Ejaculatory urine incontinence after radical prostatectomy

doi:10.1016/j.urology.2006.08.1097

Urology

Volume 68, Issue 6, December 2006, Pages 1248-1252

https://doi.org/10.1016/j.urology.2006.08.1097 Get rights and content

Abstract

Objectives

Urinary incontinence and erectile dysfunction remain the long-term complications that affect most patients’ lives after radical prostatectomy. Previous reports evaluating incontinence have focused on volumes of urine loss and daily pad use to assess these issues. We have observed that small volumes of urinary incontinence during sexual activity can be just as disconcerting to patients. We attempt to further describe and assess the phenomenon of urinary incontinence with ejaculation in a series of patients.

Methods

We reviewed the experience of one physician who received referrals for the treatment of erectile dysfunction after radical prostatectomy from July 2002 to March 2005 and identified 26 men experiencing urine leak predominantly during ejaculation. Questionnaires assessing urinary incontinence were sent to all these patients.

Results

The mean age was 62 years (range 54 to 73). Sixteen patients underwent bilateral nerve-sparing, five unilateral nerve-sparing, and five nonnerve-sparing radical retropubic prostatectomy. At a median follow-up of 42 months (range 15 to 118), all patients had experienced urine leakage (volume 0.5 teaspoon to 1 cup) during ejaculation. The incontinence questionnaire revealed that most patients had mild incontinence; however, they experienced ejaculatory urine incontinence “most, or all of the time” and considered it a “big problem.”

Conclusions

Although the prevalence of ejaculatory urine incontinence is unclear, in our experience it occurs often enough to be considered a part of the routine postprostatectomy evaluation. A better understanding of the pathophysiology of postprostatectomy incontinence will lead to targeted therapy and an improved quality of life for the patient.

Section snippets

Material and methods

After approval from the institutional review board at our institution, we reviewed the experience of a single staff physician who specializes in sexual dysfunction and receives referrals for postprostatectomy ED. From July 2002 to March 2005, we identified 26 patients who complained of urinary incontinence during ejaculation while being evaluated for ED. During their visit, patients were asked to estimate the volume of urine loss during ejaculation (ie, in teaspoons, tablespoons, or cups). The

Results

Bilateral nerve-sparing prostatectomy was performed in 16 of the 26 patients, unilateral nerve-sparing prostatectomy in 5 patients, and nonnerve-sparing surgery in 5 patients. Of these cases, 7 were done using a laparoscopic approach, with 19 done using an open retropubic approach. The mean patient age at surgery was 62 years (range 54 to 73). The mean preoperative prostate-specific antigen level was 6.7 ng/mL. In all but 2 patients, the preoperative clinical stage was T1c. Two patients

Comment

The postprostatectomy incontinence rates have ranged from 2% to 87%.1, 2 Previous studies focusing on this have qualified incontinence in terms of the volume of loss, demonstrating that greater degrees of urine loss correlate with greater bother and more significant lifestyle changes.³ However, we found that in certain circumstances, small volumes of urine loss can have a major impact on patients’ quality of life. All patients in our study were referred for ED after radical prostatectomy and

References (6)

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M. Jonler et al.
A prospective study of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy
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K.V. Carslon et al.
Prevention and management of incontinence following radical prostatectomy
Urol Clin North Am
(2001)

There are more references available in the full text version of this article.

Cited by (28)

