374
Neglected Side Effects After Radical Prostatectomy: A Systematic Review Anders Ullmann Frey, Jens Sønksen, MD, PhD, DSc (Med), and Mikkel Fode, MD Department of Urology, Herlev University Hospital, Herlev, Denmark DOI: 10.1111/jsm.12403
ABSTRACT
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. Frey, AU, Sønksen J, and Fode M. Neglected side effects after radical prostatectomy: A systematic review. J Sex Med 2014;11:374–385. Key Words. Climacturia; Dysorgasmia; Orgasm-Associated Pain; Penile Length; Radical Prostatectomy
Introduction
P
rostate cancer is a common disease with more than 650,000 new cases each year in the developed countries alone [1]. Radical prostatectomy (RP) has been shown to reduce mortality [2]. Unfortunately, the operation is not without side effects. Destruction or disruption of nerves, blood vessels, and muscular tissue during surgery is known to cause erectile dysfunction (ED) and urinary incontinence (UI). These side effects are well described in the literature [3,4]. Meanwhile, a series of additional sexually related side effects to
J Sex Med 2014;11:374–385
RP has been studied in recent years. These include orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasmassociated pain (OAP), penile shortening (PS), and penile deformity [5].
Aims
The aim of this systematic review is to summarize the literature regarding the sexually related side effects mentioned above. © 2013 International Society for Sexual Medicine
375
Neglected Side Effects After Radical Prostatectomy Table 1
Search strategy for electronic databases
Keywords Prostatectomy AND orgas* “Prostate cancer” AND orgas* Prostatectomy AND penil* “Prostate cancer” AND penil* “sexual stimulation” AND incontinence AND prostatectomy “foreplay incontinence” AND prostatectomy Climacturia “Altered perception of orgasm” Anorgasm Dysorgasmia “orgasmic dysfunction” AND prostatectomy “Orgasmic related pain” “Peyronies disease” AND prostatectomy
Methods
The review was conducted according to the PRISMA guidelines [6]. The review protocol and search strategy were registered online at http://www.crd.york.ac.uk/Prospero/ under the title “Rare post prostatectomy side effects: a systematic review” (registration number CRD42012003165). We included articles in English, published between January 1980 and June 2013, which investigated orgasmic dysfunction, morphological penile changes, and/or sexually related UI as side effects after open, laparoscopic, and robot-assisted RP. Human studies were considered, and all study designs were included with the exception of case reports. A systematic search of Medline, Web of science, and the online Cochrane library was performed using a predefined search strategy (Table 1). Reference lists from relevant articles were searched manually. Screening of titles, abstracts, and full texts was performed by the primary reviewer (A.F.) and reviewed by the remaining authors to ensure quality. The assessments of biases were performed in accordance with the Cochrane Collaboration’s tool for assessing biases. Extraction of data was performed with a formula including year of publication, authors, sample size, sample mean/median age, time since surgery, incidence of side effects, pathophysiology, changes in side effects over time, treatment, and predicting factors of observed side effects. Only correlations reaching statistical significance on multivariate analyses were included. The results are reported in the same manner as in the original articles. No meta-analysis was conducted because of heterogeneity of the studies.
Main Outcome Measures
The main outcome measure was incidence of the side effects mentioned above. Results from multivariate analyses specifying predicting or associated factors were also included, and pathophysiology and treatment options were described. Results
Included Articles A total of 1,327 articles remained after removing doublets. After screening titles and abstracts, 95 articles were found eligible for full text assessment, and 41 articles were included. Two additional articles were added after screening of reference lists (Figure 1). UI During Sexual Activity OAI after RP was first reported by Koeman et al. in 1996 with 9/14 patients complaining of the problem [7]. Later, Barnas et al. found that, 93% of RP patients had experienced OAI at some point after RP (n = 239) [8]. A more thorough investigation was performed by Lee et al. who found that 19/42 RP patients had the problem at the time of the study [9]. Interestingly, only 47% of these men were bothered by their OAI. Furthermore, 21% considered it a bother to their partners. Coping strategies included emptying the bladder before sexual activity (74%) and the use of condoms (11%). In the samples of both Barnas et al. and Lee et al., 2/3 of men with OAI experienced the problem occasionally or with every orgasm, whereas it was a rare occurrence in the remaining 1/3.
Figure 1 PRISMA flow diagram.
