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ADULT UROLOGY CME ARTICLE

SEXUAL FUNCTION AFTER PARTIAL PENECTOMY FOR PENILE CANCER FREDERICO RAMALHO ROMERO, KAREN RICHTER PEREIRA DOS SANTOS ROMERO, MARCUS AUGUSTO ELIAS DE MATTOS, CARLOS RICARDO CAMARGO GARCIA, RONI DE CARVALHO FERNANDES, AND MARJO DENINSON CARDENUTO PEREZ

ABSTRACT Objectives. To compare sexual function and satisfaction before and after partial penectomy and to evaluate possible dysfunctions that could modify postoperative sexual functioning. Methods. A total of 18 patients underwent a personal interview and answered the International Index of Erectile Function questionnaire to determine erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction with sexual life. Domain scores were computed by summing the scores for individual answers, and the final scores were compared before and after partial penectomy. Results. The median patient age was 52 years. The medium penile length after partial penectomy was 4 cm in the flaccid state; 55.6% of patients reported erectile function that allowed sexual intercourse. The main reason for not resuming sexual intercourse appeared to be related to feelings of shame owing to the small penis size and the absence of the glans penis found in 50% of sexually abstinent patients. Surgical complications also compromised the resumption of sexual activity after amputation in 33.3% of these patients. However, 66.7% sustained the same frequency and level of sexual desire as before surgery, and 72.2% continued to have ejaculation and orgasm every time they had sexual stimulation or intercourse. Only 33.3% maintained their preoperative sexual intercourse frequency and were satisfied with their sexual relationship with their partners and their overall sex life. Conclusions. The preoperative and postoperative scores were statistically different for all domains of sexual function after partial penectomy. UROLOGY 66: 1292–1295, 2005. © 2005 Elsevier Inc.

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ancer of the penis has a very low reported incidence worldwide. The prevalence of penile cancer in Brazil is one of the greatest in the world, accounting for 17% of all malignancies in men in some areas.1 Although in developed countries, the incidence of penile cancer is usually less than 2 per 100,000,2,3 São Paulo has an incidence of 28 per 100,000.3 In some northeastern Brazilian states, the incidence reaches 50 per 100,000.3 Aggressive therapy with partial or total penectomy is still the conventional treatment for cancer of the penis.3–5 Partial penectomy is used when enough of the penile shaft can be preserved to allow the patient to direct his urinary stream comfortably.6 However, penectomy can have a devasFrom the Division of Urology, Santa Casa Medical School, São Paulo, São Paulo, Brazil Reprint requests: Frederico Ramalho Romero, M.D., Rua Emiliano Perneta, 653 ap. 41, Centro, Curitiba, PR 80420-080, Brasil. E-mail: fredromero@terra.com.br Submitted: March 31, 2005, accepted (with revisions): June 14, 2005 © 2005 ELSEVIER INC. 1292

ALL RIGHTS RESERVED

tating effect on a man’s self-image and sex life.7 Few reviews have dealt with the quality of life and, in particular, sexual function of these patients.8 To contribute to the understanding of posttreatment sexual activity, we analyzed the results of a semistructured personal interview with 18 patients who underwent partial penectomy in a 5-year period and compared their sexual function and satisfaction before and after treatment. Additionally, we investigated any eventual sexual dysfunction for possible causal associations. MATERIAL AND METHODS The criteria for inclusion in this study were partial penectomy for penile carcinoma, regular sexual activity before surgery, and a final minimal penile length in the flaccid state of 2.5 cm after surgery. The exclusion criteria included treatment with conservative methods or total penectomy, recurrence and/or metastasis, diagnosis of a serious chronic illness that could interfere with sexual function or recall to the interview, and nonacceptance to participate in this survey. Of 54 patients treated for penile cancer at our institution between 1998 and 0090-4295/05/$30.00 doi:10.1016/j.urology.2005.06.081


TABLE I. Median and standard deviations of sexual function and satisfaction before and after partial penectomy Domain Erectile function Orgasmic function Sexual desire Intercourse satisfaction Overall satisfaction

Before

After

P Value*

29.56 ⫾ 1.42 9.94 ⫾ 0.24 8.89 ⫾ 0.76 12.67 ⫾ 1.46 8.61 ⫾ 1.58

19.39 ⫾ 12.44 7.67 ⫾ 3.90 7.61 ⫾ 1.94 6.89 ⫾ 5.57 6.11 ⫾ 2.65

0.012 0.027 0.018 0.002 0.001

* Wilcoxon signed rank test.

