Older men and sexual function: is BPH treatment a high stakes decision?

How the possibility of treatment-induced sexual dysfunction affects men's decision making about benign prostatic hyperplasia (BPH) treatment has not been well studied. As part of a study (N = 188) of older men's reactions to a videotape BPH treatment decision aid, narrative data were analyzed for 74 men who stated concerns about treatment-induced sexual dysfunction. College-educated men (n = 54) were more likely than non-college educated men (n = 20) to mention sexual concerns. A substantial proportion of men appeared to view BPH treatment decision making as "high stakes" due to the risk of sexual dysfunction, including 23% who preferred watchful waiting to "riskier" medications or surgery. The extent to which these concerns also occur but are not necessarily stated by non-college educated men requires additional investigation. Within a partnership health care approach, clinicians who are counseling men about BPH treatment options should ask about possible concerns about treatment-induced sexual dysfunction.

Keywords: benign prostatic hyperplasia; decision-making; sexual function; treatment preferences

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Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that is highly prevalent in older men. BPH can cause bothersome symptoms such as urinary hesitancy and frequency that can significantly impact the quality of life. However, BPH treatments can cause unwanted side effects that include the possibility of impaired sexual function. Limited information is available about how men view tradeoffs between BPH symptoms and treatment risks. Older adults often remain and value being sexually active well into later life (Meston, 1997). Enhanced healthcare partnership approaches (Coulter, 1999) place a heightened emphasis on patient preferences regarding the acceptability of benefit/risk tradeoffs in treatment decisions that impact quality of life, such as sexual well-being.

The purpose of the analysis in this paper is to examine how the possibility of sexual dysfunction is incorporated in the BPH treatment decision making of older black and white American men. The context of the analysis is the viewing of a videotape BPH treatment decision aid. The partnership model of collaboration between clinicians and patients is supported via tools such as patient decision aids that inform and empower patients for collaborative treatment decision making. The analysis is part of a larger study done to assess the responses of older men (N = 188) (Rovner et al., 2004) to a previously well-tested BPH decision aid (FIMDM, 2000).

METHODS

SAMPLE

The data for this analysis arose from the spontaneous comments of 74 men (from among N = 188) who expressed concerns about sexual dysfunction as they were interviewed while watching the BPH videotape. The 74 men included black and white American men with college and noncollege levels of education, recruited from community settings in an area of Michigan (see Table 1 for sample characteristics).

CLINICAL CHARACTERISTICS AND MEASURES

Men of the appropriate age to experience BPH (age 43-83; M = 61 [+ or -] 8 years) were selected for the relevance of the health decision task. The men were on average experiencing mild/moderate symptoms of BPH and low "symptom bother" at the time of the interview (Rovner et al., 2004). BPH symptom severity was measured using the American Urologic Association (AUA) scale, and symptom bother was assessed via a modified version of the Barry et al. (Barry, Mulley, Fowler, & Wennberg, 1988) scale. General health was measured on a five-point scale from the Short Form 36 health status measure. Most men reported being in good health (M = 3.6, SD = 1.0); 54 were married, 16 divorced/separated, two never married, and one widowed, and one did not specify his marital status. College educated men (n = 54) were more likely than non-college educated men (n = 20) to mention sexual concerns. Neither symptom severity nor level of symptom bother was associated with men's spontaneous statements of concern about treatment-induced sexual dysfunction. Symptom severity and symptom bother were unrelated to treatment preference patterns (Wills et al., in press).

BPH VIDEOTAPE AND DATA COLLECTION

Details of the larger study are presented elsewhere (Rovner et al., 2004). The 47 minute professionally produced BPH videotape (FIMDM, 2000) has been extensively field-tested, was most recently updated in 1999, and includes balanced benefit/risk information about three key treatment options for BPH: watchful waiting, medications, and surgery. The videotape is intended as decision support for men to incorporate their personal values into decision making about treatment benefit/risk tradeoffs. Possible sexual side effects of BPH treatment are addressed by the videotape narrator and in testimonials of four different men who chose to undergo BPH treatment. Key videotape content regarding sexual functioning is summarized in Table 2. The videotape narrator presents information about risks of retrograde ejaculation and impotence in context of BPH treatment. In the video, clips were provided of four different men giving personal experience testimonials about sexual functioning following BPH treatment (quotes included in Table 2). The study interview protocol included no questions about sex, sexual function, or possible sexual side effects of treatment. Study participants' comments were audiotaped during videotape viewing by male interviewers.

