In this narrative review we summarize neglected side effects of curative intended treatment for prostate cancer. They include climacturia, arousal incontinence (AI), orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia), ejaculatory dysfunction, and morphological penile alterations in the form of shortening and deformity. Even though they have not received as much interest as erectile dysfunction (ED) or urinary incontinence, these side effects have been shown to negatively impact patient’s quality of life. They are common and rates of climacturia after radical prostatectomy (RP) range from 20% and 45%, less after external beam radiation therapy (EBRT). Decreased orgasmic sensation ranges from 3.9% to 60% after RP and between 36–57% after EBRT. Dysorgasmia ranges from 9.5–15% for both RP and EBRT. Anejculation after EBRT ranges from 11–71% and rates of penile shortening are reported between 0 and 100%. There are no internationally validated questionnaires that adequately asses these side effects. This is necessary if we are to align patient and partner expectations properly and consequently manage them optimally. Neglected side effects should be discussed with patients and their partners preoperatively, as they are associated with bother and may lead to patient’s avoiding sexual activity.
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Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394–424.
Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, et al. 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375:1415–24.
Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, 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.
Donovan JL, Hamdy FC, Lane JA, Mason M, Metcalfe C, Walsh E, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375:1425–37.
Frey AU, Sønksen J, Fode M. Neglected side effects after radical prostatectomy: a systematic review. J Sex Med. 2014;11:374–85.
Frey A, Pedersen C, Lindberg H, Bisbjerg R, Sønksen J, Fode M. Prevalence and predicting factors for commonly neglected sexual side effects to external-beam radiation therapy for prostate cancer. J Sex Med. 2017;14:558–65.
Salonia A, Burnett AL, Graefen M, Hatzimouratidis K, Montorsi F, Mulhall JP, et al. Prevention and management of postprostatectomy sexual dysfunctions part 2: Recovery and preservation of erectile function, sexual desire, and orgasmic function. Eur Urol. 2012;62:273–86.
Lee J, Hersey K, Lee CT, Fleshner N. Climacturia following radical prostatectomy: prevalence and risk factors. J Urol. 2006;176:2562–5.
Koeman M, van Driel MF, Schultz WC, Mensink HJ. Orgasm after radical prostatectomy. Br J Urol. 1996;77:861–4.
Barnas JL, Pierpaoli S, Ladd P, Valenzuela R, Aviv N, Parker M, et al. The prevalence and nature of orgasmic dysfunction after radical prostatectomy. BJU Int. 2004;94:603–5.
Choi JM, Nelson CJ, Stasi J, Mulhall JP. Orgasm associated incontinence (climacturia) following radical pelvic surgery: rates of occurrence and predictors. J Urol. 2007;177:2223–6.
Nilsson AE, Carlsson S, Johansson E, Jonsson MN, Adding C, Nyberg T, et al. Orgasm‐associated urinary incontinence and sexual life after radical prostatectomy. J Sex Med. 2011;8:2632–9.
Messaoudi R, Menard J, Ripert T, Parquet H, Staerman F. Erectile dysfunction and sexual health after radical prostatectomy: impact of sexual motivation. Int J Impot Res. 2011;23:81–86.
Mitchell SA, Jain RK, Laze J, Lepor H, M SA, J RK, et al. Post-prostatectomy incontinence during sexual activity: a single center prevalence study. J Urol. 2011;186:982–5.
O’Neil BB, Presson A, Gannon J, Stephenson RA, Lowrance W, Dechet CB, et al. Climacturia after definitive treatment of prostate cancer. J Urol. 2014;191:159–63.
Frey A, Sønksen J, Jakobsen H, Fode M. Prevalence and predicting factors for commonly neglected sexual side effects to radical prostatectomies: results from a cross-sectional questionnaire-based study. J Sex Med. 2014;11:2318–26.
Capogrosso P, Ventimiglia E, Serino A, Stabile A, Boeri L, Gandaglia G, et al. Orgasmic dysfunction after robot-assisted versus open radical prostatectomy. Eur Urol. 2016;70:223–6.
