RUNNING HEAD: BLADDER CANCER and SEXUAL FUNCTION

Transcription

1 Sexual Functioning after Diagnosis and/or Treatment of Bladder Cancer: a Systematic Review Bachelor thesis Department of Medical Psychology, Tilburg University Author: Manon van Eekelen Supervisor: Dr. Brenda den Oudsten Date of publication: May 2012

2 2 Abstract Background: The purpose of this review is to provide an overview of studies that addressed sexual function in bladder cancer. More specifically, we determined (i) the prevalence of sexual function in patients with bladder cancer and (ii) the role of sociodemographic, treatment-related, and psychosocial factors of sexual functioning. Methods: The databases PUBMED (75 hits) and PsycINFO (2 hits) were systematically searched to identify relevant articles. Twenty-four articles were included. Results: The percentage of preoperatively potent men that experienced sexual dysfunction postoperatively varied from 14% to 100%. Postoperatively, none to 88% of the sexual active women experienced sexual dysfunction. Sexual function mainly returned within 2 months to 1 year. Non-nerve-sparing radical cystectomy predicted more sexual dysfunction then nerve-sparing cystectomy. A younger age (< 65years) predicted a better recovery of sexual function after surgery. Postoperatively, women reported a decrease in sexual satisfaction. It seems that social support is a beneficial factor for sexual activity. Postoperatively, men and women can overcome their sexual inability by receiving treatment for sexual dysfunction (e.g., sildenafil, estrogen cream). The mean quality score was 9. Existing studies suffer from methodological shortcomings, such as cross-sectional designs and small sample sizes. Conclusion: Many patients suffer from their sexual dysfunction after the treatment for bladder cancer. It is important to offer treatment for sexual dysfunction after surgery. Further research is needed to investigate the effects that radiation can have on sexual function and the effects of retrograde ejaculation on sexual satisfaction. It is important that sexuality is investigated prospectively from a biopsychosocial model. Key words: bladder cancer; sexuality; sexual function; sexual dysfunction; systematic review

3 3 Introduction Annually, about 386,300 persons are diagnosed worldwide with bladder cancer (Jemal et al., 2011). There are two kinds of bladder cancer, non-muscle-invasive and muscleinvasive. The focus of this review will be on muscle-invasive cases, since it is likely that this type will cause the most serious sexual dysfunction in patients. In the Netherlands, about 3000 persons are diagnosed with muscle-invasive bladder cancer. This cancer is more common in men than women, about 4:1 ( =1&direction=left#table). The highest risk factor of bladder carcinoma is smoking. There are two reasons why it is important to assess sexuality in patients with bladder cancer. First, its treatment can have a detrimental effect on the sexual organs of patients. The most frequently used treatments of muscle-invasive bladder cancer are radiotherapy, chemotherapy, and radical cystectomy. During radiotherapy there is a risk that the surrounding organs receive radiation and get affected. Chemotherapy attacks cancer cells, however, will also kills healthy cells. Radical cystectomy is a kind of surgery where the bladder, surrounding lymph nodes and some sexual organs (e.g., ovary, urethra, part of the vagina, uterus, prostate, and seminal vesicles) are completely removed from the body. After removing these parts, a construction of a urinary diversion is made ( Cross, & Whelan, 2010). Some persons need to live with a stoma and experience problems with sexuality and sexual function. Black (1994) labeled this as one of the hidden problems of living with a stoma. Persons with a stoma experience a decrease in the enjoyment of sex and a lack of sexual desire (Follick, Smith, & Turk, 1984; Huish, Kumar, & Stones, 1998). Second, sexuality has a positive effect on health and well-being of men and women (Levin, 2007). If someone s sexual functioning is poor, it may affect the various factors of sexuality and the person s quality of life. A sexual dysfunction is characterized by a disturbance in the four phases (desire, excitement, orgasm, and resolution) of Masters and Johnson (1966) or by pain associated with intercourse (DSM-IV-TR, 2001). According to Basson et al. (2010) and Verschuren et al. (2010) sexual function or dysfunction need to be examined from the biopsychosocial

4 4 perspective. Not only the biological aspects are important (e.g., possibility to get an erection or the moistness of the vagina), but also the psychosocial aspects (e.g., mood, relationships, and body-image). These factors can have an effect on sexual function and affect well-being. It is important for health professionals to have knowledge on how bladder cancer and its treatments affect patients, so they can better support those patients. The purpose of this review is to provide an overview of studies that addressed sexual function in bladder cancer. More specifically, to determine the prevalence of sexual function in patients with bladder cancer and the role of sociodemographic, treatment-related, and psychosocial factors of sexual functioning. Method Search strategy A systematic search of the literature was carried out in PUBMED (75 hits) and PsycINFO (2 hits). The databases were searched with combinations of bladder cancer (bladder carcinoma, urinary bladder neoplasms, urinary bladder), sexuality, sexual function (sexual physiology) and sexual dysfunction (sexual physiopathology). The search was restricted to studies written in English or Dutch, included are only original full text reports and adults. In all reports, the reference lists were used to identify studies that were not found in computerized database searches. Selection criteria Studies that matched the following criteria were included: (1) the study population that separately analyzed patients with muscle-invasive bladder cancer; (2) the studies investigated sexual function or sexual dysfunction; (3) sexual function, or sexual dysfunction and/or sexuality were measured by self-reports or an interview; (4) the studies were original full text report in English or Dutch; (5) studies were published in peer-reviewed journals; (6) the study population exclusively concerned adults, men and/or women; (7) Case studies, benign tumors and non-muscle-invasive tumors were excluded.

