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Sexuality, Quality Of Life, And Emotional Distress Following Radical Prostatectomy For Carcinoma Of The Prostate

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Sexuality, Quality Of Life, And Emotional Distress Following Radical Prostatectomy For Carcinoma Of The Prostate

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SEXUALITY, QUALITY OF LIFE, AND EMOTIONAL DISTRESS
FOLLOWING RADICAL PROSTATECTOMY FOR
CARCINOMA OF THE PROSTATE
By
Martin A. Perez
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(Psychology)
December 1995
©1995 Martin A. Perez
UMI Number: 1378429
Copyright 1995 by
Perez, Martin Alberto
All rights reserved.
UMI Microform 1378429
Copyright 1996, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized
copying under Title 17, United States Code.
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UNIVERSITY O F SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
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LOS ANGELES. CALIFORNIA 9 0 0 0 7
This thesis, written by
under the direction of h.±&....Thesis Committee,
and approved by all its members, has been pre
sented to and accepted by the Dean of The
Graduate School, in partial fulfillment of the
requirements for the degree of
..
Dian
THESIS COMMITTEE
Itrman
ii
Acknowledgments
Contributions to this study by Beth E. Meyerowitz, my
research advisor, are gratefully acknowledged.
iii
Table of Contents
Acknowledgments ............................................ i
List of Tables ........................................... v
Abstract .................................................... vi
Page
Introduction ............................................... 1
Methods .................. ,............................... 10
Subjects ................................................ 10
Procedures .............................................. 11
Instruments ............................................ 13
Statistical Analysis .................................. 20
Results .................................................... 21
Participants vs. Nonparticipants .................... 21
Sample Characteristics .............................. 23
Presurgical Sex Life ................................ 26
Quality of Life, Emotional Distress, and
Postsurgical Sexuality ........................... 26
Changes in Sexuality Following Radical
Prostatectomy ....................................... 28
Urinary Incontinence and Activities of
Daily Living ...................................... 29
Relationship Between Treatment Subgroups and
Patients' Quality of Life ....................... 29
Predictors of Patients' Quality of Life and
Emotional Distress ................................. 33
Discussion ................................................. 36
Footnotes .................................................. 45
References
Appendix A
V
List of Tables
Table Page
1. Demographic and Medical Variables of
Participants and Nonparticipants
(N = 453) 22
2. Sample Characteristics of Treatment
Subgroups (N = 248) 24
3. Key Outcome Variables and Scale Scores for
Treatment Subgroups (N =248) 30
4. Correlation Matrix of Key Variables
(N = 250) 34
5. Significant Predictors of Patients' Quality
of Life and Emotional Distress: Multiple
Regression Analysis with Beta Weights
Reported (N = 250) 35
6. Multiple Regression Analysis Predicting
Quality of Life and Emotional Distress
With An Interaction of Presurgical
Sexuality and Physiological-Sexual
Functioning (N = 250) 37
Abstract
We used standardized measures and questionnaires
adapted for this study to directly assess postsurgical sex
uality, quality of life, and emotional distress in 250 men
who had undergone radical prostatectomy. Specifically, we
aimed to measure distinct components of male sexuality that
include areas other than just erectile functioning. De
spite problems in postsurgical sexuality, patients reported
good overall quality of life and low emotional distress.
Inter- estingly, physiological sexual functioning was not a
significant predictor of quality of life or emotional
distress. Rather, body image and relationship adjustment
appear to play a more important role.
When use of erection aids was considered, patients who
underwent nerve-sparing prostatectomy were no different on
most measures of postsurgical sexuality, than patients who
underwent standard prostatectomy and used erection aids.
However, patients who used erection aids reported better
physiological sexual functioning than nerve-sparing
patients.
Introduction
Cancer of the prostate is the most commonly diagnosed
cancer in men and represents the second most common cause
of male cancer deaths in the United States. It is esti
mated that over 200,000 men are diagnosed with prostate
cancer each year, 60% of which are projected to have
early-stage disease (Boring, Squires, Tong, & Montgumery,
1994). Despite the high incidence of this disease, pa
tients treated for early stage prostate cancer have a low
race of disease-specific deaths and often live for years
following treatment (Catalona & Scott, 1986). There are
currently medical options for patients with early stage
prostate cancer including surgery, radiation, and "watchful
waiting" (monitoring the course of the tumor without treat
ment) . Consequently, there is a greater need to understand
how various treatment outcomes are related to psychosocial
adjustment.
Although there is controversy about the best treatment
approach for localized carcinoma of the prostate, including
questions about whether any treatment is necessary (Krahn
et al., 1994; Fleming, Wasson, Ablertsen, Barry, &
Wenneberg, 1993), radical prostatectomy is the most widely
used intervention for treating early stage prostate cancer.
The number of newly diagnosed patients undergoing radical
prostatectomy is growing (Mettlin, Jones, & Murphy, 1993) .
This increase partly stems from improvements in screening
procedures to detect confined tumors (Lu-Yao, McLerran,
Wosson, & Wennberg, 1993) , as well as the high failure rate
of radiation therapy to sterilize the local disease (Freiha
& Bagshaw, 1985).
However, in spite of the popularity of treating early
stage prostate cancer with radical prostatectomy, findings
from the medical literature establish that this treatment
has potentially disruptive side effects. For example,
radical prostatectomy is a notorious cause of erectile
dysfunction. A review of the literature indicates that up
to 90% of patients undergoing standard radical prostatec
tomy, report diminished erectile capabilities or complete
erectile failure after surgery (Andersen, 1985; Walsh &
Donker, 1982) . Findings also indicate that postsurgical
incidence of urinary incontinence can be high for these
patients (Wasson et al., 1993). However, disruption of
urinary function appears to be less common than erectile
dysfunction following surgery (Fowler et al., 1993; NCI,
1992). Consequently, researchers assume erectile dysfunc
tion to be a particularly problematic outcome in this
population.
In an effort to decrease the incidence of erectile
dysfunction following radical prostatectomy, physicians
have developed several strategies: (a) a modification in
surgical technique known as nerve-sparing radical pros
tatectomy (Walsh, Lepor, & Eggleston, 1983), and (b) the
use of erection aids following surgery. When the nerve-
sparing procedure is used, the prostate is excised without
injuring the neurovascular bundles that contain the
cavernous nerves and vessels (Catalona & Bigg, 1990). This
is done by carefully detaching the fibrous sheath that
surrounds the prostate and contains the nerves to the pe
nis. As a result, the likelihood of preserving erectile
potency is presumably increased. However, sparing the
nerves that allow for erection does not preclude the
possibility of erectile dysfunction. The nerves can be
traumatized during surgery and loss of potency may still
result. For instance, Leandri and his colleagues (Leandri,
Rossignol, Gautier, & Ramon, 1992) studied 106 prostate
cancer patients who were sexually functional prior to un
dergoing nerve-sparing radical prostatectomy. Findings
from questionnaires assessing potency showed that after one
year, 36% of patients were not fully potent. Other studies
indicate that following nerve-sparing prostatectomy, only
50% of patients can attain erections usable for intercourse
(Brendler, Steinberg, Marshall, Mostwin, & Walsh, 1990) .
