Self-perceived penile shortening after radical prostatectomy

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Abstract

The postoperative effect on penile length after radical prostatectomy has been the subject of studies with conflicting results. We analyzed self-perceived penile shortening, quality of life and self-esteem after radical prostatectomy. In this cross-sectional study of a cohort of 1411 men who underwent a radical prostatectomy at Karolinska University Hospital between 2002 and 2006, we used a study-specific questionnaire. Patients and controls were asked about their perceived penile shortening by comparing present penile length now and at age 30 years. All subjects were also asked about their present quality of life and self-esteem. Patients were compared with 442 age-matched population-based controls. Among 1288 who underwent radical prostatectomy and answered the questionnaire (response rate 91%), 663 patients reported self-perceived penile shortening (55%), as compared with 85 (26%) of 350 men in the control group, corresponding to a relative risk (RR) of 2.1 (95% confidence interval (CI) 1.8–2.6) of self-perceived penile shortening compared with the age-matched control group. Age, grade of erectile dysfunction and angina were correlated with self-perceived penile shortening in both the operated and the control group. After adjustments for all of these mentioned potential confounders, we obtained a RR of 1.7 (95% CI 1.4–2.1) of self-perceived penile shortening compared with the controls. We also found that self-assessed penile shortening was associated with a RR of 1.2 (95% CI 1.1–1.3) for a low-to-moderate self-assessed quality of life and a RR of 1.2 (95% CI 1.1–1.4) for a low-to-moderate self estimation of self-esteem. Extensive nerve-sparing technique seems to be associated with less self-perceived penile shortening compared with radical prostatectomy with lower degree of nerve-sparing approach. These data indicate that radical prostatectomy is associated with self-perceived penile shortening and suggests that erectile function is a key factor in penile shortening.

Introduction

It has been hypothesized and reported that the penis is shortened by radical prostatectomy. The abundance of articles on the size of the penis in the lay literature and media indicates that the size of the penis does matter to many people. Penile size, especially during erection, is a symbol of masculinity and of great importance for some men.1 There are numerous historical anecdotes demonstrating the efforts taken and resourcefulness of men who want a larger penis. The Topinama of Brazil, for example, encourage poisonous snakes to bite their penis to enlarge it for 6 months.2 Perhaps, unexpectedly, research on body image and disfigurement suggests that the severity and type of disfigurement influences the perception of body change less than the individual psychological investment in the altered body feature.3, 4, 5 Thus, although a potential shortening of penile length after prostatectomy may seem trivial in relation to other health problems, this shortening probably does matter to many in the increasingly younger population of operated men.

The exact mechanism of penile shortening is not clear, but a study by Gontero et al.6 shows that nerve-sparing surgery as well as recovery of erectile function has a protective effect on penile length 1 year after surgery. Seven previous studies have assessed the potential change in penile length after prostatectomy.6, 7, 8, 9, 10, 11, 12 Drawing supportable conclusions from these studies is hampered, however, by somewhat conflicting results with one study stating that no penile shortening occurred postoperatively10 and another recent study showing recovery of penile shortening 9 months after surgery.12 All studies published to date used the measurement of penile length (flaccid, stretched or erected) as their outcome measure. This is the first study to put the patient's perspective and perception in the spotlight and this is also the first study to associate length loss with quality of life and self-esteem.

Aims

The aim of the present study was to evaluate self-assessed penile shortening in prostate cancer survivors after a radical prostatectomy.

Materials and Methods

We invited all of the 1418 men operated on for prostate cancer with radical prostatectomy between January 2002 and December 2006 at the Department of Urology, Karolinska University Hospital to participate. No exclusion criteria were used. An external comparison group of 442 men matched by age and residency was identified in the general population in a randomized fashion and invited to participate. Clinical data on the prostate-cancer patients (age, clinical stage, biopsy Gleason score and preoperative prostate-specific antigen) were collected at the time of operation. We invited the eligible study subjects by mail between February and December 2007, and we then followed up this letter with oral informed consent and a postal questionnaire. The local ethics committee in Stockholm, Sweden approved the study, including means of data collection.

