madman
Super Moderator
ABSTRACT
Background: Patients may remain dissatisfied after penile prosthesis implantation for the treatment of erectile dysfunction. Studies showing the results of standardized protocols for preoperative psychological evaluation are lacking.
Purpose: To estimate the rate of patients considered psychologically unfit for penile prosthesis implantation and to compare their characteristics with those considered fit after the implementation of a standardized psychological profile evaluation protocol for men with erectile dysfunction.
Methods: Cross-sectional evaluation of men referred for penile prosthesis implantation by their urologists, based on organic causes for the erectile dysfunction, including a semi-structured (sexual and relational anamnesis of the patient and their partner, information about expectations about the results of the penile prosthesis implantation and possible complications) and a structured instrument including validated tools for the evaluation of depression and/or anxiety symptoms. These were the Self Reporting Questionnaire (SRQ-20), the 36-Item Short-Form Health Survey for quality of life, and the Five-Factor Model (FFM) for behavioral tendencies. After at least 3 interviews, the psychology team rated the patients as fit or unfit for surgery. Unfit patients were those with any of a set of warning signals indicating risk for dissatisfaction even after penile implantation.
Main outcome measure: The prevalence of patients considered “unfit for surgery.”
Results: The quality of life scores were good, but 27.6% of patients (95% confidence interval, CI: 16.7-40.9%) were unfit for surgery. Being unfit was associated with obesity (P ¼ .027), anxiety and/or depression symptoms (P < .001), and high levels of neuroticism (P ¼ .001).
Conclusion: The preoperative evaluation protocol combining standardized and validated tools shows that more than one-quarter of patients with a medical indication for penile prosthesis implantation were not in good psychological conditions for the surgery. The development of psychological evaluation protocols can help identify patients in need of adequate care before penile implantation.
INTRODUCTION
The prevalence of erectile dysfunction varies widely in literature due to its various definitions,1,2 distinct research tools for evaluation, and the different inclusion criteria in studies. It is estimated that the erectile dysfunction prevalence in men aged 40 or over varies between 37.2% in Brazil to 48.6% in Italy, according to a cross-sectional study conducted in 8 countries with 97,159 men.3 Erectile dysfunction’s prevalence increases with age,3 and it may be above 50% in those aged 70 or older.4,5
In men aged under 40 years, 83% of erectile dysfunction cases have a psychogenic origin, while in men aged 40 years or older, 59.3% have an organic etiology.6 Organic causes comprehend vascular, neurological (central or peripheral), hormonal or anatomical alterations and side effects of medication7 or psychoactive substances.8 Penile curvature, either congenital or caused by Peyronie’s disease, can also be associated with erectile dysfunction.9
The treatment options for erectile dysfunction depend on the cause and comprehend cognitive behavioral therapy, oral and intracavernous pharmaceuticals, vacuum constrictive devices, and penile prosthesis implants. Less invasive treatments are prioritized at first.10 Patients with organically caused erectile dysfunction who did not obtain satisfactory results with less invasive treatments are referred to surgical intervention with penile prosthesis implants. Whatever the cause, the partner’s involvement in the clinical assessments and discussing the patient’s and their partner’s expectations are crucial in choosing the best suitable treatment.11
The levels of satisfaction among patients that underwent penile prosthesis implantation can be high,12 calculated at 69-89% in the 1980s and 1990s, and reaching 100% in some studies published from 2000 onwards.13 However, some patients remain dissatisfied with the surgical results due to reduction in penile size, expectations not met, prosthesis not allowing sexual intercourse, artificial or unnatural appearance, retarded ejaculation, prosthesis malfunction, and the difficulty to satisfy one’s partner.14 There are few studies published on the implantation of a penile prosthesis for the treatment of erectile dysfunction in Brazil,15,16 and these show high satisfaction indicators and a small incidence of postoperative complications. However, none of these reported a psychological evaluation before surgery.
Ulloa et al (2008), in a literature review, proposed that a preoperative evaluation be composed of medical history, including organic and psychogenic causes of erectile dysfunction; psychological history; sexual history; records of previous nonsurgical treatments for erectile dysfunction and results; characteristics of their relationship with the partner; knowledge and expectations about the penile prosthesis.17 The assessment of the expectations of sexual partners of patients who are candidates for penile prosthesis implantation is also recommended by the European Society for Sexual Medicine.11 Still, we could not find studies using preoperative structured psychological evaluation protocols.
On considering the need for identifying patients at a higher risk of dissatisfaction after penile implantation, our urology service introduced an in-depth psychological evaluation as an obligatory step toward surgery in May 2018. The objective of this study is to estimate the rate of patients considered psychologically unfit for surgery and to compare their characteristics with those considered fit after the implementation of a psychological profile evaluation protocol for patients with erectile dysfunction referred for penile prosthesis implantation. The research question was formulated as: is there any association between sociodemographic and clinical characteristics of patients, their depressive and anxious symptoms and behavior, and being considered unfit for penile implantation surgery?
According to the present findings of this study, around 25% of candidates for penile prosthesis implantation were unfit for surgery and needed psychotherapy or psychiatric treatment before surgery. We plan to improve the preoperative evaluation, with the proposition of structured or semi-structured instruments for a more detailed investigation of the patient’s and their partner’s beliefs and expectations, and to include the postoperative psychological revaluation process. This will allow more patients to be submitted to the procedure under better psychological conditions, and therefore have a higher probability of achieving satisfactory results.
