'Potency': the validation of information from a self-administered questionnaire using objective measurements of night-time erections and test-retest reliability

Depression and prostate cancer: implications for urologists and oncologists

Many patients with prostate cancer experience severe levels of depression, which can negatively affect their treatment and disease course. Some prostate cancer treatments can increase the severity of a patient's depression, for example, by increasing anhedonia and erectile dysfunction. Depression is often thought of as a unitary phenomenon, but multiple subtypes can be distinguished. This variety of manifestations challenges the successful application of universal antidepressant treatment options and argues for a multi-symptom assessment process that considers a patient's disease burden and their particular form of depression. Inclusion of screening and detailed diagnosis of depression can be argued to be part of good practice, and clinicians are urged to consider when and how this might be accomplished within their urological practice.

Removing the urinary catheter on post-operative day 2 after robot-assisted laparoscopic radical prostatectomy: a feasibility study from a single high-volume referral centre

The indwelling urinary catheter (UC) is a significant bother for men after radical prostatectomy (RP) and should be removed as soon as possible without jeopardizing the outcome. Our aim was to assess the feasibility and safety of its removal on postoperative day (POD) 2 after robot-assisted laparoscopic RP (RALP). A consecutive series of patients undergoing RALP for localized prostate cancer (PCa) were prospectively enrolled. Inclusion criteria were: no bladder-neck reconstruction, watertight urethrovesical anastomosis at 150 ml filling, ≤ 200 ml of intraoperative bleeding, ≤ 80 ml of fluid from the drain on POD 1, clear urine from the UC on POD 2. Patients were discharged on POD 2. Continence was assessed at catheter removal and 1, 3 and 6 months after surgery. Urethrovesical anastomosis was performed with a standard technique on 3 layers. Sixty-six patients were enrolled. The UC was removed on POD 2 in all the cases and 96.4% of the patients were discharged on POD 2. Re-catheterization was needed 16 times and it was always performed easily. Twenty-four complications were reported by 20 patients, mostly Clavien-Dindo (CD) grade II; 2 CD IIIB complications were observed. No anastomotic strictures were diagnosed. At catheter removal, 29% of the patients were completely continent, 41% at 1 month, 67% at 3 months and 92% at 6 months. In selected patients, removing the UC 48 h after RALP is feasible and safe and has no negative impact on continence if compared with the best international standards.

Age-stratified cut-off points for the nocturnal penile tumescence measurement using Nocturnal Electrobioimpedance Volumetric Assessment (NEVA(®) ) in sexually active healthy men

The current nocturnal penile tumescence (NPT) measurement is based on standard cut-off levels defined regardless of age. This study was conducted to provide age-stratified cut-off points for NPT measurement. Forty sexually active healthy men between 20 and 60 years old were enrolled and divided equally into four groups defined by age (20-29, 30-39, 40-49 and 50-60 years.). None of the candidates had sexual dysfunction or sleep disturbance or used supportive medication to enhance sexual function. Erectile function was evaluated by using the 5-item version of the international index of erectile function (IIEF-5). NPT was observed using the nocturnal electrobioimpedance volumetric assessment (NEVA(®) ). The NPT values of healthy men aged 20-60 years varied from 268.7% to 202.3%. The NPT differed significantly between age groups (P < 0.0009); however, no significant differences between men aged 30-39 and 40-49 (P = 0.593) were observed. Age was weakly associated with IIEF-5 scores (P = 0.004), whereas a strong and negative correlation between age and NPT (P < 0.0001) was found. IEF-5 scores were not significantly associated with NPT (P = 0.95). Therefore, the standard values for NPT testing should be considered in the evaluation of the nocturnal penile activity of men of all ages.

Effects of hypoxia on nocturnal erection quality: a case report from the Manaslu expedition

INTRODUCTION

High altitude environment represents a fine model to study physiological and pathophysiological effects of oxygen availability on sleep-related erections (SREs).