Studies investigating the comparative benefits of undergo
ing nerve-sparing prostatectomy versus standard prostatec
tomy yield mixed findings. Some studies report post
operative morbidities to be less common in patients under
going nerve-sparing radical prostatectomy (Brendler &
Walsh, 1992; Quinlan, Epstien, Carter, & Walsh 1991).
However, a more recent study suggests that patients under
going the nerve-sparing procedure are no different in sex
ual and urinary function than patients undergoing standard
prostatectomy (Litwin et al., 1995).
Men whose nerves cannot be spared or report pre
operative erectile dysfunction, often have other options to
aid them in attaining erections following treatment. For
example, a penile prosthesis (e.g., rigid, semirigid, or
inflatable) can aid in restoring the ability to have
intercourse. Other erectile aids such as oral medication
and penile-vasodialator injections, are also available to
patients following treatment and are becoming more popular
(Telang & Farah, 1992). Although data support the ability
of these aids to allow for erections (Finney, 1982;
Zorgniotti & Lefleur, 1985), there is no research examining
how prostatectomy patients accept these aids. Furthermore,
researchers have not compared quality of life or emotional
distress in prostate cancer patients who use erection aids
to patients who do not.
Despite the focus in the literature on erectile dys
function and the commitment of the medical community to
develop treatments that minimize this morbidity, little is
known of the extent to which patients find this side-effect
problematic (Aaronson, 1988; Aaronson & da Silva, 1987;
Sharp, 1993; Fossa, Kaasa, da Silva, Suciu, & Hengeveld,
1992). Presently, the assumption guiding the field is that
erectile dysfunction is very disruptive to patients' qual
ity of life and levels of emotional distress. However,
this hypothesis has not been examined empirically.
There are several reasons why researchers presume
erectile dysfunction to be important. First, many re
searchers consider sexuality a major predictor of quality
of life and emotional distress in men (Schover, 1994).
Second, disruption in the ability to attain an erection is
often equated with complete disruption in sexual function
ing and sexuality as a whole. Consequently, studies exam
ining sexual functioning in prostate cancer patients focus
only on measuring erectile capabilities, without consider
ing other aspects of physiological sexual functioning or
activity. In fact, most of these studies assess erectile
functioning solely on the patient's ability to attain an
erection sufficient for vaginal penetration. Hence, sexu
ality is operationalized in a limited and narrow manner.
In this study, we aimed to broaden the definition of
sexuality and investigate the multiple components that
comprise the construct in order to identify specific areas
that may be distressful to patients undergoing radical
prostatectomy. Theory suggests that male sexual function
ing includes areas other than just erectile capabilities,
such as sexual desire, arousal, and ability to achieve or
gasm; implying that a deficiency in any of these variables
should be considered a sexual dysfunction (APA, 1994;
Masters & Johnson, 1966). Yet, these broader aspects of
sexual functioning are not considered in the literature on
prostate cancer.
A few summaries include speculations that other areas
of sexuality, such as sexual satisfaction, body image, and
concern over sexual capabilities, may also be related to
quality of life and emotional distress following treatment
for prostate cancer (Fossa et al., 1992; Rossignol et al.,
1991). Currently, however, studies investigating these
variables focus primarily on female cancer patients. For
instance, numerous published studies involving breast can
cer patients, focus on assessing other areas of sexuality
not limited to physiology. Some research reports a
significant relationship between body image and post
surgical psychological adjustment and emotional distress in
breast cancer patients (Meyer & Aspergen, 1989; Schag et
al., 1993). However, it is interesting how these aspects of
sexuality which are considered important in female cancer
patients, are not commonly studied in men undergoing sur
gery on their reproductive organs. Studies of men that do
include body image and concerns regarding sexual capabili
ties as outcome variables are limited to samples of younger
men (Fobair et al., 1986; Mumma, Mashberg, & Lesko, 1992).
In these studies, Hodgkin's disease patients reported sig
nificantly lower body image scores compared to physically
healthy norms (Mumma et al., 1992) and in a sample of leu
kemia patients, 26% reported that cancer had decreased
their physical attractiveness (Fobair et al., 1986). How
ever, it is unclear if these findings generalize to older-
male prostate cancer patients.
Finally for most people, sexuality is a social behav
ior involving another individual. Therefore, we also were
interested in assessing marital relationship adjustment
along with postsurgical sexuality. A patient's primary
relationship can go through major adjustments following
cancer treatment (Schover, 1993). Data indicate that the
quality of a couple's relationship after treatment for
cancer is related to patient quality of life (Fuller &
Swenson, 1992; Gotcher, 1992; Schover, 1987). However,
because data involving prostate cancer patients are not
reported in the literature, it is unclear whether being in
a good quality relationship is necessarily predictive of
good overall quality of life and low emotional distress
following radical prostatectomy.
The present study investigates quality of life out
comes in men who have undergone radical prostatectomy for
localized prostate cancer. We address three general
questions:
1. What are the issues regarding sexuality, quality
of life, and emotional distress facing prostate cancer pa
tients following radical prostatectomy? Specifically, we
wanted to measure previously unstudied aspects of male
sexuality that r.av be disrupted following treatment and
report changes in presurgical sexuality. We also aimed to
report overall quality of life and emotional distress out
comes. Lastly, since other side effects such as inconti
nence occur in this population, we measured frequency of
disruption in urinary function and activities of daily
living.
2. What are the differences in the (a) quality of
life, (b) emotional distress, (c) sexuality, (d) marital
relationship adjustment, (e) incontinence, (f) activities
of daily living between men who undergo nerve-sparing
radical prostatectomy, men who undergo standard prostatec
tomy and use erection aids, and men who undergo standard
prostatectomy and do not use erection aids? We were
interested in comparing treatment subgroups on key outcome
variables in order to examine if treatments that are be
lieved to decrease postoperative complications, are indeed
different from standard treatments. Because of the ex
ploratory nature of this study and conflicting findings
regarding the benefits of nerve-sparing radical prostatec
tomy versus the nonnerve sparing procedure, we did not ad
vance specific hypotheses.
3. As presumed in the literature, does postsurgical
sexuality and relationship adjustment predict patients'
quality of life and emotional distress? We aimed to iden
tify orthogonal components of sexuality that could be
measured reliably and hypothesized that after controlling
for patients' presurgical sexuality, measures of post
surgical sexuality and marital relationship adjustment,
would predict overall quality of life and low emotional
distress. Presurgical sexuality must be considered because
some patients report sexual problems before treatment
(Shell & Smith, 1994) suggesting that these patients'
10
disruption in postsurgical sexuality may be less, because
they are losing less. Therefore, we also advanced an hy
pothesis that patients who remain sexually functional fol
lowing surgery, will have a better quality of life than
patients who report having been dysfunctional prior to
surgery and remain sexually dysfunctional following sur
gery. Furthermore, patients who remain sexually dysfunc
tional following surgery, will have a better quality of
life than patients who become sexually dysfunctional fol
lowing surgery.
Methods
This research stems from a larger cross-sectional
study investigating quality of life following radical
prostatectomy in early-stage prostate cancer patients and
their spouses/partners. For the purposes of this project,
we only analyzed patient data.
