ORIGINAL ARTICLE Erectile dysfunction and sexual health after radical prostatectomy: impact of sexual motivation

Transcription

1 (2011) 23, & 2011 Macmillan Publishers Limited All rights reserved /11 ORIGINAL ARTICLE Erectile dysfunction and sexual health after radical prostatectomy: impact of sexual motivation R Messaoudi 1, J Menard 1, T Ripert 1, H Parquet 2 and F Staerman 1 1 Department of Urology and Andrology, Robert Debré Academic Hospital, Reims, France and 2 Clinical Research Unit, Robert Debré Academic Hospital, Reims, France The life expectancy of patients with localized prostate cancer at treatment initiation has increased, and post-treatment quality of life has become a key issue. The aim of this study is to assess the impact of Radical prostatectomy (RP) on patients sexual health and satisfaction according to sexual motivation using a self-administered questionnaire completed by two groups of RP patients, with high or lower levels of sexual motivation. A total of 63 consecutive patients were included (mean age, 63.9 years), of whom 74.6% were being treated for erectile dysfunction (ED). After RP, patients reported lower sexual desire (52.4%), reduced intercourse frequency (79.4%), anorgasmia (39.7%), less satisfying orgasm (38.1%), climacturia (25.4%), greater distress (68.3%) and/or lower partner satisfaction (56.5%). Among the most sexually motivated patients, 76.0% reported loss of masculine identity, 52% loss of self-esteem and 36.0% anxiety about performance. These rates were lower among less motivated patients (52.6, 28.9, and 18.4%, respectively). Mean overall satisfaction score was 4.8±2.9. The score was significantly lowered in motivated than less motivated patients (3.4 vs 5.8) (P ¼ 0.001). In conclusion, RP adversely affected erectile and orgasmic functions but also sexual desire, self-esteem and masculinity. The more motivated patients experienced greater distress and were less satisfied. (2011) 23, 81 86; doi: /ijir ; published online 7 April 2011 Keywords: radical prostatectomy; sexuality; erectile dysfunction; satisfaction; questionnaire; psychological impact Introduction Radical prostatectomy (RP) is a recommended standard treatment for patients with low or intermediate risk prostate cancer and a life expectancy of more than 10 years. With increasingly early diagnosis, life expectancy at treatment initiation has increased and post-treatment quality of life (QoL) has become a key issue in the choice of treatment. However, all treatments (RP, external beam radiotherapy, brachytherapy) adversely affect QoL. 1 The main side effects of RP are urinary incontinence and erectile dysfunction (ED), with ED having a possibly greater adverse impact on patients QoL in the longer term than urinary disorders and Correspondence: R Messaoudi, Département d Urologie- Andrologie, Robert Debré Academic Hospital, CHU Reims, Avenue du Général Koenig, Reims 51092, France. messaoudirabah@hotmail.com Received 10 December 2010; revised 1 February 2011; accepted 7 March 2011; published online 7 April 2011 the fear of relapse, especially in younger patients. 2 So far, most studies have focussed on ED rather than on the broader issue of quality of sex life. The urologist tends to focus on the mechanical rigidity of erections. Even so, according to a recent survey in France, only 38% of urologists routinely offer some form of pharmacological penile rehabilitation after RP, whereas 87% of the International Society for Sexual Medicine practitioners do so, with those managing over 50 RP patients per year being the most proactive. 3,4 In addition, even if erections are restored after RP, with or without treatment, sexual bother increases after RP and sexual health most often does not return to its preoperative level. 5 The aim of this study is to assess the impact of RP on patients sexual health and satisfaction according to sexual motivation. Subjects and methods We performed a review of the literature to identify the different domains relevant to male sexuality in order to devise a simple self-assessment sexual