5 5 Data extraction Titles, abstract and/or full text of the articles were examined to assess the articles relevance for the review and adherence to inclusion criteria. In total, 75 articles were found in the databases. After applying the inclusion criteria, 26 articles remained and 24 articles were used in the results 1. The flow chart of study selection is shown in Figure 1. * Insert Figure 1 about here * Quality assessment The methodological quality of the selected studies was assessed by using the criteria list shown in Table 1. This checklist was based on the criteria list of Traa, De Vries, Roukema, and Den Oudsten (2011). The list contains 15 criteria which can be scored positive (+), negative (-) or unclear (?). Quality score is the sum of all the positive scores (+). The maximum score is 15. Studies scoring 70% of the maximum score (i.e. 11 points) were labeled high quality. Studies of moderate quality scored between 50% and 70% (between 8 and 10 points) and studies scoring 50% (i.e. 7 points) were considered as low quality. * Insert Table 1 about here * Results Methodological quality The results of the methodological assessment are presented in Table 2. The overall quality score ranged from 4 (Meinhardt & Horenblas, 2003) to 12 points (Bjerre, Johansen, & Steven, 1997; Zippe et al., 2004 a ), with a mean score of 9. Methodological shortcomings mainly concerned the following items: examining both men and women 1 The full text of the studies Schover & von Eschenbach (1985) and Schover, Evans, & von Eschenbach (1986) could not be retrieved.

6 6 (79% did not match the criterion C); the study describes potential prognostic factors by using multivariate analyses or structural equation modeling (criterion G, 92%); the study sample includes at least 50 patients (arbitrarily chosen) (criterion J, 54%); The collection of data is prospectively gathered with at least two assessment points (criterion K, 63%); and the results are compared between two groups or more (criterion O, 58%). * Insert Table 2 about here * Study characteristics The number of participants included in the studies ranged from 7 (Salem, 2005) and 331 (Kessler et al., 2004). In total, 12 out of 24 studies investigated sexual function as a primary objective (Bergman, Nilsson, & Petersén, 1979; Bhatt et al., 2006; Bjerre et al., 1997; Fokdal, Høyer, Meldgaard, & von der Maase, 2004; Little & Howard, 1998; Nandipati, Bhat, & Zippe, 2006; Nieuwenhuijzen, Meinhardt, & Horenblas, 2005; Nordström & Nyman, 1992; Salem, 2005; Volkmer et al., 2004; Zippe et al., 2004 a ; Zippe et al., 2004 b ). In the other studies, sexual function was a part of clinical outcome studies or a part of studies on quality of life. The minority of these studies (27%) were cross-sectional (Fokdal et al., 2004; Hart et al., 1999; Kitamura et al., 1999; Little & Howard, 1998; Månsson et al., 2000; Meinhardt & Horenblas, 2003; Nordström & Nyman, 1992). Of the 17 prospective studies, 9 were unclear about when the postoperative sexual function exactly was measured (Bergman et al., 1979; Bjerre et al., 1997; Horenblas, Meinhardt, IJzerman, & Moonen, 2001; Nieuwenhuijzen et al., 2005; Salem, 2005; Takenaka et al., 2011; Vallancien et al., 2002; Volkmer et al., 2004; Zippe et al., 2004 b ). Of all articles, 12 investigated pre- and postoperatively sexual function (Bergman et al., 1979; Bhatt et al., 2006; Botto et al., 2004; Hart et al., 1999; Little & Howard, 1998; Nandipati et al., 2006; Nordström & Nyman, 1992; Salem, 2005; Takenaka et al., 2011; Volkmer et al., 2004; Zippe et al., 2004 a ; Zippe et al., 2004 b ). Four of those studies investigated preoperatively sexual function with retrospective questions (Hart et al., 1999; Little & Howard, 1998; Nordström & Nyman, 1992; Volkmer et al., 2004). The study of Fokdal et al. (2004) was the only study that used a healthy population as a control group. The study duration ranged from 1 year (Bhatt et

7 7 al., 2006) up to 10 years (Schoenberg et al., 1996). Sexual function in both men and women was investigated in 5 studies (Fokdal et al., 2004; Hart et al., 1999; Horenblas et al., 2001; Kitamura et al., 1999; Nordström & Nyman, 1992), 15 studies investigated men (Bergman et al., 1979; Bjerre et al., 1997; Botto et al., 2004; Kessler et al., 2004; Little & Howard, 1998; Månsson et al., 2000; Matris et al. 2005; Meinhardt & Horenblas, 2003; Muto, Bardari, D Urso & Giona, 2004; Nieuwenhuijzen et al., 2005; Salem, 2005; Schoenberg et al., 1996; Takenaka et al., 2011; Vallancien et al., 2002; Zippe et al., 2004 a ) and 4 studies investigated women (Bhatt et al., 2006; Nandipati et al., 2006; Volkmer et al., 2004; Zippe et al., 2004 b ). The results were mainly presented for sexually active persons or described the percentage of participants being sexually active. However, in 8 articles it is unclear if they only investigated a sexual active group (Horenblas et al., 2001; Kessler et al., 2004; Kitamura et al., 1999; Månsson et al., 2000; Matris et al. 2005; Muto et al., 2004; Salem, 2005; Takenaka et al., 2011). In total, 5 different standardized self-report instruments were used to assess sexual function (Table 3). For men, the International Index of Erectile Function (IIEF) (Rosen et al., 1997; Rosen et al., 1999) was most frequently used. It was assessed in 6 studies (Botto et al., 2004; Matris et al. 2005; Muto et al., 2004; Nieuwenhuijzen et al., 2005; Takenaka et al., 2011; Zippe et al., 2004 a ). The Female Sexual Function Index (FSFI) (Rosen et al., 2000) is used in 3 studies (Bhatt et al., 2006; Nandipati et al., 2006; Volkmer et al., 2004). Three studies used a combination of questionnaires and structured interviews (Little & Howard, 1998; Nieuwenhuijzen et al., 2005; Nordström & Nyman, 1992). Four other studies used non-standardized assessments (Hart et al., 1999; Kessler et al., 2004; Salem, 2005; Schoenberg et al., 1996). In the research of Vallancien et al. (2002) it is unclear how the questionnaire is composed. Kitamura et al. (1999) and Månsson et al. (2000) measured sexual function in a part of the quality of live questionnaire. In the remaining studies sexual function was measured by questionnaires and/or interviews, which the researchers produced on a scientific manner (e.g., based on clinical experience, other studies or pre-interviews). *Insert Table 3 about here*