Subj ects
Subjects were men who had undergone radical retropubic
prostatectomy from January 1990 through June 1993 at Norris
Cancer Hospital. To qualify for participation, subjects
had to be literate, physically well enough to fill out
questionnaires, and accessible at the location documented
in their medical chart or at a current forwarding address.
Four-hundred and fifty-three of the 513 patients who had
11
undergone surgery during the indicated times qualified to
participate in this study. Thirty-eight patients had moved
from the residence documented in the hospital chart, 11
were deceased, 6 were physically ill and unable to write, 3
could not read English, and 2 reported not having been
treated for prostate cancer. Hence these subjects were
ineligible to participate in the study.
Procedures
Subjects were identified through hospital computer
records of all patients who underwent radical retropubic
prostatectomy at Norris Cancer Hospital during the indi
cated time period. Hospital computer records were compared
to medical chart information in order to verify the accu
racy of patients' addresses and phone numbers. Compre
hensive questionnaires with stamped, self-addressed return
envelopes were mailed to each patient. Patients' identi
ties were protected by use of code numbers that appeared on
each questionnaire. Each patient received an informed
consent form and a personalized cover letter from his phy
sician explaining the nature of the research. Question
naires were completed confidentially by each subject and
forwarded to a central data collection point not associated
with the hospital. Thus, at no time were the physicians or
12
nurses involved in caring for these patients able to iden
tify data belonging to any individual subject.
Patients were instructed to return the blank question
naire packet if they declined participation in the study,
and no future contact was made. Patients who did not re
turn their packet within two months of the initial mailing,
were telephoned by a male researcher who requested that
they complete the questionnaires, if willing.
This researcher was not involved in any of the pa
tients' treatment and all phone calls were confidential.
If a patient reported not having received the question
naire, a new packet was forwarded to him. Subjects who
returned the questionnaires only partially completed, also
were contacted by phone. These subjects were asked to give
verbal responses to the unanswered items, or when applica
ble, new questionnaires were sent to them to complete and
return. If any patient verbally declined to participate,
stated reasons were documented and no further contact was
made. We used existing medical and demographic informa
tion, gathered previously by the hospital staff via tele
phone interview and chart review, to compare participants
to nonparticipants.
13
Instruments
The present study involves analyses of data from five
of seven questionnaires included in the packet. This sub
set of questionnaires includes standardized measures and
instruments specifically designed for this study. The five
relevant instruments are the Profile of Moods States(POMS)
(Mcnair, Lorr, & Droppleman, 1981); the Dyadic Adjustment
Scale (DAS) (Spanier, 1976); and a Quality of Life Scale
(adapted from Meyerowitz, Vasterling, Muirhead, & Frist,
1990) and Sexual History Form (SHF)(adapted from Schover,
Friedman, Weiler, Heimman, & Piccolo, 1982), developed for
this study. The SHF included a Past-Sex Life and Current-
Sex Life version that measured pre- and postsurgical sexu
ality, respectively.
Demographic information was also requested. The order
of questionnaires in the packet was as follows: (a) the
POMS, (b) SHF Past-Sex Life, (c) Quality of Life Scale, (d)
SHF Current-Sex Life, and (e) the DAS.
The Quality of Life Scale measures general and
disease-specific quality of life. This 73-item question
naire uses 7-point Likert-type scales (a) to assess pa
tients' subjective view of current physical symptoms, (b)
level of functioning, (c) disruption of daily living, (d)
beliefs about the future, (e) degree of urinary
14
incontinence, (f) body image, and (g)concerns regarding
sex.
The POMS is a commonly-used 65-item self-report
adjective checklist with good internal reliability and
documented validity (Mcnair et al., 1981). It is composed
of six mood-state subscales: (a) depression, (b) anger,
(c) tension, (d) fatigue, (e) confusion and (f) vigor. A
total mood disturbance score was obtained for each subject
by summing the subscales, except vigor which is weighted
negatively.
The Sexual History Form assesses patients' presur
gical sex life and current sex life following radical
prostatectomy. One form, SHF: Past Sex Life, is an
11-item questionnaire in which patients retrospectively
rate their degree of (a) erectile functioning, (b) fre
quency of sexual activity, (c) sexual desire, (d) arousal,
and (e) ability to achieve orgasm prior to surgery. Pa
tients choose a variety of answers on scales specific to
each question. Postoperative sex life is measured by the
SHF: Current Sex Life. This 50-item questionnaire also
uses a multiple choice format and includes questions that
address specific issues, such as satisfaction with penile
implants related to prostate cancer. In general this
questionnaire measures patients' sexual behaviors,
15
frequency and ability to engage in specified sexual activ
ities, current physiological-sexual functioning, and sexual
satisfaction levels.
The DAS is a popular instrument that measures per
ceived quality of an individual's primary relationship. On
the DAS, patients indicate the frequency with which they
engage in specific behaviors with their partner, and the
level of agreement on various relationship issues. This
measure covers four independent areas: (a) dyadic satis
faction, (b) dyadic consensus, (c) dyadic cohesion, and (d)
affectional expression. A total score, characteristic of
the overall quality of the relationship, was obtained by
summing these subscales. The DAS has good content validity
and high internal reliability (Spanier, 1976).
Below, we describe our procedures for measuring key
variables.1 All subscales were evaluated by estimation of
internal consistency reliabilities (Cronbach, 1951).
Copies of the subscales appear in Appendix A.
Quality of life and emotional distress. Overall
quality of life was assessed using a single item from the
Quality of life Scale. On this item, patients were asked
to rate their overall quality of life on a scale ranging
from "Excellent" to "Very Poor." Data suggest that a
16
global question regarding quality of life is valid and re
liable (Gough, Furnival, Schilder, & Grove, 1983).
To measure emotional distress, we used the total mood
disturbance score from the POMS (Cronbach's alpha = .90).
Lower scores on this measure indicate less emotional
distress.
Postsurgical sexuality. We were able to develop
measures of what we intended to assess. Based on a review
of the literature and a principle components analysis of
the sample data, we created five potential subscales for
measuring postsurgical sexuality. Next, we conducted a
confirmatory factor analysis in order to test these sub
scales.2 We then assessed the subjects' sex life following
surgery with the five derived scales.3 On all five scales,
lower scores indicate better outcomes. Three of the five
scales were constructed from items on the SHF: Current Sex
Life. We derived a 3-item Physiological-Sexual Functioning
Scale (Cronbach's alpha = .76) based on the Diagnostic and
Statistical Manual of Mental Disorder definition of func
tion (DSM-IV) (APA, 1994), that assessed patients' ratings
of arousal (i.e., feeling pleasure or excitement when hav
ing sex with a partner), typical degree of erection during
sexual activity, and ability to achieve orgasm. Possible
scores ranged from 0 to 12. The second scale, a 5-item
Sexual Behavior Scale (Cronbach's alpha = .69), assessed
frequency of specific behaviors such as sexual activity
with a partner and masturbation. Possible scores ranged
from 0 to 40. Lastly, a 5-item Sexual Satisfaction Scale
(Cronbach's alpha = .89) assessed the patients' overall
satisfaction with their current sexual relationship(s) and
sex life. This Sexual Satisfaction Scale also contained
one item from the Quality of Life Scale that assessed
"Satisfaction with Current Sexual Functioning." The an
chors for this item were "Totally Satisfied" to "Not at All
Satisfied." Possible scores ranged from 0 to 30. We com
bined items from the Quality of Life Scale to create
two other measures. An 11-item Sexual Concerns Scale
(Cronbach's alpha = .83) assessed the patients' reluctance
to engage in sexual activity, feelings regarding masculin
ity, and negative feelings, such as anger, depression, and
anxiety, regarding sexual capabilities. The anchors for
these items were "Strongly Agree" to "Strongly Disagree."