AIM

To describe altitude-dependent effects on quality of SREs in order to estimate the role of hypoxia in erection physiology.

METHODS

A healthy 37-year-old male mountain climber underwent a chronic high altitude-related hypoxia experience during the 43 days of the Manaslu expedition (Nepal). SREs were recorded by RigiScan (Timm Medical Technologies, Inc., Eden Prairie, MN, USA) at altitudes ranging from 0 to 5,800 m above sea level. The erection-related parameters assessed were: number, duration, event duration (% of session), event rigidity %, time rigidity %, tumescence and rigidity activated unit, and event tum % > bline (%).

MAIN OUTCOMES MEASURES

SREs were recorded by RigiScan at altitudes ranging from 0 to 5,800 m above sea level.

RESULTS

Erectile parameters showed an altitude-related reduction during the hypoxic exposure, although all functional alterations were reverted by the return to sea level.

CONCLUSIONS

Our case report supports the hypothesis that oxygen availability and delivery could play an important role in the regulation of local penile erection-related mechanisms and that low oxygen levels might be considered an etiological cofactor in erectile dysfunction.

Reliability of assessment of urgency and other symptoms indicating anal sphincter, large bowel or urinary dysfunction

OBJECTIVE

The Radiumhemmets Scale of Disease-Specific Symptom Assessment-Prostate Cancer has been used in several studies. However, no test-retest reliability study of it has been conducted concerning the assessment of urinary, anal sphincter or large bowel function. The aim of this study was to evaluate the reliability of items assessing these functions.

MATERIAL AND METHODS

We investigated 89 prostate cancer patients randomly selected from a group of patients diagnosed in Stockholm. The patients answered 24 questions assessing anal sphincter, large bowel and urinary function twice, with a 3-week interval in-between, to assess reliability.

RESULTS

Most of the questions assessing bowel and urinary symptoms showed substantial or near-perfect agreement. The kappa value for bowel symptom items was > or = 0.60 for all items, except for defecation urgency (0.40-0.55). The kappa value for urinary symptom items varied between 0.43 and 1.0, except for urinary urgency (0.30-0.39).

CONCLUSIONS

When comparing the impact of different symptoms of anal sphincter, large bowel or urinary tract dysfunction, it may be important to consider that defecation urgency and urinary urgency have the highest measuring error (low reliability). This error dilutes assessed associations with, for example, decreased quality of life. Nevertheless, the test-retest reliability for anal sphincter, large bowel and urinary symptoms indicates that surveys yield meaningful information.

Are consecutive nightly recordings required for valid evaluation of sleep-associated erections?

We questioned the need for more than one RigiScan recording for accurate assessment of sleep-associated penile erections and determine the necessity of consecutive nightly recordings for valid evaluation of sleep-associated erections. Men complaining of erectile dysfunction (ED) and referred to RigiScan evaluation for the first time participated. Recordings were performed at the patient's home during two consecutive nights, and data on test time, number of erections, erection duration, minimal and maximal base and tip tumescence and rigidity were retrieved for both nights. Normal erectile function was defined with the recording of at least one erection (70 out of 100% tip rigidity lasting for at least 10 min during either night). The main outcome measures were RigiScan recordings. Group 1 consisted of 29 men (mean age 42.4+/-13.8 years, range 22-71) who had normal erections, all during the first night. Group 2 consisted of 26 men (mean age 48.6+/-13.5 years, range 25-70) who failed to fulfill both criteria for normal erection. In Group 2, only the values for penile base rigidity and erection duration were normal during the first night: the parameters of maximal base tumescence, tip rigidity, number of effective erections and duration of effective erections that were impaired during the first night were significantly worse (P<0.01) during the second night. The required information for the diagnosis of psychogenic ED was obtained during the first night in >50% of the participants. Men with normal erections during the first night can be spared the inconvenience and cost of re-testing. Consecutive night recording should be reserved for patients whose recorded data during the first night did not fulfill the criteria for normal erection.

