In this literature review, we sought to characterize the sexual complications associated with radiation therapy and map the available sexual rehabilitation options for prostate cancer survivors experiencing sexual dysfunction as a result of radiation therapy. We identified medical, non-biomedical, counseling, and lifestyle modification options for prostate cancer survivors seeking sexual rehabilitation. Future research in this area should address the standardization of sexual side-effect reporting and investigate sexual outcomes and rehabilitation in more diverse groups and of transgender and nonheterosexual prostate cancer survivors.

Neglected side effects to curative prostate cancer treatments

In this narrative review we summarize neglected side effects of curative intended treatment for prostate cancer. They include climacturia, arousal incontinence (AI), orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia), ejaculatory dysfunction, and morphological penile alterations in the form of shortening and deformity. Even though they have not received as much interest as erectile dysfunction (ED) or urinary incontinence, these side effects have been shown to negatively impact patient's quality of life. They are common and rates of climacturia after radical prostatectomy (RP) range from 20% and 45%, less after external beam radiation therapy (EBRT). Decreased orgasmic sensation ranges from 3.9% to 60% after RP and between 36-57% after EBRT. Dysorgasmia ranges from 9.5-15% for both RP and EBRT. Anejculation after EBRT ranges from 11-71% and rates of penile shortening are reported between 0 and 100%. There are no internationally validated questionnaires that adequately asses these side effects. This is necessary if we are to align patient and partner expectations properly and consequently manage them optimally. Neglected side effects should be discussed with patients and their partners preoperatively, as they are associated with bother and may lead to patient's avoiding sexual activity.

Revisiting the penoscrotal approach to artificial urinary sphincter surgery: how does it compare to a perineal incision for initial implantation?

PURPOSE

Artificial urinary sphincters (AUS) remain the gold standard to treat male stress urinary incontinence. AUS implantation can be performed through a penoscrotal or perineal incision depending on surgeon preference.

METHODS

The present study compares initial AUS implantation through two surgical approaches focusing on outcomes of continence and revision. All AUS implanted at an academic medical center between 2000 and 2018 were retrospectively reviewed.

RESULTS

A total of 225 AUS implantations were identified, of which, 114 patients who underwent virgin AUS placement were included in the study with a mean follow-up of 28.5 months. A total of 68 patients (59.6%) had AUS placement through penoscrotal incision; while, 46 (40.4%) had a perineal incision. While operative time was significantly shorter for penoscrotal placement (98.6 min vs. 136.3 min, p = 0.001), there were no significant differences in continence rates between either surgical approach with 76.5% socially continent defined as using zero to less than 1 pad per day (safety pad). The overall rate of device erosion or infection was not significantly different between groups. However, the rate of revision or replacement was significantly higher in the perineal group (26.1% v. 8.8%; p = 0.01). On multivariate analysis, the penoscrotal incision predicted a lower rate of device revision (p = 0.01).

CONCLUSIONS

The penoscrotal approach of AUS placement is associated with shorter operative time. While we observed a lower revision rate compared to the perineal approach, there were equivalent continence outcomes.

A new male sling for minimal to moderate incontinence and climacturia

Erectile dysfunction (ED) and stress urinary incontinence (SUI) are known bothersome sequelae to radical prostatectomy. In recent years, additional attention has been placed on another less commonly described and reported side effect to this surgery, climacturia. While various noninvasive and surgical interventions have been described for the management of climacturia, until recently, none has provided reliable and meaningful results. In the past few years, the Mini-Jupette sling has gained popularity as an adjunct to inflatable penile prosthesis placement in patients with concomitant ED and climacturia. Recent data have also suggested its feasibility in patients with mild SUI. While the original technique described by Pr. Andrianne has shown long-term, reproducible, and safe results, innovative modifications such as the use of autologous rectus fascia, the Male Urethral Mini-Sling and the Mayo Clinic modified Mini-Jupette sling have also been suggested, proof of widespread interest amongst clinicians toward achieving the optimum surgical technique.