RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Sexual Functioning after Diagnosis and/or Treatment of Bladder Cancer: a Systematic
Review
Bachelor thesis
Department of Medical Psychology, Tilburg University
Author: Manon van Eekelen
Supervisor: Dr. Brenda den Oudsten
Date of publication: May 2012
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Abstract
Background: The purpose of this review is to provide an overview of studies that
addressed sexual function in bladder cancer. More specifically, we determined (i) the
prevalence of sexual function in patients with bladder cancer and (ii) the role of
sociodemographic, treatment-related, and psychosocial factors of sexual functioning.
Methods: The databases PUBMED (75 hits) and PsycINFO (2 hits) were
systematically searched to identify relevant articles. Twenty-four articles were included.
Results: The percentage of preoperatively potent men that experienced sexual
dysfunction postoperatively varied from 14% to 100%. Postoperatively, none to 88% of
the sexual active women experienced sexual dysfunction. Sexual function mainly
returned within 2 months to 1 year. Non-nerve-sparing radical cystectomy predicted
more sexual dysfunction then nerve-sparing cystectomy. A younger age (< 65years)
predicted a better recovery of sexual function after surgery. Postoperatively, women
reported a decrease in sexual satisfaction. It seems that social support is a beneficial
factor for sexual activity. Postoperatively, men and women can overcome their sexual
inability by receiving treatment for sexual dysfunction (e.g., sildenafil, estrogen cream).
The mean quality score was 9. Existing studies suffer from methodological
shortcomings, such as cross-sectional designs and small sample sizes.
Conclusion: Many patients suffer from their sexual dysfunction after the
treatment for bladder cancer. It is important to offer treatment for sexual dysfunction
after surgery. Further research is needed to investigate the effects that radiation can have
on sexual function and the effects of retrograde ejaculation on sexual satisfaction. It is
important that sexuality is investigated prospectively from a biopsychosocial model.
Key words: bladder cancer; sexuality; sexual function; sexual dysfunction; systematic
review
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Introduction
Annually, about 386,300 persons are diagnosed worldwide with bladder cancer (Jemal
et al., 2011). There are two kinds of bladder cancer, non-muscle-invasive and muscleinvasive. The focus of this review will be on muscle-invasive cases, since it is likely
that this type will cause the most serious sexual dysfunction in patients. In the
Netherlands, about 3000 persons are diagnosed with muscle-invasive bladder cancer.
This cancer is more common in men than women, about 4:1
(http://www.cijfersoverkanker.nl/selecties/dataset_1/img4fb23f60cfcf3?row=0&column
=1&direction=left#table). The highest risk factor of bladder carcinoma is smoking.
There are two reasons why it is important to assess sexuality in patients with
bladder cancer. First, its treatment can have a detrimental effect on the sexual organs of
patients. The most frequently used treatments of muscle-invasive bladder cancer are
radiotherapy, chemotherapy, and radical cystectomy. During radiotherapy there is a risk
that the surrounding organs receive radiation and get affected. Chemotherapy attacks
cancer cells, however, will also kills healthy cells. Radical cystectomy is a kind of
surgery where the bladder, surrounding lymph nodes and some sexual organs (e.g.,
ovary, urethra, part of the vagina, uterus, prostate, and seminal vesicles) are completely
removed from the body. After removing these parts, a construction of a urinary
diversion is made (http://kanker.kwfkankerbestrijding.nl/soorten-kanker/Pages/soortenkanker-blaaskanker.aspx; Cross, & Whelan, 2010). Some persons need to live with a
stoma and experience problems with sexuality and sexual function. Black (1994)
labeled this as one of the „hidden‟ problems of living with a stoma. Persons with a
stoma experience a decrease in the enjoyment of sex and a lack of sexual desire
(Follick, Smith, & Turk, 1984; Huish, Kumar, & Stones, 1998).
Second, sexuality has a positive effect on health and well-being of men and
women (Levin, 2007). If someone‟s sexual functioning is poor, it may affect the various
factors of sexuality and the person‟s quality of life. A sexual dysfunction is
characterized by a disturbance in the four phases (desire, excitement, orgasm, and
resolution) of Masters and Johnson (1966) or by pain associated with intercourse
(DSM-IV-TR, 2001). According to Basson et al. (2010) and Verschuren et al. (2010)
sexual function or dysfunction need to be examined from the biopsychosocial
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
perspective. Not only the biological aspects are important (e.g., possibility to get an
erection or the moistness of the vagina), but also the psychosocial aspects (e.g., mood,
relationships, and body-image). These factors can have an effect on sexual function and
affect well-being.
It is important for health professionals to have knowledge on how bladder cancer
and its treatments affect patients, so they can better support those patients. The purpose
of this review is to provide an overview of studies that addressed sexual function in
bladder cancer. More specifically, to determine the prevalence of sexual function in
patients with bladder cancer and the role of sociodemographic, treatment-related, and
psychosocial factors of sexual functioning.
Method
Search strategy
A systematic search of the literature was carried out in PUBMED (75 hits) and
PsycINFO (2 hits). The databases were searched with combinations of bladder cancer
(bladder carcinoma, urinary bladder neoplasms, urinary bladder), sexuality, sexual
function (sexual physiology) and sexual dysfunction (sexual physiopathology). The
search was restricted to studies written in English or Dutch, included are only original
full text reports and adults. In all reports, the reference lists were used to identify studies
that were not found in computerized database searches.
Selection criteria
Studies that matched the following criteria were included: (1) the study population that
separately analyzed patients with muscle-invasive bladder cancer; (2) the studies
investigated sexual function or sexual dysfunction; (3) sexual function, or sexual
dysfunction and/or sexuality were measured by self-reports or an interview; (4) the
studies were original full text report in English or Dutch; (5) studies were published in
peer-reviewed journals; (6) the study population exclusively concerned adults, men
and/or women; (7) Case studies, benign tumors and non-muscle-invasive tumors were
excluded.
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Data extraction
Titles, abstract and/or full text of the articles were examined to assess the articles‟
relevance for the review and adherence to inclusion criteria. In total, 75 articles were
found in the databases. After applying the inclusion criteria, 26 articles remained and 24
articles were used in the results 1. The flow chart of study selection is shown in Figure 1.
