Introduction
Prostate cancer is the most frequently diagnosed solid tumor in men in the United States.1 Approximately 1 in 7 men will be diagnosed with prostate cancer during his lifetime and over 160,000 new cases are estimated to be diagnosed in the US in 2017.2 Ninety percent of men diagnosed with prostate cancer are diagnosed with early stage disease and have excellent 5, 10, and 15-year survival rates (99%, 91%, and 82%, respectively).3 Radical prostatectomy (RP) is a gold standard treatment for early and localized prostate cancer;4 however RP carries significant sexual side effects.5 The vast majority of men who undergo RP experience some level of erectile dysfunction (ED),5 and only 16% of men will regain their pre-surgical level of erectile functioning.6-7
A growing body of research has focused on the psychological impact of these sexual side effects post-RP. This research demonstrates the deleterious impact of post-RP changes in bodily and sexual function (i.e., urinary incontinence, ED) on psychosocial functioning among these men. Specifically, ED among men, post-RP, has been associated with increased worry, anxiety, distress, depressive symptoms, and sexual bother.4-8 Furthermore, research suggests that ED, post-RP, may be particularly threatening to the masculine identity. Several qualitative studies have underscored this phenomenon in which men report feeling like changed men due to the changes in their sex life and experience subsequent lowered self-esteem and diminished intimate relations with their partners.8 Furthermore, the impact of ED and its’ associated psychosocial consequences extend beyond the patient, impacting their partners and the relationship as a whole.9 Thus, the association between ED and compromised quality of life is now well-established.10-13 This association highlights the importance of addressing sexual dysfunction as a survivorship issue for men following treatment for prostate cancer.
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For men following RP, the loss of erectile function, and its’ accompanying psychological impact, often lead to a decrease in sexual satisfaction. Research suggests that the successful treatment of ED leads to an increase in sexual satisfaction.14-15 Hence, recovery of erections is thought to prompt psychosocial recovery, including a return to pre-surgical levels of sexual satisfaction. However, both physical and psychological aspects are integral in helping prostate cancer patients and survivors restore sexual satisfaction.16 For instance, in a study of 352 men with prostate cancer, Nelson et al. found that erectile functioning, relationship closeness, anxiety, and depression were all significant predictors of sexual satisfaction.16 Additionally, clinical experience suggests that the emotional and relationship difficulties related to ED do not always resolve with the return of erectile function, and as a result, sexual satisfaction may not return to baseline levels even when sexual functioning improves.
Rossi et al. (2016) explored the question of return of overall sexual satisfaction in 652 men post-RP and reported that reaching one’s baseline IIEF Erectile Function Domain (EFD) category does not guarantee the return of overall satisfaction.17 However, these authors also reported that for men who achieved good erectile functioning (defined as EFD ≥ 22), post-RP, considered themselves satisfied.17 The goal of our analysis in this paper is to question the assumption that the recovery of “good” erectile function and recovery of sexual satisfaction occur simultaneously. We explore this question with a different methodology as compared to Rossi et al. (2016) and as a result we hope to add to the literature exploring this question. Rossi et al. (2016) used a relatively high cutoff of Overall Sexual Satisfaction Domain (OSSD) of the IIEF as the definition of “sexually satisfied” and did not consider baseline OSSD.17 In our methodology, we limit our analyses to those who have good erectile function prior to surgery and examine the IIEF Intercourse Satisfaction Domain (ISD), which measures more directly men’s satisfaction with intercourse as compared to the IIEF OSSD. We also examine if men achieve back to their baseline intercourse satisfaction as opposed to using a cutoff score for satisfaction. One concern when using a cutoff score is that results may change depending on the cutoff score selected. We also believe assessing back to baseline ISD is a more sensitive assessment compared to a cutoff score, which could potentially lead to different results. We hypothesize that the return of “good” erectile function does not necessitate a return to baseline sexual satisfaction among men post-RP.
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