8 8 The most reported demographic variables were age and sex. The most frequently presented clinical variables were type of surgery, type of urinary diversion, tumor stage (T1-T4), and (neo) adjuvant therapies. The main study findings are presented in Table 4. *Insert Table 4 about here* The prevalence of sexual function in patients with bladder cancer Patients resume sexual activity within a time frame of 2 months to 1 year. The percentage of preoperatively sexual active men ranged from 61% (Vallancien et al., 2002) to 100% (Salem, 2005 & Zippe et al., 2004 a ) across studies. The percentage of sexual active women varied from 55% (Nordström & Nyman, 1992) to 100% (Bhatt et al., 2006; Horenblas et al., 2001; Nandipati et al., 2006). In addition, postoperatively a decrease in sexual desire is a phenomenon that is often mentioned by the patients (Bhatt et al., 2006; Fokdal et al., 2004; Hart et al., 1999; Kitamura et al., 1999; Zippe et al b ). The percentage preoperatively potent men that experienced postoperatively sexual dysfunction varied from 14% (Salem, 2005) to 100% (Botto et al., 2004; Muto et al, 2004; Vallancien et al., 2002). Postoperatively, most men reported an increase of erectile dysfunction (Bergman et al., 1979; Bjerre et al., 1997; Fokdal et al., 2004; Little & Howard, 1998; Kessler et al., 2004; Månsson et al., 2000; Nordström & Nyman, 1992; Schoenberg et al., 1996; Zippe et al., ) and ejaculation dysfunction (Botto et al., 2004; Hart et al., 199; Meinhardt & Horenblas, 2003; Muto et al., 2004; Vallancien et al., 2002). The percentage of preoperatively sexual active women that experienced postoperatively dysfunction ranged from no decrease in sexual function (Horenblas, 2001) to 88% (Nandipati et al., 2006). Vaginal dryness and dyspareunia were most common (Bhatt et al., 2006; Nandipati et al., 2006; Nordström & Nyman, 1992; Zippe et al., 2004 b ). In addition, decreased ability or inability to reach an orgasm (Bhatt et al., 2006; Hart et al., 1999; Nordström & Nyman, 1992; Zippe et al., 2004 b ) and lack of arousal (Bhatt et al., 2006; Hart et al., 1999; Nandipati, Bhat, & Zippe, 2006) were mentioned.

9 9 Dissatisfaction increased postoperatively in men (Hart et al., 1999; Little & Howard, 1998; Nordström & Nyman, 1992; Takenaka et al., 2011) and in women (Bhatt et al., 2006; Hart et al., 1999; Zippe et al b ). Sociodemographic aspects in relation to sexual function Younger men have a greater opportunity to be more sexual active after radical cystectomy then older patients (Bergman et al., 1979; Bjerre et al., 1997). The crosssectional study of Fokdal et al. (2004) was consistent with these results. Patients with a sexual partner were more likely to resume sexual activity after surgery. Besides, social support can also be a beneficial factor for resuming sexual activity (Bjerre et al., 1979; Volkmer et al., 2004). Younger age (<65 years) predicted a better recovery of sexual function after surgery, independent of type of surgery (Bhatt et al., 2006; Bjerre et al., 1997; Botto et al., 2004; Horenblas et al., 2001; Kessler et al., 2004; Matris et al., 2005; Muto et al., 2004; Nandipati et al., 2006; Nieuwenhuijzen et al., 2005; Nordström & Nyman, 1992; Salem, 2005; Schoenberg et al., 1996; Vallancien et al., 2002; Volkmer et al., 2004; Zippe et al., 2004 a ). However, increasing age in men is associated with more erectile dysfunction and decreasing libido (Bergman et al., 1979). Zippe et al. b (2004) compared premenopausal women with postmenopausal women. No significant differences were found on sexual functioning before and after surgery, except for vaginal lubrication. Postmenopausal women had less vaginal lubrication before surgery. Only one research studied the impact of age on satisfaction. In this study they found that older men are less satisfied with their sexual life then younger men (Bergman et al., 1979). No prospective studies investigated the effect of being a man of women on sexual activity, dysfunction, or satisfaction. Two cross-sectional studies found that females are more likely to be sexual inactive preoperatively then men (Hart et al., 1999; Nordström & Nyman, 1992). In addition, women were less satisfied with their body (Hart et al., 1999).