Climacturia After Radical Prostatectomy: MRI-Based Predictors
2020, Journal of Sexual Medicine
Citation Excerpt :
There is also an increase in bladder tonicity.25 One hypothesis for the mechanism underlying climacturia is the ineffective bladder neck coaptation allowing urine to be expelled during orgasm, while external sphincter is relaxed.7,26 This may also explain why climacturia has been seen after transurethral resection of the prostate.9
After radical prostatectomy (RP), climacturia is a prevalent and distressing problem. To date, no specific predictors have been identified.
In this analysis, we sought to find associated pelvic magnetic resonance imaging (MRI) parameters.
We identified all men in our departmental database who (i) had climacturia post-RP, ≥3 episodes; (ii) underwent a pre-RP endorectal MRI; (iii) had no radiation or androgen deprivation therapy (ADT). Soft tissue and bony dimensions were measured by 2 raters blinded to clinical and pathological data.
MRI parameters included the following: maximum height, width, and depth of prostate, prostate volume, urethral width and length, lower conjugate of pelvis, bony femoral width, outer and inner levator distances and thickness. Point-biserial correlations were run on univariate associations. Logistic regression was used for the multivariable model.
194 consecutive pre-RP MRI studies were reviewed (56 men with and 138 without climacturia). Mean age was 60 ± 7 years, average time post-RP at assessment, 7 ± 7 months. Of MRI parameters, urethral width (r = 0.13, P = .03) and lower conjugate (r = 0.12, P = .05) were associated with presence of persistent climacturia. 2 others met criteria for multivariable analysis, prostate depth and outer levator distance. Of the non-MRI parameters, none were significantly related to climacturia and only body mass index (BMI) met criteria for multivariable analysis. On multivariable analysis, only urethral width was associated with climacturia (OR = 1.23, 95% CI: 1.01–1.49, P = .04); the wider the urethra, greater the chance of climacturia.
Improved ability to predict the occurrence of orgasm-associated incontinence in the preoperative setting.
Limitations include the fact that the MRI endorectal probe may have distorted pelvic tissues during imaging and that our study population size was small. However, prospective data collection, blinded measurements by 2 trained readers, and rigorous statistical analysis should be considered strengths.
By identifying preoperative risk factors, such as urethral width on MRI, we may be able to better understand the pathophysiology of this condition and furthermore may permit us to better counsel men regarding this postoperative outcome.
Sullivan JF, Ortega Y, Matsushita K, et al. Climacturia After Radical Prostatectomy: MRI-Based Predictors. J Sex Med 2020;17:1723–1728.
Sexual Rehabilitation After Treatment For Prostate Cancer—Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015)
2017, Journal of Sexual Medicine
Citation Excerpt :
Various coping strategies and therapies have been suggested and applied with anecdotal success in men with climacturia. Usually, men complaining of urine leakage are managed behaviorally (fluid intake restriction, bladder emptying before sexual activity, the use of condoms, and the application of a penile constricting band at the base of the penis) before foreplay.4,153,167 Anecdotally, daily use of the tricyclic antidepressant imipramine or antimuscarinic compounds has been suggested.4
Sexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer.
To provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning management strategies for post-RP erectile function impairment and to analyze post-RP sexual dysfunction other than erectile dysfunction.
A literature search was performed using Google and PubMed database for English-language original and review articles published up to August 2016.
Levels of evidence (LEs) and grades of recommendations (GRs) are provided based on a thorough analysis of the literature and committee consensus.
Nine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 6 states that the recovery of postoperative erectile function can take several years (LE = 2, GR = C). Recommendation 7 states there are conflicting data as to whether penile rehabilitation with phosphodiesterase type 5 inhibitors improves recovery of spontaneous erections (LE = 1, GR = A). Recommendation 8 states that the data are inadequate to support any specific regimen as optimal for penile rehabilitation (LE = 3, GR = C). Recommendation 9 states that men undergoing RP (any technique) are at risk of sexual changes other than erectile dysfunction, including decreased libido, changes in orgasm, anejaculation, Peyronie-like disease, and changes in penile size (LE = 2, GR = B).
This article discusses Recommendations 6 to 9 of the ICSM 2015 committee on sexual rehabilitation after RP.
Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment For Prostate Cancer–Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:297–315.
Impact of Prostate Cancer Treatments on Sexual Health
2016, Prostate Cancer: Science and Clinical Practice: Second Edition
Erectile dysfunction is the most commonly reported sexual dysfunction. However, there are several others that may cause significant patient bother and receive less attention including anejaculation, orgasmic disorders, sexual incontinence, and loss of penile length. Great strides have been made in the treatment of erectile dysfunction in the past few decades. Penile rehabilitation is commonly used to help preserve erectile function after radical prostatectomy. Rehabilitation has more recently been examined to be utilized after radiation therapy. Researchers are still working on new therapeutics to find new ways to help prevent or fix the neural/vascular injuries related to erectile dysfunction. Anejaculation, orgasmic changes like dysorgasmia and sexual incontinence, can be very bothersome to the patient and should be discussed prior to surgery to obtain proper patient expectations. Changes in penile length likely occur from the same process behind the erectile dysfunction and studies have shown that rehabilitation preserves length.
Climacturia following radical prostatectomy
2015, Revista Mexicana de Urologia
Conocer la frecuencia, asociaciones y el impacto sobre la función del orgasmo que tiene la climacturia después del tratamiento quirúrgico definitivo de cáncer de próstata en pacientes mexicanos.
Entre enero del 2003 y enero del 2013 se aplicó un cuestionario para conocer aspectos de climacturia (frecuencia, cantidad de pérdida de orina, mecanismos usados por el paciente y nivel de molestia y afrontamiento).
