Bother Associated with Climacturia after Radical Prostatectomy: Prevalence and Predictors

Abstract

Background:

Orgasm-associated incontinence, climacturia, is one of the lesser studied radical prostatectomy (RP) complications. Little is known about patient bother related to this condition, specifically, its prevalence and predictors.

Aim:

To ascertain the prevalence and predictors of patient bother associated with climacturia.

Methods:

Patients presenting for the evaluation of sexual dysfunction after RP at a single center were queried on various domains of sexual dysfunction. This included orgasmic dysfunction and sexual incontinence (including climacturia and arousal incontinence). Patients were specifically asked about the frequency and amount of climacturia. Additionally, questions addressed patient bother and the perceived bother of their partners. Descriptive statistics were used for patient characteristics. A t-test was used for comparing the frequency of patient and partner bother and the Pearson correlation test compared relationships between bother and predictors. Multivariable analysis was conducted to define predictors of climacturia-associated bother.

Outcomes:

The prevalence and predictors of climacturia-associated patient bother and perceived partner bother.

Results:

Climacturia was reported by 23% of 3,207 consecutive men analyzed. Bother of any degree was experienced by 45% of these patients and 14% reported partner bother related to this condition. Patient bother was associated with perceived partner bother (p<0.001) and inversely correlated with relationship duration (p<0.001). The overall frequency and quantity of climacturia were also predictive (p<0.001 for both). In the adjusted model, all of these factors remained significant.

Clinical Implications:

Given the prevalence of this condition and the bother associated with it, this complication should be discussed with patients preoperatively.

Strengths and Limitations:

Strengths include a large study population and specific questions on climacturia-associated bother. Limitations include the fact that it is a single center study and no direct partner questioning occurred.

Conclusion:

Climacturia and its associated bother are common after RP. The predictors of patient bother include perceived partner bother, shorter relationship duration, and increasing frequency and quantity of climacturia.

INTRODUCTION

Prostate cancer is a common malignancy in men, with a 1 in 9 lifetime risk of being diagnosed with prostate cancer in the US.¹ Treatment options for prostate cancer include active surveillance, watchful waiting, radical prostatectomy (RP), radiation therapy and androgen deprivation therapy. RP is a commonly performed operation. A study evaluating inpatient discharges after RP in the US from 20012013 found that this number could be as high as 88,381 annually.²

Sexual incontinence is a broad term encompassing both climacturia (orgasm-associated incontinence) and arousal (foreplay) incontinence. Climacturia refers to involuntary leakage of urine at the time of orgasm. Research on sexual incontinence in men is relatively new. The first study to address orgasm-associated incontinence after RP was by Koeman et al in 1996³ and the term climacturia was first coined by Lee et al⁴ in 2006.

The prevalence of climacturia varies in the literature based on the definition used, with prevalence rates ranging between 20-93%^3–9. While several series have evaluated climacturia prevalence, only two of these series have evaluated the prevalence of patient bother, with 44-48% of patients reporting significant bother and 21% perceived significant bother in their partners.^3,4

The aim of this study was to evaluate the prevalence of patient bother, perceived partner bother, and the predictors of each. The prevalence and predictors of climacturia will not be addressed, as this has been extensively researched in the literature. Arousal incontinence will not be discussed, as this is the topic of another research project.

METHODS

Study Population:

This was a retrospective analysis of data collected prospectively in our clinical practice which was approved by the Institutional Review Board (Protocol #16-469). Consecutive patients at a single center who presented for the management of postoperative sexual dysfunction between May 2006 to August 2018, who had previously undergone RP, constituted the study population. Only patients experiencing orgasm were included. Patients who underwent neoadjuvant, adjuvant, or salvage radiation therapy or androgen deprivation therapy were excluded. Salvage prostatectomy patients were also excluded. Comorbidity profile and demographics were recorded.

Questionnaire:

All patients received a proprietary intake questionnaire which addressed multiple domains of sexual function with structured questions on orgasmic dysfunction (presence, nature, dysorgasmia) and sexual incontinence. This was conducted during their first face-to-face post-RP evaluation by a sexual medicine clinician. Regarding sexual incontinence, they were specifically asked about the presence, quantity, and frequency of climacturia. Self-reported subjective quantity was categorized as small (drops), moderate (<30ml) or large amounts (≤30ml). Frequency was categorized as never, rare (<25% orgasms), occasional (25-50% orgasms) and frequent (>50% orgasms). They were also asked about their degree of bother and the perceived bother in their partner, both of which were graded as mild, moderate or severe.