2 82 health questionnaire for patients who had undergone RP. The questionnaire was comprised of 16 items assessing erectile function, ED treatments, sexual desire, orgasm and the psychological impact of ED. Overall sexual satisfaction was assessed by a visual analog scale from 0 to 10 (0 ¼ not at all satisfied; 10 ¼ highly satisfied) (Supplementary Appendix 1). Between January 2008 and July 2008, the questionnaire was administered to 64 consecutive patients during follow-up after RP. The patients completed the questionnaire in the waiting room before the start of the consultation. Demographic and clinical data were collected from their medical records. Institutional Review Board approval was obtained for the retrospective chart review. We offer postoperative ED treatment to all RP patients who are sexually active preoperatively. 6 The issue of ED treatment is raised after surgery, once anxiety over surgery is over and patients have received reassurance about their cancer treatment. Some patients request sexual management promptly, others do not. Patients were thus arbitrarily divided into two groups according to whether they had expressed a clear demand for sexual management (Group 1: sexually motivated) or not (Group 2: less sexually motivated). The two groups were compared by Student s t test or Wilcoxon s test, as appropriate. To study the influence of duration of postoperative care, we compared results for three time frames (o12, and 424 months). We used chi-square statistics with or without Yate s correction for sexual health variables (loss of masculine identity, loss of self-esteem and anxiety over performance) and ANOVA for the sexual satisfaction score (after testing for the assumptions of normality and homogeneity of variance (Bartlett s test)). Results Patient characteristics Data were available for 63 of the 64 patients as one patient refused to complete the questionnaire. The mean age of these 63 patients was 63.9±6.7 years. A total of 50 patients had undergone laparoscopic RP, 9 perineal RP, and 4 retropubic RP. No data were available for nerve sparing. The presence of cardiovascular risk factors was the main comorbidity (29 patients, 46%). The median interval between RP and administration of the questionnaire was 26.8 months (range, 6 67). Follow-up was less than 12 months in 9 patients, between 12 and 24 months in 24 patients and longer than 24 months in 30 patients. Nine patients had received adjuvant therapy after a mean delay of 21 months (8 external beam radiotherapy and 1 anti-androgen treatment). None had received neoadjuvant therapy. Prostate Table 1 Patient characteristics Patients (n ¼ 63) Mean age (years)±s.d. 63.9±6.7 Mean preoperative prostate specific 8.01 ( ) antigen (ng ml 1 ) (range) Clinical stage, n (%) T1a 4 (6.3) T1c 48 (76.2) T2a 9 (14.3) T2b 2 (3.2) Gleason score, n (%) 6 26 (41.3) 7 31 (49.2) 8 3 (4.8) Missing data 3 (4.8) Pathological stage, n (%) pt2 47 (74.6) pt3 13 (20.6) pt4 1 (1.6) Missing data 2 (3.2) Pelvic lymph node dissection, n (%) 12 (19.1) Negative 12 Positive 0 Positive margins, n(%) 11 (17.5) Adjuvant radiotherapy, n(%) 8 (12.7) Adjuvant hormonal therapy, n(%) 1 (1.6) Elevated PSA, n (%) 3 (4.7) specific antigen was detectable in only three patients at the time of the study (0.1, 0.81 and 0.21 ng ml 1 ). Patient and tumor characteristics are given in Table 1. All 63 patients were heterosexual, with partners, and claimed to have had sexually satisfactory intercourse before surgery. Six reported moderate preoperative ED that had not, however, warranted pharmacological treatment. After surgery, 25 of the 63 patients had requested ED treatment before it was offered (Group 1 motivated to stay sexually active) (mean age, 65.3 years). The remaining 38 patients were in Group 2 (less motivated) (mean age, 63.0 years). ED treatment A total of 47 patients (74.6%) were being treated for ED at the time of the survey: 39 (82%) with intracavernous prostaglandin injections (ICI), 4 (9%) with an oral type-5 phosphodiesterase inhibitor (PDE5-I) and 4 (9%) with a penile prosthesis. In Group 1 (motivated), 21/25 (84%) were under treatment. The four other patients had refused the offer of ICI but were not taking a PDEI-5 because it was ineffective and/or too expensive. In Group 2 (less motivated), 26/38 patients (68.4%) had taken up the offer of ED treatment, four had sufficiently adequate erections not to require treatment, and eight had come to terms with their ED and were