Possible scores ranged from 0 to 66. Finally, a 7-item
Body Image Scale (Cronbach's alpha = .82) assessed current
satisfaction with physical appearance and changes in
physical appearance following surgery. Possible scores
ranged from 0 to 42. We decided to measure sexuality in
this broad manner in order to include areas not limited to
18
the narrow operationalization (e.g., erectile functioning)
reported in published studies.
Marital/relationship adjustment. For married and
partnered patients, we used the total score on the DAS
(Cronbach's alpha = .85) to assess the quality of the
relationship with their significant other.4 A score above
100 on the DAS is indicative of a high-quality relationship
(Spanier, 1976).
Urinary incontinence and activities of daily living
(ADL). In order to measure morbidities other than disrup
tion in sexuality and compare patients undergoing nerve-
sparing and nonnerve-sparing procedures on all possible
side effects, we created an Incontinence Scale (Cronbach's
alpha = .80) from four items on the Quality of Life Scale.
This subscale (a) assessed degree of urinary incontinence,
(b) the level to which leakage interrupted patients' daily
activities, and (c) the degree of bother reported by pa
tients. Possible scores ranged from 0 to 24. Lower scores
are indicative of fewer problems with urinary incontinence.
We also derived an Activities of Daily Living Scale
(Cronbach's alpha = .92) from items on the Quality of Life
Scale. This 6-item scale measured how often patients think
about their physical condition, and to what extent they are
able to perform daily activities (e.g., household responsi-
19
bilities and leisure activities). Possible scores ranged
from 0 to 36, with lower scores indicating better
functioning.
Presurgical sexuality. Since some patients report
problems in their presurgical sex life, we constructed a
10-item Presurgical Sexuality Scale (Cronbach's alpha =
.85) from items on the SHF: Past Sex Life. Patients ret
rospectively rated their (a) sexual desire, (b) arousal,
(c) erectile functioning, (d) frequency of sexual activity,
(e) ability to achieve orgasm, and (f) sexual satisfaction
prior to surgery. Possible scores ranged from 0 to 40,
with lower scores indicating a good presurgical sex life.
Erection aids. Finally, we wanted to compare nerve-
sparing prostatectomy patients to standard prostatectomy
patients, taking into account use of erection aids. Using
self-reports on how often patients use erection aids, we
identified patients who underwent standard prostatectomy
and used erection aids more than 50% of the time, and
standard prostatectomy patients who do not use erection
aids, or use aids less than 50% of the time. The anchors
for this item were "Nearly always, over 90% of the time" to
"Never."
20
Statistical Analysis
To compare participants to nonparticipants, categori
cal and continuous variables were analyzed with Chi-square
analysis and independent t-tests, respectively. Basic de
scriptive statistics were used to analyze the frequency of
treatment morbidities and describe the patients' quality of
life and level of emotional distress. Surgery subgroups
were compared, adjusting statistically for age and pre
surgical sex life, using analysis of variance F statistics.
Since we were interested only in evaluating mean differ
ences on single dependent variables, multivariate analysis
of variance was not used. Pairwise group comparisons were
made, adjusting for Type I error, using a Tukey-Kramer
multiple comparison post hoc procedure. Multiple regres
sion analysis was used to examine what variables were
associated with a better quality of life and lower levels
of emotional distress.
We tested for multicollinearity by regressing each
independent variable on all other independent variables;
multiple Rs and bivariate correlations below .80 indicate
no multicollinearity among predictors (Lewis-Beck, 1980).
In each regression equation, presurgical sexuality was
force-entered as a covariate, followed by a block of pre
dictors. For tests of single predictors, we controlled for
21
Type I error using a Bonferroni adjustment. In the
regression analysis involving the interaction of presurgi
cal sexuality and physiological sexual functioning,
predictors were centered (i.e., transformed to deviation
score form with means of zero) also to deal with potential
multicollinearity (Aiken & West, 1991) . We then created
the interaction term as a product of the two centered
variables.
Results
Participants vs. Nonparticipants
Two-hundred and fifty of the 453 eligible patients
(55%) returned questionnaires and took part in the study.
Table 1 displays demographic and medical variables of par
ticipants versus nonparticipants, gathered through existing
hospital documentation. There were no significant differ
ences between patients who participated in the study and
patients who declined to participate on (a) age at time of
surgery; (b) ethnicity; (c) type of surgery (i.e., nerve-
sparing versus nonnerve-sparing); (d) urinary incontinence;
(e) preoperative potency; and (f) postoperative potency at
a one year follow-up. Patients who took part in the study,
appear to be no different from eligible patients who de
clined to participate.
22
Table 1
Demographic and Medical Variables of Participants and Non-
participants (N = 453)
Nonparticipants Variables
Participants (n = 250) (n = 203)
P
Age at Surgery
Mean (year) 66.00 66.50 NS
SD 7.47 6.79
Ethnicity
White 92.00 90.00 NS
Ethnic minority 8.00 10.00
Surgery
Standard prostatectomy 53.00 45.50 NS
Nerve-sparing prostatectomy 47.00 54.50
Preoperative Potency
Potent 80.00 81.50 NS
Impotent 20.00 18.50
Postop Potency at 1 year
Potent 16.50 17.00 NS
Impotent 83.50 83.00
Postop Continence at 1 year
Complete continence 64.00 69.00 NS
Mild incontinence 22.00 18.00
Moderate incontinence 14.00 13.00
Note . These data were previously gathered by hospital
staff via telephone interview and chart review.
23
Sample Characteristics
Self-reported sociodemographic characteristics of the
250 patients who returned completed questionnaires are
presented in Table 2. According to medical records, 117
patients underwent nerve-sparing radical prostatectomy and
133 underwent standard prostatectomy. We further divided
the standard prostatectomy group into patients who use
erection aids most of the time (n = 42) and those who do
not use erection aids (n = 89). We omitted two patients
who had undergone standard prostatectomy, because we had no
information regarding their use of erection aids. Means
and percentages are also presented for each treatment sub
group. Patients had a mean age of 68 years (47-85 years)
and were predominantly non-Hispanic Whites (92%). Patients
were also primarily married or partnered (86%), and most
had received a college or advanced degree (63%). The ma
jority of patients returned to doing some type of work
following surgery (56%) . Thirty-one percent of patients
were retired and 13% did not return to work following
surgery.