The questionnaire is built on previously validated questionnaires used by our group, and we developed a study-specific questionnaire on the basis of our previous cancer-survivor project, documented previously in numerous reports.13, 14, 15, 16 The questionnaire was refined after seven in-depth interviews with patients who underwent radical prostatectomy. Face validity was ensured with 10 patients by having an investigator accompany them while they completed the questionnaire to make sure that no questions were misinterpreted. A pilot study was conducted with 20 participants where methods of data collection were tested. This led to minor modifications of the questionnaire.

We defined self-perceived penile shortening based on the question ‘Is your penis shorter compared to when you were 30 years old?’, with response options no or yes. We asked separate questions about spontaneous morning and sexual activity-related erections for assessing erectile dysfunction (ED). The first question was ‘During the last six months how rigid was your penis during sexual activity?’ and the second question was ‘During the last six months how rigid was your penis at early morning erections?’. The response alternatives ranged from never to always. We considered the subject to have ED if his answer to both of these questions were ‘Not applicable, I have not had sexual activity/morning erections’ or ‘My penile rigidity was never sufficient for sexual intercourse’. Questions about comorbidity, previous surgery, current medication, height and weight were also included in the questionnaire. The psychological symptom (self-esteem) and quality of life was assessed with a visual digital scale with seven categories, for example, one and two is assessed as low quality of life, three to five as moderate quality of life and six and seven as high quality of life. The men marked one of seven numbers on a line anchored by, for example, no quality of life and the best possible quality of life. An independent third party collected the questionnaires.

Statistical analysis

We categorized subject variables as presented in Table 1 and calculated the prevalence proportions of patients and controls reporting self-perceived penile shortening in each category. All variables that showed a statistically significant association with self-perceived penile shortening among patients were adjusted for in comparison patients and controls, as shown in Table 2 in which the same variable categorizations were retained. Relative risks (RRs; risk ratios) and 95% confidence intervals—as well as their adjusted counterparts—were estimated through log-binomial regression. The Cochran-Armitage test for trend was used to test for a significant trend towards higher prevalence of self-perceived penile shortening with increasing grade of ED as well as decreasing grade of nerve-sparing approach (Tables 3a and b). All calculations were performed in the SAS software package (v. 9.2, SAS Institute Cary, NC, USA). Subjects with missing data were excluded in the analyses of each specific variable.

Table 1 Predictors for perceived penile shortening (PS) among men subjected to radical prostatectomy and among comparison subjects
Table 2 Prevalence and relative risk (RR) of perceived penile shortening among prostatectomy patients and comparison subjects
Table 3a Relative risk of perceived penile shortening (PS) at different levels of erectile function among prostatectomy patients and comparison subjects
Table 3b Degree of nerve-sparing and risk of perceived penile shortening (PS) of 395 patients after a radical prostatectomy

Results

Baseline characteristics for patients treated with radical prostatectomy and comparison subjects are listed in Table 4. Among the 1418 eligible patients, 1288 (91% participation rate) answered the questionnaire and 350 (79% participation rate) questionnaires were obtained from the control group. Among the non-participating patients, 33 (2%) were lost to follow up, 31 with no telephone number or address registered in population registers and 2 dead (death unrelated to prostate cancer). In all, 42 (3%) did not want to participate, 6 did not speak Swedish, 5 had dementia and 1 patient was blind and 48 (3%) did not return the questionnaire. The prostatectomy patients had a median follow-up time of 24.2 months (range 3.7–64.0) after surgery when they answered the questionnaire.

Table 4 Basic characteristics

Both ED and high age were associated with self-perceived penile shortening among men subjected to radical prostatectomy, with a RR of 1.4 (95% CI 1.3–1.6) for those experiencing ED, and 1.3 (95% CI 1.1–1.5) for the oldest compared with the youngest men. ED was associated with an increased prevalence of perceived penile shortening among comparison subjects as well (Table 1). Postoperative hormonal treatment (RR, 1.4; 95% CI, 1.3–1.7) was found to have an association with self-perceived penile shortening. Among the comparison subjects, age was more strongly associated with self-perceived penile shortening compared with the operated men. Cardiovascular diseases such as angina and heart failure were associated with self-perceived penile shortening in both groups (Table 1).

