Hypothesis / aims of study
Radical prostatectomy (RP), the main procedure in the treatment of prostate cancer, causes serious and permanent problems, with erectile dysfunction (ED) being most the prevalent long term adverse effect of this procedure.[1-3] This situation has repercussions on the quality of life and on the psychological aspects of men and has implications for conjugality.[1] Thus, the couple's perception of this issue can influence decision-making about the treatment, however, studies on this topic are scarce. The primary objective of this study is to evaluate couple's perception of quality of life and sexual health after RP. Secondary objectives are to outline the socio-demographic profile of the participants and to identify whether there is a correlation between the couple's level of understanding about the treatment and changes in quality of life and sexual health.
Study design, materials and methods
This is an exploratory cross-sectional qualitative study based on narratives and thematic-categorical content analysis developed in Brazil. The tools used in data collection were the Depression Anxiety and Stress Scale (DASS) 21 and an individual, face-to-face, semi-structured interview, guided by triggering questions regarding the repercussions of prostate cancer and RP on quality of life, sexual health and couple communication, and on communication with the healthcare team.
Couples who have at least 03 years of stable relationship, experience a closed relationship, have been in a relationship since before the diagnosis, couples with men after RP after at least 06 months, aged between 35 and 80 years and suffering with psychic complaints related to ED were included. Couples with men with severe psychiatric illnesses, with anatomical malformations in the genital region and with penile prostheses were excluded.
The research protocol was: first, application of the DASS 21 Scale; followed by the interview with the man and then with his partner, the latter not being able to exceed the period of 01 week of the first interview.
For content analysis, thematic categories were defined in the reading and rereading process, in which the registration units were identified, defined by a word, phrase or text segment coded by implicit relevance and/or frequency. Following the analysis, it was elaborated the context units and construction of categories by regrouping, which considered the entire text in the analysis. Thus, for this study, the following analytical categories were defined: conjugality; impact of erectile dysfunction on sexual health; repercussions of erectile dysfunction on mental health and communication about treatment between the health team and patient/couple.
Results
The sample consisted of 04 heterosexual couples and 02 men without their partners, since they exceeded the period established for the interview between the couples. Age ranged between 52 and 75 years. Schooling was configured as follows: 01 is literate, 03 primary education and 06 secondary education. About marital status: 03 couples are married, 02 have a stable relationship and 01 lives together without a stable relationship. Regarding the race/ethnicity criterion, 04 participants declared themselves to be black, 05 brown and 01 white. I emphasize that all men underwent RP in the Brazilian’s public health system.
The DASS 21 Scale showed the following results: a) anxiety - 02 participants with severe symptoms, 01 mild symptoms and 07 without symptoms, b) stress - 01 participant with severe symptoms, 01 participant with moderate symptoms and 08 without symptoms, c) depression - 01 participant with severe symptoms, 02 moderate symptoms, 01 mild symptoms and 06 without symptoms.
In the conjugality category, couples presented difficulty in communicating about the couple's sexuality before the surgery, which worsened after the RP. Regarding sexual practices, all couples described penetrative sex as more usual and oral sex as occasionally performed before surgery. After RP, couples described as sexual practices non-penetrative and oral sex. Regarding the couple's sexual satisfaction before the surgery: 06 men and 02 women stated that it was satisfactory, and 02 women as unsatisfactory. After the RP 06 men and 02 women stated that it is unsatisfactory, and 02 women stated that there is no more sexual practice.
In the category impact of erectile dysfunction on mental health, 02 men verbalized suicidal ideation after RP, the others reported a change in their will to live related to ED and urinary incontinence (UI). The partners reported that there was an emotional-, mood-, and behavioral change in the partners related to ED after RP. The couples stated that these changes had an impact on the relationship in general.
In the category of communication about the treatment between the healthcare team and the patient/couple, the men reported that they received explanations about the neoplasm and the RP, but the doctors stated that the improvement in the ED and the UI depended more on the post-procedure rehabilitation than on the surgical intervention. And they stated that there was no other indication for treatment. The partners reported that they had scarce information about the treatment and its consequences.
Interpretation of results
Data on conjugality showed that couples have difficulty in establishing assertive communication about the treatment, this can be explained by these men feeling insecure, scared, and ashamed to address issues about ED and UI with their partners and the partners are afraid of embarrassing them.[1,2]
Data referring to sexual practices showed a restricted repertoire, which can be justified by the taboo that still surrounds sexuality today, also, the socioeconomic and cultural contexts of these couples have to be considered.
About the sexual satisfaction of the couple, the data demonstrated dissatisfaction as predominant after RP. The concept of sexual satisfaction is subjective, influenced by several variables, but it is known that difficulties in sexual life intensify couple's conflicts, and sex/sexual satisfaction becomes a primordial factor when partners are dissatisfied.
The repercussion of ED on the sexual and mental health of men was shown to be serious, leading to psychic suffer and influencing negatively on sexual health. This can be explained by the fact that the erection, culturally, represents the potency of men and penetration is the main validated sexual practice. Thus, the erection, which was a full source of pleasure, becomes a source of disappointment and suffering, causing psychic destabilization, leading the man to doubt his own capacity. Suicidal ideation related to ED reveals the importance of treating the consequences of RP carefully, assessing the psychological condition of each patient before its indication.[1-3]
Regarding the communication between the healthcare team and the patient/couple, the data demonstrated that the physicians explained the possible consequences of the RP but associated the improvement of ED and UI with post-surgical rehabilitation. This can be explained by the predominance of the biomedical model, which recognizes in an incipient way the biopsychosocial aspects, a point of deficiency in medical training.[2,3]