10 10 Treatment-related aspects in relation to sexual function and sexual life Non-nerve sparing radical cystectomy predicted less sexual activity in both men and women (Bergman et al., 1979; Bjerre et al., 1997; Bhatt et al., 2006; Nandipati et al., 2006; Zippe et al b ). Only the prospective research of Volkmer et al. (2004) predicted that the minority of the women (35%) became sexual inactive after surgery. However, radical cystectomy is positively associated with the presence of sexual dysfunction in both men and women (Bergman et al., 1979; Bjerre et al., 1997; Bhatt et al., 2006; Kessler et al., 2004; Nandipati et al., 2006; Zippe et al., 2004 a ; Zippe et al b ). It will cause, erectile dysfunction in men (Bergman et al., 1979; Kessler et al., 2004; Zippe et al., 2004 a ), difficulty in achieving orgasms, and less lubrication in women (Bhatt et al., 2006; Nandipati et al., 2006; Zippe et al., 2004 b ). Women also reported less sexual satisfaction (Volkmer et al., 2004; Zippe et al., 2004 b ). The crosssectional studies of Hart et al. (1999), Månsson et al. (2000), and Nordström & Nyman (1992) are consistent with these results. Patients were sexual active before surgery in studies where they perform a nerve-preserving cystectomy, because the desire to retain sexual function was an inclusion criterion. This surgery predicted a better recovery of sexual function in both men and women, then in radical cystectomy (Bhatt et al., 2006; Botto et al., 2004; Horenblas et al., 2001; Matris et al. 2005; Muto et al., 2004; Nandipati et al., 2006; Nieuwenhuijzen et al., 2005; Salem, 2005; Schoenberg et al., 1996; Vallancien et al., 2002; Zippe et al., 2004 a ; Zippe et al., 2004 b ). Kessler et al. (2004) found that sparing both neurovascular bundles predicted the best recovery of erectile function and sparing one neurovascular bundles was better than no nerve sparing. In 78% to 100% of the men, full erectile function returned after surgery (Horenblas, Meinhardt, IJzerman, & Moonen, 2001) to 100% (Matris et al., 2005& Salem, 2005). In de research of Schoenberg et al. (1996) they only examined whether men have erection sufficient for intercourse of not. This outcome is worse than in men who can achieve an erection (58% versus 78%). The majority of the potent men (66-100%) have retrograde or varying ejaculation (Botto et al., 2004; Muto et al., 2004; Nieuwenhuijzen et al., 2005; Vallancien et al., 2002). In studies that investigated female patients, there is no significant difference between preoperatively and postoperatively sexual function (Bhatt et al., 2006; Horenblas et al., 2001; Nandipati et al., 2006). Cross-sectional research

11 11 confirms the results about men (Meinhardt & Horenblas, 2003). Little research has been done about the satisfaction of patient s sexual life after surgery. In Salem (2005) they found that all men were satisfied. Women experienced a decreased in satisfaction after surgery (Bhatt et al., 2006). By nerve-preserving cystectomy incidents of comorbid disorders, as hypertension, diabetes, coronary artery diseases, was similar in both the sexually active and impotent groups (Kessler et al., 2004) and there was no correlation found between postoperatively potency and pathological stage of disease (Schoenberg et al., 1996). But these clinical variables were only investigated in those studies, so it is difficult to draw conclusions. Independent of the type of surgery, erection ability is mainly returned between 2 months and 1 year (Bergman et al., 1979; Botto et al., 2004; Matris et al., 2005; Salem, 2005). Men who received pre-radiation by radical cystectomy predicted a higher percentage of becoming inactive then those who had no pre-radiation (Bergman et al., 1979). Radiation significantly increases the risk in men of feeling less sexually attractive (Bjerre et al., 1997). Radical radiotherapy only was investigated in two crosssectional studies (Fokdal et al., 2004; Little & Howard, 1998). In Fokdal et al. (2004) there was no significant difference in decreased sexual activity in men who received radical radiotherapy and with the healthy control group. In both studies some patients (24%-44%) experienced problems with erectile function after the treatment. In Fokdal et al. (2004) the minority of the patients (25%) noted a decrease in sexual satisfaction and in Little and Howard (1998) the majority (70%). Men with an ileal conduit diversion experienced more loss of potency and were less sexual active, than bladder substitution patients. Patients with bladder substitution have more coitus, then cutaneous continent patients (Bjerre et al., 1997; Zippe et al., 2004 a ). However, this finding was not clinically significant (Zippe et al., 2004 a ). This is consistent with the cross-sectional research of Kitamura et al. (1999). In women, Indiana pouches and Studor pouches did not differ significantly in the total sexual function. This suggests that preservation of the anterior vaginal wall will not result in

12 12 improved sexual function after radical cystectomy, but preservation as much as possible is important to maintain vaginal lubrication (Bhatt et al., 2006; Zippe et al., 2004 b ). Psychosocial factors on sexual functioning. The effect of psychosocial factors on sexual functioning is investigated in a few studies. It seems that social support is a beneficial factor for sexual activity (Bjerre et al., 1979; Volkmer et al., 2004). In the research of Bjerre et al. (1979), 21% of the men believed that their partner was unwilling to have intercourse. Further, some of the partners (30%) had a decrease in desire for sexual activity owing to apprehension and physical imperfection with urostomy (Zippe et al., 2004 b ). The cross-sectional study of Little & Howard (1998) confirms the results. The effect of aids on sexual dysfunction Three studies examined the effect of aids or medical treatment on erectile dysfunction. The majority of the men (66%-96%), who received aids or medical treatment after nonnerve sparing radical cystectomy, did not have a successful effect. Men received treatments as self injection therapy, sildenafil citrate, and penile implants. Afterwards, men were not able to maintain an erection for sexual intercourse (Bjerre et al., 1997; Zippe et al., 2004 a ). Men who received such treatment have a significant greater risk to feel less attractive, but they also have a bigger chance to be sexual active (Bjerre et al., 1997). This is consistent with the cross-sectional research of Hart et al. (1999). Most men, who undergo a nerve-preserving cystectomy and have erectile dysfunction postoperatively, can overcome this inability by using erectile aid (e.g., sildenafil citrate or intracavernosal injection) (Botto et al., 2004; Horenblas et al., 2001; Muto et al., 2004; Nieuwenhuijzen et al., 2005). None of the studies investigated treatment to overcome women s sexual dysfunction after radical cystectomy. However, in other cancer types vaginal dilation, water-based vaginal lubricants and estrogen creams can decrease genital pain (Schover, 1987).

