Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy

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.

Male delayed orgasm and anorgasmia: a practical guide for sexual medicine providers

Delayed orgasm (DO) is defined as increased latency of orgasm despite adequate sexual stimulation and desire. Anorgasmia (AO) is characterized as the absence of orgasm. Etiologies of DO/AO include medication-induced, psychogenic, endocrine, and genitopelvic dysesthesia. Given the multifactorial complex nature of this disorder, a thorough history and physical examination represent the most critical components of patient evaluation in the clinical setting. Treating DO/AO can be challenging due to the lack of standardized FDA-approved pharmacotherapies. There is no standardized treatment plan for DO/AO, though common treatments plans are often multidisciplinary and may include adjustment of offending medications and sex therapy. In this review, we summarize the etiology, diagnosis, and treatment of DO/AO.

Evaluation of sexual function after robot-assisted radical prostatectomy: A farewell to IIEF questionnaire

Longevity with localized prostate cancer (PCa) has been achieved, and the contribution of robot-assisted radical prostatectomy (RARP) to cancer control is evident. The next step to investigate in the treatment of localized PCa is improvement of the quality of life (QOL) after RARP. Erectile dysfunction has been considered a major surgical complication, and patient satisfaction after RARP has not improved despite the development of nerve preservation and penile rehabilitation. To comprehensively understand sexual dysfunction after RARP, we must investigate other complications with regard to sexual health, including low sexual desire, disturbed orgasmic function (i.e., anejaculation, orgasm intensity, painful orgasm, and climacturia), shortening of penile length, penile curvature (Peyronie's disease) and unique psychological alterations after the diagnosis of PCa, which are neglected side effects after prostatectomy. In this context, routine evaluation of erectile function by the International Index of Erectile Function only is not sufficient to understand patients' difficulties. A questionnaire is just one way of enabling patients to evaluate their pre- and postoperative concerns; listening to patients face-to-face is warranted to detect symptoms. Understanding the relationship between symptoms and preserved nerve localization can ultimately provide an individualized nerve-sparing procedure and improve patient satisfaction after RARP. In combination with psychological counseling, including the partner and medical treatment, such as testosterone replacement, it is time to reconsider ways to improve sexual dysfunction after RARP.

Incidence and predictive factors of orgasmic dysfunction after robot-assisted radical prostatectomy: A cross-sectional, questionnaire-based study

OBJECTIVE

We sought to evaluate the incidence and extent of orgasmic dysfunction in patients after robot-assisted radical prostatectomy and to identify factors that could predict patients at risk.

METHODS

A single-center, questionnaire-based, cross-sectional study was conducted on patients who underwent robot-assisted radical prostatectomy (n = 523) between October 2010 and November 2019. In addition to six questions about sexual activity, orgasmic function, altered perception of orgasms, dysorgasmia, and climacturia, the International Consultation on Incontinence Questionnaire Short Form was administered. In February 2020, a letter was mailed inviting patients to participate in the survey. The primary outcome measure was the rate of orgasmic dysfunction. Logistic regression analyses were used to identify predictors of orgasmic dysfunction.

RESULTS

Overall, 259 questionnaires were used for analysis. Among sexually active patients (n = 145), 33 (22.8%) reported anorgasmia, and 83 (57.2%) reported decreased orgasm intensity. Twenty-two (15.1%) patients reported dysorgasmia; among these patients, the pain was experienced almost always or always in 13.6%, sometimes in 13.6%, and a few times in 72.8% of cases. Climacturia was reported by 44 patients (30.3%). Nerve-sparing procedures decreased the risk of anorgasmia (odds ratio 0.37, 95% confidence interval 0.15-0.88) and urinary incontinence increased the risk of climacturia (odds ratio 3.13, 95% confidence interval 1.20-8.15).

CONCLUSIONS

These results indicate that orgasmic dysfunction after robot-assisted radical prostatectomy is relatively common.