Comparison of the International Index of Erectile Function erectile domain scores and nocturnal penile tumescence and rigidity measurements: does one predict the other?

OBJECTIVE

To describe the relationship between the International Index of Erectile Function (IIEF) erectile domain score, and nocturnal penile tumescence and rigidity values measured by RigiScan (Timm Medical Technologies, Eden Prairie, MN).

PATIENTS AND METHODS

In all, 73 men were evaluated with the IIEF and 2 nights of continuous penile monitoring with the RigiScan. Twenty-six men were evaluated before and after prostatectomy, for a total of 99 pairs of data points. We dichotomized the RigiScan results as 'adequate' (no erectile dysfunction, ED), or 'inadequate' (having ED), based on the 'best erectile event' over the 2 nights of monitoring. Two separate criteria for adequate erectile function were used, one of >70% rigidity for > or = 10 min, and the other >60% rigidity for > or = 10 min. The erectile domain score of the IIEF was calculated in the standard fashion.

RESULTS

Using both the 70% and the 60% rigidity criteria, there was a statistically significant association between the IIEF erectile domain scores and the RigiScan data (r = 0.27, P = 0.008 and r = 0.29, P = 0.003, respectively). However, the sensitivity of the IIEF to predict ED based on RigiScan results using the 70% rigidity criteria was 68.9%, and the specificity was 57.1%. When the IIEF was used as a continuous predictor of RigiScan results, the area under the receiver-operating characteristic (ROC) curve was 0.66. Using the 60% criteria, the sensitivity was 55.8% and the specificity was 73.2%; the area under the ROC curve was 0.72.

CONCLUSIONS

IIEF erectile domain scores and nocturnal penile tumescence and rigidity measurements are weakly associated, and the clinical utility of one test to predict the other is limited. However, because of the differences in the measured outcomes (perception of erectile function vs physiological capacity), a weak association does not disqualify either test's individual utility.

Toward a definition of a threshold for harmless doses to the anal-sphincter region and the rectum

PURPOSE

To investigate dysfunction caused by unwanted radiation to the anal-sphincter region and the rectum.

METHODS AND MATERIALS

A questionnaire assessing bowel symptoms, sexual function, and urinary symptoms was sent to 72 patients with clinically localized prostatic adenocarcinoma treated by external beam radiation therapy at the Radiumhemmet, Karolinska Hospital, in Stockholm, Sweden, 2-4 years after treatment. The mean percentage dose-volume histograms for patients with and without the specific symptom were calculated.

RESULTS

Of the 65 patients providing information, 9 reported fecal leakage, 10 blood and mucus in stools, 10 defecation urgency, and 7 diarrhea or loose stools. None of the 19 and 13 patients who received, respectively, a dose of > or =35 Gy to < or =60% or > or =40 Gy to < or =40% of the anal-sphincter region volume reported fecal leakage (p < 0.05). In dose-volume histograms, a statistically significant correlation was found between radiation to the anal-sphincter region and the risk of fecal leakage in the interval 45-55 Gy. There was also a statistically significant correlation between radiation to the rectum and the risk of defecation urgency and diarrhea or loose stools in the interval 25-42 Gy. No relationship was found between anatomic rectal wall volume and the investigated late effects.

CONCLUSIONS

Although the limited data in this study prevent the definition of a conclusive threshold regarding volume and dose to the anal-sphincter region and untoward morbidity, it seems that careful monitoring of unnecessary irradiation to this area should be done because it can potentially help reduce the risk of adverse effects, such as fecal leakage. Future studies should pay more attention to the anal-sphincter region and help to more rigorously define its radiotherapeutic tolerance.

