Pretreatment evaluation of sexual function in patients with adenocarcinoma of the prostate

Prostatic irradiation-induced sexual dysfunction: A review and multidisciplinary guide to management in the radical radiotherapy era (Part II on Urological Management)

Prostate cancer is the most common malignancy in men and the second leading cause of cancer-related death in men. Radiotherapy is a curative option that is administered via external beam radiation, brachytherapy, or in combination. Sexual dysfunction is a common toxicity following radiotherapy, similar to men undergoing radical prostatectomy, but the etiology is different. The pathophysiology of radiation-induced sexual dysfunction is multi-factorial, and the toxicity is a major cause of impaired quality of life among long-term prostate cancer survivors. Management of a patient's sexual function during and after radiotherapy requires multidisciplinary coordination of care between radiation oncology, urology, psychiatry, pharmacy, and dermatology. This review provides a framework for clinicians to better understand prostatic radiotherapy-induced sexual dysfunction diagnosis, evaluation, and a patient-centered approach to toxicity preventive strategies and management.

Changes in sexual functioning from 6 to 12 months following traumatic brain injury: a prospective TBI model system multicenter study

OBJECTIVE

To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury.

MAIN MEASURES

Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI).

RESULTS

Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied).

CONCLUSIONS AND IMPLICATIONS

Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: a TBI model systems multicenter study

OBJECTIVE

To investigate predictors of sexual functioning 1 year following traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

A total of 255 persons with TBI (187 males; 68 females) who had been treated at 1 of 6 TBI Model Systems inpatient rehabilitation units and were living in the community.

MAIN MEASURES

Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Satisfaction With Sexual Functioning (Global Sexual Satisfaction Index); Participation Assessment With Recombined Tools-Objective; Patient Health Questionnaire-9.

RESULTS

Older age, female gender, and more severe injury were associated with greater sexual dysfunction 1 year following injury. As age increased from 24 to 49 years, the odds of sexual impairment increased more than 3-fold (95% confidence interval: 1.82-5.88). Females had a 2.5 increase in odds of sexual impairment compared with males (95% confidence interval: 1.23-5.26). Greater social participation was predictive of better sexual functioning. Dissatisfaction with sexual functioning was predicted by older age and depression.

CONCLUSIONS AND IMPLICATIONS

Older persons and females appear to be at greater risk for sexual dysfunction after TBI and may benefit from specialized assessment and treatment services. Relationships were identified between social participation and sexual function and between depression and sexual satisfaction that may serve as clinical indicators for further assessment and intervention. Further research is needed to elucidate these relationships and identify effective clinical approaches.

A systematic review of sexual dysfunction measures for gay men: how do current measures measure up?

The measurement of subjective components of sexual functioning is of increasing importance in clinical research and practice. Differences have been reported in prevalence rates and experiences of sexual difficulties between heterosexual and gay men. The aim of this article is to identify reliable and valid measures of sexual dysfunction suitable for use with gay men. Seven measures were reviewed; details about item development, dimensionality, reliability, and validity are provided. Heteronormative and heterosexist wording were evident throughout. Several areas of concern emerged in relation to psychometric properties (e.g., questionable validity). No psychometrically robust sexual function measure was identified for use with gay populations.

Sexual functioning 1 year after traumatic brain injury: findings from a prospective traumatic brain injury model systems collaborative study

OBJECTIVE

To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals.

RESULTS

Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all.

CONCLUSIONS

Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning.

Sexuality after treatment of head and neck cancer: findings based on modification of sexual adjustment questionnaire

OBJECTIVES/HYPOTHESIS

Evaluate sexual dysfunction in patients after treatment for head and neck cancer.

STUDY DESIGN

Single-institution cross-sectional study.

METHODS

Our modified Sexual Adjustment Questionnaire was administered to 42 patients (mean age, 55.1 years) and included seven questions (total score, 7-35). Based on sexual satisfaction ratings, we categorized three groups as unsatisfied (7-16), satisfied (17-25), and very satisfied (26-35). Clinical information was obtained by reviewing medical records. Bivariate analysis tested associations between sexual satisfaction and patient-related factors (e.g., sex, age, site/cancer stage, treatment, time between treatment and survey, partner, alcohol/tobacco consumption). Pearson correlation was used to analyze two continuous variables, and multivariate logistic regression analysis was used to evaluate the independent impact of each factor.