Mapping the prevalence and use of questionnaires to detect the neglected sexual side effects after prostate cancer treatment: a scoping review

BACKGROUND

Early prostate cancer (PCa) treatment interventions may leave men with debilitating sexual side effects, especially when not diagnosed or present at initial follow-up treatment. Men are often embarrassed to disclose their sexual dysfunction. This may lead to sexual side effects related to PCa treatment remaining untreated, adding to their burden of disability. This study was conducted to map the evidence on the prevalence of neglected sexual side effects (NSSE) after radical prostatectomy (RP) surgery or radiation treatment (RT) for PCa treatment and the reported use of questionnaires to identify such side effects.

METHODS

This systematic scoping review's search strategy involved searching MEDLINE/PubMed, Science Direct and Google Scholar databases. Guided by eligibility criteria, two independent reviewers conducted title, abstract and full-text screening. Data from the included studies were extracted. The review team explored the implications of the findings in relation to the research question and aims of the study. The Mixed Method Appraisal Tool was used to appraise the quality of the included studies. This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

Searches of the databases identified 1369 articles, with 23 eventually included for review. The prevalence of NSSE ranged between 0 and 78% in studies reporting on early PCa treatment of RP and RT patients. Orgasmic dysfunction (5-78%), penile curvature changes (10-15.9%) and penile length shortening (0-55%) similarly showed a low to moderate prevalence. Climacturia had low prevalence (4-5.2%) after RT and moderate prevalence (21-38%) after RP, whilst anejaculation had low to high prevalence (11-72%) after RT. No validated questionnaire was used to detect any NSSE after early PCa treatment. Studies mainly modified other questionnaires, and two studies used non-validated questionnaires to identify some NSSE. Participants in the included studies reported being inadequately informed about the possible sexual side effects of their treatment.

CONCLUSION

This study showed a low to a high prevalence of NSSE in men after RP and RT for early PCa treatment. Questionnaires helped detect individual NSSEs after PCa treatment but there is currently no evidence of a valid, reliable and comprehensive questionnaire to detect the NSSE collectively.

SCOPING REVIEW REGISTRATION

N/A.

Radical Prostatectomy: Sequelae in the Course of Time

Objective: Radical prostatectomy (RP) is a frequent treatment for men suffering from localized prostate cancer (PCa). Whilst offering a high chance for cure, it does not come without a significant impact on health-related quality of life. Herein we review the common adverse effects RP may have over the course of time. Methods: A collaborative narrative review was performed with the identification of the principal studies on the topic. The search was executed by a relevant term search on PubMed from 2010 to February 2021. Results: Rates of major complications in patients undergoing RP are generally low. The main adverse effects are erectile dysfunction varying from 11 to 87% and urinary incontinence varying from 0 to 87% with a peak in functional decline shortly after surgery, and dependent on definitions. Different less frequent side effects also need to be taken into account. The highest rate of recovery is seen within the first year after RP, but even long-term improvements are possible. Nevertheless, for some men these adverse effects are long lasting and different, less frequent side effects also need to be taken into account. Despite many technical advances over the last two decades no surgical approach can be clearly favored when looking at long-term outcome, as surgical volume and experience as well as individual patient characteristics are still the most influential variables. Conclusions: The frequency of erectile function and urinary continence side effects after RP, and the trajectory of recovery, need to be taken into account when counseling patients about their treatment options for prostate cancer.

Focusing on sexual rehabilitation besides penile rehabilitation following radical prostatectomy is important

Erectile dysfunction is commonly reported after radical prostatectomy. Besides the loss of erections, sexual life after prostatectomy is impacted by urinary incontinence, orgasmic dysfunction, and psychological stress. In this review, we describe classical medical therapies used for erectile function rehabilitation such as PDE5 inhibitors and injection therapy. A vast amount of data support the idea of focusing on restoration of sexual function on top of erectile function after prostatectomy. The important strategies described to rehabilitate sexual function include pelvic floor muscle therapy, couple therapy, appropriate preoperative counseling, and focusing on non-penetrative alternatives. A multidisciplinary approach and including the partner is important. Erectile function alone is not sufficient for satisfactory sexual experience and may not be used as a proxy for sexual quality of life. Adding full-spectrum sexual rehabilitation to a standard penile rehabilitation regimen has the highest chances of obtaining satisfactory sexual outcomes in men and their partners after 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.