THE CONTEMPORARY MANAGEMENT OF PROSTATE CANCER IN THE UNITED STATES: LESSONS FROM THE CANCER OF THE PROSTATE STRATEGIC UROLOGIC RESEARCH ENDEAVOR (CAPSURE), A NATIONAL DISEASE REGISTRY

PURPOSE

The epidemiology and treatment of prostate cancer have changed dramatically in the prostate specific antigen era. A large disease registry facilitates the longitudinal observation of trends in disease presentation, management and outcomes.

MATERIALS AND METHODS

The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) is a national disease registry of more than 10000 men with prostate cancer accrued at 31 primarily community based sites across the United States. Demographic, clinical, quality of life and resource use variables are collected on each patient. We reviewed key findings from the data base in the last 8 years in the areas of disease management trends, and oncological and quality of life outcomes.

RESULTS

Prostate cancer is increasingly diagnosed with low risk clinical characteristics. With time patients have become less likely to receive pretreatment imaging tests, less likely to pursue watchful waiting and more likely to receive brachytherapy or hormonal therapy. Relatively few patients treated with radical prostatectomy in the database are under graded or under staged before surgery, whereas the surgical margin rate is comparable to that in academic series. CaPSURE data confirm the usefulness of percent positive biopsies in risk assessment and they have further been used to validate multiple preoperative nomograms. CaPSURE results strongly affirm the necessity of patient reported quality of life assessment. Multiple studies have compared the quality of life impact of various treatment options, particularly in terms of urinary and sexual function, and bother.

CONCLUSIONS

The presentation and management of prostate cancer have changed substantially in the last decade. CaPSURE will continue to track these trends as well as oncological and quality of life outcomes, and will continue to be an invaluable resource for the study of prostate cancer at the national level.

Relative importance of sources of symptom-induced distress in urinary bladder cancer survivors

OBJECTIVE

The influence of specific symptoms on emotions and social activities in the individual patient varies. Little is known about this variation in urinary bladder cancer survivors (in other words, about the relative importance of sources of symptom-induced distress).

METHODS

We attempted to enroll 404 surgical patients treated with cystectomy and a conduit or reservoir in four Swedish towns (Stockholm, Orebro, Jönköping, Linköping), 101 surgical patients treated with cystectomy and orthotopic neobladder at the Herlev Hospital in Copenhagen, Denmark, and 71 patients treated with radical radiotherapy for bladder cancer, as well as 581 men and women controls in Stockholm and Copenhagen. An anonymous postal questionnaire was used to collect the information.

RESULTS

A total of 503 out of 576 (87%) treated patients and 422 out of 581 (73%) controls participated but 59 patients were excluded. The primary source of self-assessed distress among cystectomised patients was compromised sexual function; reduced intercourse frequency caused great distress in 19% of the conduit patients, 20% of the reservoir patients and 19% of the bladder substitute patients. The primary source of self-assessed distress in patients treated with radical radiotherapy was symptoms from the bowel; 17% reported great distress due to diarrhoea, 16% due to abdominal pain, 14% due to defecation urgency and 14% due to faecal leakage. The highest proportion of subjects being distressed was 93% (substantial: 43%, moderate: 29% and little: 21%) for treated upper or lower urinary retention (indwelling catheter or nephrostomy).

CONCLUSION

The distress caused by a specific symptom varies considerably and the prevalence of symptoms causing great distress differs between treatments in bladder cancer survivors. It is possible that patient care and clinical research can be made more effective by focusing on important sources of symptom-induced distress.

Time after surgery, symptoms and well-being in survivors of urinary bladder cancer

OBJECTIVE

To evaluate how an increasing burden of symptoms influences well-being, anxiety and depression at different intervals after a radical cystectomy with urostomy for bladder cancer, as this therapy can induce long-term distressful symptoms.

PATIENTS AND METHODS

Patients with bladder cancer undergoing radical cystectomy in Stockholm between 1969 and 1995 were matched with 434 controls from the normal population; all 404 patients operated on between 1985 and 1995 at three other hospitals in Sweden were invited to enter the study. The final analysis included 306 patients and 310 controls, all assessed for symptoms and well-being.