J Sex Med 2014;11:374–385
376
J Sex Med 2014;11:374–385
BNS = bilaterally nerve-spared; FU = follow-up; OAI = orgasm-associated incontinence; SD = standard deviation; SEM = standard error of then mean; UI = urinary incontinence; UISS = urinary incontinence in relation to sexual stimulation; UNS = unilaterally nerve-spared
OAI: 9 out of 14 OAI: 93% OAI: 45% OAI: 20–24% UISS: 38% OAI/UISS: 44% OAI: 39% OAI: 25% Not reported Not reported Not reported 88% BNS, 7% UNS 8 BNS, 12 UNS BNS 83%, UNS 15% Not reported Not reported 14 239 42 475 Subgroup of 24 1,358 691 (sexually active only) 63 Mean 63.1 (range 56–75) Mean 62 (SD 13) Mean 58.9 (range 51–71) Mean 60 (SD 8) Median 59 Mean 58.4 (SEM 6.8) Median 65 (range 41–79) Mean 63.9 (SD 6.7) Koeman et al. (1996) [7] Barnas et al. (2004) [8] Lee et al. (2006) Choi et al. (2007) [10] Guay et al. (2008) [11] Mitchell et al. (2011) [12] Nilsson et al. (2011) [13] Messaoudi et al. (2011) [14]
Mean 27 (range 7–54) months 39.5 (SD 20.8) months 23.6 (range 12–60) months Median 7 months Mean 7.2 (SD 1.2) FU at 3, 6, 12, and 24 months Median 2.2 (range 1–5) years Median 26.8 (range 6–67) months
Incidence of sex UI Nerve-sparing status Sample size Time since surgery Age (years) Author (Year)
Sexually associated urinary incontinence
Pathophysiology of OAI and UISS To date, only one study has investigated the cause of OAI after RP. Here, video-urodynamic evaluations of seven patients with OAI and five controls without OAI were performed. It was found that
Table 2
In a cross-sectional study including 475 RP patients, Choi et al. investigated the incidence of OAI with different surgical techniques [10]. Incidences of 20% and 24% were found with open and laparoscopic RP, respectively. The prevalence of OAI was lowest in patients who had undergone RP more than 12 months before the study (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.22– 0.70, P < 0.01). OAP (OR 2.98, 95% CI 1.17–7.59, P < 0.05) and PS (OR 2.58, 95% CI 1.58–4.19, P < 0.01) were both associated with OAI. No association was found between OAI and nerve-sparing status, UI, or age. In 2008, Guay and Seftel showed that sexually related incontinence is not necessarily restricted to the moment of orgasm [11]. They found that in a group of 24 RP patients without daytime UI, 38% suffered from UISS, defined as leakage in conjunction with kissing, hugging, and genital caressing. The largest study to date investigating UI during sexual activity was conducted by Mitchell et al. [12]. This prospective study included 1,358 RP patients and used the University of California, Los Angeles-prostate cancer index (UCLA-PCI), which does not make a distinction between OAI and UISS. The authors found that 44% complained of some degree of bother 3 months after surgery. This number gradually decreased to 36% 24 months after RP. A total of 22% and 12% complained of major bother because of UI during sexual activity at 3 and 24 months, respectively. A strong association with daytime UI was found (P < 0.0001). A recent study (n = 691) reported that 39% of sexually active RP patients had experienced OAI and that 11% had urine loss during more than half their orgasms [13]. PS (relative risk [RR] 1.4, 95% CI 1.1–1.7), daytime UI (RR 2.0, 95% CI 1.6–2.4), ED (RR 1.3, 95% CI 1.1–1.6), and previous transurethral resection of the prostate (TURP) (RR 1.4, 95% CI 1.0–2.0) were associated with OAI. Adding to the strength of this study was the use of a validated, study-specific questionnaire. Finally, Messaoudi et al. found that 16/63 RP patients had OAI [14]. Out of these patients, 56% found it to be bothersome. Results for UI during sexual activity are summarized in Table 2.
Frey et al.
Neglected Side Effects After Radical Prostatectomy the OAI patients had significantly shorter functional urethral length compared with controls (P = 0.02) [15]. In addition to this finding, it can be speculated that damage to the bladder neck and/or sympathetic nerve damage during surgery may play a role as sympathetic nerve fibers constrict the bladder neck and relax the external sphincter during normal antegrade ejaculation. No studies have been performed on the pathophysiology of UISS, and it is not clear whether it is appropriate to distinguish between OAI and UISS with regard to the pathophysiology.