We compared these demographic variables across treat
ment subgroups and found no differences in ethnicity and
relationship status. However, the nerve-sparing group was
Table 2
Sample Characteristics of Treatment Subgroups (N = 248)
Variables
All Patients
(n = 250)
Group la
(n = 117)
Group 2
(n = 42)
Group 3C
(n = 89)
Age
Mean (year) 68.0
SD 7.7
Ethnicity (%)
White 92.0
Black 1.0
Latino 2.0
Other 5.0
Education (%)
Grades 1-11 3.0
High School Gradate 12.0
Some College 21.0
College or
Advanced Degree 64 . 0
64. 0d
7.2
92.0
8.0
26.0
74.0
68. 0£
7.2
86.0
14.0
43.0
57.0
72. 0£
6.3
94.0
6.0
46.0
54.0
<.0001
NS
<.01
N>
4>
Table 2. (continued)
Variables
All Patients
(n = 250)
Group 1*
(n = 117)
Group 2b
(n = 42)
Group 3C
(n = 89)
E
Relationship Status
Married/Partnered 86.0 87.0 93.0 81.0 NS
Single/Widowed 14 . 0 13.0 7.0 19.0
Note. Means in the same row that do not share subscripts differ at £ <.05 in the
Tukey-Kramer comparison.
aNerve-sparing prostatectomy. bStandard prostatectomy group who uses aids. cStandard
prostatectomy group no using erection aids.
to
U1
26
significantly younger than the radical prostatectomy group
who used erection aids, which was significantly younger
than the group who did not use erection aids, F (2, 222) =
29.86, p < .0001. The nerve-sparing group included a
significantly greater number of men who had attained higher
levels of education than the standard prostatectomy groups,
X2 (2, N =235) = 9.195, p < .01.
Presurgical Sex Life
Retrospective reports reveal that before surgery most
patients engaged in sex at least once per week (63%),
experience sexual desire at least once per week (84%), and
"nearly always, 90% of the time," felt aroused during sex
ual activity with a partner (75%). The majority of pa
tients reported "seldom" to "never" having trouble getting
an erection (80%) . Most typically had firm to rigid erec
tions during sexual activity with a partner (89%), and most
nearly always achieved orgasm through sexual activity with
a partner (76%). Almost all patients (84%) were satisfied
with their sex life before surgery.
Quality of Life, Emotional Distress, and Postsurgical
Sexuality
Overall quality of life following surgery was good to
excellent for 74% of the patients. The mean score for the
27
POMS was 2.84 (SD, 29.3), indicating a group tendency to
wards low emotional distress.
However, patients reported problems in some areas of
postsurgical sexuality. Only 20% of the patients reported
typically having firm erections during sexual activity with
a partner. While 14% of patients reported regularly waking
from sleep with firm erections, 60% of patients reported
never waking from sleep with any kind of erection.
Although the majority of patients (55%) reported ide
ally wanting to engage in sexual activity at least twice
per week, only 16% of patients were actually engaging in
sex that often. The majority of patients (61%) reported
feeling sexual desire at least twice per week, and 79% felt
sexually aroused with a partner 75% of the time. Fifty-
four percent of patients reported being able to achieve
orgasm through intercourse more than half the time, while
46% achieved orgasm through masturbation more than half the
time. The majority of patients (52%) reported being
unsatisfied with their overall sex life and some patients
felt anxious (49%), depressed (43%), or angry (28%) about
their sexual capabilities. Thirty percent of patients re
ported being reluctant to engage in sex because they were
unsure how successful it would be. Some patients reported
28
that they felt like less of a man because of cancer (22%)
or their current sexual functioning (33%).
The majority of patients did not report many problems
concerning their body image. However, there was variabil
ity in their responses. Sixty-nine percent of patients
reported being satisfied with their physical appearance,
82% felt that their physical appearance had not changed
following surgery, and 69% felt their partner was satisfied
with their physical appearance. The majority of patients
also were satisfied with their face (70.5%), appearance of
genitals (52%), and upper body (65%) .
Changes in Sexuality Following Radical Prostatectomy
In order to assess changes in sexuality following
surgery, we calculated differences between identical items
from the past and current sex life versions of the Sexual
History Form. The following findings represent the per
centage of subjects with negative change scores. When
compared to retrospective reports, 78% of patients reported
diminished erectile functioning when not using erection
aids. The majority of patients also reported a decrease in
frequency of sexual activity with a partner (61%), less
ability to achieve orgasm through intercourse (57%), and
lower levels of sexual satisfaction (69%). However, only
23% reported lower levels of sexual arousal compared to
29
presurgical levels; 34% and 44% reported lower levels of
sexual desire and less ability to achieve orgasm through
masturbation, respectively.
Urinary Incontinence and Activities of Daily Living
The majority of patients {14%) rarely reported or
never having interference in daily activities due to other
health problems; and almost all patients reported being
able to perform household responsibilities (95%) and lei
sure activities (93%) with no problem. Nonetheless, 55% of
subjects did report that they leaked some urine at least
once per week. However, only 9.6% felt that the leakage
caused moderate to severe interference with their daily
activities, and 29.8% reported that it was at least some
what upsetting. Most patients wear none (59.7%) or one
(14.5%) pad per day.
Relationship Between Treatment Subgroups and Patients'
Quality of Life
Erectile aids were used by 45.8% of subjects (penile
implants, 26.6%; pharmacoerection program, 19.2%). Of
these patients, 32% used the aid more than 50% of the time.
Forty-eight percent reported they were moderately or ex
tremely satisfied with the aid.
Table 3 displays group differences in key outcome
variables. The nerve-sparing group and the standard
Table 3
Key Outcome Variables and Scale Scores for Treatment Subgroups (N = 248)
Variable (actual range)
Group
(n =
la Group 2b
117) (n = 42)
Group 3C
(n = 89)
E
df F
Presurgical sexuality (0-39) 7 • 60d 9 • 13d 12.80e <.0010 (2,206) 15.260
Overall quality of life (0-6) 1.51 1.71 1.83 NS (4,190) .145
Emotional distress (-39-166) 1.70 3.80 5.57 NS (4.186) .344
Marital relationship
adjustment (60-151) 121.00 117.00 120.00 NS (4,145) 647.000
Physiological-sexual
functioning (0-12) 3 • 82d 1-69.
8.15f <.0001 (4,135) 29.130
Sexual behaviors (3-40) 2 0 . 4 6d 20.55d 2 6.07e <.0020 (4,158) 6.305
Sexual satisfaction (0-30) 14.68d 11.68d 19. 56e <.0020 (4,134) 6.811
Body image (0-39) 13.64 14.28 13.26 NS (4,188) .473
Sexual concerns (0-59) 21•84d 17 .00d 27.94e <.0010 (4,175) 2.464
Table 3. (continued)
Group 1* Group 2b Group 3°
Variable (actual range) (n = 117) (n = 42) (n = 89)
E
df F
Incontinence (0-23) 8.59 9.77 10.77< NS (4,175) 2.464
Physical function (1-30) 5.51 6.26 9.11 NS (4,188) 2.274
Note. Except for marital/relationship adjustment scores, lower scores indicate better
outcomes. With the exception of presurgical sex life, all variables presented statis
tically adjusting for age and presurgical sex life. Means in the same row that do not
share subscripts differ at jo < .05 in the Tukey-Kramer comparison.