RESULTS

All 42 patients rated that head and neck cancer negatively impacted their sexual relationships, including 21 (50%) rating effects as negative or extremely negative. Men reported higher satisfaction scores with sexual function (mean ± standard deviation) than women (19.9 ± 5.0 vs. 16.3 ± 6.5, respectively; P = .06). Respondents with partners reported higher scores than those without partners (19.9 ± 5.3 vs. 14.1 ± 4.4, respectively; P = .01). When the survey was administered (median, 12 months; range, 4-33 months) after the first treatment, mean score was 19; 57% of respondents were sexually satisfied, 31% were unsatisfied, and 12% were very satisfied. Instrument reliability was .82 (Cronbach alpha).

CONCLUSIONS

Patients who are male and ≤ 60 years have a higher probability of sexual satisfaction during recovery. Our sexual dysfunction questionnaire will be administered in further prospective studies in patients with head and neck cancer.

Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction"

OBJECTIVE

To explore perceptions of the impact of erectile dysfunction on men who had undergone definitive treatment for early nonmetastatic prostate cancer.

DESIGN

Seven focus groups of men with early prostate cancer. The groups were semistructured to explore men's experiences and quality-of-life concerns associated with prostate cancer and its treatment.

SETTING

A staff model health maintenance organization, and a Veterans Affairs medical center.

PATIENTS

Forty-eight men who had been treated for early prostate cancer 12 to 24 months previously.

RESULTS

Men confirmed the substantial effect of sexual dysfunction on the quality of their lives. Four domains of quality of life related to men's sexuality were identified: 1) the qualities of sexual intimacy; 2) everyday interactions with women; 3) sexual imagining and fantasy life; and 4) men's perceptions of their masculinity. Erectile problems were found to affect men in both their intimate and nonintimate lives, including how they saw themselves as sexual beings.

CONCLUSIONS

Erectile dysfunction, the most common side effect of treatment for early prostate cancer, has far-reaching effects upon men's lives. Assessment of quality of life related to sexual dysfunction should address these broad impacts of erectile function on men's lives. Physicians should consider these effects when advising men regarding treatment options. Physicians caring for patients who have undergone treatment should address these psychosocial issues when counseling men with erectile dysfunction.

Sexual functioning in patients with localized prostate cancer awaiting treatment

This article evaluates current sexual functioning in patients with prostate cancer who are awaiting treatment. One-hundred fifty-eight patients filled out a 15-item questionnaire regarding current sexual functioning. Median age was 67 years. Sixty percent reported to have spontaneous erections at least once a week, and 37% reported a good firmness. Thirty-five percent reported that during sexual activity they had no difficulty in getting erections, and 33% reported that they had no difficulty in maintaining an erection. After diagnosis, all patients reported a decrease in sexual interest, activity, and pleasure. Diagnosis of prostate cancer does have an impact on sexual functioning, therefore sexual counseling prior to treatment is advised.

Sexual difficulties of chronic pain patients

OBJECTIVE

Description of the specific physical and psychological problems associated with sexual activity in patients with chronic pain.

DESIGN

Self-completion questionnaire on extent and nature of sexual difficulties related to pain; data on psychological and physical function in respondents; personal and medical data for respondents and nonrespondents.

PATIENTS

Three hundred twenty-seven patients with chronic pain in inpatient and outpatient pain programs; 237 (72%) completed the questionnaire.

MEASURES

Extent of general and specific sexual problems; anxiety and depression (Hospital Anxiety and Depression Scale [HAD]); pain self-efficacy; pain-related disability (Sickness Impact Profile); drug use.

RESULTS

Respondents were younger and had less depressed mood than nonrespondents, but there were no other major differences. Seventy-three percent of respondents had pain-related difficulty with sexual activity; most had several, in various combinations of problems with arousal, position, exacerbating pain, low confidence, performance worries, and relationship problems. All except position difficulties were associated with less frequent sexual activity. There were few differences between men and women, and only weak relations emerged between specific problems and mood and disability.

CONCLUSIONS

There is a high prevalence of sexual difficulties in patients with chronic pain attending treatment, nearly double that of a general UK survey. These difficulties are not simply related to mood or disability. The range of problems and patients' expressed preferences for help suggest that multidisciplinary intervention is required.

Sexuality and sexual adjustment of patients with chronic pain

PURPOSE

To describe sexual functioning and its relationship with psychological measures in chronic pain patients.

