Climacturia is defined as the leakage of urine during orgasm and is a usually neglected adverse effect of radical prostatectomy.
Our objective was to determine if various preoperative MRI pelvic floor measurements were associated with the risk of climacturia following robot-assisted laparoscopic radical prostatectomy (RALP).

A prospective study was conducted involving 57 patients who underwent RALP. MRI measurements were analysed by 2 urologists and 2 radiologists. The MRI measurements studied included membranous urethral lenght, levator ani muscle thickness, prostatic urethral length, obturator internus muscle thickness, puborectalis muscle thickness, intravesical prostatic protrusion, urethral width, prostate volume, angle between membranous urethra and prostate axis and ratio levator ani/prostate volume (figure 1). 
Measurements were conducted by 2 urologists and 2 radiologists. Other patient baseline features were also analysed: age, BMI, history of LUTS and DM, ASA risk, ISUP grade, prostate cancer risk, radiological stage, surgeon experience, neurovascular preservation and pathological stage.  
To analyse the presence of climacturia, a questionnaire based on the study by Parra-López et al (1) was employed after obtaining their permission. Climacturia was defined as the leakeage of any urine during orgasm.
Follow-up was made at 3, 6, and 12 months using an orgasmic function questionnaire. We analysed all measurements, along with other patient, surgery, and tumour characteristics, categorizing patients into two groups based on the presence or absence of climacturia. A logistic regression model was applied among statistically significant variables.

Baseline features can be seen in table 1.

The proportion of patients with climacturia among patients with orgasms after RALP was: 11 out of 33 patients at 3 months, 12/33 patients at 6 months and 14/34 patients at 12 months.

Shorter prostatic urethral length was associated with higher risk of climacturia at 3 months [mean prostatic urethral length in patients with climacturia:40.81 mm (SD 3.85) and in patients without climacturia: 45.30 mm (SD 6.04) (p=0.024)].  OR=0.83(95%CI 0.688-0.98)(p=0.038). 

Patients with climacturia at 6 months had greater urethral width [mean urethral width in patients with climacturia:13.05 mm(SD 1.50) and in patients without climacturia:11.80 mm (SD 1.33)(p=0.02)]. They also were significantly younger [median age with climacturia:56 years (IQR 52-59) vs without climacturia:64(IQR 60-65)]. In the multivariate logistic regression analysis, neither of the two variables showed an association with climacturia (p=0.155),(p=0.17). 

Finally, patients with climacturia at 12 months had higher proportion of history of LUTS (57.14% vs. 20%, p>0.05) but no association was found in the logistic regression (p=0.09, OR=2.92 (95% CI 0.82-10.44). The presence of storage LUTS was not associated with higher risk of climacturia at 1,3,6 and 12 months (p>0.05). 

Patients with post-prostatectomy urinary incontinence had higher risk of climacturia at 6 months after RALP (OR=5.42, 95% CI 1.31-22.34) (p=0.001) and at 12 months after the prostatectomy (OR=5.04, 95% CI 1.40-18.18) (p=0.005).

This is the first prospective study analyzing preoperative MRI risk factors of climacturia.

The patients affected by climacturia at 3 months post-RALP exhibited shorter preoperative prostatic urethral length. Each millimetre reduction in preoperative prostatic urethral length correlated with a 17% increase in the risk of experiencing climacturia. This association has not been documented in previous publications.

Additionally, patients with climacturia at 12 months had higher proportion of pre-operative LUTS. A history of LUTS has been associated with higher risk of post-prostatectomy incontinence (2). Additionally, an association has been found between detrusor hyperactivity and a higher risk of orgasmic incontinence in women. Physiopathologically, LUTS might be associated with higher risk of climacturia after prostatectomy because patients with detrusor hyperactivity might experience involuntary bladder contractions during orgasm, ultimately leading to the involuntary leakage of urine (3).

In conclusion, shorter prostatic urethral length on preoperative MRI is associated with higher risk of climacturia following robotic radical prostatectomy.

Parra López ML, Lozano Blasco JM, Osman García I, Congregado Ruiz B, Conde Sánchez JM, Medina López RA. Climacturia after robot-assisted laparoscopic radical prostatectomy. Rev Int Androl. 2021;19(1):49–52.
Lavigueur-Blouin H, Noriega AC, Valdivieso R, Hueber PA, Bienz M, Alhathal N, et al. Predictors of early continence following robot-assisted radical prostatectomy. Can J Urol. 2015;9(1–2):93.
Serati M, Salvatore S, Uccella S, Cromi A, Khullar V, Cardozo L, et al. Urinary Incontinence at Orgasm: Relation to Detrusor Overactivity and Treatment Efficacy. Eur Urol. 2008;54(4):911–7.