“Nerve-sparing prostatectomy group. bStandard prostatectomy group who uses erection
aids. cStandard prostatectomy group not using erection aids.
32
prostatectomy group who used aids retrospectively, reported
having had an overall better presurgical sex life than the
standard prostatectomy group who did not use aids. These
group differences remained even after we controlled for
age, F (3, 195) = 4.98, p < .008. Consequently, due to
significant differences in presurgical sexuality and dif
ferences in age among subgroups, the following ANOVA F-
statistics are statistically adjusted to control for these
two variables.
Groups did not differ significantly in overall quality
of life, emotional distress, activities of daily living,
levels of urinary incontinence, body image or marital/
relationship adjustment.
Group differences were detected in four out of five
measures of postsurgical sexuality. In levels of sexual
satisfaction, concerns regarding sexual capabilities, and
measures of sexual behavior, patients who underwent nerve-
sparing surgery, were statistically indistinguishable from
patients who underwent standard prostatectomy and use
erection aids. In all these cases, the group not using
erection aids scored worse than the other two groups. We
were able to statistically detect differences in physio
logical sexual functioning between all three groups. In
this case, the erection aid group scored better than the
33
nerve-sparing group, which in turn scored better than the
standard prostatectomy group not using aids.5
Predictors of Patients1 Quality of Life and Emotional
Distress
We did not find any problems of multicollinearity with
the independent variables used in the equations (Table 4
for a correlation matrix of key variables). The results
from the two multiple regression analyses using overall
quality of life and the POMS as dependent variables, are
presented in Table 5. In all the equations we forced-
entered the Presurgical Sexuality Scale to control the
amount of variance it accounted for in quality of life and
emotional distress. We then used the five measures of
postsurgical sexuality, and marital/relationship adjustment
as predictors. These predictors accounted for 35% of the
variance in quality of life after controlling for pre
surgical sexuality. Body image and marital/relationship
adjustment were the only predictors significantly related
to better overall quality of life. Body image and marital/
relationship adjustment significantly predicted low emo
tional distress, with all predictors in the equation
accounting for 36% of the variance after controlling for
presurgical sexuality.6 Emotional distress and overall
Table 4
Correlation Matrix of Key Variables (N = 250)
Quality Physiological
of Life POMS Sex Function
Sexual
Behavior
Sexual
Satis.
Sexual
Concerns
Body
Image DAS
Incon
tinence ADL
Presurgical
Sexuality
Quality of
life 1.00 .68*** .12 .12* .29*** .37*** .53*** -.39*** .26*** .62*** .18***
POMS 1.00 ..15* .0002 .15* .32*** . 49*** -.40*** .32*** .51*** .08
Physiological
sexual
functioning 1.00 .34*** .45*** .41*** .13 -.04 .12 .18* .34***
Sexual behavior 1.00 .39*** .18** .12 -.07 .09 .29*** .42***
Sexual satisfaction 1.00 .57*** .31*** -.20** .20*** .25*** .10
Sexual concerns 1.00 .36*** -.13* .30*** .31*** .15*
Body image 1.00 -.32*** .17** .49*** .11
DAS 1.00 -.07 -.12 -.10
Incontinence 1.00 .43*** .06
Activities of Daily Living (ADL) 1.00 .27***
Presurgical sexuality 1.00
Note. Except for DAS scores, lower scores indicate better outcomes.
*E < .05. **e < .01. ***e < -001.
35
Table 5
Significant Predictors of Patients' Quality of Life and
Emotional Distress: Multiple Regression Analysis with Beta
Weights Reported (N = 250)
Quality Emotional
Predictor Life Distress
Step 1
Presurgical sexuality .18 ’.08
R . 18 ’.08
Step 2
Presurgical sexuality .12 -.01
Sexual satisfaction .04 -.18
Marital/relationship adjustment -.26** -.29***
Body image/sense of masculinity .37*** .37***
Physiological-sexual functioning -.08 .11
Sexual behaviors -.01 -.06
Sexual concerns .20 .23
R .62*** .60***
Note. When predicting quality of life, R2 =.03 for step 1;
DR2 = .35*** for step 2. When predicting emotional dis
tress, R2 =.01 for step 1; AR2 =.36*** for step 2.
*p < .05. **p < .01. ***£ < .001.
36
quality of life are highly and significantly correlated
(r = .68).
In response to the hypothesis we advanced in question
3, we forced-entered the Presurgical Sexuality Scale fol
lowed by the Physiological-Sexual Functioning scale into a
regression equation. We then entered the product of the
two terms. This interaction was not a significant predic
tor, and did not account for a significant portion of the
variance in quality of life or emotional distress (Table
6) .
Discussion
The present study highlights the importance of
measuring quality of life in prostate cancer patients un
dergoing radical prostatectomy, and advances several sta
tistically significant findings that are relevant and
clinically meaningful. Below we describe implications for
these findings..
First, we found that despite reports of problems with
sexuality following treatment, the majority of patients
reported good quality of life. This finding is consistent
with data from other studies involving prostate cancer pa
tients (Braslis, Santa-Cruz, Brickman, & Soloway, 1995;
Litwin et al., 1995). Patients reported much lower
37
Table 6
Multiple Regression Analysis Predicting Quality of Life and
Emotional Distress with an Interaction of Presurgical Sexu-
ality and Physiological-Sexual Functioning (N = 250)
Quality Emotional
Predictor Life Distress
Step 1
Presurgical sexuality •
00
*
‘.08
R
- X
00
H
•
‘. 08
Step 2
Presurgical sexuality .16 . 03
Physiological-sexual functioning .06 .14
R .19 .15
Step 3
Resurgical sexuality .13 .09
Physiological-sexual functioning . 06 .14
Interaction . 06 -.12
R .20 .19
2
Note. AR was nonsignificant.
*p < .05.
38
emotional distress when compared to norms of men with other
cancers (Celia, Tross, & Orav, 1989), and rated their
primary relationships within the norms for good quality
relationships reported for the DAS (Spanier, 1976). These
findings are interesting because recent decision analyses
(Fleming et al., 1993; Krahn et al., 1994), using medical
and quality of life outcomes, suggest that patients who
undergo radical prostatectomy have little advantage in
quality of life as compared to patients who receive no
treatment. Unfortunately, existing data on quality of life
in this population are insufficient to make accurate as
sumptions regarding the costs and benefits of radical
prostatectomy and its side effects. Also, few data exist
on prostate cancer patients who do not undergo treatment.
Hence, because little has been written about overall qual
ity of life and emotional distress ratings in this popula
tion, our findings enhance existing data and indicate that
radical prostatectomy may have minimal overall impact upon
patients' psychosocial functioning. Future research should
examine this assumption prospectively and compare patients'
quality of life before and after treatment.
Our findings also provide insight into the multiple
components of male sexuality that have been overlooked by
previous researchers studying this population. For
39
example, although patients report erectile disturbances
following radical prostatectomy, desire, arousal, and
ability to achieve orgasm continue to be experienced.