RESULTS

A low or moderate level of well-being was reported by 35% of the patients having none or one of the symptoms studied, by 39% with two symptoms, by 45% with three symptoms and by 66% of those with four or more symptoms. The values, irrespective of symptom burden, were 45% after 2-5 years of follow-up, 58% after 6-10 years and 38% at>10 years after surgery. The total symptom burden also influenced the risk of anxiety and depression. Symptom prevalence remained largely unaffected by the duration of follow-up, except for defecation urgency.

CONCLUSIONS

The number of long-term symptoms after radical surgery with a urostomy for urinary bladder cancer affects the risk of anxiety, depression and low or moderate well-being.

How potent is potent? Evaluation of sexual function and bother in men who report potency after treatment for prostate cancer: data from CaPSURE

OBJECTIVES

To characterize the association between potency and comprehensive sexual function. The accurate assessment of sexual function is critical for the evaluation of outcomes after treatment of prostate cancer. The assessments of potency typically used in this context, however, may be oversimplified.

METHODS

CaPSURE is a large, observational database of men with prostate cancer. Participants complete health-related quality-of-life questionnaires, including the University of California, Los Angeles Prostate Cancer Index, every 6 months after treatment. A total of 5135 men completed at least one questionnaire and did not use medications for erectile function. The men were categorized as potent or impotent based on their ability to have erections and/or intercourse in the prior 4 weeks. Using the remaining questions on the Prostate Cancer Index, sexual function and bother scores were calculated for each group.

RESULTS

Of the 5135 men, 27.4% were potent. The mean sexual function scores were 56 and 13 for potent and impotent men, respectively (P <0.0001). The corresponding mean bother scores were 62 and 36 (P <0.0001). The function scores ranged from 0 to 100 and 0 to 92 among potent and impotent men, respectively, and bother scores from 0 to 100 in both groups. Function was inversely associated with age in both groups, but bother did not change among potent men and ameliorated among impotent men. Individual Prostate Cancer Index questions correlated with potency to a variable extent.

CONCLUSIONS

Although potent and impotent men have divergent sexual function and bother scores after treatment, the wide range of these scores in both groups denotes a complex picture of sexual function. The simple documentation of potency after treatment provides an insufficient measure of sexual health-related quality of life and should be supplemented with more comprehensive measures.

Quality of life after radical prostatectomy or watchful waiting

BACKGROUND

We evaluated symptoms and self-assessments of quality of life in men with localized prostate cancer who participated in a randomized comparison between radical prostatectomy and watchful waiting.

METHODS

Between 1989 and 1999, a group of Swedish urologists randomly assigned men with localized prostate cancer to radical prostatectomy or watchful waiting. In this follow-up study, we obtained information from 326 of 376 eligible men (87 percent) concerning certain symptoms, symptom-induced distress, well-being, and the subjective assessment of quality of life by means of a mailed questionnaire.

RESULTS

Erectile dysfunction (80 percent vs. 45 percent) and urinary leakage (49 percent vs. 21 percent) were more common after radical prostatectomy, whereas urinary obstruction (e.g., 28 percent vs. 44 percent for weak urinary stream) was less common. Bowel function, the prevalence of anxiety, the prevalence of depression, well-being, and the subjective quality of life were similar in the two groups.

CONCLUSIONS

The assignment of patients to watchful waiting or radical prostatectomy entails different risks of erectile dysfunction, urinary leakage, and urinary obstruction, but on average, the choice has little if any influence on well-being or the subjective quality of life after a mean follow-up of four years.

Distressful symptoms and well-being after radical cystectomy and orthotopic bladder substitution compared with a matched control population

PURPOSE

We compared subjective quality of life, well-being, urinary tract symptoms and distress in patients after radical cystectomy and orthotopic urinary reconstruction with those in a matched control population.