Ejaculatory and Orgasmic Dysfunction Following Prostate Cancer Therapy: Clinical Management

The majority of sexual health research has focused on erectile dysfunction following prostate cancer treatment. Ejaculatory and orgasmic dysfunction are significant side effects following the treatment of prostate cancer. Orgasmic dysfunction covers a range of issues including premature ejaculation, anorgasmia, dysorgasmia, and climacturia. This review provides an overview of prevalence and management options to deal with orgasmic dysfunction. A Medline Pubmed search was used to identify articles relating to these problems. We found that orgasmic dysfunction has a very large impact on patients’ lives following prostate cancer treatment and there are ways for physicians to treat it. Management of patients’ sexual health should be focused not only on erectile dysfunction, but on orgasmic dysfunction as well in order to ensure a healthy sexual life for patients and their partners.

Robotics in urology

Twenty years after it was introduced, robotic surgery has become more commonplace in urology – we examine its current uses and controversies

Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature

INTRODUCTION

The sexual problem after radical prostatectomy (RP) that has received the most focus in the current literature is erectile dysfunction. However, there are orgasmic complications that encompass orgasm-associated urinary incontinence (climacturia), anorgasmia, changes in orgasmic sensation, and painful orgasm (dysorgasmia). Although the body of research is still growing, there remains a need for physician and patient awareness of these potentially problematic complications.

AIM

To review the prevalence and management options for different orgasmic dysfunctions after RP.

METHODS

A Medline PubMed search was used to identify articles related to orgasmic dysfunction, including climacturia, dysorgasmia, anorgasmia, and altered sensation after RP.

MAIN OUTCOME MEASURE

Rates and types of orgasmic dysfunction after RP.

RESULTS

Orgasmic dysfunction encompasses a series of conditions that affect men after RP. These include climacturia, dysorgasmia, anorgasmia, and altered sensation. Although the etiologies and management options remain uncertain, their effect on the sexual health of patients is not negligible.

CONCLUSION

To provide proper counseling to patients, physicians should be aware of the prevalence of orgasmic side effects after RP. Post-prostatectomy sexual recovery should be focused not only on penile erectile function but also on a satisfactory and healthy sexual life for patients and their partners. Clavell-Hernández J, Martin C, Wang R. Orgasmic Dysfunction Following Radical Prostatectomy: Review of Current Literature. Sex Med Rev 2018;6:124-134.

Orgasmic Function after Radical Prostatectomy

PURPOSE

We examined postprostatectomy orgasmic function and assessed for potential predictors.

MATERIALS AND METHODS

Between 2005 and 2013, 499 men underwent radical prostatectomy and completed quality of life questionnaires prospectively before surgery and at regular postoperative intervals. We used mixed effects logistic regression models to evaluate average differences in followup measures and interactions with time.

RESULTS

At a median followup of 36 months orgasmic function was worse, stable or improved in 300 (60.1%), 152 (30.5%) and 47 men (9.4%), respectively. Orgasmic function recovery plateaued at 15 to 21 months. High postoperative orgasmic function was positively associated with younger age (50 years or younger vs 51 to 60 OR 3.40, 95% CI 1.56-7.41), nerve sparing (bilateral OR 7.11, 95% CI 2.55-19.77, modified 4.34, 95% CI 1.38-13.58 and unilateral OR 3.93, 95% CI 1.17-13.16), erectile function (OR 4.67, 95% CI 3.32-6.57) and sexual desire (OR 5.51, 95% CI 3.95-7.68) but negatively associated with lower urinary tract symptoms (OR 0.58, 95% CI 0.41-0.82) and urinary incontinence (OR 0.38, 95% CI 0.25-0.56). Although robotic status did not influence orgasmic function in the overall cohort, it was associated with faster recovery on subgroup analysis of 356 patients with long followup. On another subgroup analysis of 235 men with long followup and poor erectile function the association of high preoperative orgasmic function and bilateral nerve sparing with high orgasmic function persisted, suggesting an independent effect on orgasmic function apart from that on erectile function.