* Insert Figure 1 about here *
Quality assessment
The methodological quality of the selected studies was assessed by using the criteria list
shown in Table 1. This checklist was based on the criteria list of Traa, De Vries,
Roukema, and Den Oudsten (2011). The list contains 15 criteria which can be scored
positive (+), negative (-) or unclear (?). Quality score is the sum of all the positive
scores (+). The maximum score is 15. Studies scoring ≥ 70% of the maximum score (i.e.
≥ 11 points) were labeled „high quality‟. Studies of „moderate quality‟ scored between
50% and 70% (between 8 and 10 points) and studies scoring ≤ 50% (i.e. ≤ 7 points)
were considered as „low quality‟.
* Insert Table 1 about here *
Results
Methodological quality
The results of the methodological assessment are presented in Table 2. The overall
quality score ranged from 4 (Meinhardt & Horenblas, 2003) to 12 points (Bjerre,
Johansen, & Steven, 1997; Zippe et al., 2004a), with a mean score of 9. Methodological
shortcomings mainly concerned the following items: examining both men and women
1
The full text of the studies Schover & von Eschenbach (1985) and Schover, Evans, & von Eschenbach
(1986) could not be retrieved.
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
(79% did not match the criterion C); the study describes potential prognostic factors by
using multivariate analyses or structural equation modeling (criterion G , 92%); the
study sample includes at least 50 patients (arbitrarily chosen) (criterion J, 54%); The
collection of data is prospectively gathered with at least two assessment points (criterion
K, 63%); and the results are compared between two groups or more (criterion O, 58%).
* Insert Table 2 about here *
Study characteristics
The number of participants included in the studies ranged from 7 (Salem, 2005) and 331
(Kessler et al., 2004). In total, 12 out of 24 studies investigated sexual function as a
primary objective (Bergman, Nilsson, & Petersén, 1979; Bhatt et al., 2006; Bjerre et al.,
1997; Fokdal, Høyer, Meldgaard, & von der Maase, 2004; Little & Howard, 1998;
Nandipati, Bhat, & Zippe, 2006; Nieuwenhuijzen, Meinhardt, & Horenblas, 2005;
Nordström & Nyman, 1992; Salem, 2005; Volkmer et al., 2004; Zippe et al., 2004 a;
Zippe et al., 2004b). In the other studies, sexual function was a part of clinical outcome
studies or a part of studies on quality of life. The minority of these studies (27%) were
cross-sectional (Fokdal et al., 2004; Hart et al., 1999; Kitamura et al., 1999; Little &
Howard, 1998; Månsson et al., 2000; Meinhardt & Horenblas, 2003; Nordström &
Nyman, 1992). Of the 17 prospective studies, 9 were unclear about when the
postoperative sexual function exactly was measured (Bergman et al., 1979; Bjerre et al.,
1997; Horenblas, Meinhardt, IJzerman, & Moonen, 2001; Nieuwenhuijzen et al., 2005;
Salem, 2005; Takenaka et al., 2011; Vallancien et al., 2002; Volkmer et al., 2004; Zippe
et al., 2004b). Of all articles, 12 investigated pre- and postoperatively sexual function
(Bergman et al., 1979; Bhatt et al., 2006; Botto et al., 2004; Hart et al., 1999; Little &
Howard, 1998; Nandipati et al., 2006; Nordström & Nyman, 1992; Salem, 2005;
Takenaka et al., 2011; Volkmer et al., 2004; Zippe et al., 2004a; Zippe et al., 2004b).
Four of those studies investigated preoperatively sexual function with retrospective
questions (Hart et al., 1999; Little & Howard, 1998; Nordström & Nyman, 1992;
Volkmer et al., 2004). The study of Fokdal et al. (2004) was the only study that used a
healthy population as a control group. The study duration ranged from 1 year (Bhatt et
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
al., 2006) up to 10 years (Schoenberg et al., 1996). Sexual function in both men and
women was investigated in 5 studies (Fokdal et al., 2004; Hart et al., 1999; Horenblas et
al., 2001; Kitamura et al., 1999; Nordström & Nyman, 1992), 15 studies investigated
men (Bergman et al., 1979; Bjerre et al., 1997; Botto et al., 2004; Kessler et al., 2004;
Little & Howard, 1998; Månsson et al., 2000; Matris et al. 2005; Meinhardt &
Horenblas, 2003; Muto, Bardari, D‟Urso & Giona, 2004; Nieuwenhuijzen et al., 2005;
Salem, 2005; Schoenberg et al., 1996; Takenaka et al., 2011; Vallancien et al., 2002;
Zippe et al., 2004a) and 4 studies investigated women (Bhatt et al., 2006; Nandipati et
al., 2006; Volkmer et al., 2004; Zippe et al., 2004b). The results were mainly presented
for sexually active persons or described the percentage of participants being sexually
active. However, in 8 articles it is unclear if they only investigated a sexual active group
(Horenblas et al., 2001; Kessler et al., 2004; Kitamura et al., 1999; Månsson et al.,
2000; Matris et al. 2005; Muto et al., 2004; Salem, 2005; Takenaka et al., 2011).
In total, 5 different standardized self-report instruments were used to assess
sexual function (Table 3). For men, the International Index of Erectile Function (IIEF)
(Rosen et al., 1997; Rosen et al., 1999) was most frequently used. It was assessed in 6
studies (Botto et al., 2004; Matris et al. 2005; Muto et al., 2004; Nieuwenhuijzen et al.,
2005; Takenaka et al., 2011; Zippe et al., 2004a). The Female Sexual Function Index
(FSFI) (Rosen et al., 2000) is used in 3 studies (Bhatt et al., 2006; Nandipati et al.,
2006; Volkmer et al., 2004). Three studies used a combination of questionnaires and
structured interviews (Little & Howard, 1998; Nieuwenhuijzen et al., 2005; Nordström
& Nyman, 1992). Four other studies used non-standardized assessments (Hart et al.,
1999; Kessler et al., 2004; Salem, 2005; Schoenberg et al., 1996). In the research of
Vallancien et al. (2002) it is unclear how the questionnaire is composed. Kitamura et al.
