The NSSE after PCa treatment has gained some attention over the last few years. However, more attention is given to individual NSSE rather than the collective group, and more studies focus on the NSSE related to RP than RT. Comparisons across studies were limited as different methodologies, assessment time frames, varying treatment approaches, and the use of non-validated questionnaires varied and impacted the criteria for comparisons.

Prevalence of NSSE

Orgasmic dysfunction had a low to high prevalence. However, it was almost exclusively reported in RP studies (5–78%), except for one RT study reporting a 24% prevalence amongst their participants [4]. Possible reasons for the considerable variation in the results across studies may be due to the variable lengths of time reported after the intervention, participant age, nerve sparing status and various methods/questionnaires to determine orgasmic dysfunction. This observation concurs with a 2014 systematic review where 80% of RP patients were reported to have some degree of orgasmic dysfunction after RP with similar variables influencing the prevalence [7].

Altered perception of orgasm showed a similar moderate prevalence (50–60%) between RP and RT studies [4, 5]. Orgasmic pain similarly showed a low prevalence (10–15%) between RP and RT studies [4, 5, 25, 26, 41]. One study further described that the orgasmic pain felt mainly (70% of the time) was felt in the penis [26]. At the same time, another made the association between bilateral seminal vesicle sparing procedures as a possible cause of orgasmic pain [25]. This notion was concurred in the systematic review by Frey et al., who reported that sparing the tips of the seminal vesicles doubles the risk of orgasmic pain [7].

Penile length changes showed a low to moderate prevalence (055%) after RP and RT [4, 5, 33,34,35,36,37,38,39]. Nerve-sparing procedures reportedly reduced the risk of self-perceived penile length shortening [37], whilst younger age and better preoperative erectile function were associated with complete penile length recovery [33]. Penile length shortening was also associated with treatment regret [36]. Furthermore, the self-perceived penile length shortening was found to be much more than actual penile length shortening measured using a ruler [37]. The study by Parekh et al. is of particular interest as an outlier study, as they only reported a 3.73% RP and a 0% RT prevalence of penile length shortening [36]. This study relied on self-reported patient outcomes, but participants were not instructed on the required measuring procedures (stretched or relaxed flaccid penile length or erect penile length). Furthermore, the majority of the participants (75.4%) in Park et al.’s study were aged between 60 and 80 years old. The lack of available baseline data compromised the ability to determine penile length loss objectively. Frey et al. reported a 1568% prevalence of penile length shortening in their study [7], placing the results of a 42% (RT study) [4] and 47% (RP study) [5] more within the expected range.

Penile curvature changes were also similar between RP and RT studies, showing a low prevalence (10–15.9%) [4, 5, 40], and the average reported abnormal penile curvature angle was 31° [40]. Penile sensory changes showed an almost similar moderate prevalence between RP (25%) and RT (27%) participants [4, 5].

Anejaculation was found to have a low to high prevalence (11–72%) after RT [4, 31, 32]. According to this review, anejaculation is a consequence of RT [31, 32], and it is at its worst 5 years after treatment [32]. Conserved ejaculatory function is often associated with a reduction in ejaculate volume. Higher RT dose, older age and smaller prostates at the time of treatment increased the likelihood of failure to ejaculate [32]. Anejaculation is, however, also a given consequence of RP, as the ejaculatory apparatus (prostate, seminal vesicles and ejaculatory ducts) are removed [7, 42]. However, the authors could not source any studies within our search parameters that met the study inclusion criteria.

Climacturia has a reported moderate prevalence (21–38%) after RP [5, 27,28,29,30] and a low prevalence (4–5.2%) after RT [4, 27]. A comparative study concluded that the orgasm-associated incontinence rates after RP were six times more than that of RT (28.3% vs 5.2%) [27]. Climacturia is associated with major sexual inconvenience and bother [29].