Background: Patients may remain dissatisfied after penile prosthesis implantation for the treatment of erectile dysfunction. Studies showing the results of standardized protocols for preoperative psychological evaluation are lacking.
Purpose: To estimate the rate of patients considered psychologically unfit for penile prosthesis implantation and to compare their characteristics with those considered fit after the implementation of a standardized psychological profile evaluation protocol for men with erectile dysfunction.
Methods: Cross-sectional evaluation of men referred for penile prosthesis implantation by their urologists, based on organic causes for the erectile dysfunction, including a semi-structured (sexual and relational anamnesis of the patient and their partner, information about expectations about the results of the penile prosthesis implantation and possible complications) and a structured instrument including validated tools for the evaluation of depression and/or anxiety symptoms. These were the Self Reporting Questionnaire (SRQ-20), the 36-Item Short-Form Health Survey for quality of life, and the Five-Factor Model (FFM) for behavioral tendencies. After at least 3 interviews, the psychology team rated the patients as fit or unfit for surgery. Unfit patients were those with any of a set of warning signals indicating risk for dissatisfaction even after penile implantation.
Main outcome measure: The prevalence of patients considered “unfit for surgery.”
Results: The quality of life scores were good, but 27.6% of patients (95% confidence interval, CI: 16.7-40.9%) were unfit for surgery. Being unfit was associated with obesity (P ¼ .027), anxiety and/or depression symptoms (P < .001), and high levels of neuroticism (P ¼ .001).
Conclusion: The preoperative evaluation protocol combining standardized and validated tools shows that more than one-quarter of patients with a medical indication for penile prosthesis implantation were not in good psychological conditions for the surgery. The development of psychological evaluation protocols can help identify patients in need of adequate care before penile implantation.
INTRODUCTION
The prevalence of erectile dysfunction varies widely in literature due to its various definitions,1,2 distinct research tools for evaluation, and the different inclusion criteria in studies. It is estimated that the erectile dysfunction prevalence in men aged 40 or over varies between 37.2% in Brazil to 48.6% in Italy, according to a cross-sectional study conducted in 8 countries with 97,159 men.3 Erectile dysfunction’s prevalence increases with age,3 and it may be above 50% in those aged 70 or older.4,5
In men aged under 40 years, 83% of erectile dysfunction cases have a psychogenic origin, while in men aged 40 years or older, 59.3% have an organic etiology.6 Organic causes comprehend vascular, neurological (central or peripheral), hormonal or anatomical alterations and side effects of medication7 or psychoactive substances.8 Penile curvature, either congenital or caused by Peyronie’s disease, can also be associated with erectile dysfunction.9
The treatment options for erectile dysfunction depend on the cause and comprehend cognitive behavioral therapy, oral and intracavernous pharmaceuticals, vacuum constrictive devices, and penile prosthesis implants. Less invasive treatments are prioritized at first.10 Patients with organically caused erectile dysfunction who did not obtain satisfactory results with less invasive treatments are referred to surgical intervention with penile prosthesis implants. Whatever the cause, the partner’s involvement in the clinical assessments and discussing the patient’s and their partner’s expectations are crucial in choosing the best suitable treatment.11
The levels of satisfaction among patients that underwent penile prosthesis implantation can be high,12 calculated at 69-89% in the 1980s and 1990s, and reaching 100% in some studies published from 2000 onwards.13 However, some patients remain dissatisfied with the surgical results due to reduction in penile size, expectations not met, prosthesis not allowing sexual intercourse, artificial or unnatural appearance, retarded ejaculation, prosthesis malfunction, and the difficulty to satisfy one’s partner.14 There are few studies published on the implantation of a penile prosthesis for the treatment of erectile dysfunction in Brazil,15,16 and these show high satisfaction indicators and a small incidence of postoperative complications. However, none of these reported a psychological evaluation before surgery.
Ulloa et al (2008), in a literature review, proposed that a preoperative evaluation be composed of medical history, including organic and psychogenic causes of erectile dysfunction; psychological history; sexual history; records of previous nonsurgical treatments for erectile dysfunction and results; characteristics of their relationship with the partner; knowledge and expectations about the penile prosthesis.17 The assessment of the expectations of sexual partners of patients who are candidates for penile prosthesis implantation is also recommended by the European Society for Sexual Medicine.11 Still, we could not find studies using preoperative structured psychological evaluation protocols.
On considering the need for identifying patients at a higher risk of dissatisfaction after penile implantation, our urology service introduced an in-depth psychological evaluation as an obligatory step toward surgery in May 2018. The objective of this study is to estimate the rate of patients considered psychologically unfit for surgery and to compare their characteristics with those considered fit after the implementation of a psychological profile evaluation protocol for patients with erectile dysfunction referred for penile prosthesis implantation. The research question was formulated as: is there any association between sociodemographic and clinical characteristics of patients, their depressive and anxious symptoms and behavior, and being considered unfit for penile implantation surgery?
According to the present findings of this study, around 25% of candidates for penile prosthesis implantation were unfit for surgery and needed psychotherapy or psychiatric treatment before surgery. We plan to improve the preoperative evaluation, with the proposition of structured or semi-structured instruments for a more detailed investigation of the patient’s and their partner’s beliefs and expectations, and to include the postoperative psychological revaluation process. This will allow more patients to be submitted to the procedure under better psychological conditions, and therefore have a higher probability of achieving satisfactory results.