MATERIALS AND METHODS

Included in this study were 101 consecutive recurrence-free patients who underwent radical cystectomy and orthotopic bladder substitution with an ileal urethral Kock neobladder at Herlev Hospital with a minimum followup of 1 year. A frequency matched control group comprising 147 individuals was selected from the same geographical region. Information was collected by an anonymous postal questionnaire and analyzed externally in Sweden.

RESULTS

The prevalence of low or moderate psychological well-being (32% versus 36%) and subjective quality of life (30% versus 38%), and high or moderate anxiety (23% versus 18%) and depression (26% versus 37%) was similar in patients with an orthotopic neobladder and population controls. Patients with a neobladder felt as attractive as the control population. Of the operated men 94% had erectile dysfunction compared with 48% of controls. Daytime and nighttime urinary frequency was similar in patients and controls (3% and 3%, and 15% and 13%, respectively), while the prevalence of urinary leakage at least once monthly was higher in patients (18% versus 5%). Intermittent self-catheterization was performed by 26% of patients with a neobladder. Urinary tract infection (14% versus 6%) was more common and the prevalence of distressful bowel symptoms (14% versus 9%) was slightly more common in patients than in controls.

CONCLUSIONS

Well-being and subjective quality of life in patients after radical cystectomy and orthotopic bladder substitution were similar to those in a matched control population.

Distressful symptoms after radical radiotherapy for urinary bladder cancer

BACKGROUND

Radical radiotherapy for muscle-invasive urinary bladder cancer can sterilize the tumour with preserved organ function. Here we studied symptoms, symptom distress and trade-off among long-term survivors and compared figures to those of population controls and patients who had undergone cystectomy.

MATERIALS AND METHODS

We identified 71 patients who had had urinary bladder cancer treated with radical radiotherapy before 1995. For comparison, 325 patients treated with radical cystectomy and urostomy, continent or non-continent, during the same period and 460 individuals randomly selected from the general population were included. Information was collected by means of an anonymously answered postal questionnaire to avoid investigator-related bias.

RESULTS

Answers were obtained from 58 (82%) radiated patients, 251 (85%) cystectomized patients and 310 (71%) population controls. Of the radiated patients, 74% reported little or no distress from symptoms from the urinary tract, 38% had had intercourse the previous month and 57% (men) reported they had ejaculated. Among the cystectomized patients, 13% had had intercourse and 0% (men) had ejaculated. Moderate or much distress from symptoms from the gastrointestinal tract was reported by 32% of the radiated patients, 24% of the cystectomized patients and 9% of the population controls. After radical radiotherapy, 46% of the patients were willing to accept some risk of decreased survival to become symptom-free.

CONCLUSIONS

About 3/4 of these long-term survivors after radical radiotherapy for bladder cancer had a functioning urinary bladder with little or no distress from the urinary tract. The prevalence of sexual dysfunction was lower than after cystectomy and the prevalence of distress from the gastrointestinal tract was comparable.

New concept parameters of RigiScan in differentiation of vascular erectile dysfunction: is it a useful test?

BACKGROUND

The aim of this study is to investigate the value of new nocturnal penile tumescence recording parameters, such as tumescence activity unit and rigidity activity unit values, total erection number and erection times, in differentiating between psychogenic erectile dysfunction and organic erectile dysfunction. We also aimed to determine the role of these parameters in differentiating arterial erectile dysfunction from veno-occlusive dysfunction.

METHODS

Eighty-seven consecutive patients were allocated into three groups as psychogenic, arterial and venous erectile dysfunction after investigations. Nocturnal penile tumescence recording parameters between psychogenic and vascular erectile dysfunction and arterial and veno-occlusive dysfunction were compared. Mann-Whitney U-test, Pearson's chi2 test and correlation coefficient tests were used for statistical analysis.