Questionnaire used in assessing NSSE

None of the retrieved studies reported on a validated, standardised questionnaire to investigate the NSSE after early PCa treatment. Most studies incorporated either some aspects of other questionnaires or designed their own. Two studies used a non-validated questionnaire that was able to identify the majority of the collective group of NSSE [4, 5]. This questionnaire enquired about orgasmic dysfunction, orgasm-associated pain, climacturia, penile sensory changes, penile length shortening and penile deformity. These two studies looked mainly and the prevalence and predicting factors of the NSSE.

Interestingly, a limited number of studies reportedly described the use of the Expanded Prostate Cancer Index questionnaire [11] to gather patient data relating to orgasmic dysfunction [20,21,22]. However, the Expanded Prostate Cancer Index questionnaire was inadequate to report on the NSSE, and additional questions that inquired into orgasmic function were added [20, 22]. The Expanded Prostate Cancer Index-26 questionnaire was similarly inadequate to detect NSSE. It merely asked respondents to “rate their ability to reach orgasm” without exploring any symptoms relating to the other NSSE [21].

A 2011 study used the Expanded Prostate Cancer Index questionnaire similarly at regular intervals after surgery to investigate orgasmic outcomes [22]. In addition, patients were asked to evaluate their orgasm and state whether they experienced any pain during orgasms. One study also incorporated the Dysorgasmia Frequency Scale [26]. The International Index Erectile Function was used in many studies [5, 22, 24, 28, 32, 34, 35, 38, 39] but served no purpose in detecting any of the NSSE. The Erection Hardness Scale [43] was used in a few studies [5, 34] and had no role in detecting the NSSE. The Sexual Health Inventory for Men questionnaire (a modified 5-item version of the International Index Erectile Function) was used in two studies [20, 33], and another study [31] based their informal questionnaire on the Male Sexual Health Questionnaire [44].

Orgasm-associated incontinence/climacturia was further assessed by a non-validated author designed questionnaire [27] and a study-specific questionnaire based on the Scandinavian Prostate Cancer Group 4 questionnaire [29] in two separate studies. A telephonic interview was added to a non-NSSE questionnaire to probe the presence of climacturia in a 2012 study [28].

Anejaculation was assessed in a study that used the International Index of Erectile Function questionnaire [32]. A sexual medicine physician initially interviewed the participants. They were then questioned about their ejaculatory function (presence/absence, intensity and ease of achievement) and orgasm (presence/absence, intensity and ease of achievement). Only those who were sexually active were asked to complete the questionnaire. Questions 9 and 10 respectively asked: “When you had sexual stimulation or intercourse, how often did you ejaculate?” and “When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?” [32]. A 2009 study used a modified version (5 items, not 7) of the Male Sexual Health questionnaire that specifically addressed: (i) frequency, (ii) volume, (iii) dryness, (iv) pleasure and (v) pain during ejaculation [31].

Penile length shortening was assessed in a 2012 study using an author designed questionnaire containing questions relating to self-perceived penile length shortening [37]. Penile length shortening and penile deformity/Peyronie’s disease were not assessed by any other questionnaires apart from the collective NSSE questionnaire mentioned [4, 5], but rather through physical examinations. Three studies used a semi-rigid ruler for a physical penile length examination [34, 35, 39]. Vasconcelos et al. used an anthropometric ruler as a physical measurement to assess shortening [38]. Parekh et al. reported in their study that physicians completed a questionnaire based on their patients, and one question includes under “the complaints section” referred to reduced penile length [36].

Penile deformity was assessed in one additional study by Tal et al., where they assessed a penile curvature with a goniometer if the patient reported an abnormal curvature [40].

Strengths and limitations of the study

The methodology used and the search period used allowed for the systematic and extensive literature search, which sought to map only the most recent developments on the prevalence of NSSE and the use of questionnaires to identify NSSE. Additionally, the scoping review results were presented following the PRISMA recommendations, which ensured complete and transparent reporting. The MMAT tool version 2011 was used to assess the methodological quality of the included studies.

Limitations of this study included the fact that the studies included variables that were not consistent between studies. The reader should be cautioned when interpreting the results of the prevalence indicators for different NSSEs.

Furthermore, only original research was included, and other sources of information could have further clarified some discrepancies in the results.

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