2004, 18 fulfilled the selection criteria and were eligible to participate in this investigation. Partial penectomy was performed as proposed by Spaulding and Grabstald9 in 1979, with a 2-cm margin of tumor-free tissue. Squamous cell carcinoma of the penis was the histologic type in all cases. Twelve patients had Stage T1, two had T2, and four had T3. The average tumor size was 3.4 cm. Modified lymphadenectomy was performed in 12 patients between 1 and 14 months after partial penectomy. One of the investigators who had not been involved in the surgery of the patients interviewed and examined all subjects at their regular follow-up visit at the hospital to measure the remaining penile shaft in the flaccid state and to assess for surgical complications. Patients twice answered the validated Portuguese version of the International Index of Erectile Function.10 Retrospectively, each patient evaluated his premorbid sexual function and then his current function. The resulting numeric values for each domain of sexual function were compared statistically before and after surgery with the nonparametric Wilcoxon signed rank test. Statistical significance was assessed with a two-tailed test at P ⬍0.05. We used the Statistical Package for Social Sciences, version 12.0, for Windows (SPSS, Chicago, Ill) for the computations.

RESULTS At the interview, the median patient age was 52 years (range 35 to 86). Each interview took approximately 45 minutes, and the median time that had elapsed from surgery to the present investigation was 23.5 months (range 6 to 62). Fourteen patients had a steady partner relationship. The medium length of the penis after partial amputation was 4 cm in the flaccid state. Table I shows the median values and standard deviations of sexual function and satisfaction before and after partial penectomy according to the International Index of Erectile Function-15. The preoperative and postoperative scores were statistically different for all domains of sexual function. ERECTILE FUNCTION When questioned about sexual intercourse, 10 of 18 patients reported erection of the penile stump hard enough for penetration “most times” or “always” during the entire sexual intercourse, similar to before surgery. Two patients complained of a reduction in erectile function from “always” to “sometimes” and “almost never,” and six reported UROLOGY 66 (6), 2005

having “no sexual activity.” When asked specifically about erection, 14 of 18 patients claimed “high” or “very high” confidence that they could get and keep an erection, and 3 reported “moderate” confidence. ORGASMIC FUNCTION Thirteen patients responded that they ejaculate and have the feeling of orgasm “almost always” or “always” when they had sexual stimulation or intercourse, two reported ejaculation and orgasm “a few times” or “sometimes,” and, three, no orgasmic function after treatment compared with “almost always” or “always” before surgery. SEXUAL DESIRE Eight patients affirmed they had felt sexual desire “most times” or “always,” with a “high” or “very high” level of desire before and after surgery. Four patients kept, after surgery, the same “moderate” level of sexual desire they had had preoperatively, and six reported a reduction in frequency (“a few times” to “sometimes”) and/or level (“moderate” to “low”) of sexual desire. INTERCOURSE SATISFACTION Six patients maintained the same sexual intercourse frequency as before penectomy. In 4 weeks, the sexual frequency of 3 patients was “7 to 10”; in 2 patients, it was “5 to 6”; and in 1, it was “3 to 4.” The other 12 patients presented with reduced sexual frequency, decreased from more than seven attempts to less than four in 8 patients, including 2 who “did not attempt intercourse,” and from one to six attempts to “no attempts” in 4 patients. Sexual intercourse was “almost always” or “always” satisfactory for 10 patients, and 2 patients considered sexual intercourse only “a few times” satisfactory after treatment. The grade of satisfaction also varied. Three patients maintained their satisfaction as “highly enjoyable” or “very highly enjoyable.” Five patients maintained it as “fairly enjoyable,” and four decreased their satisfaction to “not very enjoyable” or “fairly enjoyable.” The remaining 6 patients had “no intercourse” postoperatively and 1293