Statistics:

Descriptive statistics were calculated for climacturia and bother characteristics. Baseline characteristics were compared between men who reported climacturia versus those that did not using a series of independent samples t-tests and Chi-square tests. Analyses related to bother were limited to patients who reported climacturia. Unadjusted logistic regression models were used to assess associations between patient characteristics and presence of bother, for either patients or partners. Two final models were then fitted including all predictors found significant in the unadjusted models as well as an adjustment for age.

RESULTS

Study population:

(Table 1) A total of 3,207 post-RP men were included in the analysis. The mean age was 61±7 years. Most (97%) were heterosexual and 82% were Caucasian. Comorbidities included diabetes (11%), hypertension (45%), dyslipidemia (50%). 88% of men were in stable relationships with a mean duration of 27±13 years. Mean partner age was 56±9years. The median time between RP and survey date was 203 days (interquartile range 85 – 428 days). 45% of men were less than 6 months postop, 25% between 6-12 months post-op, and 30% were more than 12 months post-op. With regard to surgery type, 41% of men had a robotic-assisted laparoscopic prostatectomy (RALP), 35% had an open radical prostatectomy (oRP) and 24% underwent a laparoscopic prostatectomy (LP). 75% of men had bilateral nerve sparing procedures (with complete or partial nerve preservation) whereas 25% had complete nerve resection unilaterally or bilaterally. Men with climacturia were slightly younger (mean 60.3 years vs. 61.6 years for men without climacturia, p<0.001), had slightly younger partners (mean 55.7 years vs. 56.6 years, p=0.03), and had higher erectile function grade (mean 2.90 vs 2.58, p=0.01), but did not differ significantly on other characteristics.

Table 1:

Patient (N=3,207) and Partner (N=2,745) Demographics

Parameter	All	Climacturia	No Climacturia
Patient age (years, mean ± SD)	61 ± 7	60 ± 7	62 ± 7
Partner age (years, mean ± SD)	56 ± 9	56 ± 9	57 ± 9
Percentage of men in stable relationships	88%	90%	88%
Relationship duration (years, mean ± SD)	27 ± 13	26 ± 13	27 ± 13
Sexual orientation, (%)
Heterosexual	97%	97%	97%
Gay	3%	3%	3%
Bisexual	1%	1%	1%
Race, (%)
Asian	2%	2%	2%
Black	12%	12%	12%
White	82%	82%	82%
Other	1%	<1%	2%
Refused	3%	4%	2%
Comorbidities, (%)
Hypertension	45%	44%	46%
Diabetes	11%	10%	11%
Hyperlipidemia	50%	50%	50%
Sleep Apnea	11%	11%	11%
CAD	5%	4%	5%
Smoking Status, (%)
Current	9%	8%	9%
Former	37%	38%	36%
Never	54%	53%	55%
Disease Status, (%)
High Risk	39%	39%	39%
Low Risk	61%	61%	61%
Nerve Sparing Status, (%)
Preserved Bilaterally	75%	74%	75%
Not Preserved Bilaterally	25%	26%	25%
Erectile Grade, (mean ± SD)	2.7 ± 2.7	2.9 ± 2.7	2.6 ± 2.7
RP Type, (%)
LP	24%	25%	24%
RALP	41%	42%	41%
oRP	35%	34%	36%

Climacturia:

(Table 2) 745 men (23%) experienced climacturia post-RP. Of these men, 70% reported a small volume of urine leakage (drops) whereas 24% reported moderate volume (<30ml) and only 6% had large volume (≥30ml). With regards to frequency, this was categorized as rare in 31% of men, occasional in 47% and frequent in 22% of men. Men were separated into 3 groups based on time since RP: < 6 months, 6-12 months, and > 12 months. Neither frequency (p=0.36) nor quantity (p=0.89) differed by time since RP.