Jimbo M, Alom M, Pfeifer ZD, Haile ES, Stephens DA, Gopalakrishna A, et al. Prevalence and predictors of climacturia and associated patient/partner bother in patients with history of definitive therapy for prostate cancer. J Sex Med. 2020. https://doi.org/10.1016/j.jsxm.2020.02.016.
Salter CA, Bach PV, Miranda E, Jenkins LC, Benfante N, Schofield E, et al. Bother associated with climacturia after radical prostatectomy: prevalence and predictors. J Sex Med. 2020;17:731–6.
Mykoniatis I, van Renterghem K, Sokolakis I, Hatzichristodoulou G, Sempels M, Andrianne R. Climacturia: a comprehensive review assessing pathophysiology, prevalence, impact, and treatment options regarding the ‘leak of pleasure’. Int. J. Impot. Res. 2020. https://doi.org/10.1038/s41443-020-0257-1.
Manassero F, Di Paola G, Paperini D, Mogorovich A, Pistolesi D, Valent F, et al. Orgasm‐associated incontinence (CLimacturia) after bladder neck‐sparing radical prostatectomy: clinical and video‐urodynamic evaluation. J Sex Med. 2012;9:2150–6.
Bernard S, Ouellet MP, Moffet H, Roy JS, Dumoulin C. Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: a systematic review. J Cancer Surviv. 2016;10:351–62.
Mehta A, Deveci S, Mulhall JP. Efficacy of a penile variable tension loop for improving climacturia after radical prostatectomy. BJU Int. 2013;111:500–4.
Sighinolfi MC, Rivalta M, Mofferdin A, Micali S, De Stefani S, Bianchi G. Potential effectiveness of pelvic floor rehabilitation treatment for postradical prostatectomy incontinence, climacturia, and erectile dysfunction: a case series. J Sex Med. 2009;6:3496–9.
Kannan P, Winser SJ, Choi Ho L, Hei LC, Kin LC, Agnieszka GE, et al. Effectiveness of physiotherapy interventions for improving erectile function and climacturia in men after prostatectomy: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2019;33:1298–309.
Jain R, Mitchell S, Laze J, Lepor H. The effect of surgical intervention for stress urinary incontinence (UI) on post-prostatectomy UI during sexual activity. BJU Int. 2012;109:1208–12.
Christine B, Bella AJ. MP48-04 climacturia: an under-addressed sequela of radical prostatectomy, but treatment is only a sling away. J Urol. 2016;195:e636.
Guay A, Seftel AD. Sexual foreplay incontinence in men with erectile dysfunction after radical prostatectomy: a clinical observation. Int J Impot Res. 2008;20:199–201.
Bach PV, Salter CA, Katz D, Schofield E, Nelson CJ, Mulhall JP. Arousal incontinence in men following radical prostatectomy: prevalence, impact and predictors. J Sex Med. 2019;16:1947–52.
Salter CA, Bach PV, Katz D, Schofield E, Nelson CJ, Mulhall JP. The relationship and psychosocial impact of arousal incontinence after radical prostatectomy. J Sex Med. 2020;17:94–98.
Clavell-Hernández J, Martin C, Wang R. Orgasmic dysfunction following radical prostatectomy: review of current literature. Sex Med Rev. 2018;6:124–34.
Tewari A, Grover S, Sooriakumaran P, Srivastava A, Rao S, Gupta A, et al. Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy. BJU Int. 2012;109:596–602.
Fode M, Serefoglu EC, Albersen M, Sønksen J. Sexuality following radical prostatectomy: is restoration of erectile function enough? Sex Med Rev. 2017;5:110–9.
Hollenbeck BK, Dunn RL, Wei JT, Montie JE, Sanda MG. Determinants of long-term sexual health outcome after radical prostatectomy measured by a validated instrument. J Urol. 2003;169:1453–7.
Dubbelman Y, Wildhagen M, Schröder F, Bangma C, Dohle G. Orgasmic dysfunction after open radical prostatectomy: clinical correlates and prognostic factors. J Sex Med. 2010;7:1216–23.