Un total de 122 pacientes fueron seleccionados y 84 cumplieron los criterios de inclusión. La edad media fue 55.3 años. Un 45.2% de los pacientes informaron presentar climacturia cuya prevalencia fue de 0.45. El 23.6% de los pacientes con climacturia declararon que lo experimentaron en raras ocasiones, 47.3% ocasionalmente, 10.5% a menudo, 13.15% la mayor parte del tiempo y 5.26%, todo el tiempo. En cuanto a la satisfacción del paciente y su percepción negativa durante el acto sexual, 23 pacientes declararon que no se trataba de una molestia significativa. Solo 9 pacientes creen que sí llega a molestar a su pareja de manera importante.
Existe un alto número de pacientes con climacturia después de la prostatectomía radical. La climacturia no se asocia necesariamente con un impacto negativo en la satisfacción sexual.
To know the frequency, associations, and impact of climacturia on the function of orgasm after definitive surgical treatment of prostate cancer in Mexican patients.
A questionnaire was applied between January 2003 and January 2013 to know the aspects of climacturia (frequency, quantity of urine leakage, mechanisms used by the patient, and the level of discomfort and coping).
A total of 122 patients were selected and 84 met the inclusion criteria. The mean age was 55.3 years. A total of 45.2% of the patients stated that they presented with climacturia, resulting in a prevalence of 0.45. Of those patients, 23.6% said they rarely experienced the condition, 47.3% occasionally, 10.5% often, 13.15% the majority of the time, and 5.26% all the time. In relation to patient satisfaction and negative perception during sexual intercourse, 23 patients stated that it was not a significant problem. Only 9 patients said that it represented an important level of discomfort for their partner.
There is a high number of patients with climacturia following radical prostatectomy and the condition is not necessarily associated with a negative impact on sexual satisfaction.
Climacturia after definitive treatment of prostate cancer
2014, Journal of Urology
Prostate cancer treatment results in several sexually related side effects beyond the well studied erectile dysfunction. Climacturia (leakage of urine during orgasm) has been reported after prostatectomy but studies have been limited by multiple factors. In this study we examine the prevalence, causes and impact on orgasm function of climacturia after definitive treatment of prostate cancer with surgery or radiation.
A total of 906 anonymous surveys were sent to patients with prostate cancer treated with surgery and/or radiation. Respondents were asked about the presence of urinary leakage, climacturia and various elements related to sexual and orgasmic function. We estimated the prevalence of climacturia, evaluated the differences between those with and without climacturia, and assessed the impact of climacturia on orgasmic function.
Overall 412 surveys were returned and available for analysis, and of these respondents 75.2% were sexually active or experiencing orgasms. Climacturia was reported by 22.6% of these respondents, and by 28.3%, 5.2% and 28.6% of those treated with surgery, radiation, or both, respectively (p <0.001). The use of aides to obtain an erection (OR 2.24, 95% CI 1.08–4.93, p = 0.035) and the presence of urinary incontinence (OR 3.09, 95% CI 1.66–5.88, p <0.001) were also associated with climacturia in a multivariate logistic regression model. Climacturia had no significant impact on orgasmic function and satisfaction.
Climacturia is experienced by a substantial proportion of men after undergoing definitive treatment of prostate cancer. We found a complex relationship between stress urinary incontinence and climacturia, and noted that the presence of climacturia does not necessarily negatively impact sexual satisfaction.
Sexual Rehabilitation and Cancer Survivorship: A State of Art Review of Current Literature and Management Strategies in Male Sexual Dysfunction Among Prostate Cancer Survivors
2013, Journal of Sexual Medicine
The challenges for prostate cancer survivors include the surveillance of prostate cancer recurrence and management of physical, cognitive, sexual, and socioeconomic quality of life issues. Sexual function remains an important issue in men, who often continue to be interested in sex after prostate cancer treatment. The various post‐prostate cancer treatment‐related sexual dysfunctions are penile deformities and erectile dysfunction (ED); sexual desire and mental health; ejaculatory and orgasmic dysfunctions; and changes in partner relationship and dynamics.
The aim of this study is to provide state of art review of the various male sexual dysfunctions in prostate cancer survivors and the management strategies in sexual rehabilitation.
A literature search for English language original and review articles either published or e‐published was performed using PubMed database. Keywords included prostate cancer, prostate cancer treatment, prostate prostatectomy (RP), sexual dysfunction, erectile dysfunction (ED), sexual desire, mental health, ejaculation, orgasmic, climacturia, and relationship.
There has been considerable volume of publication in recent years on prostate cancer‐related male sexual dysfunction. Penile deformities and ED shared similar pathophysiology and that penile smooth muscle fibrosis ultimately results in structural alterations and end‐organ failure. Penile rehabilitation using oral phosphodiesterase type 5 (PDE5) inhibitors is considered the standard of care especially in patients who received nerve‐sparing RP and should be instituted as soon as possible to protect and prevent corporal endothelial and smooth muscle damage. However, there is no consensus on the exact timing, dose, and duration of PDE5 inhibitors and its impact in non‐nerve‐sparing RP and other forms of prostate cancer treatment modalities. Current literature on hypoactive sexual desire, ejaculatory, and orgasmic dysfunctions in patients who received prostate cancer treatment is limited. Psychological and sexual counseling play an important role in rehabilitation and treatment of various forms of male sexual dysfunctions.
While several preventive and treatment strategies for the preservation and recovery of sexual function are available, no specific recommendation or consensus guidelines exist regarding the optimal rehabilitation or treatment protocol. While medical and surgical therapies are effective in erectile function recovery and/or preservation, psychological and sexual counseling are equally important in sexual rehabilitation. Chung E and Brock G. Sexual rehabilitation and cancer survivorship: A state of art review of current literature and management strategies in male sexual dysfunction among prostate cancer survivors. J Sex Med 2013;10(suppl 1):102–111.

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Adult urologyEjaculatory urine incontinence after radical prostatectomy

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Urol Clin North Am

Urology

Prevention and management of incontinence following radical prostatectomy

Urol Clin North Am

Adult urology
Ejaculatory urine incontinence after radical prostatectomy