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EAU 2019

EAU 2019: Neglected Sexual Side Effects of Radical Prostatectomy and Pelvic Radiotherapy

Barcelona, Spain (UroToday.com) In this session, Dr. Vendeira reviewed the “dark side” of sexual dysfunctions beyond erectile dysfunction following radical prostatectomy and pelvic radiotherapy. It is theorized that these occur due to lesions in the neurovascular bundle, mechanical manipulation, thermal injury, ischemic effects, local inflammation, damage to the penile vasculature, and structural changes to cavernous tissue.   Dr. Vendeira reviewed climacturia, orgasmic disturbances, penile shortening, and de novo penile curvature. Significant data exists in the post-prostatectomy erectile dysfunction space, however, there is a relative paucity of evidence investigating orgasmic dysfunction.

Climacturia, defined as urinary incontinence at the time of orgasm or arousal is present in 20-64% of post prostatectomy patients. It is associated with depression and worse quality of life. A 2007 Journal of Urology study demonstrated that incidence decreases with time following prostatectomy and faster recovery appears to be with robotic as opposed to open surgery. Climacturia is due to the removal of the internal urethral sphincter with relaxation of the external sphincter. Management includes pre-sexual voiding, condoms, suitable positions, imipramine, pelvic floor muscle rehabilitation, penile tensions loops and/or insertion of sphincters or slings.

Roughly 80% of men describe alteration of their orgasmic function following radical prostatectomy and 4% report increased intensity of their orgasm. 30-40% of men report anorgasmia, however younger age, nerve-sparing surgery, and recovery of erections appear to be protective. Surprisingly, Dr. Vendeira reported that 60% of patients are unaware that they would not expel semen after prostatectomy –urologists need to improve communication and awareness so expectations can be appropriately adjusted.

Dysorgasmia, or pain associated with orgasm, is present in 3-20% of the patient following radical prostatectomy and appears to be associated with sparing portions of the seminal vesicle. It is hypothesized that filling and contraction leads to pain. However, it may also be associated with neourethral anastomosis spasms or pelvic floor muscle dystonia. Recommendations include encouraging patients to stay sexually active, alpha blockers, psychosocial therapy, or NSAIDs.

Lastly, penile shortening or curvatures are likely due to higher BMI and increased pre-pubic fat pad. Dr. Vendeira suggests that preoperative measurement is essential with regular treatment with PDE5 inhibitors or vacuum assist devices.

In summary, this session reviewed some of the less discussed side effects of prostatectomy and pelvic radiotherapy. It is crucial to discuss this information with your patients prior to treatment.

Presented by: Pedro Vendeira, MD, PhD, Department of Urology and Andrology, Saude Atlantica Clinica do Dragao, Oporto, Portugal

Written by: David B. Cahn, DO, MBS@dbcahn Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.