could not respond about the frequency or grade of satisfaction. OVERALL SATISFACTION Although all 18 patients considered they were “moderately” or “very satisfied” with their overall sex life and sexual relationship with their partners before surgical treatment, only 6 patients sustained their degree of satisfaction after it. Five patients claimed they were “equally satisfied and dissatisfied,” four became “moderately dissatisfied,” and three were “very dissatisfied” after partial penectomy. The reasons reported by 3 of the 6 patients who had not resumed sexual intercourse at the time of the interview were feelings of low self-esteem and shame for the small size of the penis and an absence of the glans penis. One additional patient who had resumed intercourse, reduced it, importantly, for the same motive. The presence of surgical complications, namely, meatal stricture and excessive penile shaft skin, was the reason for 2 patients who did not reestablish their preoperative sexual functioning. One patient reported sexual abstinence because he had no partner, and another patient developed erectile dysfunction 1.5 years after partial amputation. Between the surgery and the development of erectile dysfunction, all domains of erectile function remained equal to that preoperatively, diminishing thereafter. COMMENT Of all urogenital cancers, the one that most obviously jeopardizes sexual function is penile carcinoma.6 If the lesion is early and noninvasive, conservative treatment with local resection, Mohs micrographic surgery, topical chemotherapy, external beam radiotherapy, interstitial brachytherapy, cryosurgery, or laser therapy can be used, with only marginal compromise of sexual function and satisfaction.2,4,5,11 A survey from Sweden showed unchanged sexual activity in up to 80% of patients after laser treatment for penile cancer.2 More commonly, however, partial or total amputation of the penis is necessary to control the cancer. Several individually reported impressions evidenced that the remaining shaft of the penis may still become erect with excitement and that patients and their partners can reach orgasm and achieve normal ejaculation after partial penectomy.3,6 However, larger studies evaluating sexual function after partial penectomy are scarce, and the results are controversial. In a Norwegian study, overall sexual function was normal or slightly reduced in only 2 (22%) of 9 patients who had undergone partial amputation,8 and a Brazilian study showed that sexual interest, sexual function, and fre1294

quency of sexual intercourse were considered normal or slightly decreased in 9 (64%) of 14 cases.3 These differences may reflect variations in the methods used, but may also reflect differences between cultures and/or the level of education of the population.3 In the present study, a statistically significant decrease in sexual function and satisfaction occurred after partial penectomy, with only 55.6% of the patients reporting erectile function that allowed regular sexual intercourse. Although the reduction occurred in all domains of sexual functioning, intercourse satisfaction and overall satisfaction were the most affected, with merely 33.3% of patients maintaining their preoperative sexual intercourse frequency and satisfied with their sexual relationship with their partners and their overall sex life. In contrast, changes in sexual desire and orgasmic function were less pronounced because 66.7% sustained the same frequency and level of sexual desire as before surgery, and 72.2% continued to have ejaculation and orgasm every time they had sexual stimulation or intercourse. The relatively high index of orgasmic function compared with the low rates of sexual intercourse was because 77.8% of the patients were capable of getting and maintaining an erection, even though some did not attempt intercourse. The main reason for not resuming sexual intercourse appeared to be related to feelings of shame owing to the small penile size and absence of glans penis in 3 of 6 patients, despite having an average penis length similar to that of the other patients. In this respect, amputation of part of the penis may result in sensations of decreased virility owing to the great physical impact on masculine self-image. These feelings may also have an emotional basis and be associated with unconscious fears from childhood anxieties of “castration,” guilt, and punishment fantasies. Furthermore, being “too small” may be experienced as very humiliating in many cultures. Multidisciplinary follow-up with psychologists trained in sex therapy is necessary and should begin when treatment is being decided6 to help patients and their partners to discuss their feelings and facilitate the return of sexual functioning. Patients should be reassured that although their penis will be smaller after surgery, it may be possible to penetrate the vagina and have pleasant sexual intercourse. Pretreatment education may even prevent psychologically based sexual problems.6 Surgical complications may also compromise resumption of sexual activity after amputation. Meatal stricture is the most frequent complication after partial penectomy.12 Excessive penile shaft skin has not been described as a complication; keeping it may give the postpenectomy phallus an appearUROLOGY 66 (6), 2005