3 Table 2 Changes in sexual health after RP Table 3 Psychological impact and satisfaction 83 Decrease No change Increase Sexual desire, n (%) 33 (52.4) 27 (42.9) 3 (4.7) Frequency of intercourse, n (%) 50 (79.4) 13 (20.6) 0 (0) Orgasm, n (%) 49 (77.8) a 9 (14.3) 5 (7.9) Abbreviation: RP, radical prostatectomy. a Anorgasmia, n (%): 25 (39.7). uninterested in treatment. Overall, 16/63 patients (25.4%) were not receiving ED treatment and 51/63 (81%) had erections firm enough for intercourse. Most patients (33/47, 70.2%) reported that they were satisfied with their treatment for ED. Sexual desire, frequency of intercourse and orgasm after RP Results are summarized in Table 2. After RP, half of the patients reported a decrease in sexual desire and three quarters reported decreased frequency of intercourse, anorgasmia or a less satisfying orgasm. Before RP, all 63 patients had achieved orgasm (77.8% at each intercourse). Inadvertent urine leakage at orgasm (climacturia) was reported by 16 patients (25.4%) and considered to be bothersome by 9/16 patients (56.3%), but not to the extent of precluding intercourse. Four of the 16 patients who experienced climacturia were incontinent. The absence of ejaculation was considered bothersome by 33/61 patients (54.1%) and bothersome enough to avoid intercourse by 5/61 patients (8.2%). Two patients did not answer this question. Psychological impact Overall, 43 patients (68.3%) experienced at least one of the following: loss of masculine identity (n ¼ 39, 61.9% of patients), loss of self-esteem (n ¼ 24, 38.1%) and anxiety over performance (n ¼ 16, 25.4%). The feeling of loss of masculine identity could be either overwhelming (10/39, 25.6%) or partial (29/39, 74.4%). The adverse psychological impact was greatest in Group 1 patients (Table 3) and did not depend on length of follow-up (Table 4). Overall sexual satisfaction Mean sexual satisfaction score on the visual analog scale was 4.8±2.9 (out of 10). Group 2 patients had a higher mean score than Group 1 patients; untreated Group 1 patients were less satisfied than treated patients; treated and untreated Group 2 patients had similar scores (Table 2). Patients with a penile prosthesis had the highest mean score (8.1). The score did not depend on length of follow-up (Table 4), patient age and tumor characteristics (Table 5). Overall, 56.5% of patients claimed that their partner felt less sexual satisfaction since the operation had taken place. Discussion Group 1 (motivated) N ¼ 25 Group 2 (less motivated) N ¼ 38 Psychological impact, n (%) Loss of masculinity 19 (76) 20 (52.6) Loss of self-esteem 13 (52) 11 (28.9) Anxiety about performance 9 (36) 7 (18.4) Mean satisfaction score (VAS) All patients 3.4 (n ¼ 25) 5.8 a (n ¼ 38) ED treated 3.9 (n ¼ 21) 5.3 (n ¼ 26) ICI 2.9 (n ¼ 14) 5.4 (n ¼ 25) PDEI (n ¼ 3) 3 (n ¼ 1) Penile prosthesis 8.1 (n ¼ 4) n ¼ 0 Untreated 0.5 b (n ¼ 4) 6.9 b (n ¼ 12) a Group 1 vs Group 2: P ¼ b Untreated vs treated: Group 1: P ¼ ; Group 2: P ¼ When advocating RP in young men with prostate cancer, simply focusing on ED, especially in those patients who most value their sexual activity, is not enough. Other important QoL sexual domains such as libido and orgasm need to be considered. For a satisfactory sexual relationship, maintaining a sufficiently rigid erection is important. Early penile rehabilitation can significantly improve the rate of postoperative spontaneous erections and sexual QoL, and administration of a PDEI-5 such as sildenafil can help to enhance rigidity. 7 9 According to a literature review, the efficacy of sildenafil ranges from 14 to 53%, but this range can be extended to 14 85% on switching to ICI. 10,11 Penile rehabilitation should be discussed with all patients, regardless of their sexual motivation, and initiated promptly after RP. 9,12,13 Among our 63 RP patients, 74.6% were regularly using ED treatment and 81% had erections adequate for intercourse with or without pharmacological assistance. Most treated patients were using ICI (82%) for reasons of efficacy and cost despite a preference for less invasive treatment (French national health insurance reimburses ICI but not PDEI-5s). Most patients (70.2%) reported that they were satisfied with their ED treatment. Despite their ED treatment, half of our patients experienced diminished sexual desire and three quarters less frequent intercourse after a median follow-up of 2 years. This agrees with published