13 13 Discussion The objective of this qualitative systematic review was to provide an overview of studies that addressed sexual function in bladder cancer. More specifically, with regard to the prevalence of sexual function and sociodemographic, treatment-related and psychosocial aspects in relation to sexual function. This review included 24 studies. Sexual dysfunction after radical cystectomy is a prevalent problem. It is a problem for all men and women, but young persons have the most trouble coping with the problems. This is because they are more likely to retain sexuality. Therefore, younger age is an important factor in research on sexual activity, functioning and satisfaction after surgery. Nerve-preserving cystectomy is a better treatment for patients who would like to retain their sexual function. But this procedure can only be performed when the cancer is in an early-stage (i.e., no metastasis). Men and women with tumor infiltration in the bladder neck and trigone, men with tumors in prostate and prostatic urethra, and women with metastasis in the vaginal wall cannot receive this surgery (Bhatt et al., 2006; Botto et al., 2004; Hart et al., 1999; Matris et al. 2005; Meinhardt & Horenblas, 2003; Nieuwenhuijzen et al., 2005; Salem, 2005; Schoenberg et al., 1996; Vallancien et al., 2002). Therefore, it is important to offer treatment for sexual dysfunction to men (e.g., self injection therapy, sildenafil, and penile implant) and women (e.g., vaginal lubricants, vaginal dilation, and estrogen cream) after surgery. This can have a positive result on their sexual life and make sexual intercourse possible or pleasant. In some cases impotence treatment does not help, then it is important to give enough sexual counseling. Methodologically, there is room for improvement. Approximately, 30% of the studies were cross-sectional. The effect of radical radiotherapy on sexual function only was investigated in cross-sectional designs. However, prospective studies are needed. It is important to have at least two assessment points, the first preoperatively and the second at least 1 year after surgery. Only then we can better determine what the effect of treatment is on sexual activity, sexual functioning, and satisfaction of a patient. In addition, the sample size of most studies was rather small. There was more data collected in men, perhaps partially due to the fact that bladder cancer is more common in men then in women. To draw meaningful conclusions on differences between men

14 14 and women, it is important for future large sample studies to focus on both sexes. Studies did not examine the satisfaction of the patients after nerve-sparing surgery. Men had better recovery of their sexual function. Most men were able to achieve an erection and reach an orgasm. However, retrograde ejaculation remained. As such, it is important to know if retrograde ejaculation has an impact on sexual life. Most studies measured sexual function with a limited number of questions. In some questionnaires the difference between almost never or never does not differ from did not attempt. There is no clear difference between patients that have sexual dysfunction or patients that did not try to have sexual intercourse. It is therefore difficult to draw meaningful conclusions from the current data. In future studies, more questions and an explicit different between scaling in warranted. Furthermore, most studies measured sexual function after bladder cancer treatment with more biomedical instruments (e.g., the FSFI for women and the IIEF for men). But if you want to describe the subjective evaluation of a patient s sexual dysfunction, instruments measuring the quality of sexual life are needed. The best way to measure sexual function remains uncertain (Arrington, Cofrancesco, & Wu, 2004). Sexuality should be seen from a biopsychosocial perspective, so you can investigate the quality of sexual life. But in the reviewed studies there was too little research on psychosocial problems that men and women could experience after the treatment. It seems that social support is a beneficial factor for sexual activity (Bjerre et al., 1979; Volkmer et al., 2004). So the relationship between psychosocial aspects (e.g., self-esteem, body image, personality characteristics, and the partners feelings about the patient disease or appearance) and sexual function in patients with bladder cancer should be investigated more extensively. Conclusion In conclusion, many patients, especially the younger patients, suffer from their sexual dysfunction after the treatment for bladder cancer. It is important to offer impotence treatment and sexual counseling after the treatment. Most studies on sexual function following bladder cancer treatment suffer from methodological problems, such as a cross-sectional design and a small sample size. Further research is needed to investigate

15 15 the effects of radiation on sexual function postoperatively and the effects of and retrograde ejaculation on sexual satisfaction. It is important that sexuality is investigated prospectively from a biopsychosocial model.

16 16 References American Psychiatric Association (2001). Diagnostic and Statistical Manual for Mental Disorders Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association. Arrington, R., Cofrancesco, J., & Wu, A.W. (2004). Questionnaires to measure sexual quality of life. Quality of Life Research, 13, Basson R., Rees P., Wang R., Montejo A.L., & Incrocci, L. (2010). Sexual function in chronic illness. Journal of Sexual Medicine, 7, Bergman, B., Nilsson, S., & Petersén, I. (1979). The Effect on Erection and Orgasm of Cystectomy, Prostatectomy and Vesiculectomy for Cancer of the Bladder: A Clinical and Electromyographic Study. British Journal of Urology, 51, Bhatt, A., Nandipati, K., Dhar, N., Ulchaker, J., Jones, S., Rackley, R., & Zippe, C. (2006). Neurovascular preservation in orthotopic cystectomy: impact on female sexual function. Urology, 67, Bjerre, B.D., Johansen, C., & Steven, K. (1998). Sexological problems after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire study of male patients. Scandinavian Journal of Urology and Nephrology, 32, Black, P.K. (1994). Hidden problems of stoma care. British Journal of Nursing, 3, Botto, H., Sebe, P., Molinie, V., Herve, J.M., Yonneau, L., & Lebret, T. (2004). Prostatic capsule- and seminal-sparing cystectomy for bladder carcinoma: initial results for selected patients. British Journal of Urology International, 94, Cross, W., & Whelan, P. (2010). Bladder Cancer. Surgery (Oxford), 28, Fokdal, L., Høyer, M., Meldgaard, P., & Maase, H. von der (2004). Long-term bladder, colorectal, and sexual functions after radical radiotherapy for urinary bladder cancer. Radiotherapy & Oncology, 72, Follick, M.J., Smith, T.W., & Turk, D.C. (1984). Psychosocial adjustment following ostomy. Health Psychology, 3, Jemal, A., Bray, F., Center, M.M., Ferlay, J., Ward, E., & Forman, D. (2011). Global cancer statistics. CA: A Cancer Journal for Clinicians, 61, Hart, S., Skinner, E.C., Meyerowitz, B.E., Boyd, S., Lieskovsky, G., & Skinner, D.G. (1999). Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral kock pouch. Journal of Urology, 162,