CONCLUSIONS

Orgasmic function recovery after radical prostatectomy is a lengthy process. Predictors of orgasmic function include preoperative orgasmic function, age, nerve sparing status, erectile function, sexual desire and urinary control and function.

Extended versus Standard Pelvic Lymph Node Dissection in Radical Prostatectomy on Oncological and Functional Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

We evaluated the effect of the extent of pelvic lymph node dissection (PLND) on oncological and functional outcomes in patients with intermediate- to high-risk prostate cancer (PCa) by conducting a systematic review and meta-analysis.

METHODS

Two independent researchers performed a systematic review of radical prostatectomy (RP) with extended PLND (ePLND), and RP with standard (sPLND) or limited PLND (lPLND) in patients with PCa using the PubMed, EMBASE, and Cochrane Library databases and using the terms 'prostatectomy', 'lymph node excision', and 'prostatic neoplasm'. The primary outcome was biochemical-free survival, which was analyzed by extracting survival data from the published Kaplan-Meier (KM) curves. In addition, we obtained summarized survival curves by reconstructing the KM data. Secondary outcomes of the recovery of erection and continence were also analyzed.

RESULTS

Nine studies involving over 1554 patients were included, one of which was a randomized controlled trial. The pooled analysis showed a significant difference in biochemical recurrence between ePLND and sPLND (hazard ratio 0.71, 95% confidence interval 0.56-0.90, p = 0.005), with no significant between-study heterogeneity (I ² = 37%). From the summary survival curves, it can be observed that the curves for the two groups diverged more and more as a function of time. From the analyses of functional outcomes including only three studies, no statistically significant differences in the recovery of erectile function and continence were observed. No evidence of significant publication bias was found.

CONCLUSIONS

In patients with PCa, ePLND could be an oncological benefit; however, a functional compromise cannot be determined.

Orgasmic Dysfunction after Radical Prostatectomy

In addition to urinary incontinence and erectile dysfunction, several other impairments of sexual function potentially occurring after radical prostatectomy (RP) have been described; as a whole, these less frequently assessed disorders are referred to as neglected side effects. In particular, orgasmic dysfunctions (ODs) have been reported in a non-negligible number of cases, with detrimental impacts on patients' overall sexual life. This review aimed to comprehensively discuss the prevalence and physiopathology of post-RP ODs, as well as potential treatment options. Orgasm-associated incontinence (climacturia) has been reported to occur in between 20% and 93% of patients after RP. Similarly, up to 19% of patients complain of postoperative orgasm-associated pain, mainly referred pain at the level of the penis. Moreover, impairment in the sensation of orgasm or even complete anorgasmia has been reported in 33% to 77% of patients after surgery. Clinical and surgical factors including age, the use of a nerve-sparing technique, and robotic surgery have been variably associated with the risk of ODs after RP, although robust and reliable data allowing for a proper estimation of the risk of postoperative orgasmic function impairment are still lacking. Likewise, little evidence regarding the management of postoperative ODs is currently available. In general, physicians should be aware of the prevalence of ODs after RP, in order to properly counsel all patients both preoperatively and immediately post-RP about the potential occurrence of bothersome and distressful changes in their overall sexual function.

Ability to Reach Orgasm in Patients With Prostate Cancer Treated With Robot-assisted Laparoscopic Prostatectomy

OBJECTIVES

To study the ability to reach orgasm after robot-assisted laparoscopic prostatectomy (RALP) in relation to demographic, cancer-related, and surgical variables, and the use of erectile aids.