Physicians and clinicians working with this population can
begin to use this information to attempt to adequately
predict consequences of treatment, while future researchers
can continue to identify areas that may be important to
patients following radical prostatectomy.
Next, after controlling for age and presurgical sexu
ality, we found that treatment subgroups were statistically
(a) indistinguishable on measures of overall quality of
life, (b) emotional distress, (c) marital/relationship ad
justment, (d) activities of daily living, and (e) urinary
incontinence. Patients who underwent nerve-sparing pros
tatectomy, did not differ significantly from those who un
derwent standard prostatectomy and used erection aids on
measures of overall sexual satisfaction, sexual behaviors,
and concerns regarding sexual capabilities. The standard
prostatectomy group not using erection aids, generally
scored worse than the other two groups on all three of
these measures. However, body image, another measure of
postsurgical sexuality, did not differ between any group.
The treatment groups did differ on reports of physio
logical sexual functioning. Although some studies indicate
40
that when compared to standard prostatectomy patients,
nerve-sparing patients have better erectile functioning
following surgery (Brendler & Walsh, 1992; Quinlan et al.,
1991), it is not surprising that the erection aid group
scored better on measures of physiological-sexual func
tioning. For instance, patients using erection aids may
have a better ability to attain erections and achieve or
gasm through intercourse than nerve-sparing patients who
potentially may have suffered nerve damage during surgery.
However, it appears that other measures of sexuality not
related to the ability to have an erection, are comparable
across these two groups. This is clinically relevant for
patients who may not be eligible for the nerve-sparing
procedure (e.g., whose tumor nodule is too large, or report
presurgical problems with erectile capabilities,) yet are
concerned about postoperative sexuality. These findings
suggest that using erection aids following radical pros
tatectomy may contribute to better overall outcomes of
sexuality, as compared to patients who do not use aids and
undergo standard prostatectomy.
It is important to point out that unlike findings that
indicate no differences in patients undergoing nerve-
sparing prostatectomy, as compared to patients undergoing
standard prostatectomy (Litwin et al., 1995), nerve-sparing
patients seem to have better overall outcomes in postsur-
gical sexuality than standard prostatectomy patients not
using aids. Litwin and his colleagues (1995), who found no
differences between nerve-sparing and standard prostatec
tomy patients, may have been unable to detect differences
between their subgroups because only 19 subjects had
undergone the nerve-sparing procedure. Hence, statistical
power was lacking. They also had no patient information
regarding use of erection aids. At this point little is
known about why men choose to use erections aids, how phy
sicians feel about offering this option, how treatment de
cisions are made, and what aspects about using an erection
aid are related to post-surgical sexuality and quality of
life.
Lastly, we found that neither physiological sexual
functioning or the interaction of physiological sexual
functioning with presurgical sexuality was a significant
predictor of quality of life or emotional distress. More
over, patients' sexual behaviors, overall sexual satisfac
tion, and concerns regarding sexual capabilities were non
significant predictors of quality of life and emotional
distress following surgery. Instead, we found that body
image and the quality of patients' primary relationships
significantly predicted quality of life and emotional
42
distress. These data are clinically intriguing and suggest
that male sexuality is more complex than simple reports of
erection used in most research with prostate cancer
patients.
Presently, there are no uniform measures of sexual
functioning in this population. However, we believe that
our study contributes to the existing literature by relia
bly measuring distinct components of male sexuality.
Rather than solely studying erectile functioning as an
outcome variable, our study is the first to examine the
hypothesis that postsurgical sexuality more broadly defined
predicts quality of life and emotional distress in radical
prostatectomy patients, as presumed in the literature.
Interestingly, our findings suggest that components of
sexuality other than physiological sexual functioning— body
image, and the quality of patients' primary relationships—
appear to play a more important role. Nonetheless, it is
still unclear why these particular predictors are
significant.
Incidentally, the relationship between marital/
relationship adjustment and sexuality is at best moderate
(Table 4), suggesting that for this population, being in a
good relationship is not necessarily related to one's
sexuality. Hence, future research should focus on
43
measuring these variables and begin measuring outcomes of
existing interventions for problems with body-image (But
ters & Cash, 1987) and relationship adjustment following
cancer treatment (Schover, 1984) in samples of early stage
prostate cancer patients. Because radical prostatectomy
does not necessarily obviously change physical appearance,
more research is needed to understand the role body image
plays for older adult males in general.
Although these findings shed new insight into the gaps
of current data, methodological limitations must be con
sidered when interpreting our findings. The study's
cross-sectional design precludes any interpretation of
causation. Hence, we are not able to establish that pros
tate cancer or radical prostatectomy caused specific pa
tient outcomes. Bias due to choice of treatment and an
erection aid, cannot be controlled because this was not a
randomized controlled trial. Generalizability is also
limited because our sample was almost entirely White, upper
middle-class men. We cannot assume that quality of life or
emotional distress following radical prostatectomy would be
equal regardless of racial, ethnic, or cultural background.
Finally, it has been suggested that sex surveys with
moderate response rates, such as the Sexual History Form
used in this study, ensure better validity and less
44
volunteer bias (Clement, 1990). However, our response rate
of 55% may have compromised the value of the data from
these men.
Despite these limitations, our findings contribute to
the existing literature and confirm that careful assessment
of quality of life and emotional distress in prostate can
cer patients undergoing radical prostatectomy, yields
meaningful findings that have clinical implications. How
ever, more prospective and longitudinal data are needed
before physicians treating this population can begin to
precisely inform patients regarding consequences following
treatment. Continued research on specific predictors of
postsurgical quality of life and emotional distress, will
help clinicians identify specific areas for psychological
intervention.
Footnotes
hissing data were handled using subscale means. If
there were 20% or fewer missing items on a subscale, the
subscale mean was derived using the available data. When
more than 20% of the data were missing, the entire subscale
score was considered missing. There is no gold standard
for replacing missing data, but substituting the scale mean
is the most conservative approach, as compared to "guess
ing" and replacing based on existing information, and does
not change the mean for the distribution as a whole
(Tabachnick & Fidel, 1989). We did not use a regression
approach to predict missing data because we used regression
equations to analyze the data.
2Based on the five identified clusters of postsurgical
sexuality items, we specified the number of factors in the
analysis. Items originating from the SHF: Current Sex
Life (3 factors) were tested separately from items origi
nating from the Quality of Life Scale (2 factors). Items
from an identified cluster with factor loadings of .30 or
greater were included on the subscales. If an item had a
factor loading less than .30, that item was eliminated.
These scales were then evaluated by estimation of internal
consistency reliabilities (Cronbach, 1951).
46
3Several scales contained items with unequal ranges.
We transformed items on the Sexual Satisfaction Scale, and
Presurgical Sexuality Scale to have equal metrics within
each scale (Rosenthal & Rosnow, 1987). Possible ranges on
these scales were large, so means were divided by the num
ber of items on the particular scale and reported as such.
40ne item on the Dyadic Satisfaction subscale of the
DAS was accidentally omitted from the questionnaire. For
tunately, this is the scale with the highest internal con
sistency (Cronbach's alpha = .93). We corrected this error
by substituting each person's mean on the scale for the
missing value. Consequently, all scores are within the
same range reported in the manual.