17 17 Horenblas, S., Meinhardt, W., Ijzerman, W., & Moonen, L.F. (2001). Sexuality preserving cystectomy and neobladder: initial results. Journal of Urology, 166, Huish, M., Kumar, D., & Stones, C. (1998). Stoma surgery and sexual problems in osteomates. Sexual and Marital Therapy, 13, Intergraal Kankercentrum Nederland (2011). Cijfers over kanker [Data file]. Retrieved May 15, 2012 from fcf3?row=0&column=1&direction=left#table Kaplan, S.A., Reis, R.B., Kohn, I.J., Ikeguchi, E.F., Laor, E., Te, A.E., & Martins, A.C.P. (1999). Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction. Urology, 53, Kessler, T.M., Burkhard, F.C., Perimenis, P., Danuser, H., Thalmann, G.N., Hochreiter, W.W., & Studer, U.E. (2004). Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. Journal of Urology, 172, Kitamura, H., Miyao, N., Yanase, M., Masumori, N., Matsukawa, M., Takahashi, A., Itoh, N., & Tsukamoto, T. (1999). Quality of life in patients having an ileal conduit, continent reservoir or orthotopic neobladder after cystectomy for bladder carcinoma. International Journal of Urology, 6, KWF Kankerbestrijding (n.d.). Blaaskanker. Retrieved May 15, 2012 from ker.kwfkankerbestrijding.nl/soorten-kanker/pages/soorten-kanker-blaaskanker.aspx LENT SOMA tables (1995). Radiotherapy & Oncology, 35, Levin, R.J., (2007). Sexual activity, health and well-being: The beneficial roles of coitus and masturbation. Sexual and Relationship Therapy, 22, Little, F.A., & Howard, G.C. (1998). Sexual function following radical radiotherapy for bladder cancer. Radiotherapy & Oncology, 49, Månsson, A., Caruso, A., Capovilla, E., Colleen, S., Bassi, P., Pagano, F., & Månsson, W. (2000). Quality of life after radical cystectomy and orthotopic bladder substitution: a comparison between Italian and Swedish men. British Journal of Urology International, 85, Martis, G., D Elia, G., Diana, M., Ombres, M., & Mastrangeli, B. (2005). Prostatic capsule- and nerve-sparing cystectomy in organ-confined bladder cancer: preliminary results. World Journal of Surgery, 29, Masters, W.J, & Johnson, V.E. (1966). Human Sexual Response. Boston: Little, Brown and Company.

18 18 Meinhardt, W. & Horenblas, S. (2003). Sexuality preserving cystectomy and neobladder (SPCN): functional results of a neobladder anastomosed to the prostate. European Urology, 43, Muto, G., Bardari, F., D Urso, L., & Giona, C. (2004). Seminal sparing cystectomy and ileocapsuloplasty: long-term follow up results. Journal of Urology, 172, Nandipati, K.C., Bhat, A., & Zippe, C.D. (2006). Neurovascular preservation in female orthotopic radical cystectomy significantly improves sexual function. Urology, 67, Nieuwenhuijzen, J.A., Meinhardt, W., & Horenblas, S. (2008). Clinical outcomes after sexuality preserving cystectomy and neobladder (prostate sparing cystectomy) in 44 patients. Journal of Urology, 179, S Nordström, G.M., & Nyman, C.R. (1992). Male and female sexual function and activity following ileal conduit urinary diversion. British Journal of Urology, 70, Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., Ferguson, D., & D agostino, R.Jr. (2000). The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex & Marital Therapy, 26, Rosen, R.C., Cappelleri, J.C., Smith, M.D., Lipsky, J., & Peña, B.M. (1999). Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research, 11, Rosen, R.C., Riley, A., Wagner, G., Osterloh, I.H., Kirkpatrick, J., & Mishra, A. (1997). The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology, 49, Salem, H.K. (2005). Preservation of ejaculatory and erectile function after radical cystectomy for urothelial malignancy. Journal of the Egyptian National Cancer Institute, 17, Schoenberg, M.P., Walsh, P.C., Breazeale, D.R., Marshall, F.F., Mostwin, J.L., & Brendler, C.B. (1996). Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year follow up. Journal of Urology., 155, Schover, L.R. (1987). Sexuality and Fertility in Urologic Cancer Patients. Cancer, 60, Schover, L.R., & von Eschenbach, A.C. (1985). Sexual function and female radical cystectomy: A case series. Journal of Urology, 134,

19 19 Schover, L.R., Evans, R.B., & von Eschenbach, A.C. (1986). Sexual rehabilitation and male radical cystectomy. Journal of Urology, 10, Takenaka, A., Hara, I., Soga, H., Sakai, I., Terakawa, T., Muramaki, M., Miyake, H., Tanaka, K., & Fujisawa, M. (2011). Assessment of long-term quality of life in patients with orthotopic neobladder followed for more than 5 years. International Urology & Nephrology, 43, Traa, M.J., Vries, J. de, Roukema, J.A., & Oudsten, B.L. den (2012). Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: A systematic review. Annals of Oncology, 23, Vallancien, G., Abou El Fettouh, H., Cathelineau, X., Baumert, H., Fromont, G., & Guillonneau, B. (2002). Cystectomy with prostate sparing for bladder cancer in 100 patients: 10-year experience. Journal of Urology, 168, Verschuren, J.E.A., Enzlin, P., Dijkstra, P.U., Geertzen, J.H.B, & Dekker, R. (2010). Chronic Disease and Sexuality: A Generic Conceptual Framework. Journal of Sex Research, 47, Volkmer, B.G., Gschwend, J.E., Herkommer, K., Simon, J., Küfer, R., & Hautmann, R.E. (2004). Cystectomy and orthotopic ileal neobladder: the impact on female sexuality. Journal of Urology, 172, Zippe, C.D., Raina, R., Shah, A.D., Massanyi, E.Z., Agarwal, A., Ulchaker, J., Jones, S., & Klein, E. (2004) a. Sexual function after male radical cystectomy in a sexually active population. Urology, 64, Zippe, C.D., Raina, R., Shah, A.D., Massanyi, E.Z., Agarwal, A., Ulchaker, J., Jones, S., & Klein, E. (2004) b. Female sexual dysfunction after radical cystectomy: a new outcome measure. Urology, 63,