(1999) and Månsson et al. (2000) measured sexual function in a part of the quality of
live questionnaire. In the remaining studies sexual function was measured by
questionnaires and/or interviews, which the researchers produced on a scientific manner
(e.g., based on clinical experience, other studies or pre-interviews).
*Insert Table 3 about here*
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
The most reported demographic variables were age and sex. The most frequently
presented clinical variables were type of surgery, type of urinary diversion, tumor stage
(T1-T4), and (neo) adjuvant therapies. The main study findings are presented in Table 4.
*Insert Table 4 about here*
The prevalence of sexual function in patients with bladder cancer
Patients resume sexual activity within a time frame of 2 months to 1 year. The
percentage of preoperatively sexual active men ranged from 61% (Vallancien et al.,
2002) to 100% (Salem, 2005 & Zippe et al., 2004a) across studies. The percentage of
sexual active women varied from 55% (Nordström & Nyman, 1992) to 100% (Bhatt et
al., 2006; Horenblas et al., 2001; Nandipati et al., 2006). In addition, postoperatively a
decrease in sexual desire is a phenomenon that is often mentioned by the patients (Bhatt
et al., 2006; Fokdal et al., 2004; Hart et al., 1999; Kitamura et al., 1999; Zippe et al.
2004b).
The percentage preoperatively potent men that experienced postoperatively
sexual dysfunction varied from 14% (Salem, 2005) to 100% (Botto et al., 2004; Muto et
al, 2004; Vallancien et al., 2002). Postoperatively, most men reported an increase of
erectile dysfunction (Bergman et al., 1979; Bjerre et al., 1997; Fokdal et al., 2004; Little
& Howard, 1998; Kessler et al., 2004; Månsson et al., 2000; Nordström & Nyman,
1992; Schoenberg et al., 1996; Zippe et al., 20041) and ejaculation dysfunction (Botto et
al., 2004; Hart et al., 199; Meinhardt & Horenblas, 2003; Muto et al., 2004; Vallancien
et al., 2002). The percentage of preoperatively sexual active women that experienced
postoperatively dysfunction ranged from no decrease in sexual function (Horenblas,
2001) to 88% (Nandipati et al., 2006). Vaginal dryness and dyspareunia were most
common (Bhatt et al., 2006; Nandipati et al., 2006; Nordström & Nyman, 1992; Zippe
et al., 2004b). In addition, decreased ability or inability to reach an orgasm (Bhatt et al.,
2006; Hart et al., 1999; Nordström & Nyman, 1992; Zippe et al., 2004b) and lack of
arousal (Bhatt et al., 2006; Hart et al., 1999; Nandipati, Bhat, & Zippe, 2006) were
mentioned.
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Dissatisfaction increased postoperatively in men (Hart et al., 1999; Little &
Howard, 1998; Nordström & Nyman, 1992; Takenaka et al., 2011) and in women (Bhatt
et al., 2006; Hart et al., 1999; Zippe et al. 2004b).
Sociodemographic aspects in relation to sexual function
Younger men have a greater opportunity to be more sexual active after radical
cystectomy then older patients (Bergman et al., 1979; Bjerre et al., 1997). The crosssectional study of Fokdal et al. (2004) was consistent with these results. Patients with a
sexual partner were more likely to resume sexual activity after surgery. Besides, social
support can also be a beneficial factor for resuming sexual activity (Bjerre et al., 1979;
Volkmer et al., 2004).
Younger age (<65 years) predicted a better recovery of sexual function after
surgery, independent of type of surgery (Bhatt et al., 2006; Bjerre et al., 1997; Botto et
al., 2004; Horenblas et al., 2001; Kessler et al., 2004; Matris et al., 2005; Muto et al.,
2004; Nandipati et al., 2006; Nieuwenhuijzen et al., 2005; Nordström & Nyman, 1992;
Salem, 2005; Schoenberg et al., 1996; Vallancien et al., 2002; Volkmer et al., 2004;
Zippe et al., 2004a). However, increasing age in men is associated with more erectile
dysfunction and decreasing libido (Bergman et al., 1979). Zippe et al. b (2004) compared
premenopausal women with postmenopausal women. No significant differences were
found on sexual functioning before and after surgery, except for vaginal lubrication.
Postmenopausal women had less vaginal lubrication before surgery.
Only one research studied the impact of age on satisfaction. In this study they
found that older men are less satisfied with their sexual life then younger men (Bergman
et al., 1979).
No prospective studies investigated the effect of being a man of women on
sexual activity, dysfunction, or satisfaction. Two cross-sectional studies found that
females are more likely to be sexual inactive preoperatively then men (Hart et al., 1999;
Nordström & Nyman, 1992). In addition, women were less satisfied with their body
(Hart et al., 1999).
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Treatment-related aspects in relation to sexual function and sexual life
Non-nerve sparing radical cystectomy predicted less sexual activity in both men and
women (Bergman et al., 1979; Bjerre et al., 1997; Bhatt et al., 2006; Nandipati et al.,
2006; Zippe et al. 2004b). Only the prospective research of Volkmer et al. (2004)
predicted that the minority of the women (35%) became sexual inactive after surgery.
However, radical cystectomy is positively associated with the presence of sexual
dysfunction in both men and women (Bergman et al., 1979; Bjerre et al., 1997; Bhatt et
al., 2006; Kessler et al., 2004; Nandipati et al., 2006; Zippe et al., 2004a; Zippe et al.
2004b). It will cause, erectile dysfunction in men (Bergman et al., 1979; Kessler et al.,
2004; Zippe et al., 2004a), difficulty in achieving orgasms, and less lubrication in
women (Bhatt et al., 2006; Nandipati et al., 2006; Zippe et al., 2004 b). Women also
reported less sexual satisfaction (Volkmer et al., 2004; Zippe et al., 2004 b). The crosssectional studies of Hart et al. (1999), Månsson et al. (2000), and Nordström & Nyman
(1992) are consistent with these results.