METHODS

In this cross-sectional study at a mean of 3 years after RALP at Oslo University Hospital, 982 men were invited to complete a mailed questionnaire, and 777 responded. Respondents who reported postoperative radiotherapy or hormone treatment, or did not report on orgasm were omitted, leaving 609 patients for analysis. Ability to reach orgasm was rated on 1 question from The Expanded Prostate Cancer Index Composite 26-item version, and dichotomized into "good" or "poor."

RESULTS

Overall, 27% of the men reported good ability to reach orgasm: 22% among those did not use erectile aids and 34% among those did (P = .001). Univariate analysis of men with good versus poor ability to reach orgasm showed many significant differences. In multivariate analysis, being older, having a reduced physical quality of life, and erectile dysfunction were significantly associated with poor ability to reach orgasm. Erectile dysfunction showed an odds ratio of 4.86 for poor orgasmic ability. The 48% of men who used erectile aids had significantly better orgasmic ability than the nonusers.

CONCLUSION

In our sample, 27% had good ability to reach orgasm at a mean of 3 years after RALP. Poor orgasmic ability was associated with being older, poor erectile function, and a reduced physical quality of life. Using erectile aids increased the rate of good ability to reach orgasm.

Exploratory Decision-Tree Modeling of Data from the Randomized REACTT Trial of Tadalafil Versus Placebo to Predict Recovery of Erectile Function After Bilateral Nerve-Sparing Radical Prostatectomy

BACKGROUND

Understanding predictors for the recovery of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) might help clinicians and patients in preoperative counseling and expectation management of EF rehabilitation strategies.

OBJECTIVE

To describe the effect of potential predictors on EF recovery after nsRP by post hoc decision-tree modeling of data from A Study of Tadalafil After Radical Prostatectomy (REACTT).

DESIGN, SETTING, AND PARTICIPANTS

Randomized double-blind double-dummy placebo-controlled trial in 423 men aged <68 yr with adenocarcinoma of the prostate (Gleason ≤7, normal preoperative EF) who underwent nsRP at 50 centers from nine European countries and Canada.

INTERVENTION

Postsurgery 1:1:1 randomization to 9-mo double-blind treatment with tadalafil 5mg once a day (OaD), tadalafil 20mg on demand, or placebo, followed by a 6-wk drug-free-washout, and a 3-mo open-label tadalafil OaD treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Three decision-tree models, using the International Index of Erectile Function-Erectile Function (IIEF-EF) domain score at the end of double-blind treatment, washout, and open-label treatment as response variable. Each model evaluated the association between potential predictors: presurgery IIEF domain and IIEF single-item scores, surgical approach, nerve-sparing score (NSS), and postsurgery randomized treatment group.

RESULTS AND LIMITATIONS

The first decision-tree model (n=422, intention-to-treat population) identified high presurgery sexual desire (IIEF item 12: ≥3.5 and <3.5) as the key predictor for IIEF-EF at the end of double-blind treatment (mean IIEF-EF: 14.9 and 11.1), followed by high confidence to get and maintain an erection (IIEF item 15: ≥3.5 and <3.5; IIEF-EF: 15.4 and 7.1). For patients meeting these criteria, additional non-IIEF-related predictors included robot-assisted laparoscopic surgery (yes or no; IIEF-EF: 19.3 and 12.6), quality of nerve sparing (NSS: <2.5 and ≥2.5; IIEF-EF: 14.3 and 10.5), and treatment with tadalafil OaD (yes and no; IIEF-EF: 17.6 and 14.3). Additional analyses after washout and open-label treatment identified high presurgery intercourse satisfaction as the key predictor.

CONCLUSIONS

Exploratory decision-tree analyses identified high presurgery sexual desire, confidence, and intercourse satisfaction as key predictors for EF recovery. Patients meeting these criteria might benefit the most from conserving surgery and early postsurgery EF rehabilitation. Strategies for improving EF after surgery should be discussed preoperatively with all patients; this information may support expectation management for functional recovery on an individual patient level.