4 84 Table 4 Psychological impact according to time frame of follow-up Follow-up (months) P o Patients, n (%) 25 (39.7) 13 (20.6) 25 (39.7) Overall psychological impact, n (%) 16 (64.0) 10 (76.9) 17 (68.0) 0.72 a Loss of masculinity 15 (60.0) 9 (69.2) 15 (60.0) 0.83 b Loss of self-esteem 8 (32.0) 6 (46.2) 10 (40.0) 0.67 b Anxiety over performance 8 (32.0) 2 (15.4) 6 (24.0) 0.53 b Mean satisfaction score±s.d. 4.7± ± ± c a Chi-square test. b Chi-square test with Yate s correction (only one expected frequency o5 and 43). c ANOVA (test of normality and equal variances (Bartlett s test, P ¼ 0.96)). Table 5 Age, pathological stage and Gleason score according to satisfaction score Satisfaction scorex5 (N ¼ 38) Satisfaction scoreo5 (N ¼ 24) Age, n (%) p65 years 20 (60.6) 13 (39.4) 465 years 18 (62.1) 11 (37.9) Pathological stage, n (%) pt2 28 (59.6) 19 (40.4) PT3 9 (75.0) 3 (25.0) PT4 1 (100.0) 0 (0) Gleason score, n (%) o7 16 (61.5) 10 (38.5) X7 21 (63.6) 12 (36.4) a Pearson s Chi-square test. b Fisher s Exact Test. decreased libido rates (45 55%) after RP. 14,15 The decrease may be related to hypogonadonism and may be amenable to androgen replacement therapy in patients whose prostate cancer is under control. 16,17 A prospective study found a high serum luteinizing hormone level and a decrease in serum dihydrotestosterone but none in total or free testosterone. 18 We did not perform any hormone assays to assess hypogonadism in our study. Most of our patients experienced compromised orgasm (anorgasmia, 39.7%; less satisfying orgasm, 38.1%). This observation supports the results of a study in 239 RP patients showing a 37% prevalence of complete absence of orgasm, as well as of decreased orgasm intensity. 19 Orgasmic function improves linearly over the 48 months after RP but is not improved by IPDE-5 administration. 20 The physiology of orgasm has not yet been fully elucidated. Orgasm includes involuntary muscle contractions, contraction of the seminal vesicles and prostate, changes in heart and respiratory rates, and modified consciousness. After RP, the absence P 0.91 a 0.69 b 0.87 a of a feeling of seminal vesicle and prostate contraction may account for less satisfying orgasms. In addition, some patients may be bothered by the absence of ejaculation (54.1% in our study). Among our patients, 8.2% avoided intercourse for this reason. It is therefore important to inform patients that the prostate and seminal vesicles are not required for orgasm, which can occur without ejaculation and/or with a flaccid penis. Patients should be counseled to persevere and prolong intercourse. Urine leakage at orgasm might also explain less satisfying orgasms. This surgical complication has received little attention. A quarter of our patients suffered from climacturia and over half of these found it bothersome. Climacturia was first reported by Koeman et al. 15 who recorded a high 64% incidence among 20 sexually active RP patients. Later studies give lower rates, namely, 20.2% among 475 RP or cystectomy patients (with a lower rate for cystectomy) and 45% among 42 RP patients. 21,22 Of these patients, 48% found it bothersome. 22 Climacturia can often be associated with moderate stress incontinence 23 but this was the case in only 4 of our 16 patients. Impaired sphincter function was therefore not the cause of the climacturia in most of our patients. A possible cause might be lack of sphincter smooth muscle tissue associated with normal relaxation of the external sphincter at orgasm. 15 But data on climacturia as a function of bladder neck preservation during RP are lacking. Recommended management is emptying the bladder before intercourse and/or use of a condom, or possibly pelvic floor rehabilitation treatment. 24 Studies of tricyclic antidepressant administration and penis rings are anecdotal. Compromised sexual function had a strong psychological and emotional impact on our patient. This impact was greater in the more sexually motivated patients. Two-thirds of patients experienced at least one of the following: loss of masculine identity, loss of self-esteem and anxiety over performance. Loss of masculine identity affected