Patients were sexual active before surgery in studies where they perform a
nerve-preserving cystectomy, because the desire to retain sexual function was an
inclusion criterion. This surgery predicted a better recovery of sexual function in both
men and women, then in radical cystectomy (Bhatt et al., 2006; Botto et al., 2004;
Horenblas et al., 2001; Matris et al. 2005; Muto et al., 2004; Nandipati et al., 2006;
Nieuwenhuijzen et al., 2005; Salem, 2005; Schoenberg et al., 1996; Vallancien et al.,
2002; Zippe et al., 2004a; Zippe et al., 2004b). Kessler et al. (2004) found that sparing
both neurovascular bundles predicted the best recovery of erectile function and sparing
one neurovascular bundles was better than no nerve sparing. In 78% to 100% of the
men, full erectile function returned after surgery (Horenblas, Meinhardt, IJzerman, &
Moonen, 2001) to 100% (Matris et al., 2005& Salem, 2005). In de research of
Schoenberg et al. (1996) they only examined whether men have erection sufficient for
intercourse of not. This outcome is worse than in men who can achieve an erection
(58% versus 78%). The majority of the potent men (66-100%) have retrograde or
varying ejaculation (Botto et al., 2004; Muto et al., 2004; Nieuwenhuijzen et al., 2005;
Vallancien et al., 2002). In studies that investigated female patients, there is no
significant difference between preoperatively and postoperatively sexual function (Bhatt
et al., 2006; Horenblas et al., 2001; Nandipati et al., 2006). Cross-sectional research
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
confirms the results about men (Meinhardt & Horenblas, 2003). Little research has been
done about the satisfaction of patient‟s sexual life after surgery. In Salem (2005) they
found that all men were satisfied. Women experienced a decreased in satisfaction after
surgery (Bhatt et al., 2006).
By nerve-preserving cystectomy incidents of comorbid disorders, as
hypertension, diabetes, coronary artery diseases, was similar in both the sexually active
and impotent groups (Kessler et al., 2004) and there was no correlation found between
postoperatively potency and pathological stage of disease (Schoenberg et al., 1996). But
these clinical variables were only investigated in those studies, so it is difficult to draw
conclusions.
Independent of the type of surgery, erection ability is mainly returned between 2
months and 1 year (Bergman et al., 1979; Botto et al., 2004; Matris et al., 2005; Salem,
2005).
Men who received pre-radiation by radical cystectomy predicted a higher
percentage of becoming inactive then those who had no pre-radiation (Bergman et al.,
1979). Radiation significantly increases the risk in men of feeling less sexually
attractive (Bjerre et al., 1997). Radical radiotherapy only was investigated in two crosssectional studies (Fokdal et al., 2004; Little & Howard, 1998). In Fokdal et al. (2004)
there was no significant difference in decreased sexual activity in men who received
radical radiotherapy and with the healthy control group. In both studies some patients
(24%-44%) experienced problems with erectile function after the treatment. In Fokdal et
al. (2004) the minority of the patients (25%) noted a decrease in sexual satisfaction and
in Little and Howard (1998) the majority (70%).
Men with an ileal conduit diversion experienced more loss of potency and were
less sexual active, than bladder substitution patients. Patients with bladder substitution
have more coitus, then cutaneous continent patients (Bjerre et al., 1997; Zippe et al.,
2004a). However, this finding was not clinically significant (Zippe et al., 2004a). This is
consistent with the cross-sectional research of Kitamura et al. (1999). In women,
Indiana pouches and Studor pouches did not differ significantly in the total sexual
function. This suggests that preservation of the anterior vaginal wall will not result in
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
improved sexual function after radical cystectomy, but preservation as much as possible
is important to maintain vaginal lubrication (Bhatt et al., 2006; Zippe et al., 2004b).
Psychosocial factors on sexual functioning.
The effect of psychosocial factors on sexual functioning is investigated in a few studies.
It seems that social support is a beneficial factor for sexual activity (Bjerre et al., 1979;
Volkmer et al., 2004). In the research of Bjerre et al. (1979), 21% of the men believed
that their partner was unwilling to have intercourse. Further, some of the partners (30%)
had a decrease in desire for sexual activity owing to apprehension and physical
imperfection with urostomy (Zippe et al., 2004b). The cross-sectional study of Little &
Howard (1998) confirms the results.
The effect of aids on sexual dysfunction
Three studies examined the effect of aids or medical treatment on erectile dysfunction.
The majority of the men (66%-96%), who received aids or medical treatment after nonnerve sparing radical cystectomy, did not have a successful effect. Men received
treatments as self injection therapy, sildenafil citrate, and penile implants. Afterwards,
men were not able to maintain an erection for sexual intercourse (Bjerre et al., 1997;
Zippe et al., 2004a). Men who received such treatment have a significant greater risk to
feel less attractive, but they also have a bigger chance to be sexual active (Bjerre et al.,
1997). This is consistent with the cross-sectional research of Hart et al. (1999).
Most men, who undergo a nerve-preserving cystectomy and have erectile
dysfunction postoperatively, can overcome this inability by using erectile aid (e.g.,
sildenafil citrate or intracavernosal injection) (Botto et al., 2004; Horenblas et al., 2001;
Muto et al., 2004; Nieuwenhuijzen et al., 2005).
None of the studies investigated treatment to overcome women‟s sexual
dysfunction after radical cystectomy. However, in other cancer types vaginal dilation,
water-based vaginal lubricants and estrogen creams can decrease genital pain (Schover,
1987).
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Discussion
The objective of this qualitative systematic review was to provide an overview of
studies that addressed sexual function in bladder cancer. More specifically, with regard
to the prevalence of sexual function and sociodemographic, treatment-related and
psychosocial aspects in relation to sexual function. This review included 24 studies.
