ADULT UROLOGY

CME ARTICLE

SEXUAL FUNCTION AFTER PARTIAL PENECTOMY FOR

PENILE CANCER
FREDERICO RAMALHO ROMERO, KAREN RICHTER PEREIRA DOS SANTOS ROMERO,
MARCUS AUGUSTO ELIAS DE MATTOS, CARLOS RICARDO CAMARGO GARCIA,
RONI DE CARVALHO FERNANDES, AND MARJO DENINSON CARDENUTO PEREZ

ABSTRACT
Objectives. To compare sexual function and satisfaction before and after partial penectomy and to evaluate
possible dysfunctions that could modify postoperative sexual functioning.
Methods. A total of 18 patients underwent a personal interview and answered the International Index of
Erectile Function questionnaire to determine erectile function, orgasmic function, sexual desire, intercourse
satisfaction, and overall satisfaction with sexual life. Domain scores were computed by summing the scores
for individual answers, and the final scores were compared before and after partial penectomy.
Results. The median patient age was 52 years. The medium penile length after partial penectomy was 4 cm
in the flaccid state; 55.6% of patients reported erectile function that allowed sexual intercourse. The main
reason for not resuming sexual intercourse appeared to be related to feelings of shame owing to the small
penis size and the absence of the glans penis found in 50% of sexually abstinent patients. Surgical
complications also compromised the resumption of sexual activity after amputation in 33.3% of these
patients. However, 66.7% sustained the same frequency and level of sexual desire as before surgery, and
72.2% continued to have ejaculation and orgasm every time they had sexual stimulation or intercourse. Only
33.3% maintained their preoperative sexual intercourse frequency and were satisfied with their sexual
relationship with their partners and their overall sex life.
Conclusions. The preoperative and postoperative scores were statistically different for all domains of sexual
function after partial penectomy. UROLOGY 66: 1292–1295, 2005. © 2005 Elsevier Inc.

C ancer of the penis has a very low reported in-

cidence worldwide. The prevalence of penile
cancer in Brazil is one of the greatest in the world,
tating effect on a man’s self-image and sex life.7
Few reviews have dealt with the quality of life and,
in particular, sexual function of these patients.8 To
accounting for 17% of all malignancies in men in contribute to the understanding of posttreatment
some areas.1 Although in developed countries, the sexual activity, we analyzed the results of a semi-
incidence of penile cancer is usually less than 2 per structured personal interview with 18 patients who
100,000,2,3 São Paulo has an incidence of 28 per underwent partial penectomy in a 5-year period
100,000.3 In some northeastern Brazilian states, and compared their sexual function and satisfac-
the incidence reaches 50 per 100,000.3 tion before and after treatment. Additionally, we
Aggressive therapy with partial or total penec- investigated any eventual sexual dysfunction for
tomy is still the conventional treatment for cancer possible causal associations.
of the penis.3–5 Partial penectomy is used when
enough of the penile shaft can be preserved to al-
low the patient to direct his urinary stream com- MATERIAL AND METHODS
fortably.6 However, penectomy can have a devas- The criteria for inclusion in this study were partial penec-
tomy for penile carcinoma, regular sexual activity before sur-
From the Division of Urology, Santa Casa Medical School, São gery, and a final minimal penile length in the flaccid state of
Paulo, São Paulo, Brazil 2.5 cm after surgery. The exclusion criteria included treatment
Reprint requests: Frederico Ramalho Romero, M.D., Rua Emili- with conservative methods or total penectomy, recurrence
ano Perneta, 653 ap. 41, Centro, Curitiba, PR 80420-080, Brasil. and/or metastasis, diagnosis of a serious chronic illness that
E-mail: [email protected] could interfere with sexual function or recall to the interview,
Submitted: March 31, 2005, accepted (with revisions): June 14, and nonacceptance to participate in this survey. Of 54 patients
2005 treated for penile cancer at our institution between 1998 and

© 2005 ELSEVIER INC. 0090-4295/05/$30.00

1292 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.06.081
 TABLE I. Median and standard deviations of sexual function and
satisfaction before and after partial penectomy
Domain Before After P Value*
Erectile function 29.56 ⫾ 1.42 19.39 ⫾ 12.44 0.012
Orgasmic function 9.94 ⫾ 0.24 7.67 ⫾ 3.90 0.027
Sexual desire 8.89 ⫾ 0.76 7.61 ⫾ 1.94 0.018
Intercourse satisfaction 12.67 ⫾ 1.46 6.89 ⫾ 5.57 0.002
Overall satisfaction 8.61 ⫾ 1.58 6.11 ⫾ 2.65 0.001
* Wilcoxon signed rank test.