Table 2:

Comparison of the Degree of Climacturia across Time Points

Characteristic	Group	<6m (n=339)	6-12m (n=199)	>12m (n=209)	p-value
Quantity	Small (drops)	69%	72%	69%	0.89*
	Moderate (<30 mL)	26%	21%	24%
	Large (≥ 30mL)	5%	7%	7%
Frequency	Rare (<25% orgasms)	31%	34%	28%	0.36*
	Occasional (25-50% orgasms)	48%	46%	47%
	Frequent (>50% orgasms)	21%	20%	26%

^*Chi-square analysis to compare the distribution of the quantity and frequency of climacturia across time points post-RP

Bother:

Of the men who experienced climacturia, 45% admitted to being bothered by their symptoms. 62% reported mild bother, 29% moderate, and 9% severe. When asked what they perceived their partner bother to be, only 15% of men believed that their partners were troubled by the climacturia. When evaluating predictors of bother, on univariable analysis, patient bother was associated with perceived partner bother (p<0.001) and inversely correlated with relationship duration (p<0.001). The overall frequency and quantity of climacturia (Table 3) were also predictive (p<0.001 for both). Low versus high risk disease, nerve sparing status, RP type, erectile grade, and patient or partner age were not predictive of patient bother. On multivariable analysis of patient bother, perceived partner bother (p<0.001), shorter relationship duration (p=0.007), frequency (overall p<0.001) and quantity (overall p=0.01) all remained significant (Table 4). Perceived partner bother was not significantly associated with relationship duration or quantity but was associated with patient bother (p<0.001) and frequency (p<0.001). In the adjusted model of perceived partner bother, both patient bother (p<0.001) and frequency (overall p=0.004) were still significant (Table 5).

Table 3:

Unadjusted Models of Patient Bother

	OR	95% CI	P-value
Frequency of Climacturia (Frequent vs Rare)	7.60	(4.67, 12.39)	<0.001
Frequency of Climacturia (Occasional vs Rare)	2.82	(1.85, 4.30)	0.89
Quantity of Climacturia (Large vs Small)	3.60	(1.86, 7.01)	0.03
Quantity of Climacturia (Moderate vs Small)	3.01	(2.08, 4.36)	0.05
Perceived Partner Bother (Yes vs No)	5.26	(2.99, 9.25)	<0.001
Patient Age (per Year)	1.00	(0.98, 1.02)	0.98
Disease, High Risk vs Low	0.87	(0.64, 1.19)	0.38
Nerve Sparing Status, Preserved vs Not	1.38	(0.96, 1.99)	0.08
RP Type (LP vs RP)	1.24	(0.84, 1.84)	0.72
RP Type (RALP vs RP)	1.35	(0.96, 1.91)	0.21
Erectile Grade	1.01	(0.95, 1.07)	0.81
Partner Age (per Year)	0.99	(0.97, 1.01)	0.24
Relationship Duration (per Year)	0.98	(0.97, 0.99)	<0.001

Table 4:

Predictors of Patient Bother on Multivariable Analysis

	OR	CI	p-value
Frequency: Frequent vs. Rare	5.61	(2.62, 12.01)	<0.001
Frequency: Occasional vs. Rare	1.96	(1.06, 3.64)	0.033
Perceived Partner Bother (Yes vs. No)	3.41	(1.71, 6.80)	0.001
Quantity: Moderate vs. Small	2.22	(1.25, 3.95)	0.006
Quantity: Large vs. Small	2.63	(0.78, 8.90)	0.12
Relationship Duration (years)	0.97	(0.95, 0.99)	0.007
Patient Age (years)	1.00	(0.97, 1.04)	0.90

Table 5:

Predictors of Perceived Partner Bother on Multivariable Analysis

	OR	95% CI	p-value
Patient Bother	4.57	(2.44, 8.55)	<0.001
Frequency: Frequent vs. Rare	3.46	(1.47, 8.15)	0.005
Frequency: Occasional vs. Rare	1.42	(0.62, 3.23)	0.41
Age	0.98	(0.95, 1.02)	0.39

DISCUSSION

Prostate cancer is most common non-skin cancer in US men, with an estimated 164,690 new cases and 29,430 deaths from prostate cancer in the US in 2018.¹ Many men elect to undergo RP for treatment of their prostate cancer. A study using the SEER (Surveillance, Epidemiology and End Result) database from 2004-2014 found that RP was the single most common treatment modality chosen by men with prostate cancer and 37% of men elected this option.¹⁰ Thus, given the frequency of prostate cancer and RP, climacturia is a wide-spread issue. Interestingly, patients who undergo RP have a higher rate of climacturia compared to those undergoing radiation therapy. A study of 412 men undergoing RP or radiation found that those status-post RP had a 28% rate of climacturia compared to only 5% in the radiation group (p<0.001).⁵