METHOD

It is a self report survey with a convenience sample. Seventy consenting chronic pain patients responded to a questionnaire. Mean age was 49.9 years (range 29-74); mean pain duration was 146.7 months (range 6-624). Participants endorsed a wide variety of pain conditions. INSTRUMENTS USED: (1) Derogatis Inventory of Sexual Functioning; (2) Multidimensional Pain Inventory; (3) Center for Epidemiological Studies Depression Scale: (4) Multidimensional Health Locus of Control; (5) Hopkins Symptom Check List; (6) Vanderbilt Pain Management Inventory; (7) Coping Strategies Questionnaire.

RESULTS

Sixty-six per cent of patients were interested in sex, 50% were satisfied with current sexual partner and 20% considered current sexual life to be adequate. Over 70% fantasized at least once a month. Only 44% experienced normal arousal during intercourse; 33% practiced masturbation and 47% were involved in sexual intercourse or oral sex at least once a month. The majority were dissatisfied with orgasmic activities. No relationship was found between pain severity, duration, frequency and sexual functioning. A relationship was found between disability status, age and several psychological variables and various domains of sexual functioning. CONCLUSIONS; Sexual problems are common in chronic pain patients. Patients who reported symptoms of depression and distress had more sexual problems.

Sexuality in head and neck cancer patients

OBJECTIVE

To describe sexual functioning and its relationship with age, extent of disfigurement, performance status, and psychological functioning in head and neck cancer patients following radiation therapy with or without surgery.

DESIGN

Descriptive study, self-report survey, convenience sample.

SETTING

Academic tertiary care Veterans Administration Medical Center.

PATIENTS

Fifty-five of 101 consenting patients responded to the questionnaire. Mean age of the patients was 65.1 years (range 48 to 76); 54 were men. The mean duration since diagnosis was 30.6 months (range 3 to 216). All patients received radiation therapy and 26 also underwent surgery.

MAIN OUTCOME MEASURES

Instruments included were: The Derogatis inventory of Sexual Functioning, Multidimensional Health Locus of Control. The Center for Epidemiological Studies Depression Scale, Hopkins Symptom Check List, and List Performance Status Scale.

RESULTS

Eighty-five percent showed interest in sex. Fifty-eight percent were satisfied with their current sexual partner and 49% were satisfied with their current sexual functioning. Most of them were able to fantasize: however, a majority reported arousal problems, 58% did not participate in sexual intercourse, and 58% had orgasmic problems. Most patients were not depressed. As a group these patients reported significantly more somatic distress but significantly less generalized feeling of distress when compared with a group of nonpatient nurses. Patients with "powerful others" locus of control showed significantly worse sexual functioning. There was no correlation between sexual functioning and performance status or severity of disfigurement. Patients younger than 65 years of age had more advanced disease, lower performance status and significantly poorer sexual functioning; those older than 65 years were more satisfied with their sexual partner and current sexual functioning.

CONCLUSION

Despite experiencing sexual problems, sexuality continues to be a priority in the majority of patients studied.

The Derogatis Interview for Sexual Functioning (DISF/DISF-SR): an introductory report

The current report describes a program of research designed to demonstrate the psychometric characteristics and validity of the Derogatis Interview for Sexual Functioning (DISF/DISF-SR), a set of brief, gender-keyed, multidimensional outcome measures designed to measure quality of sexual functioning. The primary goals of the development of the DISF/DISF-SR are outlined within the context of the principal measurement parameters involved in human sexual functioning. The development and rationale for both interview (DISF) and matching self-report (DISF-SR) versions of the instrument are presented, as is the rationale for developing distinct male and female forms. The studies described evaluate the reliabilities of both modalities of the DISF/DISF-SR and demonstrate confirmation for the hypothesized internal structure of the test. Research is provided that demonstrates dimensional uniqueness in subtest-total score relationships, and several studies are reviewed that show high discriminative validity for the DISF/DISF-SR in medical and community cohorts. The initial norms for the DISF/DISF-SR are also reviewed and described.

Sexual potency following interactive ultrasound-guided brachytherapy for prostate cancer

PURPOSE

The effect of a therapeutic modality on sexual potency is often an important consideration for patients choosing a treatment for prostate cancer. We prospectively assessed patients' penile erectile function before and following interactive ultrasound-guided transperineal permanent radioactive seed implantation to determine its effect on sexual function.