PATIENT SUMMARY

Understanding how patient characteristics and different treatment options affect the recovery of erectile function (EF) after radical surgery for prostate cancer might help physicians select the optimal treatment for their patients. This analysis of data from a clinical trial suggested that high presurgery sexual desire, sexual confidence, and intercourse satisfaction are key factors predicting EF recovery. Patients meeting these criteria might benefit the most from conserving surgery (robot-assisted surgery, perfect nerve sparing) and postsurgery medical rehabilitation of EF.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01026818.

Multiple Orgasms in Men-What We Know So Far

INTRODUCTION

There is much popular discussion on strategies to facilitate multiple orgasms in men (ie, 100,000+ hits in Google), yet the topic has not received an objective comprehensive review in the literature.

AIM

To review the literature on male multiple orgasms.

METHODS

We searched the literature for publications on "male multiple orgasms" and factors influencing male multiple orgasms in Google, PubMed, and PsychINFO. This yielded 15 relevant publications.

MAIN OUTCOME MEASURES

A comprehensive overview on the topic of male multiple orgasms and factors that influence the propensity of men to experience multiple orgasms.

RESULTS

Few men are multiorgasmic: <10% for those in their 20s, and <7% after the age of 30. The literature suggests 2 types of male multiple orgasms: "sporadic" multiorgasms, with interorgasmic intervals of several minutes, and "condensed" multiorgasms, with bursts of 2-4 orgasms within a few seconds to 2 minutes. Multiple orgasms appear physiologically similar to the single orgasm in mono-orgasmic men. However, in a single case study, a multiorgasmic man did not experience with his first orgasm the prolactin surge that usually occurs with orgasm in mono-orgasmic men. Various factors may facilitate multiple orgasms: (1) practicing to have an orgasm without ejaculation; (2) using psychostimulant drugs; (3) having multiple and/or novel sexual partners; or (4) using sex toys to enhance tactile stimulation. However, confirmatory physiological data on any of these factors are few. In some cases, the ability to experience multiple orgasms may increase after medical procedures that reduce ejaculation (eg, prostatectomy or castration), but what factor(s) influence this phenomenon is poorly investigated.

CONCLUSION

Despite popular interest, the topic of male multiple orgasms has received surprisingly little scientific assessment. The role of ejaculation and physiological change during the refractory period in inhibiting multiple orgasms has barely been investigated.

Pharmacologic and surgical therapies for sexual dysfunction in male cancer survivors

The recent recognition that many men experience sexual dysfunction following their diagnosis and treatment of genitourinary cancers, has led to the development multiple varied strategies that attempt to restore or preserve that function. In this manuscript we review the understanding of why it happens, highlight novel management strategies and discuss the concept of penile rehabilitation (PR) following prostate cancer (PCa) treatment, glans preserving strategies among men diagnosed with penile cancer and address the controversial issue of testosterone therapy in men with PCa.

The effect of PnTx2-6 protein from Phoneutria nigriventer spider toxin on improvement of erectile dysfunction in a rat model of cavernous nerve injury

OBJECTIVE

To explore the therapeutic potential of PnTx2-6 injected 3 times a week for 4 weeks into the intracavernosal tissue in a rat model of bilateral cavernous nerve crush injury (BCNI).

METHODS

Eight-week-old male Sprague-Dawley rats were randomly divided into the following 6 groups (n = 5 per group): age-matched control (normal group), BCNI (injury group), post-BCNI phosphate-buffered saline injection (PBS group), post-BCNI Sf9 cell-lysate injection (N/C group), post-BCNI injection of cell lysate from S9 cells infected with wild-type recombinant baculovirus (W/T group), and post-BCNI injection of cell lysate from S9 cells infected with recombinant baculovirus containing PnTx2-6 (PnTx2-6 group). Injections were delivered 3 times a week for 4 weeks. After 4 weeks, intracavernosal pressure-to-mean arterial pressure ratio, smooth muscle and collagen content via the Masson trichrome staining, levels of neural nitric oxide synthase, phosphoendothelial nitric oxide synthase, and cyclic guanosine monophosphate were all measured.