Treatment for OAI and UISS Some patients with OAI cope by voiding before sexual activity and/or by using a condom. The effectiveness of these strategies has not been investigated, and the practicality of condom use by patients who might suffer from some degree of ED is questionable. Another option is the use of a variable tension penile loop designed to compress the urethra during sexual activity. A case series (n = 124) showed that both the amount (P < 0.01) and frequency (P < 0.01) of urinary leakage at orgasm were reduced with the variable tension penile loop [16]. In effect, bother was reduced for both patients and partners (P < 0.01). A total of 48% of the patients had complete resolution of OAI. Regarding surgical treatments, Jain et al. investigated the effects of artificial urinary sphincters and urethral slings on OAI and UISS in 11 RP patients [17]. They found improvements in sexual quality of life with both treatments. The results suggest that surgical interventions could be a last resort for patients with severe OAI or UISS. Altered Orgasmic Function Helgason et al. were the first to note that 13/20 RP patients experienced distress because of decreased pleasure with orgasm [18]. Koeman et al. found similar results in a study of 14 RP patients [7]. Here, only 4/14 reported unchanged orgasmic function, and 7/14 reported a weakened sensation of orgasm. In both studies, more than half the patients were bothered by dry orgasms. In a larger study, Hollenbeck et al., found that 20% of 671 RP patients had lost the ability to achieve orgasm [19]. Nerve sparing (bilateral vs. nonnerve sparing, P < 0.001) and lower age (P < 0.001) were found to be protective for the orgasmic function. In addition, a prostate weight of 60 years (P = 0.002), as well as poor nerve-sparing status (P = 0.001), was found. Salonia et al. measured orgasmic function with the IIEF-OD in 334 bilaterally nerve-spared (BNS) RP patients [22]. They found an initial decrease in the orgasm frequency scores from an average score of 4.8 before surgery to 3.1 1 year after surgery. Between 2 and 4 years after surgery, scores normalized to 4.7 (95% CI 3.9–5.0). Good erectile function and urinary control were associated with better orgasmic function. Unfortunately, this study suffered a high dropout rate as only 6% of the subjects were included in the analysis 4 years after surgery. In a prospective study, using the orgasm domain of the UCLAPCI, Le et al. included 620 patients before RP [23]. The percentage of patients with a “good” or “very good” ability to achieve orgasm was reduced from 65% at baseline to between 25% and 30% after the operation. Positive correlations with the ability to reach orgasm were found for age
Neglected Side Effects After Radical Prostatectomy: A Systematic Review Anders Ullmann Frey, Jens Sønksen, MD, PhD, DSc (Med), and Mikkel Fode, MD Department of Urology, Herlev University Hospital, Herlev, Denmark DOI: 10.1111/jsm.12403
ABSTRACT
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. Frey, AU, Sønksen J, and Fode M. Neglected side effects after radical prostatectomy: A systematic review. J Sex Med 2014;11:374–385. Key Words. Climacturia; Dysorgasmia; Orgasm-Associated Pain; Penile Length; Radical Prostatectomy
Introduction
P
rostate cancer is a common disease with more than 650,000 new cases each year in the developed countries alone [1]. Radical prostatectomy (RP) has been shown to reduce mortality [2]. Unfortunately, the operation is not without side effects. Destruction or disruption of nerves, blood vessels, and muscular tissue during surgery is known to cause erectile dysfunction (ED) and urinary incontinence (UI). These side effects are well described in the literature [3,4]. Meanwhile, a series of additional sexually related side effects to
J Sex Med 2014;11:374–385
RP has been studied in recent years. These include orgasm-associated incontinence (OAI), urinary incontinence in relation to sexual stimulation (UISS), altered perception of orgasm, orgasmassociated pain (OAP), penile shortening (PS), and penile deformity [5].
Aims
The aim of this systematic review is to summarize the literature regarding the sexually related side effects mentioned above. © 2013 International Society for Sexual Medicine
375
Neglected Side Effects After Radical Prostatectomy Table 1
Search strategy for electronic databases
Keywords Prostatectomy AND orgas* “Prostate cancer” AND orgas* Prostatectomy AND penil* “Prostate cancer” AND penil* “sexual stimulation” AND incontinence AND prostatectomy “foreplay incontinence” AND prostatectomy Climacturia “Altered perception of orgasm” Anorgasm Dysorgasmia “orgasmic dysfunction” AND prostatectomy “Orgasmic related pain” “Peyronies disease” AND prostatectomy
Methods
The review was conducted according to the PRISMA guidelines [6]. The review protocol and search strategy were registered online at http://www.crd.york.ac.uk/Prospero/ under the title “Rare post prostatectomy side effects: a systematic review” (registration number CRD42012003165). We included articles in English, published between January 1980 and June 2013, which investigated orgasmic dysfunction, morphological penile changes, and/or sexually related UI as side effects after open, laparoscopic, and robot-assisted RP. Human studies were considered, and all study designs were included with the exception of case reports. A systematic search of Medline, Web of science, and the online Cochrane library was performed using a predefined search strategy (Table 1). Reference lists from relevant articles were searched manually. Screening of titles, abstracts, and full texts was performed by the primary reviewer (A.F.) and reviewed by the remaining authors to ensure quality. The assessments of biases were performed in accordance with the Cochrane Collaboration’s tool for assessing biases. Extraction of data was performed with a formula including year of publication, authors, sample size, sample mean/median age, time since surgery, incidence of side effects, pathophysiology, changes in side effects over time, treatment, and predicting factors of observed side effects. Only correlations reaching statistical significance on multivariate analyses were included. The results are reported in the same manner as in the original articles. No meta-analysis was conducted because of heterogeneity of the studies.