METHODS AND MATERIALS

Eighty-nine patients underwent permanent radioactive seed implantation from June 1990 to April 1994 for localized prostate cancer (T1-T2) and were followed for a median of 15 months (1.5-52 months). 125I seeds were implanted in 73 patients with a combined Gleason grade of 2-6, and 103Pd seeds were implanted in 16 patients with higher grade lesions. The sexual potency of these patients was assessed prior to, at 3 and 6 months, and every 6 months after implantation. Erectile function was graded using a numerical score of 0 to 3 (0 = impotent (no erections), 1 = ability to have erections but insufficient for vaginal penetration, 2 = erectile function sufficient for vaginal penetration but suboptimal, 3 = normal erectile function). The pretreatment potency scores were as follows: 0 in 24 patients, 1 in 6 patients, 2 in 22 patients, and 3 in 37 patients.

RESULTS

The actuarial impotency rates (score = 0) following implantation for those patients possessing some degree of erectile function prior to implantation (65 patients) were 2.5% at 1 year and 6% at 2 years. The actuarial decrease in sexual function rates (a drop in score of at least one point) were 29% at 1 year and 39% at 2 years. Only two patients became impotent following treatment and this occurred at 1 year and 16 months. The time period for a decrease in erectile function to occur ranged from 1.8 months to 32.7 months, with a median of 6.8 months. Patients with higher grade tumors showed a greater decrease in potency score compared to patients with lower grade tumors.

CONCLUSION

Interactive ultrasound-guided transperineal brachytherapy for the treatment of localized prostate cancer is associated with preservation of erectile function in the vast majority of patients, although a minor decrease in potency is not uncommon.

Preservation of function in genitourinary cancers: psychosexual and psychosocial issues

GU cancers are commonly associated with treatment-related sexual dysfunction, varying from mild to severe. For the clinical oncologist, it is important to be aware that sexual problems or sexual dysfunction may occur as a result of any aspect of cancer and cancer treatment. Sexual function is sensitive to the effects of trauma, both physical and emotional. This is particularly the case for patients whose cancer affects their genitals. Despite some commonalities of psychosocial and psychosexual issues in GU patients across diagnostic categories, GU patients do not present as one distinct, homogeneous group. GU neoplasms, with the exception of bladder cancer, affect mostly men. Men and women tend to differ in their ways of dealing with emotional distress and physical illness. While the man may typically do well using denial as a defense and may not want to discuss his feelings about his diagnosis and treatment, his partner may suffer if her way of coping is oriented toward communicating thoughts and feelings about the situation. Another important difference in this population is related to age and developmental differences. Testicular cancer typically is diagnosed in young men between the ages of 15 and 34 (46). The patients often still live with their parents or have just formed families of their own. In contrast, prostate cancer is diagnosed in older men, who are at a completely different stage in their lives when they have to deal with this challenge. Developmental stage at the time of diagnosis and treatment is an important variable in adaptation to cancer (47). Since GU malignancies and their treatments directly or indirectly affect sexual organs and sexual functioning, issues of sexual body image and identity as men or women are frequent concerns for GU patients. This is most obviously the case for men facing penectomy or orchiectomy. Similarly, women undergoing cystectomy with its simultaneous removal of uterus, ovaries, and parts of the vaginal wall face issues regarding their femininity as well as doubts about future sexual functioning. However, body image concerns are not limited to these two groups but may affect any cancer patient. The experience of having lost all hair due to chemotherapy, bearing of surgical scars, lost or altered functioning, and just the realization of having had cancer may change the way a patient feels about his/her body permanently.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexual rehabilitation after treatment for prostate cancer

Although there is little evidence that sexual behavior causes prostate cancer, men with prostate cancer often have sexual dysfunction before the cancer diagnosis is made. Each treatment for prostate cancer increases the prevalence of sexual problems. After nerve-sparing radical prostatectomy, the chance of recovering erections is better for men who are younger and in whom both neurovascular bundles can be spared. Definitions of "potency" after nerve-sparing surgery have not specified the rigidity of the erections achieved. Thus, some men classified as "potent" may wish additional sexual rehabilitation. The chance that definitive radiation therapy will cause erectile dysfunction probably has been overestimated. The prevalence rate may be closer to 25% of men with new problems compared with the 50% often cited in the literature. Men are more at risk to have erection problems after radiation therapy if the quality of erections before treatment was borderline. Hormonal therapy has an impact on the central mechanisms mediating sexual desire and arousability. Therefore, with most treatment methods, only approximately 20% of men remain sexually functional. Newer antiandrogenic drugs interfere less with sexual function, but their long-term ability to control prostate cancer is still under investigation. Sexual rehabilitation should be addressed by the primary care team. Sexual partners should be included in brief sexual counseling, even when a mechanical treatment for erectile dysfunction is prescribed.