DATA CODING

Transcripts of the interviews were analyzed using QSR N5 ("QSR N5," 2000) software for narrative analysis. Initial common themes were identified on the basis of interview questions, research questions, information from transcripts, and feedback from interviewers. The protocol for coding was systematically reviewed and refined into a comprehensive coding structure via a consensus building process involving an interdisciplinary research team. Two members of the research team coded transcripts (KK, JL). Inter-rater reliability across all codes was 98%.

RESULTS

BPH TREATMENT PREFERENCES AND SEXUAL DYSFUNCTION

Seventeen of the 74 men spontaneously stated that sexual functioning concerns were important in their BPH treatment preferences. The 17 men did not differ from the overall sample of 188 men on age, race, or education. Thirteen were college-educated, and none were black non-college educated men. Twelve men preferred watchful waiting (monitoring symptoms without active medical treatment) due to viewing medication and surgery as having the highest risk for inducing sexual impairment. As one of the men explained,

   I don't want surgery, you know, and even with the medication-now
   even with the medication there's a slight chance of sexual
   dysfunction, so, you know, because of that slight chance I'm really
   going to be more skeptical about taking any type of medications.

Another man declared,

   ... I'm definitely going to look at the probability of men having
   sexual dysfunction before I make a decision.

Sexual concerns generally influenced treatment preferences by relegating treatments perceived as too risky to lower preference orders. For example, in considering the possibility of surgery, some men indicated a fear of something going wrong in surgery, such as "a slip" that would prevent ever having an erection again and having to depend on a urine bag, as illustrated in the following exchange:

Q: Okay. And then your final one was surgery.

A: Why is that choice number three?

Q: Yeah.

A: Because what if there is a slip up, and I can never have an erection again, or I have to use a bag to urinate for the rest of my life?

Q: Okay, so you'd be concerned about what could be the adverse effects of surgery.

A: Exactly.

Another participant indicated a loss of "manhood":

   If you remove it [prostate], then you're going to take away the
   manhood in me.

Another explained the "family jewels" were important to a man:

   That is an area that is personal to a man, the family jewels and
   things, and it's difficult to handle. And it let you know you can
   expect problems, and a lot of men have problems with that.

For the 74 men, comments about sexual concerns and treatment choice tended to focus on retaining the physical ability to perform sex, with concerns expressed about the risk of treatment-induced sexual impairment. This concern included the possibility of retrograde ejaculation (backward flow of semen into the bladder duringorgasm). This specific side effect of surgery to remove prostate gland tissue was discussed in the BPH videotape. Typical comments expressing a wish to avoid this side effect of surgery included:

   ... my most drastic choice is surgery. Especially now that this
   retrograde thing pops up ... at this point in time I am not ready
   to make any drastic changes in my sexual life.

   The risks involved. It seemed like there was a significant amount
   of risk with impotence and with retrograde ejaculation. Even with
   the surgical treatments, the problem returning, chance of returning,
   would put that least preferential to me.

ROLE OF AGE

A few men mentioned age in relation to adverse effects of BPH treatment:

   And then surgery would be the last choice.... At my age, sexual
   function is important to me.

   As you age and get older, your sex drive lowers; if you have this
   done, you're going to blame it [surgery].

Notably, the gentleman making the following statement about fertility was 73 years old:

   It ain't too bad; you just can't make no babies. But if you have
   surgery, you can't make no babies anyway.

ROLE OF SEXUAL PARTNER

Several men stated a concern for the needs of a sexual partner. These comments suggest that men who are considering BPH treatment may wish to involve their partners in the treatment decision:

   ... if you had the open surgery and they went in and took your
   prostate, I guess that really takes care of your sex life. If that's
   gone, you're gone. That part of your life is gone. Living with a
   young lady for the last seven or eight years, I don't think that
   would go over very well with her.