Main Outcome Measures
The main outcome measure was incidence of the side effects mentioned above. Results from multivariate analyses specifying predicting or associated factors were also included, and pathophysiology and treatment options were described. Results
Included Articles A total of 1,327 articles remained after removing doublets. After screening titles and abstracts, 95 articles were found eligible for full text assessment, and 41 articles were included. Two additional articles were added after screening of reference lists (Figure 1). UI During Sexual Activity OAI after RP was first reported by Koeman et al. in 1996 with 9/14 patients complaining of the problem [7]. Later, Barnas et al. found that, 93% of RP patients had experienced OAI at some point after RP (n = 239) [8]. A more thorough investigation was performed by Lee et al. who found that 19/42 RP patients had the problem at the time of the study [9]. Interestingly, only 47% of these men were bothered by their OAI. Furthermore, 21% considered it a bother to their partners. Coping strategies included emptying the bladder before sexual activity (74%) and the use of condoms (11%). In the samples of both Barnas et al. and Lee et al., 2/3 of men with OAI experienced the problem occasionally or with every orgasm, whereas it was a rare occurrence in the remaining 1/3.
Figure 1 PRISMA flow diagram.
J Sex Med 2014;11:374–385
376
J Sex Med 2014;11:374–385
BNS = bilaterally nerve-spared; FU = follow-up; OAI = orgasm-associated incontinence; SD = standard deviation; SEM = standard error of then mean; UI = urinary incontinence; UISS = urinary incontinence in relation to sexual stimulation; UNS = unilaterally nerve-spared
OAI: 9 out of 14 OAI: 93% OAI: 45% OAI: 20–24% UISS: 38% OAI/UISS: 44% OAI: 39% OAI: 25% Not reported Not reported Not reported 88% BNS, 7% UNS 8 BNS, 12 UNS BNS 83%, UNS 15% Not reported Not reported 14 239 42 475 Subgroup of 24 1,358 691 (sexually active only) 63 Mean 63.1 (range 56–75) Mean 62 (SD 13) Mean 58.9 (range 51–71) Mean 60 (SD 8) Median 59 Mean 58.4 (SEM 6.8) Median 65 (range 41–79) Mean 63.9 (SD 6.7) Koeman et al. (1996) [7] Barnas et al. (2004) [8] Lee et al. (2006) Choi et al. (2007) [10] Guay et al. (2008) [11] Mitchell et al. (2011) [12] Nilsson et al. (2011) [13] Messaoudi et al. (2011) [14]
Mean 27 (range 7–54) months 39.5 (SD 20.8) months 23.6 (range 12–60) months Median 7 months Mean 7.2 (SD 1.2) FU at 3, 6, 12, and 24 months Median 2.2 (range 1–5) years Median 26.8 (range 6–67) months
Incidence of sex UI Nerve-sparing status Sample size Time since surgery Age (years) Author (Year)
Sexually associated urinary incontinence
Pathophysiology of OAI and UISS To date, only one study has investigated the cause of OAI after RP. Here, video-urodynamic evaluations of seven patients with OAI and five controls without OAI were performed. It was found that
Table 2
In a cross-sectional study including 475 RP patients, Choi et al. investigated the incidence of OAI with different surgical techniques [10]. Incidences of 20% and 24% were found with open and laparoscopic RP, respectively. The prevalence of OAI was lowest in patients who had undergone RP more than 12 months before the study (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.22– 0.70, P < 0.01). OAP (OR 2.98, 95% CI 1.17–7.59, P < 0.05) and PS (OR 2.58, 95% CI 1.58–4.19, P < 0.01) were both associated with OAI. No association was found between OAI and nerve-sparing status, UI, or age. In 2008, Guay and Seftel showed that sexually related incontinence is not necessarily restricted to the moment of orgasm [11]. They found that in a group of 24 RP patients without daytime UI, 38% suffered from UISS, defined as leakage in conjunction with kissing, hugging, and genital caressing. The largest study to date investigating UI during sexual activity was conducted by Mitchell et al. [12]. This prospective study included 1,358 RP patients and used the University of California, Los Angeles-prostate cancer index (UCLA-PCI), which does not make a distinction between OAI and UISS. The authors found that 44% complained of some degree of bother 3 months after surgery. This number gradually decreased to 36% 24 months