Sexual dysfunction after radical cystectomy is a prevalent problem. It is a
problem for all men and women, but young persons have the most trouble coping with
the problems. This is because they are more likely to retain sexuality. Therefore,
younger age is an important factor in research on sexual activity, functioning and
satisfaction after surgery. Nerve-preserving cystectomy is a better treatment for patients
who would like to retain their sexual function. But this procedure can only be performed
when the cancer is in an early-stage (i.e., no metastasis). Men and women with tumor
infiltration in the bladder neck and trigone, men with tumors in prostate and prostatic
urethra, and women with metastasis in the vaginal wall cannot receive this surgery
(Bhatt et al., 2006; Botto et al., 2004; Hart et al., 1999; Matris et al. 2005; Meinhardt &
Horenblas, 2003; Nieuwenhuijzen et al., 2005; Salem, 2005; Schoenberg et al., 1996;
Vallancien et al., 2002). Therefore, it is important to offer treatment for sexual
dysfunction to men (e.g., self injection therapy, sildenafil, and penile implant) and
women (e.g., vaginal lubricants, vaginal dilation, and estrogen cream) after surgery.
This can have a positive result on their sexual life and make sexual intercourse possible
or pleasant. In some cases impotence treatment does not help, then it is important to
give enough sexual counseling.
Methodologically, there is room for improvement. Approximately, 30% of the
studies were cross-sectional. The effect of radical radiotherapy on sexual function only
was investigated in cross-sectional designs. However, prospective studies are needed. It
is important to have at least two assessment points, the first preoperatively and the
second at least 1 year after surgery. Only then we can better determine what the effect
of treatment is on sexual activity, sexual functioning, and satisfaction of a patient. In
addition, the sample size of most studies was rather small. There was more data
collected in men, perhaps partially due to the fact that bladder cancer is more common
in men then in women. To draw meaningful conclusions on differences between men
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
and women, it is important for future large sample studies to focus on both sexes.
Studies did not examine the satisfaction of the patients after nerve-sparing surgery. Men
had better recovery of their sexual function. Most men were able to achieve an erection
and reach an orgasm. However, retrograde ejaculation remained. As such, it is important
to know if retrograde ejaculation has an impact on sexual life.
Most studies measured sexual function with a limited number of questions. In
some questionnaires the difference between “almost never or never” does not differ
from “did not attempt”. There is no clear difference between patients that have sexual
dysfunction or patients that did not try to have sexual intercourse. It is therefore difficult
to draw meaningful conclusions from the current data. In future studies, more questions
and an explicit different between scaling in warranted.
Furthermore, most studies measured sexual function after bladder cancer
treatment with more biomedical instruments (e.g., the FSFI for women and the IIEF for
men). But if you want to describe the subjective evaluation of a patient‟s sexual
dysfunction, instruments measuring the quality of sexual life are needed. The best way
to measure sexual function remains uncertain (Arrington, Cofrancesco, & Wu, 2004).
Sexuality should be seen from a biopsychosocial perspective, so you can
investigate the quality of sexual life. But in the reviewed studies there was too little
research on psychosocial problems that men and women could experience after the
treatment. It seems that social support is a beneficial factor for sexual activity (Bjerre et
al., 1979; Volkmer et al., 2004). So the relationship between psychosocial aspects (e.g.,
self-esteem, body image, personality characteristics, and the partners‟ feelings about the
patient‟ disease or appearance) and sexual function in patients with bladder cancer
should be investigated more extensively.
Conclusion
In conclusion, many patients, especially the younger patients, suffer from their sexual
dysfunction after the treatment for bladder cancer. It is important to offer impotence
treatment and sexual counseling after the treatment. Most studies on sexual function
following bladder cancer treatment suffer from methodological problems, such as a
cross-sectional design and a small sample size. Further research is needed to investigate
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
the effects of radiation on sexual function postoperatively and the effects of and
retrograde ejaculation on sexual satisfaction. It is important that sexuality is investigated
prospectively from a biopsychosocial model.
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
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(2006). Neurovascular preservation in orthotopic cystectomy: impact on female sexual
function. Urology, 67, 742-745.
Bjerre, B.D., Johansen, C., & Steven, K. (1998). Sexological problems after
cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire
study of male patients. Scandinavian Journal of Urology and Nephrology, 32, 187-193.
Black, P.K. (1994). Hidden problems of stoma care. British Journal of Nursing, 3, 707711.
Botto, H., Sebe, P., Molinie, V., Herve, J.M., Yonneau, L., & Lebret, T. (2004).
Prostatic capsule- and seminal-sparing cystectomy for bladder carcinoma: initial results
for selected patients. British Journal of Urology International, 94, 1021-1025.
Cross, W., & Whelan, P. (2010). Bladder Cancer. Surgery (Oxford), 28, 599-604.
Fokdal, L., Høyer, M., Meldgaard, P., & Maase, H. von der (2004). Long-term bladder,
colorectal, and sexual functions after radical radiotherapy for urinary bladder cancer.
Radiotherapy & Oncology, 72, 139-145.
Follick, M.J., Smith, T.W., & Turk, D.C. (1984). Psychosocial adjustment following
ostomy. Health Psychology, 3, 505-517.
Jemal, A., Bray, F., Center, M.M., Ferlay, J., Ward, E., & Forman, D. (2011). Global
cancer statistics. CA: A Cancer Journal for Clinicians, 61, 69-90.
Hart, S., Skinner, E.C., Meyerowitz, B.E., Boyd, S., Lieskovsky, G., & Skinner, D.G.
(1999). Quality of life after radical cystectomy for bladder cancer in patients with an
ileal conduit, cutaneous or urethral kock pouch. Journal of Urology, 162, 77-81.
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Horenblas, S., Meinhardt, W., Ijzerman, W., & Moonen, L.F. (2001). Sexuality
preserving cystectomy and neobladder: initial results. Journal of Urology, 166, 837840.
Huish, M., Kumar, D., & Stones, C. (1998). Stoma surgery and sexual problems in
osteomates. Sexual and Marital Therapy, 13, 311-328.
Intergraal Kankercentrum Nederland (2011). Cijfers over kanker [Data file]. Retrieved
May 15, 2012 from http://www.cijfersoverkanker.nl/selecties/dataset_1/img4fb23f60c
fcf3?row=0&column=1&direction=left#table
Kaplan, S.A., Reis, R.B., Kohn, I.J., Ikeguchi, E.F., Laor, E., Te, A.E., & Martins,
A.C.P. (1999). Safety and efficacy of sildenafil in postmenopausal women with sexual
dysfunction. Urology, 53, 481-486.