5 the most patients (61.9%) and has been frequently reported in the literature. 25 It can affect everyday relationships with women, sexual intimacy and fantasy life. 26 Loss of self-esteem was experienced by 28.9% of the less motivated patients and 52% of the motivated patients, and anxiety over performance before intercourse by 25.4% of all patients. These rates are somewhat lower than published rates (75% for self-esteem, % for anxiety over performance 27 ). The psychological impact of compromised sexual function did not depend on the time-frame of follow-up after RP (o12, 12 24, 424 months), confirming the difficulty patients have in coping psychologically with continued compromised sexual function. Erections may improve, but sexual bother tends to worsen or remain stable during the 24 months after RP. 5 To improve patients and their partners sex-lives, it is thus necessary not only to treat the mechanics (ED treatment), but also to provide appropriate psychological or sexual counseling to help cope with the impact of RP on sexual desire and orgasm. 6,28 In our study, the patients who were most motivated to remain sexually active after RP (Group 1) experienced a greater degree of bother and had a lower overall sexual satisfaction score than the less motivated patients. Their satisfaction score was very low (0.5/10) when they were not receiving ED treatment but higher on treatment (3.9/10), thus confirming the benefit of treatment in motivated patients. 29 The benefit of ED treatment on satisfaction was not apparent in the less motivated patients. These patients had a higher satisfaction score than motivated patients and their score did not depend on treatment (6.9 vs 5.3; P ¼ 0.088). Untreated less motivated patients (12.7%) did not find the absence of an erection as bothersome. Despite the lack of ED treatment, they had a satisfying sex-life with physical intimacy not involving intercourse. A 50% rate of indifference to ED has been reported among prostate cancer survivors. 30 Patients attitude to their sex-life is thus a key factor to be taken into account when choosing treatment for localized prostate cancer. The most motivated to maintain erections are the most difficult to satisfy. If RP is indicated, patients should be provided with full information on repercussions on sexual health and undergo close postoperative follow up to reduce distress and improve QoL. Our prospective study has several limitations: a small sample size, a cross-sectional and not longitudinal design, no preoperative baseline (we had to rely on patients recall of their earlier sexuality), lack of data on nerve-sparing surgery and use of unvalidated psychometric instruments. We devised our own questionnaire for sexual health because available validated questionnaires omit key items in our study (eg, climacturia and lack of ejaculation), if they are simple and easy-to-use, or if they do contain these items, they are too complex for daily clinical use. Our questionnaire also had the advantage of enabling comparison between two groups of patients with different expectations with regard to their sexuality. Conclusion Postoperative management of the sexual health of RP patients should consider not only the mechanics of erections but also aspects such as sexual desire, orgasm, climacturia and the psychological impact of compromised sexuality (loss of masculine identity, loss of self-esteem and anxiety about performance). Adverse repercussions engendered greater distress in sexually more motivated patients, even if their ED treatment was seen to be satisfactory, than in less motivated patients whose sex-life proved to be more satisfying despite ED. The urologist should bring up the issues of ED and other aspects of sexual dysfunction when treatment options for localized prostate cancer are being reviewed with the patient. Further studies on a larger population are needed to confirm our results. Conflict of interest The authors declare no conflict of interest. Acknowledgments We disclose the sources of any support for the work, received in the form of grants and/or equipment and drugs. References 1 Huang GJ, Sadetsky N, Penson DF. Health related quality of life for men treated for localised prostate cancer with longterm followup. J Urol 2010; 183: Crowe H, Costello AJ. Prostate cancer: perspectives on quality of life and impact of treatments on patients and their partners. Urol Nurs 2003; 