after RP. A total of 22% and 12% complained of major bother because of UI during sexual activity at 3 and 24 months, respectively. A strong association with daytime UI was found (P < 0.0001). A recent study (n = 691) reported that 39% of sexually active RP patients had experienced OAI and that 11% had urine loss during more than half their orgasms [13]. PS (relative risk [RR] 1.4, 95% CI 1.1–1.7), daytime UI (RR 2.0, 95% CI 1.6–2.4), ED (RR 1.3, 95% CI 1.1–1.6), and previous transurethral resection of the prostate (TURP) (RR 1.4, 95% CI 1.0–2.0) were associated with OAI. Adding to the strength of this study was the use of a validated, study-specific questionnaire. Finally, Messaoudi et al. found that 16/63 RP patients had OAI [14]. Out of these patients, 56% found it to be bothersome. Results for UI during sexual activity are summarized in Table 2.
Frey et al.
Neglected Side Effects After Radical Prostatectomy the OAI patients had significantly shorter functional urethral length compared with controls (P = 0.02) [15]. In addition to this finding, it can be speculated that damage to the bladder neck and/or sympathetic nerve damage during surgery may play a role as sympathetic nerve fibers constrict the bladder neck and relax the external sphincter during normal antegrade ejaculation. No studies have been performed on the pathophysiology of UISS, and it is not clear whether it is appropriate to distinguish between OAI and UISS with regard to the pathophysiology.
Treatment for OAI and UISS Some patients with OAI cope by voiding before sexual activity and/or by using a condom. The effectiveness of these strategies has not been investigated, and the practicality of condom use by patients who might suffer from some degree of ED is questionable. Another option is the use of a variable tension penile loop designed to compress the urethra during sexual activity. A case series (n = 124) showed that both the amount (P < 0.01) and frequency (P < 0.01) of urinary leakage at orgasm were reduced with the variable tension penile loop [16]. In effect, bother was reduced for both patients and partners (P < 0.01). A total of 48% of the patients had complete resolution of OAI. Regarding surgical treatments, Jain et al. investigated the effects of artificial urinary sphincters and urethral slings on OAI and UISS in 11 RP patients [17]. They found improvements in sexual quality of life with both treatments. The results suggest that surgical interventions could be a last resort for patients with severe OAI or UISS. Altered Orgasmic Function Helgason et al. were the first to note that 13/20 RP patients experienced distress because of decreased pleasure with orgasm [18]. Koeman et al. found similar results in a study of 14 RP patients [7]. Here, only 4/14 reported unchanged orgasmic function, and 7/14 reported a weakened sensation of orgasm. In both studies, more than half the patients were bothered by dry orgasms. In a larger study, Hollenbeck et al., found that 20% of 671 RP patients had lost the ability to achieve orgasm [19]. Nerve sparing (bilateral vs. nonnerve sparing, P < 0.001) and lower age (P < 0.001) were found to be protective for the orgasmic function. In addition, a prostate weight of 60 years (P = 0.002), as well as poor nerve-sparing status (P = 0.001), was found. Salonia et al. measured orgasmic function with the IIEF-OD in 334 bilaterally nerve-spared (BNS) RP patients [22]. They found an initial decrease in the orgasm frequency scores from an average score of 4.8 before surgery to 3.1 1 year after surgery. Between 2 and 4 years after surgery, scores normalized to 4.7 (95% CI 3.9–5.0). Good erectile function and urinary control were associated with better orgasmic function. Unfortunately, this study suffered a high dropout rate as only 6% of the subjects were included in the analysis 4 years after surgery. In a prospective study, using the orgasm domain of the UCLAPCI, Le et al. included 620 patients before RP [23]. The percentage of patients with a “good” or “very good” ability to achieve orgasm was reduced from 65% at baseline to between 25% and 30% after the operation. Positive correlations with the ability to reach orgasm were found for age