Kessler, T.M., Burkhard, F.C., Perimenis, P., Danuser, H., Thalmann, G.N., Hochreiter,
W.W., & Studer, U.E. (2004). Attempted nerve sparing surgery and age have a
significant effect on urinary continence and erectile function after radical
cystoprostatectomy and ileal orthotopic bladder substitution. Journal of Urology, 172,
1323-1327.
Kitamura, H., Miyao, N., Yanase, M., Masumori, N., Matsukawa, M., Takahashi, A.,
Itoh, N., & Tsukamoto, T. (1999). Quality of life in patients having an ileal conduit,
continent reservoir or orthotopic neobladder after cystectomy for bladder carcinoma.
International Journal of Urology, 6, 393-399.
KWF Kankerbestrijding (n.d.). Blaaskanker. Retrieved May 15, 2012 from http://kan
ker.kwfkankerbestrijding.nl/soorten-kanker/Pages/soorten-kanker-blaaskanker.aspx
LENT SOMA tables (1995). Radiotherapy & Oncology, 35, 17-60.
Levin, R.J., (2007). Sexual activity, health and well-being: The beneficial roles of coitus
and masturbation. Sexual and Relationship Therapy, 22, 135-148.
Little, F.A., & Howard, G.C. (1998). Sexual function following radical radiotherapy for
bladder cancer. Radiotherapy & Oncology, 49, 157-161.
Månsson, A., Caruso, A., Capovilla, E., Colleen, S., Bassi, P., Pagano, F., & Månsson,
W. (2000). Quality of life after radical cystectomy and orthotopic bladder substitution: a
comparison between Italian and Swedish men. British Journal of Urology International,
85, 26-31.
Martis, G., D‟Elia, G., Diana, M., Ombres, M., & Mastrangeli, B. (2005). Prostatic
capsule- and nerve-sparing cystectomy in organ-confined bladder cancer: preliminary
results. World Journal of Surgery, 29, 1277-1288.
Masters, W.J, & Johnson, V.E. (1966). Human Sexual Response. Boston: Little, Brown
and Company.
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RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Meinhardt, W. & Horenblas, S. (2003). Sexuality preserving cystectomy and neobladder
(SPCN): functional results of a neobladder anastomosed to the prostate. European
Urology, 43, 646-650.
Muto, G., Bardari, F., D‟Urso, L., & Giona, C. (2004). Seminal sparing cystectomy and
ileocapsuloplasty: long-term follow up results. Journal of Urology, 172, 76-80.
Nandipati, K.C., Bhat, A., & Zippe, C.D. (2006). Neurovascular preservation in female
orthotopic radical cystectomy significantly improves sexual function. Urology, 67, 185186.
Nieuwenhuijzen, J.A., Meinhardt, W., & Horenblas, S. (2008). Clinical outcomes after
sexuality preserving cystectomy and neobladder (prostate sparing cystectomy) in 44
patients. Journal of Urology, 179, S35-38.
Nordström, G.M., & Nyman, C.R. (1992). Male and female sexual function and activity
following ileal conduit urinary diversion. British Journal of Urology, 70, 33-39.
Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., Ferguson, D.,
& D‟agostino, R.Jr. (2000). The Female Sexual Function Index (FSFI): a
multidimensional self-report instrument for the assessment of female sexual function.
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Rosen, R.C., Cappelleri, J.C., Smith, M.D., Lipsky, J., & Peña, B.M. (1999).
Development and evaluation of an abridged, 5-item version of the International Index of
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The international index of erectile function (IIEF): a multidimensional scale for
assessment of erectile dysfunction. Urology, 49, 822-830.
Salem, H.K. (2005). Preservation of ejaculatory and erectile function after radical
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Schoenberg, M.P., Walsh, P.C., Breazeale, D.R., Marshall, F.F., Mostwin, J.L., &
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19
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
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Takenaka, A., Hara, I., Soga, H., Sakai, I., Terakawa, T., Muramaki, M., Miyake, H.,
Tanaka, K., & Fujisawa, M. (2011). Assessment of long-term quality of life in patients
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20
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Appendix
Table 1. List of criteria for assessing the methodological quality of studies on sexual
function in patients with bladder cancer
Positive if
Sexual function
A. A psychometrically sound questionnaire is used
B. Examining sexual function was a primary objective of the study
Study population concerning sexual function
C. Examining both men and women
D. A description is included of at least two sociodemographic variables (e.g., age, sex,
employment status, educational status)
E. A description is present of at least two clinical variables (e.g., TNM or Dukes classification,
type of surgery, tumor location)
F. Inclusion and/or exclusion criteria are provided
G. The study describes potential prognostic factors by using multivariate analyses or structural
equation modeling
H. Participation rates for patient groups are described (defined as the percentage of eligible
patients who gave their informed consent) and these rates are >75%
I. The ratio non-responders versus responders is given (defined as the ratio of patients who
withdrew their initial informed consent), Including reasons for withdrawal
Study design concerning sexual function
J. The study sample includes at least 50 patients (arbitrarily chosen).
K. The collection of data is prospectively gathered with at least two assessment points
L. The design is longitudinal (>1 year)
M. The process of data collection is described (e.g., interview or self-report)
N. The loss to follow-up is described and is <20%
Results
O. The results are compared between two groups or more (e.g., healthy population, groups with
different disease stages, or treatment types)
21
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Table 2. Results of the methodological assessment of selected studies
First author
Nordström et al. 1992
Hart et al. 1999
Kitamura et al. 1999
Horenblas et al. 2001
Fokdal et al. 2004
Bergman et al. 1979
Schoenberg et al. 1996
Bjerre et al. 1997
Little et al. 1998
Månsson et al. 2000
Vallancien et al. 2002
Meinhardt et al. 2003
Botto et al. 2004
Kessler et al. 2004
Muto et al. 2004
Zippe et al. 2004 (1)
Matris et al. 2005
Nieuwenhuijzen et al. 2005
Salem. 2005
Takenaka et al. 2011
Volkmer et al. 2004
Zippe et al. 2004 (2)
Bhatt et al. 2006
Nandipati et al. 2006
Sample size
analyzed
44
224
79
13
53
42
59
76
18
66
100
24
29
331
61
49
32
44
7
78
29
27
11
11
Study
design
CSS
CSS
CSS
PS
CSS
PS
PS
PS
CSS
CSS
PS
CSS
PS
PS
PS
PS
PS
PS
PS
PS
PS
PS
PS
PS
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
+
+
+
+
?