RESULTS

Depending on intracavernous injection, penile Doppler ultrasonography and cavernosometry tests, 37 patients (43%) had psychogenic impotence while 50 (57%) had organic pathologies. Of the 50 patients diagnosed with vascular impotence, 29 (48%) had arterial failure and 21 (42%) had veno-occlusive dysfunction. Nocturnal penile tumescence recording revealed psychogenic erectile dysfunction in 34 patients (39%) and vascular erectile dysfunction in 53 patients (61%). Nocturnal penile tumescence recording has been regarded as the gold standard and, in our series, it showed 90.6% sensitivity and 88.2% specificity in differentiating the cause of erectile dysfunction. Values of rigidity activity unit and tumescence activity unit were significantly higher in patients with psychogenic impotence (P < 0.001), when compared with vascular impotence. In patients with a vascular cause, no difference was found between arterial failure and veno-occlusive dysfunction with regard to tip tumescence activity unit, base tumescence activity unit, tip rigidity activity unit, base rigidity activity unit and erection time (P > 0.001). However, patients with arterial failure had less erection than patients with veno-occlusive dysfunction (P < 0.001).

CONCLUSION

New recording parameters of nocturnal penile tumescence can differentiate organic and psychogenic erectile dysfunction more precisely. However, these recording parameters cannot distinguish subgroups with a vascular cause of erectile dysfunction.

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.

Klinisch-psychologische Aspekte der erektilen Dysfunktion: Die Bedeutung psychosozialer Faktoren

Zusammenfassung.Theoretischer Hintergrund: In den vergangenen 20 Jahren hat der medizinische Erkenntnisfortschritt zu einer erheblichen Verbesserung der Diagnostik und Therapie von Erektionsstörungen geführt und die psychosoziale Dimension der Symptomatik nahezu in Vergessenheit geraten lassen. Fragestellung: In wie weit liegen für die an Entstehung und Aufrechterhaltung einer Erektionsstörung postulierten psychosozialen Faktoren empirisch gesicherte Erkenntnisse vor? Methode: Die Literatur zu klinisch orientierten Untersuchungen, epidemiologischen Studien und zu psychophysiologischen Laborexperimenten wurde analysiert. Ergebnisse: Der differenzierten Untersuchung psychischer Aspekte der Erektionsstörung wurde in der Forschung bisher wenig Aufmerksamkeit geschenkt. Die empirische Überprüfung der Annahmen, die der Sexualpsychotherapie zugrunde liegen, befindet sich noch in der Anfangsphase. Schlussfolgerungen: Es erscheint insbesondere notwendig, geeignete psychometrische Verfahren zur Diagnostik klinisch-psychologischer Aspekte von Erektionsstörungen zu entwickeln.

Improving the preservation of erectile function after external beam radiation therapy for prostate cancer

BACKGROUND AND PURPOSE

To investigate whether the type of collimation technique, target dose and treated volume influence the prevalence of intact erectile function after external beam radiation therapy for localized prostate cancer.

PATIENTS AND METHODS

A prospective study was conducted to assess erection stiffness before treatment and after follow-ups of 9-18 months and 4-5.5 years. Information was collected using the Radiumhemmet Scale of Sexual Function.

RESULTS

Thirty-one men were 'potent' before the radiation. Fourteen of them were treated with a conventional collimator and 17 were given three-dimensional conformal therapy with the aid of a multileaf collimator. Preserved erectile function at 9-18 months was found in 17 of the 31 men (55%) and at the 4-5-year follow-up in five of 22 (23%). Preservation of potency was related to the treatment procedure but not to the treatment volume.

CONCLUSIONS

Conformal therapy may increase the percentage of men preserving erectile function during radiotherapy for localized prostate cancer; it is possible that the differences to conventional therapy do not depend on treated volume.

Results from different patient populations using combined therapy with alprostadil and sildenafil: predictors of satisfaction

OBJECTIVE

To evaluate the outcome of combined therapy (using intraurethral alprostadil and oral sildenafil) in private and clinic patients with erectile dysfunction, and thus assess predictors of satisfaction.

