The purpose of this study was to compare sexual functions and psychosexual quality of life in men treated by PB for penile cancer with age-matched controls to further understand the impact of treatment in this population. So far, little information was provided in the literature on the effects of PB on sexual behavior. All the studies evoked the persistence of sexuality after PB [6, 7, 12], without providing detailed analysis of sexual functions and behaviors. By analyzing a series of 51 patients treated between 1971 and 1989, Delannes et al. concluded that PB does not seem to impact sexual functions [5]. However, they did not use a questionnaire and there was no control group. The current study first assesses couple relationship and communication about sexuality, sexual behaviors, affect and fantasy in this population, compared with controls.
We found that a relatively high proportion of patients have erectile dysfunction after penile brachytherapy (using the IIEF as well as the BASIC IDEA questionnaires). However, our results show that erectile function IIEF subscores are better in patients after treatment than in controls.
This difference may be subtle, as illustrated by the absence of difference between patients and controls concerning frequency of erection, frequency of nocturnal erection and quality of erection using the BASIC IDEA questionnaire.
Our results are also important in that we found that both PB patients and age-matched controls similarly experienced relatively few problems with sexual functioning and sexual behavior.
In a recent review of sexual functioning and mood in men treated for penile cancer, Maddineni et al. [13]. concluded that all penile cancer treatments result in negative effects on well-being in up to 40%, with psychiatric symptoms in approximatively 50%, and up to two thirds of patients reporting a reduction in sexual function. However, this review has several limitations: First, a majority of studies only used the International Index of Erectile Function Questionnaire (IIEF) for the evaluation of sexual functions; this questionnaire is centered on erectile function and clearly limited to analysis of sexuality of men who have intercourse. Another limitation of this review is the lack of detailed information about cancer treatment modality. Among treatments of localized penile cancer, several surgical treatments, namely partial penectomy, glansectomy, and glans resurfacing, may lead to unsightly scarring and shortening of penis that may have an impact on both sexual function, as well as self-image and self-esteem. Several anatomic structures involved in erectile function may be affected by PB, notably intrinsic cavernosal erectile tissue and nerves, this by an increase radiation risk.
In our study, all patients declared that their manliness had not been altered by the treatment and there was no difference between men treated by PB and age-matched controls. The study shows that more than three quarters of patients declare they do not have any discomfort due to penile length or penile appearance. This is probably an important determinant of their feeling as a true man. We also observe that communication about sexuality in their couple, importance of sexuality for the partner, partner’s coping with sexual troubles were significantly better in the patients than in controls and that patients had more fantasy than controls. No doubt that all these factors enable that to minor the impact of treatment on glans sensitivity and erectile function, and strengthen their self-esteem and motivation.
Maddineni et al. [13] found a greater impact on sexual functions of partial amputation of the penis, with an absence of sexual function in 36 - 67% of patients. In a series of 17 patients treated with partial (n = 11) or total (n = 4) amputation of the penis, Ficarra et al. [14] found that emotional and mood disorders were common in this population, with 35% of patients experiencing “problems in social life,” 29.5% anxiety and 6% depression. The feeling of loss of manliness and the inability to penetrate is likely to cause emotional stress, and we can presume that many patients treated by total or partial amputation of the penis feel it to varying degrees.
The study showed a higher frequency of masturbation in patients than controls. The question of masturbation as an indication of better psychological and physiological health should be more thoroughly explored. Contrarily to our study, Gerressu et al. [15] observed that men who masturbate have more sexual problems. Moreover, Brody and Costa [16] showed that penile-vaginal intercourse frequency, rather than other sexual activities, was associated with sexual satisfaction, health, and well-being. The authors also found an inverse association between satisfaction and masturbation. Exploring the reasons why men and women masturbate, Das et al. [17] suggest that masturbation is often more than a simply compensatory behavior for regular partnered sex, and that masturbatory patterns are heavily influenced by early sexualization, and low socioeconomic development. The authors conclude that a complex model is needed to comprehend masturbatory practice.
At least, our results show that in such an elderly population, good sexual satisfaction does not implicate necessarily intercourse. In the future, it would be necessary to take into account the multiple representation of the sexuality during exploration of PB treatment on sexual function and sexual behavior, without limiting itself to the penetration capacity.
Limitations
Sexuality is an area highly dependent on socio-cultural factors; therefore it may be difficult to extrapolate these data to other cultures. In addition, because of the low incidence of this disease in Europe, the size of our study population was relatively small, which limits our ability to achieve a detailed analysis, including subgroups (young males, gay, low socioeconomic status, etc.).
Regarding the methodology, although we have chosen the form of self-administered questionnaire, followed by an interview so the patients are not influenced in their responses and that misunderstanding of the questions is limited, we cannot rule out the subjectivity of responses. In addition, the use of the IIEF in this population is quite questionable because it is a poor score in a population with few penetrating sexual reports. For this reason, we have completed the inquiry by a questionnaire specifically designed for the study. Our results can often be confusing, as in the contradictory results between our questionnaire and IIEF score (Tables 3 and 4 respectively). However, the conclusions drawn from this second questionnaire must be taken with caution due to the absence of validation of our questionnaire. For all these reasons, even if this study gives us the first comprehensive case–control analysis of sexual functions and behaviors in men treated by PB, it should be considered as a pilot study requiring further analysis before that definite conclusions can be drawn.
Finally, a major limitation of the study is the fact that control population had a worse sexuality than patients, possibly due to comorbidities. This should be clarified in future studies.