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-
+
+
?
+
+
+
+
+
+
+
?
?
?
+
?
+
+
+
?
+
+
?
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
?
?
+
?
+
+
?
?
?
+
+
+
+
?
+
+
?
+
+
+
+
+
+
+
+
+
+
+
+
+
-
Abbreviations: CSS: Cross-sectional study; PS: Prospective study
Quality score
(Total +)
8
11
11
8
10
10
7
12
5
9
7
4
8
10
8
12
9
9
9
9
7
11
11
11
Score (%)
53
73
73
53
67
67
47
80
33
60
47
27
53
67
53
80
60
60
60
60
47
73
73
73
22
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Table 3 Questionnaire
Questionnaire
International Index of
Erectile Function
(IIEF)1
# items
15
International Index of
Erectile Function-5
(IIEF-5)2
Female Sexual
Function Index (FSFI)3
5
Erectile function; intercourse satisfaction
19
Arousal, lubrication; orgasmic function;
sexual desire; intercourse satisfaction;
sexual pain
Pain free intercourse; degree of vaginal
lubrication; overall sexual desire and
interest; ability to achieve an orgasm;
overall sexual satisfaction
Tables: urinary bladder; small
intestine/colon; rectum; sexual function
Index of Female Sexual
Function (IFSF)4
10
Questionnaire based on
the LENT SOMA
scoring system5
38
1
Subscales
Erectile function; orgasmic function;
sexual desire; intercourse satisfaction;
overall satisfaction
Research
Botto et al., 2004;
Matris et al. 2005; Muto
et al., 2004;
Nieuwenhuijzen et al.,
2005;
Takenaka et al., 2011;
Zippe et al., 2004a
Bhatt et al., 2006;
Nandipati et al., 2006;
Volkmer et al., 2004
Zippe et al., 2004b
Fokdal et al., 2004
Rosen et al., 1997; 2 Rosen et al., 1999; 3 Rosen et al., 2000; 4 Kaplan et al., 1999; 5LENT SOMA Tables,
1995
23
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Table 4 Mean study findings
First author
Sample size
analyzed
Mean
age
Study
design*
Treatment
Results
Nordström et al. 1992
44
♂/♀
55
CSS
RC
Hart et al. 1999
224
♂/♀
59
CSS
RC
Kitamura et al. 1999
79
♂/♀
13
♂/♀
61
CSS
RC
55
PS
Sexuality
preserving RC
Fokdal et al. 2004
53
♂/♀
74
CSS
RR
Bergman et al. 1979
42♂
62
PS
RC + Pre RR
(44%)
Schoenberg et al. 1996
59 ♂
78
PS
NS RC
Bjerre et al. 1997
76 ♂
66
PS
RC
Little et al. 1998
18 ♂
70
CSS
RR
Månsson et al. 2000
66 ♂
60
CSS
RC
Vallancien et al. 2002
100 ♂
61
PS
Prostate
sparing RC
Women were more likely to be sexual inactive preoperatively then men. After RC, sexual function was impaired in 90% of
the men and 83% of the women. Men younger than 50 were more likely to remain sexual function. Half of the men (52%)
were unsatisfied about their current sex life and 16% of the women.
Postoperatively, men and women reported less frequent sexual desire, decreased ability to become aroused and more
difficult to achieve an orgasm during intercourse. Retrospectively, 16% of the patients rated moderate to high
dissatisfaction preoperatively. Postoperatively, 47% rated moderate to high dissatisfaction. Women reported more
dissatisfaction and a worse sexual desire then men. Men with a penile implant were young and reported better current
sexual function en satisfaction.
In total, 39% of the IC patients, 44% of CR patients and 63% of NB patients were not satisfied with their present sexual
life. Patients with IC had the most loss of sexual desire.
About a fifth of the sexual active men (22%) had insufficient erectile function, but they used sildenafil with success. Of
those men, 55% had normal ejaculation, 33% had retrograde ejaculation and 11% varied. All the women (3) had normal
lubrication and orgasmic feelings.
After RR, 65% was not sexually active, but not differ significant from the healthy controls. RR had a moderate or severe
impact on sexual life in 24% of the men and 29% of the women. Patients and controls showed correlations between
increasing age, not sexual active, erectile dysfunction, lack of desire and satisfaction.
Postoperatively, 64% of sexual active men before surgery tried sex after treatment. Of all men, 71% unchanged libido.
Further, 14% could perform sexual intercourse and 86% had orgasm s by masturbation. Of those men, 86% had unchanged
satisfaction and 14% reported that it was considerable impaired. Of all men, 86% had an abnormal erection, but 75% had a
normal orgasm (without full erection). Orgasm mostly returned within 3 weeks-2 months, some in 4-10 months and 1 in 18
months. Pre-RR: 35% of the men became inactive versus 24% without pre-RR.
Postoperatively, 42% of the men have an erection for intercourse. The recovery of potency postoperatively is strongly
influenced by the age of the patient at operation. Older men are less likely to regain sexual function.
Postoperatively, 20% of reported that their sexual problem was their main concern. IC patients were more in need of
sexological counseling than BS patients. Only 9% could achieve an erection, while 38% could achieve an orgasm. The
minority (41%) reported no decrease in quality of orgasm. Age has a major influence on retained orgasmic ability (elderly
patient lower degree of retained orgasmic ability). Patients with IC reported more loss of potency then patients with BS. RR
and impotence treatment increased the risk of feeling less sexually attractive. Younger patients and patients who received
impotence treatment have more chance of being sexual active.