Mogorovich A, Nilsson AE, Tyritzis SI, Carlsson S, Jonsson M, Haendler L, et al. Radical prostatectomy, sparing of the seminal vesicles, and painful orgasm. J Sex Med. 2013;10:1417–23.
Rai S, Srivastava A, Sooriakumaran P, Tewari A. Advances in imaging the neurovascular bundle. Curr Opin Urol. 2012;22:88–96.
Salonia A, Gallina A, Briganti A, Colombo R, Bertini R, Da Pozzo LF, et al. Postoperative orgasmic function increases over time in patients undergoing nerve-sparing radical prostatectomy. J Sex Med. 2010;7:149–55.
Matsushita K, Tal R, Mulhall JP. The evolution of orgasmic pain (Dysorgasmia) following radical prostatectomy. J Sex Med. 2012;9:1454–8.
Helgason AR, Fredrikson M, Adolfsson J, Steineck G. Decreased sexual capacity after external radiation therapy for prostate cancer impairs quality of life. Int J Radiat Oncol Biol Phys. 1995;32:33–39.
Olsson CE, Alsadius D, Pettersson N, Tucker SL, Wilderäng U, Johansson K-A, et al. Patient-reported sexual toxicity after radiation therapy in long-term prostate cancer survivors. Br J Cancer. 2015;113:802–8.
Gay HA, Sanda MG, Liu J, Wu N, Hamstra D, Wei JT, et al. External beam radiation therapy or brachytherapy with or without short-course neoadjuvant androgen deprivation therapy: results of a multicenter, prospective study of quality of life. Int J Radiat Oncol Biol Phys. 2017;98:304–17.
Sullivan JF, Stember DS, Deveci S, Akin‐Olugbade Y, Mulhall JP, Akin-Olugbade Y, et al. Ejaculation profiles of men following radiation therapy for prostate cancer. J Sex Med. 2013;10:1410–6.
Barnas J, Parker M, Guhring P, Mulhall JP. The utility of tamsulosin in the management of orgasm-associated pain: a pilot analysis. Eur Urol. 2005;47:361–5.
Merrick GS, Wallner K, Butler WM, Lief JH, Sutlief S. Short-term sexual function after prostate brachytherapy. Int J Cancer. 2001;96:313–9.
Finney G, Haynes A-M, Cross P, Brenner P, Boyn A, Stricker P. Cross-sectional analysis of sexual function after prostate brachytherapy. Urology. 2005;66:377–81.
Huyghe E, Delannes M, Wagner F, Delaunay B, Nohra J, Thoulouzan M, et al. Ejaculatory function after permanent 125I prostate brachytherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2009;74:126–32.
Deveci S, Gotto GT, Alex B, O’Brien K, Mulhall JP. A survey of patient expectations regarding sexual function following radical prostatectomy. BJU Int. 2016;118:641–5.
Munding MD, Wessells HB, Dalkin BL. Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy. Urology. 2001;58:567–9.
Savoie M, Kim SS, Soloway MS. No Title. J Urol. 2003;169:1462–4.
Mulhall JP. Penile length changes after radical prostatectomy. BJU Int. 2005;96:472–4.
Gontero P, Galzerano M, Bartoletti R, Magnani C, Tizzani A, Frea B, et al. New insights into the pathogenesis of penile shortening after radical prostatectomy and the role of postoperative sexual function. J Urol. 2007;178:602–7.
Vasconcelos JS, Figueiredo RT, Nascimento FLB, Damião R, Da Silva EA. The natural history of penile length after radical prostatectomy: a long-term prospective study. Urology. 2012;80:1293–7.
Savoie M, Kim SS, Soloway MS. A prospective study measuring penile length in men treated with radical prostatectomy for prostate cancer. J Urol. 2003;169:1462–4.
Briganti A, Fabbri F, Salonia A, Gallina A, Chun FK-H, Dehò F, et al. Preserved postoperative penile size correlates well with maintained erectile function after bilateral nerve-sparing radical retropubic prostatectomy. Eur Urol. 2007;52:702–7.
Engel JD, Sutherland DE, Williams SB, Wagner KR. Changes in penile length after robot-assisted laparoscopic radical prostatectomy. J Endourol. 2011;25:65–69.