Our climacturia rate (23%) is at the lower range of published literature. While Choi et al reported a 20% rate of climacturia in 475 men, they used a definition of 3 or more episodes, which explains their lower prevalence.⁶ O’Neil et al had an overall prevalence of 23% in their population of 412 men. However, they included men with radiation as a monotherapy as well as men with RP and radiation. When evaluating men with RP as a monotherapy, their climacturia rate was 28%.⁵ This rate is similar to the series of 256 men by Frey et al, which demonstrated a 27% occurrence of climacturia post-RP.⁷ Contrast this to Barnas et al, which noted a 93% rate of climacturia in 239 men post-RP, as defined as at least one episode of climacturia post-operatively.⁹ While this broad range can be explained in part by the definition of climacturia used (any episode versus 3 or more episodes) or the patient population (surgery and/or radiation), there is still a wide disparity that is not easily explained. Our study and that of Barnas et al both involved men post-RP and used the definition of any episode of climacturia. However, their study was a retrospective survey sent out to patients and had a 68% response rate.⁹ This could have introduced bias, as perhaps only the men with climacturia completed the survey. Contrast this to our current study, which queried all post-RP patients in the sexual medicine clinic, which could account for the lower prevalence.

In terms of bother, 45% of men experienced bother in our series. This is similar to the 48% of men with significant bother seen in the series of 42 men by Lee et al.⁴ In that study, patients perceived bother in 21% of their partners which is somewhat higher than the 15% seen in our series. Mitchell et al reported similar findings, with 44% of men endorsing bother from sexual incontinence at 3 months post-op¹¹.

To our knowledge, we are the largest study to evaluate predictors of bother. Intuitively, it makes sense that patients in shorter relationships or with higher perceived partner bother would be more bothered by climacturia. Similarly, it is unsurprising that worsening symptoms in terms of frequency and quantity are also predictive of bother.

There are various management strategies for climacturia described in the literature. Patients report multiple strategies such as emptying their bladder prior to sexual activity, limiting fluid intake, or using condoms.¹² The use of a variable tension penile loop in 124 men demonstrated cure of climacturia in 48% of men with improvement in the remaining patients who reported only rare or occasional climacturia while using the device.¹³ Pelvic floor muscle training (PFMT) may also have a role in treating climacturia. In a tiny study, a 3-month program of PFMT in 7 men improved climacturia in 43% of patients compared to 0% improvement in controls who did not undergo PFMT.¹⁴ While surgery would not be recommended for men with sexual incontinence who were otherwise continent, a study on 11 men with stress urinary incontinence and sexual incontinence found that all men undergoing implant of an artificial urinary sphincter and 57% of men status-post sling had improvement in their sexual quality of life.¹⁵

The strengths of this study include a much larger sample size for this specific patient population compared to other studies. Additionally, to our knowledge we are one of the first studies to assess patient bother secondary to climacturia and the first study assessing predictors of patient and perceived partner bother. This study has limitations, in that it is a single-center study and thus, the results may not be generalizable to the other centers. The study is also cross-sectional in nature; thus, we do not have time-to-event outcomes nor can all associations be assumed causal. Furthermore, the patients were all presenting to clinic for sexual dysfunction after RP which could introduce bias. The degree of climacturia was assessed subjectively by the patients. This introduces a limitation, as recall bias and subjective measurement are notoriously inaccurate. Additionally, we did not use validated questionnaires as none exist for the evaluation of sexual incontinence. Lastly, we were unable to assess partner bother directly and relied on patient perceptions.

In terms of future directions for research, it would be ideal to obtain first-hand information on partner bother, the next step being to query the partners themselves. Additionally, we would like to assess the efficacy of preoperative climacturia counseling and postoperative management strategies on preventing patient bother.

CONCLUSIONS

Climacturia occurs in over one fifth of men post-RP in this analysis. 45% of men reported bother related to their climacturia, while their perceived partner bother was relatively low, being reported by 15% of patients. Predictors of patient bother include worsening climacturia (frequency and quantity), perceived partner bother and shorter relationship duration.