ance of a short uncircumcised, but normal, penis. However, when the excessive skin disturbs the functional aspect of the penis, it should be considered and treated as a complication. Both complications can be corrected as an outpatient procedure, but ideally they are best avoided. Whisnant and Litvak12 proposed modifications to the partial penectomy technique to avoid such complications. It is well-known that the prevalence of erectile dysfunction increases with age.2 Given that penile carcinoma most frequently appears later in life, some patients may develop erectile dysfunction after treatment, such as happened with 1 of our patients, regardless of the therapeutic method used. As such, it should be treated accordingly. The strength of this study was in the sample size and in that all patients were interviewed by the same interviewer, using a well-validated instrument, with statistical interpretation of the results. However, the study was flawed because we had no control group. Even though sexual impairment after penile amputation is self-evident, other known circumstantial changes related to oncologic surgery may also play a role.6 Future research should include control groups to reduce the risk of bias. CONCLUSIONS Erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction were significantly reduced in this sample of patients who underwent partial penectomy for penile carcinoma as a consequence of psychological and organic causes. However, a high percentage of patients maintained erectile and orgasmic function, leading us to believe that proper

UROLOGY 66 (6), 2005

follow-up with a multidisciplinary team and correction of surgical complications may improve sexual function after partial penectomy. However, it remains to be demonstrated. REFERENCES 1. Pow-Sang MP, Benavente V, Pow-Sang JE, et al: Cancer of the penis. Cancer Control 9: 305–314, 2004. 2. Windahl T, Skeppner E, Anderson SO, et al: Sexual function and satisfaction in men after laser treatment for penile carcinoma. J Urol 172: 648 – 651, 2004. 3. D’Ancona CAL, Botega NJ, Moraes C, et al: Quality of life after partial penectomy for penile carcinoma. Urology 50: 593–596, 1997. 4. Micali G, Nasca MR, Innocenzi D, et al: Invasive penile carcinoma: a review. Dermatol Surg 30: 311–320, 2004. 5. Stancik I, and Höltl W: Penile cancer: review of the recent literature. Curr Opin Urol 13: 467– 472, 2003. 6. Schover LR, von Eschenbach AC, Smith DB, et al: Sexual rehabilitation of urologic cancer patients: a practical approach. CA Cancer J Clin 34: 66 –74, 1984. 7. Sexual impact of penectomy (American Cancer Society). Available at http://www.cancer.org/docroot/CRI/content/ CRI_2_4_4X_Sexual_Impact_of_Penectomy_35.asp. Accessed May 5, 2005. 8. Opjordsmoen S, Waehre H, Aass N, et al: Sexuality in patients treated for penile cancer: patients’ experience and doctors’ judgement. Br J Urol 73: 554 –560, 1994. 9. Spaulding JT, and Grabstald H: Surgery of penile carcinoma, in Harrison JH, Gittes RF, Perlmutter AD, et al (Eds): Campbells’ Urology, 4th ed. Philadelphia, WB Saunders, 1979, vol 3, pp 2438 –2452. 10. Ferraz MB, and Ciconelli RM: Tradução e adaptação cultural do índice internacional de função erétil para a língua portuguesa. Rev Bras Med 55: 35– 40, 1998. 11. Pietrzak P, Corbishley C, and Watkin N: Organ-sparing surgery for invasive penile cancer: early follow-up data. BJU Int 94: 1253–1257, 2004. 12. Whisnant JD, and Litvak AS: Partial penectomy: technique to eliminate meatal stricture. Urology 13: 52–53, 1979.

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Sexual function after partial penectomy for penile cancer