Among 1208 who underwent radical prostatectomy, provided information and responded to the question on self-perceived penile shortening, 663 patients reported self-perceived penile shortening (55%), as compared with 85 (26%) of 329 men in the comparison group, corresponding to a RR of 2.1 (95% CI 1.8–2–6; Table 2). Adjustments for measured potential confounders did not change the point estimate substantially.

Patients who after the radical prostatectomy showed the lowest grade of erectile function (rigidity never sufficient for intercourse) also reported the highest frequency of self-perceived penile shortening (60%, Table 3a). Among these patients, 261 (60%) reported self-perceived penile shortening, compared with 37 (35%) in the group with no ED, corresponding to a RR of 1.7 (1.3–2.3; Table 3a). In a subgroup analysis of 395 after radical prostatectomy (data on nerve-sparing technique were available only in this subgroup), 45 patients (58%) reported self-perceived penile shortening after unilateral nerve-sparing radical prostatectomy, compared with 14 patients (33%) after bilateral intrafascial nerve-sparing radical prostatectomy, corresponding to a RR of 1.8 (1.1–2.8). With increasing degree of nerve-sparing operative procedure, the risk of self-perceived penile shortening decreased (P=0.0014)

Self-perceived penile shortening among prostatectomy patients who were sexually active was associated with a RR of 1.2 (95% CI 1.1–1.3) for a low-to-moderate self-assessed quality of life and a RR of 1.2 (95% CI 1.1–1.4) for a low-to-moderate self estimation of self-esteem. These results remained after adjustment for ED and age (Table 5).

Table 5 Effect of perceived penile shortening on self-assessed quality of life and self estimation of self-esteem among prostatectomy patients and comparison subjects

Discussion

We found that radical prostatectomy is associated with self-estimated penile shortening. Men who had been operated on with nerve-sparing surgery had a lower prevalence of self-assessed penile shortening than men who did not have preserved erectile function.

Furthermore, among prostate cancer survivors who have experienced self-perceived penile shortening, as compared with those who are sexually active but did not experience self-perceived penile shortening postoperatively, we found a higher prevalence of low-to-moderate self-assessed quality of life and low-to-moderate self estimation of self-esteem.

The collective evidence of our study and those of others suggests that radical prostatectomy can cause penile shortening. Penile shortening after radical prostatectomy has been reported in previous studies by 68–71% of the patients,6, 8, 9 which corresponds well with our results. Men undergoing a radical prostatectomy are at an almost twofold risk of perceiving penile shortening compared with age- and residency-matched population-based controls.

Patients who underwent radical prostatectomy with no attempt at nerve-sparing surgery or with the lowest degree of nerve-sparing surgery, an approach resulting in postoperative ED, experienced self-perceived penile shortening almost twice as often as patients who had gone through nerve-sparing surgery. Interestingly, the correlation between ED and self-perceived penile shortening was also evident among controls. Furthermore, evidence of cardiovascular disease in this control group such as myocardial infarction, heart failure, angina and hypertension, all of which are risk factors for ED, were all associated with perceived penile shortening. Gontero et al.6 have shown that return to functional erections after radical prostatectomy may be protective against penile length loss and Briganti et al.10 have shown that penile length preservation is directly related to postoperative erectile function. In Briganti's study of 33 men all of whom had good erectile function 6 months postoperatively, approximately the same as before surgery (mean IIEF score of 27.2 versus 26.7), no penile shortening was found. Fraiman et al.7 reported that a non-operated group of 130 men with ED had an average penile morphometric similar to the operated group (with no patient having erection sufficient for vaginal penetration). They stated that this non-operated group of men already had end-organ (penis) changes from their longstanding ED. Recently, Engel et al.,12 in a study of 127 patients after robot-assisted radical prostatectomy, found a median penile shortening of 0.64 cm 1 month postoperatively, but found that after 9 months penile length had returned to the preoperative measurement. They concluded that penile shortening could be a surrogate measure of erectile function after a radical prostatectomy. Thus, available evidence indicates that erectile function is a key factor in penile shortening.