   The wife would have to be there to say, well, honey, maybe the
   medication or the watchful waiting ... maybe something like that.
   [My wife would be] involved in making that treatment choice.

DISCUSSION

A key finding from this analysis was that treatment-induced sexual dysfunction was a key concern for (elicited spontaneous comments from) almost 40% of the overall sample of men. Men appeared quite hesitant to choose "high stakes" treatments that might negatively impact their sexual functioning. The generalizability of the results is limited by the restriction of the sample to one Midwestern U.S. urban community. It is possible that an interview approach specifically designed to assess sexual conceres might have resulted in different study findings.

CONCLUSION

The BPH videotape coverage of risks of treatments generated sexual dysfunction concerns for a substantial proportion of men. The extent to which sexual dysfunction concerns also occur but are not necessarily stated by non-college educated men requires additional investigation. The perception of potentially adverse side effects of BPH treatment is evaluated in the context of men's desire to experience life as fully functional sexual beings. Moreover, partner issues, particularly for men in relationships, may play a substantial role in decision making. Within a partnership healthcare approach, clinicians who are counseling men about BPH treatment options should ask about possible concerns about treatment-induced sexual dysfunction. Additionally, there is a need to routinely include partners in treatment discussions in an expanded model of collaborative decision making.

REFERENCES

Barry, M.J., Mulley, A.G., Fowler, F.J., & Wennberg, J.W. (1988). Watchful waiting vs. immediate transurethral resection for symptomatic prostatism. The importance of patients' preferences. JAMA, 259(20), 3010-3017.

Coulter, A. (1999). Paternalism or partnership? British Medical Journal, 319, 719-720.

FIMDM. (2000). Benign prostatic hyperplasia: Choosing surgical or nonsurgical treatment [videotape]: Foundation for Informed Medical Decision Making (FIMDM).

Meston, C.M. (1997). Aging and sexuality. Western Journal of Medicine, 167, 285290.

QSR N5. (2000). [computer software]. Bundoora, Victoria Australia: QSR International Pty. Ltd.

Rovner, D.R., Wills, C.E., Bonham, V., Williams, G., Lillie, J., Kelly-Blake, K., et al. (2004). Decision aids for benign prostatic hyperplasia: Applicability across race and education. Medical Decision Making, 24, 359-366.

Wills, C.E., Holmes-Rovner, M., Rovner, D., Lillie, J., Kelly-Blake, K., Bonham, V., et al. (in press). Treatment preference patterns during a videotape decision aid for benign prostatic hyperplasia (BPH). Patient Education and Counseling.

KAREN KELLY-BLAKE

Michigan State University

Department of Anthropology

East Lansing, MI

MARGARET HOLMES-ROVNER

College of Human Medicine

Center for Ethics and Humanities in the Life Sciences

East Lansing, MI

JANET LILLIE

College of Communication

Arts and Sciences

East Lansing, MI

CELIA E. WILLS

Michigan State University

College of Nursing

East Lansing, MI

DAVID ROVNER

College of Human Medicine

East Lansing, MI

CHRYSTAL PRICE

College of Human Medicine

East Lansing, MI

VENCE BONHAM

College of Human Medicine

East Lansing, MI

This research was supported by an AHRQ R01 grant (HS10608), "Information Interpretation in Patient Decision Support" (Holmes-Rovner, PI).

Correspondence concerning this article should be sent to Celia E. Wills, Ph.D., R.N., Michigan State University, College of Nursing, W109 Owen Hall, East Lansing, MI 48825. Electronic mail: [e-mail].