RESULTS

The PnTx2-6 group showed significantly higher intracavernosal pressure-to-mean arterial pressure ratio (P <.05), smooth muscle-to-collagen ratio (P <.01), expression levels of neural nitric oxide synthase, phosphoendothelial nitric oxide synthase (P <.05), and cyclic guanosine monophosphate (P <.05) than all other experimental groups.

CONCLUSION

We conclude that PnTx2-6 improved erectile function and prevented muscle atrophy in a rat model of BCNI via increased synthesis of nitric oxide and cyclic guanosine monophosphate.

Perioperative changes in pro and anticoagulant factors in prostate cancer patients undergoing laparoscopic and robotic radical prostatectomy with different anaesthetic techniques

BACKGROUND

Laparoscopic prostatectomy (LRP) may activate clotting system influencing the risk of perioperative thrombosis in patients with prostate cancer. Moreover, different anaesthetic techniques can also modify coagulant factors. Thus, the aim of this study was to investigate the effects on pro- and anti-coagulant and fibrinolytic factors of two established types of anaesthesia in patients with prostate cancer undergoing elective LRP.

METHODS

102 patients with primary prostate cancer, who underwent conventional LRP or robot-assisted laparoscopic prostatectomy (RALP), were studied and divided into 2 groups to receive total intravenous anesthesia with target-controlled infusion (TIVA-TCI) or balanced inhalation anaesthesia (BAL) prior to surgery. Before the induction of anaesthesia (T0), 1 hr (T1) and 24 hrs post-surgery (T2), some pro-coagulant factors, fibronolysis markers, p-selectin and haemostatic system inhibitors were evaluated.

RESULTS

Both TIVA-TCI and BAL patients showed a marked and significant increase in pro-coagulant factors and consequent reduction in haemostatic system inhibitors in the early post operative period (p ≤ 0.004 for each markers). Use of RALP showed a significant increase in prothrombotic markers as compared to LRP. In TIVA patients undergoing LRP, a significant reduction of p-selectin levels between T0 and T2 (p = 0.001) was observed as compared to BAL, suggesting a better protective effect on platelet activation of anaesthetic agents used for TIVA.

CONCLUSIONS

Both anaesthetic techniques significantly seem to increase the risk of thrombosis in prostate cancer patients undergoing LRP, mainly when the robotic device was utilized, encouraging the use of a peri-operative thromboembolic prophylaxis in these patients.

Prevalence and predicting factors for commonly neglected sexual side effects to radical prostatectomies: results from a cross-sectional questionnaire-based study

INTRODUCTION

Altered perception of orgasm, orgasm-associated pain, penile sensory changes, urinary incontinence (UI) during sexual activity, penile shortening (PS), and penile deformity following radical prostatectomy (RP) have received increasing attention from researchers.

AIM

The aim of this study is to describe the prevalence and predictors of the above-mentioned side effects.

METHODS

This was a cross-sectional questionnaire-based study among men who had undergone RP between 3 and 36 months prior to study inclusion. Predicting factors were identified through logistic regression analyses.

MAIN OUTCOME MEASURES

The primary outcome measures were prevalence rates of the above-mentioned side effects.

RESULTS

Overall, 316 questionnaires were available for analyses. Of the sexually active patients (n = 256), 12 (5%) reported anorgasmia, whereas 153 (60%) reported decreased orgasm intensity. Delayed orgasms were reported by 146 (57%). Twenty-three patients (10%) had experienced pain during orgasm. UI during sexual activity were reported by 99 patients (38%). Out of the whole population, 77 patients (25%) reported sensory changes in the penis. A total of 143 patients (47%) reported a subjective loss of penile length of >1 cm. An altered curvature of the penis was reported by 30 patients (10%). Patients had increasing risk of UI during sexual activity (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.10-1.25) and orgasmic dysfunction (OR 1.09; 95% CI 1.01-1.16) with increasing International Consultation on Incontinence Questionnaire scores. Erectile dysfunction (OR 1.81; 95% CI 1.07-3.10) and a high body mass index (OR 1.10; 95% CI 1.02-1.19) increased the risk of PS after RP. Nerve-sparing (OR 0.32; 95% CI 0.16-0.95) reduced the risk of PS.