Kwon YS, Farber N, Yu JW, Rhee K, Han C, Ney P, et al. Longitudinal recovery patterns of penile length and the underexplored benefit of long-term phosphodiesterase-5 inhibitor use after radical prostatectomy. BMC Urol. 2018;18:37.
Capogrosso P, Ventimiglia E, Cazzaniga W, Stabile A, Pederzoli F, Boeri L, et al. Long-term penile morphometric alterations in patients treated with robot-assisted versus open radical prostatectomy. Andrology. 2018;6:136–41.
Haliloglu A, Baltaci S, Yaman O. Penile length changes in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer. J Urol. 2007;177:128–30.
Carlsson S, Nilsson AE, Johansson E, Nyberg T, Akre O, Steineck G. Self-perceived penile shortening after radical prostatectomy. Int J Impot Res. 2012;24:179–84.
Tal R, Heck M, Teloken P, Siegrist T, Nelson CJ, Mulhall JP. Peyronie’s disease following radical prostatectomy: incidence and predictors. J Sex Med. 2010;7:1254–61.
Berookhim BM, Nelson CJ, Kunzel B, Mulhall JP, Narus JB. Prospective analysis of penile length changes after radical prostatectomy. BJU Int. 2014;113:E131–6.
Köhler TS, Pedro R, Hendlin K, Utz W, Ugarte R, Reddy P, et al. A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy. BJU Int. 2007;100:858–62.
Raina R, Pahlajani G, Agarwal A, Jones S, Zippe C. Long-term potency after early use of a vacuum erection device following radical prostatectomy. BJU Int. 2010;106:1719–22.
Montorsi F, Brock G, Stolzenburg J-U, Mulhall J, Moncada I, Patel HRH, et al. Effects of tadalafil treatment on erectile function recovery following bilateral nerve-sparing radical prostatectomy: a randomised placebo-controlled study (REACTT). Eur Urol. 2014;65:587–96.
Capogrosso P, Pozzi EPietro, Celentano V, Sanchez-Salas R, Salonia A. Erectile recovery after radical pelvic surgery: methodological challenges and recommendations for data reporting. J Sex Med. 2020;17:7–16.
Lovegrove CC, Ficarra V, Montorsi F, N’Dow J, Salonia A, Minhas S. Sexual function outcomes following interventions for prostate cancer: are contemporary reports on functional outcomes misleading? Int J Impot Res. 2019;32. https://doi.org/10.1038/s41443-019-0220-1.
Sandhu JS, Breyer B, Comiter C, Eastham JA, Gomez C, Kirages DJ, et al. Incontinence after prostate treatment: AUA/SUFU Guideline. J Urol. 2019;202:369–78.
Wassersug RJ, Lyons A, Duncan D, Dowsett GW, Pitts M. Diagnostic and outcome differences between heterosexual and nonheterosexual men treated for prostate cancer. Urology. 2013;82:565–71.
Ussher JM, Perz J, Kellett A, Chambers S, Latini D, Davis ID, et al. Health-related quality of life, psychological distress, and sexual changes following prostate cancer: a comparison of gay and bisexual men with heterosexual men. J Sex Med. 2016;13:425–34.
Blank TO. Gay men and prostate cancer: Invisible diversity. J Clin Oncol. 2005;23:2593–6.
Grondhuis Palacios LA, van Zanten P, den Ouden MEM, Krouwel EM, Beck JJH, Reisman Y, et al. Discrepancy between expectations and experiences after prostate cancer treatment: A Dutch Multicenter Study. Urology. 2019;134:135–42.
Conflict of interest
MF is a speaker for Astellas Pharma and an advisor for Ferring Pharmaceuticals. The remaining authors declare no conflict of interest.
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Nolsøe, A.B., Jensen, C.F.S., Østergren, P.B. et al. Neglected side effects to curative prostate cancer treatments. Int J Impot Res 33, 428–438 (2021). https://doi.org/10.1038/s41443-020-00386-4
International Journal of Impotence Research (2021)