PATIENTS AND METHODS

In all, 360 men were treated for erectile dysfunction using single and/or combined therapy, comprising 214 private-practice and 166 clinic patients. Responses were evaluated using the International Index for Erectile Function (IIEF) questionnaire before and after treatment. Serum testosterone levels, education and socio-economic status were also assessed. Group 1a consisted of 33 private patients and Group 1b of 24 clinic patients who tried the maximum dose of intraurethral alprostadil monotherapy initially, followed by the maximum dose of sildenafil monotherapy, and remained dissatisfied. Group 2a consisted of 32 private patients and group 2b of 31 clinic patients who tried the maximum dose of sildenafil monotherapy initially, followed by the maximum dose of alprostadil monotherapy, and were also dissatisfied. These two groups of 65 private and 55 clinic patients then underwent combined therapy.

RESULTS

The mean (SD) score for erectile function was 24.1 (2) for combined therapy (a 123% improvement), and 19.8 (1. 8) (83% improvement) and 15.2 (1.6) (41% improvement) for sildenafil and alprostadil monotherapies (P < 0.05 for both patient groups). The men also reported an improvement in their satisfaction with intercourse. However, at 18 months, 60 of the 65 private patients but only 40 of the 55 clinic patients continued with combined therapy; thus, the discontinuation rate was three times greater among clinic than among private patients. Furthermore, the private patients had an overall improvement in the satisfaction score of 128%, compared with 51% for the clinic patients.

CONCLUSION

Although there were no significant differences in erectile function improvement within the two satisfied combined therapy groups, the differences in overall satisfaction and long-term withdrawal rates suggests that other factors beside motivation must be involved for success, e.g. education, persistence, realistic expectations, and certain psychological factors. Combined therapy should be considered for those patients who have a suboptimal response to monotherapy and refuse or are not candidates for surgical options. Generally, those patients with a higher education, greater persistence and more realistic expectations were more satisfied with combined therapy.

Prostate cancer treated by anti-androgens: is sexual function preserved? EORTC Genitourinary Group. European Organization for Research and Treatment of Cancer

This paper reports on results of the EORTC protocol 30892, an open, prospective, randomized study of 310 patients with previously untreated metastatic prostate cancer with favourable prognostic factors who were treated by either flutamide (FLU) or cyproterone acetate (CPA) monotherapy. The final analysis with regard to the main end points, time to progression and survival are still pending. Final results related to the evaluation of sexual functioning prior to and under treatment are reported here. Of 310 randomized patients 294 were eligible for evaluation within this side study. The median age was 71 years (range 48-85). Potential risk factors related to age, general health and prostate cancer were evaluated. For evaluation of sexual functions a five-item questionnaire was used which was administered by the investigator. The protocol allowed time dependent observations at 3-monthly follow-up visits. Sexual functioning was dependent on age but not on prostate cancer-related parameters. Sexual functions at entry were similar within the two treatment groups, spontaneous (nightly) erections and sexual activity were seen in 43-51% and 29-35% of cases. Under treatment, sexual functions under FLU and CPA declined slowly with median times of 12.9 and 5.8 months versus 13.7 and 8.9 months respectively for spontaneous erections and sexual activity. Eventually, with an average observation time in excess of 2 years, loss of spontaneous erections and of sexual activity occurred in 80% versus 92% and in 78% versus 88% of men under FLU versus CPA treatment respectively. None of these differences reached statistical significance. Maintenance of potency under treatment with FLU as reported in the literature is not confirmed in this study. However, loss of sexual functions under monotherapy with both antiandrogens is slow and 10-20% of men retain sexual activity after 2-6 years of treatment. This observation can be exploited in new treatment schemes and is likely to lead to improved quality of life. The advantage of FLU in time and total preservation of sexual functions is statistically not significant and must be balanced against the side effects of FLU and other pure antiandrogens, which may exceed those of CPA especially with respect to gynaecomastia. Hepatic toxicity may limit the long-term use of both drugs.