2004, 18 fulfilled the selection criteria and were eligible to having “no sexual activity.” When asked specifi-
participate in this investigation. cally about erection, 14 of 18 patients claimed
Partial penectomy was performed as proposed by Spaulding
and Grabstald9 in 1979, with a 2-cm margin of tumor-free
“high” or “very high” confidence that they could
tissue. Squamous cell carcinoma of the penis was the histo- get and keep an erection, and 3 reported “moder-
logic type in all cases. Twelve patients had Stage T1, two had ate” confidence.
T2, and four had T3. The average tumor size was 3.4 cm.
Modified lymphadenectomy was performed in 12 patients be-
tween 1 and 14 months after partial penectomy. ORGASMIC FUNCTION
One of the investigators who had not been involved in the Thirteen patients responded that they ejaculate
surgery of the patients interviewed and examined all subjects and have the feeling of orgasm “almost always” or
at their regular follow-up visit at the hospital to measure the “always” when they had sexual stimulation or in-
remaining penile shaft in the flaccid state and to assess for
surgical complications.
tercourse, two reported ejaculation and orgasm
Patients twice answered the validated Portuguese version of “a few times” or “sometimes,” and, three, no orgas-
the International Index of Erectile Function.10 Retrospec- mic function after treatment compared with “al-
tively, each patient evaluated his premorbid sexual function most always” or “always” before surgery.
and then his current function. The resulting numeric values
for each domain of sexual function were compared statistically
before and after surgery with the nonparametric Wilcoxon SEXUAL DESIRE
signed rank test. Statistical significance was assessed with a Eight patients affirmed they had felt sexual de-
two-tailed test at P ⬍0.05. We used the Statistical Package for sire “most times” or “always,” with a “high” or
Social Sciences, version 12.0, for Windows (SPSS, Chicago, “very high” level of desire before and after surgery.
Ill) for the computations.
Four patients kept, after surgery, the same “mod-
erate” level of sexual desire they had had preoper-
RESULTS atively, and six reported a reduction in frequency
At the interview, the median patient age was 52 (“a few times” to “sometimes”) and/or level (“mod-
years (range 35 to 86). Each interview took ap- erate” to “low”) of sexual desire.
proximately 45 minutes, and the median time that
had elapsed from surgery to the present investiga- INTERCOURSE SATISFACTION
tion was 23.5 months (range 6 to 62). Fourteen Six patients maintained the same sexual inter-
patients had a steady partner relationship. The me- course frequency as before penectomy. In 4 weeks,
dium length of the penis after partial amputation the sexual frequency of 3 patients was “7 to 10”; in
was 4 cm in the flaccid state. 2 patients, it was “5 to 6”; and in 1, it was “3 to 4.”
Table I shows the median values and standard The other 12 patients presented with reduced sex-
deviations of sexual function and satisfaction be- ual frequency, decreased from more than seven at-
fore and after partial penectomy according to the tempts to less than four in 8 patients, including 2
International Index of Erectile Function-15. The who “did not attempt intercourse,” and from one
preoperative and postoperative scores were statis- to six attempts to “no attempts” in 4 patients. Sex-
tically different for all domains of sexual function. ual intercourse was “almost always” or “always”
satisfactory for 10 patients, and 2 patients consid-
ERECTILE FUNCTION ered sexual intercourse only “a few times” satisfac-
When questioned about sexual intercourse, 10 of tory after treatment. The grade of satisfaction also
18 patients reported erection of the penile stump varied. Three patients maintained their satisfaction
hard enough for penetration “most times” or “al- as “highly enjoyable” or “very highly enjoyable.”
ways” during the entire sexual intercourse, similar Five patients maintained it as “fairly enjoyable,”
to before surgery. Two patients complained of a and four decreased their satisfaction to “not very
reduction in erectile function from “always” to enjoyable” or “fairly enjoyable.” The remaining 6
“sometimes” and “almost never,” and six reported patients had “no intercourse” postoperatively and