20 20 Appendix Table 1. List of criteria for assessing the methodological quality of studies on sexual function in patients with bladder cancer Positive if Sexual function A. A psychometrically sound questionnaire is used B. Examining sexual function was a primary objective of the study Study population concerning sexual function C. Examining both men and women D. A description is included of at least two sociodemographic variables (e.g., age, sex, employment status, educational status) E. A description is present of at least two clinical variables (e.g., TNM or Dukes classification, type of surgery, tumor location) F. Inclusion and/or exclusion criteria are provided G. The study describes potential prognostic factors by using multivariate analyses or structural equation modeling H. Participation rates for patient groups are described (defined as the percentage of eligible patients who gave their informed consent) and these rates are >75% I. The ratio non-responders versus responders is given (defined as the ratio of patients who withdrew their initial informed consent), Including reasons for withdrawal Study design concerning sexual function J. The study sample includes at least 50 patients (arbitrarily chosen). K. The collection of data is prospectively gathered with at least two assessment points L. The design is longitudinal (>1 year) M. The process of data collection is described (e.g., interview or self-report) N. The loss to follow-up is described and is <20% Results O. The results are compared between two groups or more (e.g., healthy population, groups with different disease stages, or treatment types)

21 21 Table 2. Results of the methodological assessment of selected studies First author Sample size Study A B C D E F G H I J K L M N O Quality score Score (%) analyzed design (Total +) Nordström et al CSS ? +? Hart et al CSS ? +? Kitamura et al CSS ? Horenblas et al PS Fokdal et al CSS ? +? Bergman et al PS Schoenberg et al PS? Bjerre et al PS Little et al CSS ? +? Månsson et al CSS ? Vallancien et al PS Meinhardt et al CSS ? +? Botto et al PS Kessler et al PS Muto et al PS ? Zippe et al (1) 49 PS Matris et al PS Nieuwenhuijzen et al PS ? Salem PS Takenaka et al PS Volkmer et al PS ? Zippe et al (2) 27 PS Bhatt et al PS Nandipati et al PS Abbreviations: CSS: Cross-sectional study; PS: Prospective study

22 22 Table 3 Questionnaire Questionnaire # items Subscales Research International Index of Erectile Function (IIEF) 1 15 Erectile function; orgasmic function; sexual desire; intercourse satisfaction; overall satisfaction Botto et al., 2004; Matris et al. 2005; Muto et al., 2004; Nieuwenhuijzen et al., International Index of Erectile Function-5 (IIEF-5) ; 5 Erectile function; intercourse satisfaction Takenaka et al., 2011; Zippe et al., 2004 a Female Sexual 19 Arousal, lubrication; orgasmic function; Function Index (FSFI) 3 sexual desire; intercourse satisfaction; sexual pain Index of Female Sexual Function (IFSF) 4 10 Pain free intercourse; degree of vaginal lubrication; overall sexual desire and interest; ability to achieve an orgasm; overall sexual satisfaction Questionnaire based on the LENT SOMA scoring system 5 38 Tables: urinary bladder; small intestine/colon; rectum; sexual function Bhatt et al., 2006; Nandipati et al., 2006; Volkmer et al., 2004 Zippe et al., 2004 b Fokdal et al., Rosen et al., 1997; 2 Rosen et al., 1999; 3 Rosen et al., 2000; 4 Kaplan et al., 1999; 5 LENT SOMA Tables, 1995

23 Table 4 Mean study findings 23 First author Sample size analyzed Nordström et al / Hart et al / Kitamura et al / Horenblas et al / Fokdal et al / Mean age Study design* Treatment 55 CSS RC Women were more likely to be sexual inactive preoperatively then men. After RC, sexual function was impaired in 90% of the men and 83% of the women. Men younger than 50 were more likely to remain sexual function. Half of the men (52%) were unsatisfied about their current sex life and 16% of the women. 59 CSS RC Postoperatively, men and women reported less frequent sexual desire, decreased ability to become aroused and more difficult to achieve an orgasm during intercourse. Retrospectively, 16% of the patients rated moderate to high dissatisfaction preoperatively. Postoperatively, 47% rated moderate to high dissatisfaction. Women reported more dissatisfaction and a worse sexual desire then men. Men with a penile implant were young and reported better current sexual function en satisfaction. 61 CSS RC In total, 39% of the IC patients, 44% of CR patients and 63% of NB patients were not satisfied with their present sexual life. Patients with IC had the most loss of sexual desire. 55 PS Sexuality preserving RC Bergman et al PS RC + Pre RR (44%) Results About a fifth of the sexual active men (22%) had insufficient erectile function, but they used sildenafil with success. Of those men, 55% had normal ejaculation, 33% had retrograde ejaculation and 11% varied. All the women (3) had normal lubrication and orgasmic feelings. 74 CSS RR After RR, 65% was not sexually active, but not differ significant from the healthy controls. RR had a moderate or severe impact on sexual life in 24% of the men and 29% of the women. Patients and controls showed correlations between increasing age, not sexual active, erectile dysfunction, lack of desire and satisfaction. Postoperatively, 64% of sexual active men before surgery tried sex after treatment. Of all men, 71% unchanged libido. Further, 14% could perform sexual intercourse and 86% had orgasm s by masturbation. Of those men, 86% had unchanged satisfaction and 14% reported that it was considerable impaired. Of all men, 86% had an abnormal erection, but 75% had a normal orgasm (without full erection). Orgasm mostly returned within 3 weeks-2 months, some in 4-10 months and 1 in 18 months. Pre-RR: 35% of the men became inactive versus 24% without pre-rr. Schoenberg et al PS NS RC Postoperatively, 42% of the men have an erection for intercourse. The recovery of potency postoperatively is strongly influenced by the age of the patient at operation. Older men are less likely to regain sexual function. Bjerre et al PS RC Postoperatively, 20% of reported that their sexual problem was their main concern. IC patients were more in need of sexological counseling than BS patients. Only 9% could achieve an erection, while 38% could achieve an orgasm. The minority (41%) reported no decrease in quality of orgasm. Age has a major influence on retained orgasmic ability (elderly patient lower degree of retained orgasmic ability). Patients with IC reported more loss of potency then patients with BS. RR and impotence treatment increased the risk of feeling less sexually attractive. Younger patients and patients who received impotence treatment have more chance of being sexual active. Little et al CSS RR There was a decrease from 72% to 56% in erectile ability. The majority (70%) reported a worse sexual life after RR. Of those men, 83% were concerned about it and 42% felt that their partner was concerned. It is unlikely that endocrine pathology explain impotency. Månsson et al CSS RC Patients reported a large decreased erectile ability and potency, impaired sexual drive. The majority reported that they wanted more attention to sexual problems. Vallancien et al PS Prostate sparing RC Of all men, 18% had decreased of lost potency and 82% maintain potency. But they all have retrograde ejaculation. Abbreviations: BS: Bladder substitution; CSS: Cross sectional study; CR: Continent reservoir; IC: Ileal conduit; NB: Neobladder; NS: Nerve-sparing; PS: Prospective study; RC: Radical cystectomy; RR: Radiotherapy