5We also conducted these same analyses of variance
excluding patients who were unpartnered. These analyses
yielded identical results as to those reported in Table 3.
6When using only the erection item from the Physio
logical Sexual Functioning Scale along with the other four
measures of postsurgical sexuality and marital/relationship
adjustment, typical degree of erection during sexual
activity still was not a significant predictor of quality
of life or emotional distress.
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Appendix A
54
Body Image Scale Items
Items (Anchors)
1. How satisfied are you with your physical
appearance?
(Totally satisfied; Not at all satisfied)
2. To what extent has your physical appearance
changed since your surgery?
(Greatly improved; Greatly -worsened)
3. To what extent do you believe that your spouse/
partner is satisfied with your personal appearance?
(Totally satisfied; Not at all satisfied)
4. How satisfied are you with the way your face
looks?
(Totally Satisfied; Not at all satisfied)
5. How satisfied are you with the appearance of your
genitals?
(Totally satisfied; Not at all satisfied)
6. How satisfied are you with the appearance of your
upper body/chest?
(Totally satisfied; Not at all satisfied)
7. Overall, how would you rate your feelings about
yourself?
(Extremely positive; Extremely negative)
Sexual Concerns Scale Items
55
Items (Anchors)
1. I am reluctant to engage in sex because I'm not
sure how successful it will be
(Strongly agree; Strongly disagree)
2. I worry that I might injure myself during sex.
(Strongly agree; Strongly disagree)
3. I worry that sexual activity might cause my cancer
to return.
(Strongly agree; Strongly disagree)
4. I would be reluctant to get involved in a rela
tionship that might lead to sex.
(Strongly agree; Strongly disagree)
5. I worry too much about what my partner thinks
about my sexual performance.
(Strongly agree; Strongly disagree)
6. I am anxious about my sexual capabilities.
(Strongly agree; Strongly disagree)
7. I am depressed about sexual capabilities.
(Strongly agree; Strongly disagree)
8. I am angry about sexual capabilities.
(Strongly agree; Strongly disagree)
56
9. I think about sex too much.
(Strongly agree; Strongly disagree)
10. Because of cancer, I feel like less of a man.
(Strongly agree; Strongly disagree)
11. Because of my sexual functioning, I feel like
less of a man.
(Strongly agree; Strongly disagree)
Incontinence Scale Items
Items (Anchors)
1. How often do you experience urinary frequency/
urgency?
(Almost always; Almost never)
2. How often do you leak urine?
(More than twice per day; Never)
3. To what extent is leaking urine upsetting to you
(Extremely upsetting; Not at all upsetting)
4. To what extent does leaking urine force you to
avoid certain activities? (e.g., going out?)
(A great deal; Not at all)
58
Activities of Daily Living Scale Items
Items (Anchors)
1. How would you rate your current health condition?
(Excellent; Very Poor)
2. Your household responsibilities?
(Able to perform with problem; Cannot perform)
3. Recreational and leisure activities?
(Able to perform with no problem; Cannot perform)
4. Sports and athletic activities?
(Able to perform with no problem; Cannot perform)
5. Social activities (e.g., traveling, getting to
gether with friends).
(Able to perform with no problem; Cannot perform)
6. Overall, how would you rate your physical
capabilities?
(Excellent; Very poor)
59
Sexual Satisfaction Scale Items
Items (Anchor)
1. How satisfied are you with the variety of sexual
activities in your current sex life? (This includes the
different types of kissing and caressing with a partner,
(Extremely satisfied; Extremely dissatisfied)
2. How satisfied are you with current sexual
functioning?
(Totally satisfied; Not at all satisfied)
3. Overall, how satisfactory to you is your sexual
relationship with your partner?
(Extremely satisfactory; Extremely unsatisfactory)
4. Overall, how satisfactory do you think your sexual
relationship is to your partner?
(Extremely satisfactory; Extremely unsatisfactory)
5. Overall, how satisfactory is your sexual life?
(Extremely satisfactory; Extremely unsatisfactory)
60
Sexual Behaviors Scale Items
Items (Anchors)
1. How frequently do you have sexual intercourse or
activity with a partner?
(More than once a day; Not at all)
2. How frequently would you ideally like to have
sexual intercourse or activity?
(More than once a day; Not at all)
3. How frequently do you feel sexual desire2 This
feeling may include wanting to have sex, planning to have
sex, feeling frustrated due to lack of sex, etc.
(More than once a day; Not at all)
4. How frequently do you and a partner have satisfy
ing sexual activity (kissing, caressing, hold, oral sex,
etc.) that does not include sexual intercourse?
(More than once a day; Not at all)
5. How often do you masturbate (bring yourself to
orgasm in private)?
(More than once a day; Not at all)
61
Physiological-Sexual Functioning Scale Items
Items (Anchors)
1. When you have sex with a partner, do you feel
sexually aroused (i.e., feeling "turned on," please,
excitement)?
(Nearly always, over 90% of the time; Never)
2. What is your typical degree of erection during
sexual activity with a partner?
(Rigid and uhbendable; Totally soft)
3. If you try, is it possible for you to reach orgasm
(pleasurable sensation of climax) through sexual inter
course?
(Nearly always, over 90% of the time; Never)
62
Presurgical Sexuality Scale Items
Items (Anchors)
1. Before your surgery, how frequently did you have
sexual intercourse of activity with a partner?
(More than once a day; Not at all)
2. Before your surgery, how frequently did you feel
sexual desire? This feeling may include wanting to have
sex, planning to have sex, feeling frustrated due to lack
of sex, etc.
(More than once a day; Not at all)
3. Before your surgery, when you had sex with a
partner, did you feel sexually aroused (i.e., feeling
"turned on," pleasure, excitement)?
(Nearly always, over 90% of the time; Never)
4. Before your surgery, did you have any trouble in
getting a full erection during sexual activity with a
partner?
(Nearly always, over 90% of the time; Never)
5. Before your surgery, did you lose part or all of
your erection before completing sexual activity with a
partner?
(Nearly always, over 90% of the time; Never)
63
6. Before your surgery, what was your typical degree
of erection during sexual activity with a partner?
(Rigid and unbendable; Totally soft)
7. Before your surgery, what was your typical degree
of erection during masturbation?
(Rigid and unbendable/ Totally soft)
8. Before your surgery, was it possible for you to
reach orgasm through masturbation?
(Nearly alvays, over 90% of the time; Never)
9. Before your surgery, was it possible for you to
reach orgasm through sexual intercourse?
(Nearly alvays, over 90% of the time; Never)
10. Overall, how satisfactory was your sexual life
prior to your prostate surgery?
(Extremely satisfactory; Extremely unsatisfactory)

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Asset Metadata

Creator Perez, Martin Alberto (author)

Core Title Sexuality, Quality Of Life, And Emotional Distress Following Radical Prostatectomy For Carcinoma Of The Prostate

Degree Master of Arts

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, rehabilitation and therapy,OAI-PMH Harvest,psychology, personality,psychology, physiological,psychology, social

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Meyerowitz, Beth E. (committee chair), Gatz, Margaret (committee member), Miller, Lynn Carol (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-9259

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