BACKGROUND After treatment for prostate cancer, multidisciplinary sexual rehabilitation involving couples appears more promising than traditional urologic treatment for erectile dysfunction (ED). We conducted a randomized trial comparing traditional or internet-based sexual counseling with a waitlist control. METHODS Couples were adaptively randomized to a 3-month waitlist (WL), a 3-session face-to-face format (FF), or an internet-based format with email contact with the therapist (WEB1). A second internet-based group (WEB2) was added to further examine the relationship between web site usage and outcomes. At baseline, post-waitlist, post-treatment, and at 3-, 6-, and 12-month follow-ups participants completed the International Index of Erectile Function (IIEF), the Female Sexual Function Index (FSFI), the Brief Symptom Inventory-18 to measure emotional distress, and the abbreviated Dyadic Adjustment Scale. RESULTS Outcomes did not change during the waitlist period. Of 115 couples entering the randomized trial and 71 entering the WEB2 group, 33% dropped out. However, a linear mixed model analysis including all participants confirmed improvements in IIEF scores that remained significant at 1-year follow-up (P<0.001). Women with abnormal FSFI scores initially also improved significantly (P=0.0255). Finding an effective medical treatment for ED and normal female sexual function at baseline, but not treatment format, were associated with better outcomes. In the WEB groups, only men completing more than 75% of the intervention had significant improvements in IIEF scores. CONCLUSIONS An internet-based sexual counseling program for couples is as effective as a brief, traditional sex therapy format in producing enduring improvements in men’s sexual outcomes after prostate cancer.

BACKGROUND The majority of prostate carcinoma survivors experience enduring sexual difficulties and associated distress in the years after definitive treatment. A counseling intervention aimed at improving levels of sexual satisfaction and increasing successful utilization of medical treatment for erectile dysfunction (ED) was developed and pilot‐tested for both the survivor of prostate carcinoma and his partner. METHODS All male participants were 3‐month to 5‐year survivors of localized prostate carcinoma who had been treated with radical prostatectomy or radiation therapy, and were married or in a committed relationship. Couples were randomized to attend four sessions of counseling together or to have the man attend alone. In both groups, partners completed behavioral homework. The sessions included education on prostate carcinoma and sexual function and options to treat ED as well as sexual communication and stimulation skills. Standardized questionnaires at baseline, posttreatment, and at 3‐month and 6‐month follow‐up assessed sexual function, marital adjustment, psychologic distress, and utilization of treatments for ED. RESULTS Fifty‐one of 84 couples randomized to treatment completed the intervention (61%). Attendance by the partner did not affect outcomes. Participants completing the intervention demonstrated improvment in male overall distress (P < 0.01), male global sexual function (P < 0.0001), and female global sexual function (P < 0.05) at 3‐month follow‐up, but regression toward baseline was noted at 6‐month follow‐up. However, utilization of ED treatments increased from 31% at the time of study entry to 49% at the 6‐month follow‐up (P = 0.003). CONCLUSIONS The results of this brief pilot counseling intervention demonstrated significant gains in sexual function and satisfaction and increased utilization of treatments for ED. However, modifications are needed in future randomized trials to reduce the rate of premature termination and to improve long‐term maintenance of gains. Cancer 2005. © 2005 American Cancer Society.

BACKGROUNDThe objective of this survey was to identify factors associated with good sexual outcomes in a large group of survivors of localized prostate carcinoma.METHODSA postal survey was sent to 2636 men in the Cleveland Clinic Foundation's Prostate Cancer Registry who either were treated with definitive radiotherapy or underwent prostatectomy for localized prostate carcinoma. The survey asked about demographic items, past and current sexual functioning, partner's sexual function and health, and a number of factors hypothesized to affect sexual satisfaction. Standardized questionnaires included the Sexual Self‐Schema Scale‐Male Version, the International Index of Erectile Function (IIEF), urinary and bowel symptom scales from the Los Angeles Prostate Cancer Index, and the Short Form Health Survey (SF‐36).RESULTSThe return rate was 49%, yielding a sample of 1236 men at an average of 4.3 years post‐treatment. Comparing responders with nonresponders suggested that the sample may have been somewhat biased toward men who were more interested in maintaining sexual function. At the time they were diagnosed with prostate carcinoma, 36% of men had erectile dysfunction (ED). Within the past 6 months, however, 85% of men reported having ED. Only 13% of men were having reliable, firm erections spontaneously, and another 8% of men were having erections with the aid of a medical treatment. Men were as distressed about loss of desire and trouble having satisfying orgasms as they were about ED. Of the 84% of men who reported having a current sexual partner, 66% indicated that she had a sexual problem. Younger age was associated strongly with better sexual outcome (global IIEF score). With demographic factors taken into account, better sexual outcome was related significantly to medical factors, including not having neoadjuvant or current antiandrogen therapy, undergoing bilateral nerve‐sparing prostatectomy or brachytherapy, and having better mental and physical health composite scores on the SF‐36. Sexual factors that were associated with a better outcome included having normal erections before treatment for prostate carcinoma, choosing a treatment based on the hope that it would preserve sexual function, having more sexual partners in the past year, and having a sexually functional partner.CONCLUSIONSThe great majority of men who survive prostate carcinoma do not achieve a return to functional sexual activity in the years after treatment. The priorities a man places on sexuality and on having a sexually functional partner are important factors in sexual satisfaction at follow‐up, over and above the influence of age and medical factors. Cancer 2002;95:1773–85. © 2002 American Cancer Society.DOI 10.1002/cncr.10848

BACKGROUNDThe objectives of this survey were to describe the prevalence of using a treatment for erectile dysfunction (ED) among men after therapy for localized prostate carcinoma and to construct models explaining the variance in trying a treatment, treatment success, and adherence to treatment.METHODSA postal survey was sent to 2636 men in The Cleveland Clinic Foundation's Prostate Cancer Registry who were treated initially with either definitive radiotherapy or prostatectomy for localized prostate carcinoma. The survey asked about demographic items, past and current sexual functioning, and the partner's sexual function. Men were asked about their current and intended use of medical treatments for ED. Standardized questionnaires included the Sexual Self‐Schema Scale‐Male Version, the International Index of Erectile Function, urinary and bowel symptom scales from the Los Angeles Prostate Cancer Index), and the Short‐Form Health Survey.RESULTSThe return rate was 49%. Differences between men who returned the questionnaire and men who did not respond suggest that the sample was weighted toward men who were more interested in staying active sexually. ED was a problem for 85% of men, and 59% of this group used at least 1 treatment for ED. Only 38% of men found that a medical treatment was at least somewhat helpful in improving their sex lives, however, and 30% of respondents still were using at least 1 treatment at the time of the survey. Factors that were associated with the efficacy of treatments for ED and with their continued use included having a sexual partner, younger age, choosing a treatment for prostate carcinoma that was more likely to spare some sexual function, and not having had neoadjuvant or current antiandrogen therapy. Men who tried a greater number of treatments for ED were more likely to find one that worked. Men were more likely to continue using treatments for ED that produced greater improvements in sexual function.CONCLUSIONSThe success of medical treatments for men with ED among long‐term survivors of prostate carcinoma is limited. Men prefer noninvasive treatments, although invasive treatments are more effective. Sexual counseling for men and their partners is recommended, because it may increase the use of medical therapies for ED. Creating more realistic expectations in both partners also may enhance treatment adherence. Cancer 2002;95:2397–407. © 2002 American Cancer Society.DOI 10.1002/cncr.10970

The results emphasize that family functioning is an important variable to include in future models predicting rehabilitation outcome, and the importance of family intervention as part of the rehabilitation process.