24 Table 4.2 (Continued) 24 First author Sample size analyzed Mean age Study design Treatment Meinhardt et al CSS Sexuality Sexual function is preserved, erections (79%) and anterograde ejaculation (50%). 60% of the men with sexual dysfunction preserving RC used potency treatment successfully. Botto et al PS Sexuality After 3 months 90% was potent. Of all men, 7% used vardenafil successfully and 100% had retrograde ejaculation. preserving RC Kessler et al PS RC Postoperatively, 73% could not achieve an erection, 20% had reduced erections and 7% had normal erections. All patients who reported postoperative erections achieved this function within 2 years. Some could overcome their sexual dysfunction with potency treatment. Patients younger than 65 years and those with attempted sparing of 1 or both neurovascular bundles reported significantly better recovery of erectile function. Preservation of both neurovascular bundles gave the best result. Significantly better recovery of erectile function was reported in men with negative lymph nodes compared to those with positive lymph nodes. Muto et al PS Seminal This procedure has proven to be safe (no local recurrence) and effective (95% potency preservation). In most men erectile sparing RC function recur in 1-2 months, 5% longer than 6 months. All men have retrograde ejaculation. Zippe et al a PS RC Erectile dysfunction is a prevalent problem, occurring in 86% of sexually active men after RC. They were sexually active before surgery, with a mean frequency of 2 times per week. The men who retain potency had a mean age of 51 years versus impotent men with a mean age of 59 years (not sig.). Half of the men (52%) tried sildenafil citrate, but in only 4% it was successful. Incidence of comorbid disorders was similar in both the sexually active and impotent. Matris et al PS NS RC After 24 months sexual function was retained in 80% of the men. Nieuwenhuijzen et al PS Prostate Of the sexually active men, 77.5% retained potency, 10% became impotent and 12.5% had impaired erectile function. Of sparing RC the potent men, 59% have retrograde ejaculation. Of all men, 16% used potency treatment with success. Salem PS NS RC Erectile function returned in all men in 11 months. Of all men, 86% have anterograde ejaculation. All the men were satisfied about their sexual life. Takenaka et al PS RC After RC, 88% of the men scored very low on the IIEF-5 scale (high degree of sexual dysfunction). The satisfaction of sexual life was very low: 0.98 on a scale of 10 points. Volkmer et al PS RC Postoperatively, 35% of the women lost their sexual activity after RC, but they tended to classify their current sex life as positive. Women younger than 60 years pre and post operatively, living in partnership,and more than 4 weeks sexual active preoperational and on the time of the questionnaire are beneficial factors for intact postoperative female sexuality. Resection of the upper part of the anterior vaginal wall did not affect lubrication, vaginal sensibility, and the ability to perform sexual intercourse. Zippe et al b PS RC About half of sexually active women (52%) have a sexual dysfunction and became dissatisfied after RC. No difference was found between the Indiana and Studor pouch diversions. This suggests that preservation of the anterior vaginal wall will not result in improved sexual function after RC. The ability to achieve orgasm and the degree of vaginal lubrication decreased significantly after RC. Pain free during intercourse also decline in score. No difference was found between the premenopausal and postmenopausal groups after RC. A third of the partners (30%) had a decrease in desire for sexual activity owing to apprehension and physical imperfection with urostomy. Bhatt et al PS NNS & NS Both groups showed a decreased in satisfaction after RC (greater in non-nerve sparing group). Neurovascular preservation RC maintains female sexual function after RC in all domains. All patients who had neurovascular preservation continued to participate in sexual activity versus 14% of the non-nerve-sparing group (1 year after RC). Nandipati et al PS NNS & NS Neurovascular preservation in female RC significantly improves sexual function after RC. Sexual function is an important RC outcome measure after RC of female bladder cancer. After 1 year all the NS patients were sexually active and only 14% of the NNS. Those patients had problems with vaginal dryness, lack of arousal, and intercourse is painful. Abbreviations: CSS: Cross sectional study; NNS; Non-nerve-sparing; NS: Nerve-sparing; PS: Prospective study; RC: Radical cystectomy Results