There was a decrease from 72% to 56% in erectile ability. The majority (70%) reported a worse sexual life after RR. Of
those men, 83% were concerned about it and 42% felt that their partner was concerned. It is unlikely that endocrine
pathology explain impotency.
Patients reported a large decreased erectile ability and potency, impaired sexual drive. The majority reported that they
wanted more attention to sexual problems.
Of all men, 18% had decreased of lost potency and 82% maintain potency. But they all have retrograde ejaculation.
Horenblas et al. 2001
Abbreviations: BS: Bladder substitution; CSS: Cross sectional study; CR: Continent reservoir; IC: Ileal conduit; NB: Neobladder; NS: Nerve-sparing; PS: Prospective study;
RC: Radical cystectomy; RR: Radiotherapy
24
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Table 4.2 (Continued)
First author
Sample size
analyzed
24 ♂
Mean
age
24
Study
design
CSS
Botto et al. 2004
29 ♂
61
PS
Kessler et al. 2004
331 ♂
65
PS
Muto et al. 2004
61 ♂
49
PS
Zippe et al. 2004a
49 ♂
58
PS
Matris et al. 2005
Nieuwenhuijzen et al. 2005
32 ♂
44 ♂
59
57
PS
PS
Salem. 2005
7♂
40
PS
NS RC
Prostate
sparing RC
NS RC
Takenaka et al. 2011
78 ♂
62
PS
RC
Volkmer et al. 2004
29 ♀
65
PS
RC
Zippe et al. 2004b
27 ♀
55
PS
RC
Bhatt et al. 2006
11 ♀
56
PS
NNS & NS
RC
Nandipati et al. 2006
11 ♀
56
PS
NNS & NS
RC
Meinhardt et al. 2003
Treatment
Sexuality
preserving RC
Sexuality
preserving RC
RC
Seminal
sparing RC
RC
Results
Sexual function is preserved, erections (79%) and anterograde ejaculation (50%). 60% of the men with sexual dysfunction
used potency treatment successfully.
After 3 months 90% was potent. Of all men, 7% used vardenafil successfully and 100% had retrograde ejaculation.
Postoperatively, 73% could not achieve an erection, 20% had reduced erections and 7% had normal erections. All patients
who reported postoperative erections achieved this function within 2 years. Some could overcome their sexual dysfunction
with potency treatment. Patients younger than 65 years and those with attempted sparing of 1 or both neurovascular
bundles reported significantly better recovery of erectile function. Preservation of both neurovascular bundles gave the best
result. Significantly better recovery of erectile function was reported in men with negative lymph nodes compared to those
with positive lymph nodes.
This procedure has proven to be safe (no local recurrence) and effective (95% potency preservation). In most men erectile
function recur in 1-2 months, 5% longer than 6 months. All men have retrograde ejaculation.
Erectile dysfunction is a prevalent problem, occurring in 86% of sexually active men after RC. They were sexually active
before surgery, with a mean frequency of 2 times per week. The men who retain potency had a mean age of 51 years versus
impotent men with a mean age of 59 years (not sig.). Half of the men (52%) tried sildenafil citrate, but in only 4% it was
successful. Incidence of comorbid disorders was similar in both the sexually active and impotent.
After 24 months sexual function was retained in 80% of the men.
Of the sexually active men, 77.5% retained potency, 10% became impotent and 12.5% had impaired erectile function. Of
the potent men, 59% have retrograde ejaculation. Of all men, 16% used potency treatment with success.
Erectile function returned in all men in 11 months. Of all men, 86% have anterograde ejaculation. All the men were
satisfied about their sexual life.
After RC, 88% of the men scored very low on the IIEF-5 scale (high degree of sexual dysfunction). The satisfaction of
sexual life was very low: 0.98 on a scale of 10 points.
Postoperatively, 35% of the women lost their sexual activity after RC, but they tended to classify their current sex life as
positive. Women younger than 60 years pre and post operatively, living in partnership ,and more than 4 weeks sexual
active preoperational and on the time of the questionnaire are beneficial factors for intact postoperative female sexuality.
Resection of the upper part of the anterior vaginal wall did not affect lubrication, vaginal sensibility, and the ability to
perform sexual intercourse.
About half of sexually active women (52%) have a sexual dysfunction and became dissatisfied after RC. No difference was
found between the Indiana and Studor pouch diversions. This suggests that preservation of the anterior vaginal wall will not
result in improved sexual function after RC. The ability to achieve orgasm and the degree of vaginal lubrication decreased
significantly after RC. Pain free during intercourse also decline in score. No difference was found between the
premenopausal and postmenopausal groups after RC. A third of the partners (30%) had a decrease in desire for sexual
activity owing to apprehension and physical imperfection with urostomy.
Both groups showed a decreased in satisfaction after RC (greater in non-nerve sparing group). Neurovascular preservation
maintains female sexual function after RC in all domains. All patients who had neurovascular preservation continued to
participate in sexual activity versus 14% of the non-nerve-sparing group (1 year after RC).
Neurovascular preservation in female RC significantly improves sexual function after RC. Sexual function is an important
outcome measure after RC of female bladder cancer. After 1 year all the NS patients were sexually active and only 14% of
the NNS. Those patients had problems with vaginal dryness, lack of arousal, and intercourse is painful.
Abbreviations: CSS: Cross sectional study; NNS; Non-nerve-sparing; NS: Nerve-sparing; PS: Prospective study; RC: Radical cystectomy
25
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
Figure legend
Figure 1: Flow chart of literature search
26
RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION
PUBMED
(n=75)
PsycINFO
(n=2)
Records excluded based on
criteria full text in English or
Dutch (n=23)
Records screened
(n=54)
Records excluded based on
title or abstract (n=29)
Full text articles
assessed for
eligibility (n=25)
Articles eligible
(n=13)
Articles for
qualitative
synthesis (n=26)
Articles included in
qualitative
synthesis (n=24)
Articles excluded after
inspection based on criteria
(n=12)
Articles included after a
hand search
(n=13)
Articles excluded because
the full text could not be
retrieved (n=2)