23: Giuliano F, Amar E, Chevallier D, Montaigne O, Joubert JM, Chartier-Kastler E. How urologists manage erectile dysfunction after radical prostatectomy: a national survey (REPAIR) by the French urological association. J Sex Med 2008; 5: Teloken P, Mesquita G, Montorsi F, Mulhall J. Post-radical prostatectomy pharmacological penile rehabilitation: practice patterns among the international society for sexual medicine practitioners. J Sex Med 2009; 6: Nelson CJ, Devesi S, Stasi J, Scardino PT, Mulhall J. Sexual bother following radical prostatectomy. J Sex Med 2010; 7: Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, Zippe C et al. The use of treatments for erectile dysfunction among survivors of prostate carcinoma. Cancer 2002; 95: Claes HI, Goldstein I, Althof SE, Berner MM, Cappelleri JC, Bushmakin AG et al. Understanding the effects of sildenafil 85

6 86 treatment on erection maintenance and erection hardness. J Sex Med 2010; 7: Mulhall JP, Land S, Parker M, Waters B, Flanigan RC. The use of erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med 2005; 2: Muller A, Parker M, Waters BW Flanigan RC, Mulhall JP. Penile rehabilitation following radical prostatectomy: predicting success. J Sex Med 2009; 6: Montorsi F, McCullough A. Efficacy of sildenafil citrate in men with erectile dysfunction following radical prostatectomy: a systematic review of clinical data. J Sex Med 2005; 2: Baniel J, Israilov S, Segenreich E, Livne PM. Comparative evaluation of treatment for erectile dysfunction in patients with prostate cancer after radical retropubic prostatectomy. BJU Int 2001; 88: Mulhall JP, Bella AJ, Briganti A, McCullough A, Brock G. Erectile function rehabilitation in the radical prostatectomy patient. J Sex Med 2010; 7: Mulhall JP, Parker M, Waters BW, Flanigan R. The timing of penile rehabilitation after bilateral nerve-sparing radical prostatectomy affects the recovery of erectile function. BJU Int 2010; 105: Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, Zippe C et al. Defining sexual outcomes after treatment for localized prostate carcinoma. Cancer 2002; 95: Koeman M, van Driel MF, Schultz WC, Mensink HJ. Orgasm after radical prostatectomy. BJU Int 1996; 77: Kauffman JM, Graydon RJ. Androgen replacement after curative radical prostatectomy for prostate cancer in hypogonadal men. J Urol 2004; 172: Rhoden EL, Averbeck MA, Teloken PE. Androgen replacement in men undergoing treatment for prostate cancer. J Sex Med 2008; 5: Miller LR, Partin AW, Chan DW, Bruzek DJ, Dobs AS, Epstein JI et al. Influence of radical prostatectomy on serum hormone levels. J Urol 1998; 160: 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: 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: 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: Lee J, Hersey K, Lee CT, Fleshner N. Climacturia following radical prostatectomy: prevalence and risk factors. J Urol 2006; 176: Abouassaly R, Lane BR, Lakin MM, Klein EA, Gill IS. Ejaculatory urine incontinence after radical prostatectomy. Urology 2006; 68: 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: Meyer JP, Gillatt DA, Lockyer R, Macdonagh R. The effect of erectile dysfunction on the quality of life of men after radical prostatectomy. BJU Int 2003; 92: Bokhour BG, Clark JA, Inui TS, Silliman RA, Talcott JA. Sexuality after treatment for early prostate cancer: exploring the meanings of erectile dysfunction. J Gen Intern Med 2001; 16: Matthew AG, Goldman A, Trachtenberg J, Robinson J, Horsburgh S, Currie K et al. Sexual dysfunction after radical prostatectomy: prevalence, treatment, restricted use of treatments and distress. J Urol 2005; 174: Nelson CJ, Choi JM, Mulhall JP, Roth AJ. Determinants of sexual satisfaction in men with prostate cancer. J Sex Med 2007; 4: Perez MA, Meyerowitz BE, Lieskovsky G, Skinner DG, Reynolds B, Skinner EC. Quality of life and sexuality following radical prostatectomy in patients with prostate cancer who use or do not use erectile aids. Urology 1997; 50: Miller DC, Wei JT, Dunn RL, Montie JE, Pimentel H, Sandler HM et al. Use of medications or devices for erectile dysfunction among long-term prostate cancer treatment survivors: potential influence of sexual motivation and/or indifference. Urology 2006; 68: Supplementary Information accompanies the paper on website (