Table 1
Race, Education, and Age Characteristics

                         n          Age

Total Sample (N = 188)

EurAm_College            56   64 [+ or -] 7.6
EurAm_NoCollege          44   60 [+ or -] 7.2
AfAm_College             51   60 [+ or -] 6.8
AfAm_NoCollege           37   61 [+ or -] 9.0

Stated Sexual Function Concern (n = 74)

EurAm_College            28   60 [+ or -] 8.1
EurAm_NoCollege          10   61 [+ or -] 4.9
AfAm_College             26   58 [+ or -] 9.0
AfAm_NoCollege           10   61 [+ or -] 9.1

Concern Stated as Important in Ranking of Treatments (n = 17)

EurAm_College            8    58 [+ or -] 8.0
EurAm_NoCollege          4    58 [+ or -] 4.5
AfAm_College             5    56 [+ or -] 4.2
AfAm_NoCollege           0

EurAm_College = European American college educated;
EurAm_NoCollege = European American not college educated;
AfAm_College = African American college educated;
AfAm-NoCollege = African American not college educated.
See Rovner, Wills, et al. (Rovner et al., 2004) for
additional information about sample characteristics.

Table 2
Videotape Content on BPH Treatment and Sexual Dysfunction

Videotape Section      Key Content
                       (In Order of Presentation)

Surgical and           Patient #1 testimonial: "... I now feel that
Device Treatments:     I'm ... I'm whole, but most importantly this
TURP (transurethral    has been a program of rejuvenation in a
resection of           sense. I experience now feelings that I
prostate)              haven't had for at least 20 years ...."

Surgical and           Patient #2 testimonial: "I was told that the
Device Treatments:     chance of impotence with the TUNA was
TUNA (transurethral    minute compared to a real small chance of
needle                 impotence with TURP, but still it's there."
ablation)

Complications          Videotape narrator:
of BPH Treatments      * Addresses men's concerns about sexual
[after section           functioning
on treatments]         * People may have outdated or incorrect
                         information.
                       * Retrograde ejaculation is a common
                         problem after surgery.
                       * Defines retrograde ejaculation, states
                         it is not painful or harmful and should not
                         hinder sex
                       * Retrograde ejaculation can affect ability to
                         father children, and some men don't like
                         the feeling.

                       Patient #3 testimonial: "You get to climax.
                       You reach a climax, you get the same sensa-
                       tion, but nothing passes through ... that was
                       confusing to me and still is ... it's not a very
                       happy feeling, you know."

                       Patient #1 testimonial: "Well, the sensation
                       ... I found initially the sensation wasn't as
                       intense. That is, the feeling ... that one gets
                       with ejaculation wasn't as good as previously.
                       That was the only drawback to this whole
                       TURP operation. However, even since we
                       started talking, life seems to have improved.
                       That is, the intensity is coming back."

                       Videotape narrator:

                       * Retrograde ejaculation very common
                         after surgery-77/100 experience after
                         open prostatectomy, 73/100 for TURP,
                         25/100 for TUIP.

Complications          * Lower risk after TUIP-25/100 men
of BPH Treatments      * Retrograde ejaculation is permanent
                         after surgery but temporary with alpha
                         blocker drugs-6/100 men experience.
                       * Finasteride not associated with retrograde
                         ejaculation but can be associated with
                         reduced semen volume
                       * No good risk estimates for TUNA and
                         TUMT
                       * Some men have erection problems after
                         BPH surgery-16/32 men after open prostatectomy,
                         14/100 men after TURP, 12/100
                         after TUIP.
                       * Alpha blockers have not been associated
                         with erection problems-3% had problems
                         until they stopped taking it.
                       * Problems with TUNA/TUMT seem
                         uncommon-numbers uncertain.
                       * Erection problems become more common
                         as men get older.
                       * One study compared men who had TURP
                         to no treatment-percentage of men with
                         sexual problems was about the same.
                       * Most men who could perform sex before
                         can still do so after treatment-but when
                         men have problems with urination or any
                         surgery, they may have sexual functioning
                         problems after, even if the treatment does
                         not directly affect it.

                       Patient #4 testimonial: "I mean, I still get an
                       erection, hard on, but I just don't feel it. My
                       desire has gone way down. Physically, I
                       think I'm capable of this, but because the
                       plumbing is screwed up, I just don't have the
                       the desires I used to have. And I was pretty
                       active up until this, you know."