CONCLUSIONS

Orgasm-associated problems, UI during sexual activity, penile sensory changes, PS, and penile deformity are common side effects to RP. Daytime UI, erectile dysfunction, and nerve-sparing status can help identify patients at risk.

Neglected side effects after radical prostatectomy: a systematic review

INTRODUCTION

A series of previously neglected sexually related side effects to radical prostatectomy (RP) has been identified over the recent years. These include orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasm-associated pain (OAP), penile shortening (PS), and penile deformity.

AIM

The aim of this article is to conduct a systematic review of the literature regarding the above-mentioned side effects.

METHODS

A predefined search strategy was applied in a thorough search of Medline, Web of science, and the online Cochrane library. The PRISMA guidelines for systematic reviews were followed, and protocol as well as search strategies was registered at http://www.crd.york.ac.uk/Prospero/ (RN: CRD42012003165).

MAIN OUTCOME MEASURE

The main outcome measure was incidence rates for the relevant side effects.

RESULTS

A total of 43 articles were included. OAI and UISS are experienced by 20-93% of RP patients at least a few times after surgery. Although these issues are associated to postoperative daytime incontinence, previous transurethral resection of the prostate (TURP) is the only known predicting factor. Alterations of orgasmic function are experienced by approximately 80% after RP. Erectile dysfunction seems to play an important role in waning orgasmic function. OAP is only experienced by a subset of the patients with reported rates varying between 3% and 19%. Sparing of the tips of the seminal vesicles has been shown to double the risk of OAP. PS occurs in 15-68% of RP patients. Nerve sparing and preservation of erectile function may help preserve penile length. With regard to all side effects, studies indicate that they are reduced over time.

CONCLUSIONS

The sexually related side effects summarized in this review are common after RP. Meanwhile, it is difficult to predict which patients are at risk. Daytime incontinence, previous TURP, a lack of nerve sparing, and erectile dysfunction are all associated with the above-mentioned sexually related side effects.

A systematic review of the correlates and management of nonpremature ejaculatory dysfunction in heterosexual men

INTRODUCTION

A better understanding of ejaculatory disorders has led to an increasing interest in nonpremature ejaculatory dysfunction (non-PE EjD). Current reviews on the subject use a symptom-based classification to describe ejaculatory dysfunction even when it is a single case report. While these reviews provide important information on the disorder, a clearer picture of the prevalence of non-PE EjD in relation to the community and various pathophysiologic states is needed.

OBJECTIVES

The objective of this study was to provide a systematic review of studies of non-PE EjD excluding single case reports.

METHODS

A systematic review of Medline for terms including ejaculation, orgasm or hematospermia. Association with terms delay, pain or headache was made. The search was restricted to male gender and articles written in English. Abstracts were reviewed and those mainly concerned with premature ejaculation were excluded.

RESULTS

A total of 333 articles on non-PE EjD were identified. The condition was reported in community-based studies. In certain patient populations, non-PE EjD was commonly reported in association with antidepressant and antipsychotic treatments, in patients with chronic prostatitis/chronic pelvic pain syndrome, patients with lower urinary tract symptoms particularly in association with medical or surgical treatment, patients with retroperitoneal surgery and in patients with neurological diseases. Few articles were concerned with treatment options.

CONCLUSION

There is a significant prevalence of non-PE EjD in the community and in association with particular disease states or as a side effect of medical or surgical interventions. There is a need to direct efforts to prevent and treat these conditions.