We were unable to find other studies about the impact of postoperative penile shortening on quality of life and self-esteem among prostate cancer survivors (other than a comment from Engel et al.12 that studies concerning this topic would be desirable). That self-perceived penile shortening seems to affect quality of life and self-esteem in prostate cancer survivors to a greater degree than in the control group might be attributable to the control group probably having had a longer period of time to cope with their self-perceived penile shortening than the operated group where onset can be thought to be more sudden. As the prostate cancer survivors were not counselled preoperatively about the risk of achieving this unwanted side effect, they were not mentally prepared for the change. They might have responded differently to the questions about self-assessed quality of life and self estimation of self-esteem if they had been given information about this change preoperatively.

Several mechanisms have been suggested for penile shortening after radical prostatectomy.

  1. 1

    Cavernosal nerve injury, which in a rat model results in apoptosis of corporal smooth muscle;17, 18

  2. 2

    cavernosal relative hypoxia, as a result of absence of erectile activity that could create an environment resulting in corporal fibrosis;19, 20 and

  3. 3

    sympathetic hyper-innervation, which happens after an autonomic nerve injury because sympathetic fibres regenerate more quickly resulting in a penile hypertonic state.21, 22

The above discussed underlying mechanisms of nerve injuries, causing penile shortening after radical prostatectomy, could obviously be applied also when discussing causality of ED postoperatively, as the cavernosal nerve is a part of the neurovascular bundles.23

Previous studies about penile shortening after radical prostatectomy have been performed on rather small groups of patients (n=100, 31, 124, 33, 126 and 127, respectively),6, 7, 8, 9, 10, 12 whereas the present study group is more than 10-fold larger. Further strengths of our study are the population-based approach and the high participation rate. Multivariable modelling in comparison patients and controls excluded the role of a number of possible confounders, and we conclude that radical prostatectomy may cause perceived penile shortening through damage to the erectile nerves.

A possible limitation of our study is that penile size was self assessed and not objectively measured (flaccid, stretched or erected) as in other studies.6, 7, 8, 9, 10, 12 There are, however, no highly precise measures of penile length and regardless of the choice of method, random error is likely to dilute any difference between comparison groups. Perceived penile shortening is, in our view, the most relevant measure as that is what matters to the subject. We do not know, however, if the men primarily refer to the erect or non-erect penis, or if shortening affects the erect penis as much the non-erect. The questions posed to prostate-cancer survivors and age-matched population-based controls were identical and data were collected with identical means to minimize any differential misclassification.

Another limitation of our study is that we have not performed self-assessed penile measurements at several intervals after the radical prostatectomy; thus, we have no data on the exact onset of penile shortening postoperatively and we have no data on possible recovery of penile shortening. Gontero et al.6 showed that penile shortening after radical prostatectomy peaks at the time of catheter removal and it continues to a lesser but still significant degree for at least 1 year. With a follow-up time from 3.7 to 64.0 months of our operated group, some of the patients had probably not completed their penile shortening at the time when they answered the questionnaire and some with good erectile function might have recovered their self-perceived penile shortening.

Conclusions

Men undergoing a radical prostatectomy are at an almost twofold risk of experiencing penile shortening compared with age- and residency-matched population-based controls. Patients undergoing nerve-sparing surgery had a lower prevalence of self-perceived penile shortening. When preoperatively counselling patients about unwanted effects of surgery, we may consider including information about the risk of penile shortening. Postoperatively, we may ask for psychological reactions on the change of penile length, if it has occurred.

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Acknowledgements

We thank former senior colleague Stephan Brändstedt for inspiring us to study this topic.

Author information

Correspondence to S Carlsson.

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The authors declare no conflict of interest.

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Carlsson, S., Nilsson, A., Johansson, E. et al. Self-perceived penile shortening after radical prostatectomy. Int J Impot Res 24, 179–184 (2012) doi:10.1038/ijir.2012.13

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Keywords

  • penile length
  • prostate cancer
  • quality of life
  • radical prostatectomy
  • self-esteem

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