Most of the post-radical prostatectomy sexual dysfunction literature has focused specifically on erectile dysfunction, and changes in orgasm have been reported in post-prostatectomy patients [14-16]. Orgasm, which is often considered to be a goal and reinforcer of sexual behavior, remains the least understood phase of the sexual response cycle. Alterations in orgasm, and in particular its absence, are associated with significant reductions in emotional and physical satisfaction, which in turn may lead to sexual avoidance behavior and secondary relationship discord [17-18].
Barnas et al., in a questionnaire-based analysis, demonstrated that orgasmic dysfunction is a relatively prevalent problem in the post-RP population . The alterations identified in this study include complete absence of orgasm, alterations in intensity, and orgasmic pain. Decreased intensity of orgasm or the complete lack of orgasm was reported by 74% of the patients surveyed. Fourteen percent of the patient population experienced orgasmic pain
(dysorgasmia) at some time after surgery. Goriunov etal. have reported on orgasm alterations in surgically-treated BPH patients . This group reported that 188 of 818 (23%) such patients suffered from dysorgasmia after their surgery. Koeman reported pain during orgasm in 11% post-radical prostatectomy patients, and 82% complained of diminished orgasmic intensity after surgery . Bergman's study of 43 men who had undergone cystoprostatectomy for bladder cancer found 25% of post-operatively sexually active men were unable to attain orgasm, and 17% of those able to achieve orgasm by masturbation found the sensation impaired . Teg et al. reported that 36% post-prostatectomy patients who had benign prostatic hypertrophy (BPH) described their sensation of orgasm to be "different" after surgery .
The etiology of dysorgasmia is not well understood. It has been postulated that the physiologic bladder neck closure that occurs contemporaneous with orgasm in the men, translates into spasm of the vesico-urethral anastomosis, or pelvic floor musculature dystonia in the RP population. This phenomenon has been purported to be associated with penile and testicular pain in men with chronic pelvic pain disorder . The latter group frequently reports orgasmic pain, and the similarity of the complaints between the two groups at this center are striking. The muscle spasm concept is supported by the experience that amelioration of dysorgasmia can be seen using the a-blocking agent tamsulosin (Boehinger-Ingelheim, Germany) . In 98 patients, 77% patients reported improvement in pain and 8% noted complete resolution of their pain using tamsulosin, 0.4 mg po QD. Using a visual analog scale (0 to 10) for pain tamsulosin therapy resulted in a statistically significant decrease in pain, with a mean decrease of 2.7 points between pre- and post-treatment phases. Anorgasmia and decreased intensity of orgasm are most probably psychologic events, presumably related to the multiple issues that men with a diagnosis of prostate cancer and who have undergone major radical pelvic surgery experience.
Finally, recent attention has been focused on orgasm-associated urinary incontinence (OAI), what has become to be termed "climacturia". This troubling problem is a clear barrier to the resumption of satisfactory sexual relations for many couples. Lee et al. analyzed 42 sexually active men at least one year after RP . All patients underwent IPSS score and uroflow analysis. Forty-five percent of men reported climacturia, 68% of these reported rare occurrence. Fifty-two percent of patients stated that this was not bothersome, but 21% said that this was bothersome to the partner. Age was not a predictor of climacturia. There was no association between Q max or IPSS and the incidence of climacturia (P = 0.20 and 0.15, respectively).
Aboussally et al. reported on the Cleveland Clinic experience of 200 patients evaluated, that 26 men experienced urine leak almost exclusively at the time of orgasm . The average age of the patients was 62 years and there was no clear association with degree of nerve sparing or daytime continence level. Patients experienced anywhere from 3-120 ml of urine leak (by patient self-report) at the time of orgasm.
Most recently, Choi et al. at Memorial Sloan Kettering Cancer Center analyzed 392 patients for this problem . Fourteen percent (47/392) reported orgasm-associated urine leak (OAI). No difference in OAI rates were noted based on nervesparing or type of radical pelvic surgery. Men reporting OAI were more likely to complain of penile length loss (44%) than men not reporting OAI (26%, P< 0.01). Likewise, they were more likely to report orgasm pain (18.5%) compared to men without OAI (2%, p < 0.01). On multivariate analysis, both factors remained predictive: reporting penile length loss, OR =2.25, P < 0.01; orgasm pain, OR = 10.42, P < 0.01.
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