UROLOGY 66 (6), 2005 1293

could not respond about the frequency or grade of quency of sexual intercourse were considered nor-
satisfaction. mal or slightly decreased in 9 (64%) of 14 cases.3
These differences may reflect variations in the
OVERALL SATISFACTION methods used, but may also reflect differences be-
Although all 18 patients considered they were tween cultures and/or the level of education of the
“moderately” or “very satisfied” with their overall population.3
sex life and sexual relationship with their partners In the present study, a statistically significant de-
before surgical treatment, only 6 patients sus- crease in sexual function and satisfaction occurred
tained their degree of satisfaction after it. Five after partial penectomy, with only 55.6% of the
patients claimed they were “equally satisfied and patients reporting erectile function that allowed
dissatisfied,” four became “moderately dissatis- regular sexual intercourse. Although the reduction
fied,” and three were “very dissatisfied” after par- occurred in all domains of sexual functioning, in-
tial penectomy. tercourse satisfaction and overall satisfaction were
The reasons reported by 3 of the 6 patients who the most affected, with merely 33.3% of patients
had not resumed sexual intercourse at the time of maintaining their preoperative sexual intercourse
the interview were feelings of low self-esteem and frequency and satisfied with their sexual relation-
shame for the small size of the penis and an absence ship with their partners and their overall sex life. In
of the glans penis. One additional patient who had contrast, changes in sexual desire and orgasmic
resumed intercourse, reduced it, importantly, for function were less pronounced because 66.7% sus-
the same motive. The presence of surgical compli- tained the same frequency and level of sexual de-
cations, namely, meatal stricture and excessive pe- sire as before surgery, and 72.2% continued to have
nile shaft skin, was the reason for 2 patients who ejaculation and orgasm every time they had sexual
did not reestablish their preoperative sexual func- stimulation or intercourse. The relatively high in-
tioning. One patient reported sexual abstinence dex of orgasmic function compared with the low
because he had no partner, and another patient rates of sexual intercourse was because 77.8% of
developed erectile dysfunction 1.5 years after par- the patients were capable of getting and maintain-
tial amputation. Between the surgery and the de- ing an erection, even though some did not attempt
velopment of erectile dysfunction, all domains of intercourse.
erectile function remained equal to that preopera- The main reason for not resuming sexual inter-
tively, diminishing thereafter. course appeared to be related to feelings of shame
owing to the small penile size and absence of glans
penis in 3 of 6 patients, despite having an average
COMMENT
penis length similar to that of the other patients. In
Of all urogenital cancers, the one that most ob- this respect, amputation of part of the penis may
viously jeopardizes sexual function is penile carci- result in sensations of decreased virility owing to
noma.6 If the lesion is early and noninvasive, con- the great physical impact on masculine self-image.
servative treatment with local resection, Mohs These feelings may also have an emotional basis
micrographic surgery, topical chemotherapy, ex- and be associated with unconscious fears from
ternal beam radiotherapy, interstitial brachyther- childhood anxieties of “castration,” guilt, and pun-
apy, cryosurgery, or laser therapy can be used, with ishment fantasies. Furthermore, being “too small”
only marginal compromise of sexual function and may be experienced as very humiliating in many
satisfaction.2,4,5,11 A survey from Sweden showed cultures.
unchanged sexual activity in up to 80% of patients Multidisciplinary follow-up with psychologists
after laser treatment for penile cancer.2 trained in sex therapy is necessary and should be-
More commonly, however, partial or total ampu- gin when treatment is being decided6 to help pa-
tation of the penis is necessary to control the can- tients and their partners to discuss their feelings
cer. Several individually reported impressions evi- and facilitate the return of sexual functioning. Pa-
denced that the remaining shaft of the penis may tients should be reassured that although their pe-
still become erect with excitement and that pa- nis will be smaller after surgery, it may be possible
tients and their partners can reach orgasm and to penetrate the vagina and have pleasant sexual
achieve normal ejaculation after partial penec- intercourse. Pretreatment education may even pre-
tomy.3,6 However, larger studies evaluating sexual vent psychologically based sexual problems.6
function after partial penectomy are scarce, and the Surgical complications may also compromise re-
results are controversial. In a Norwegian study, sumption of sexual activity after amputation. Meatal
overall sexual function was normal or slightly re- stricture is the most frequent complication after
duced in only 2 (22%) of 9 patients who had un- partial penectomy.12 Excessive penile shaft skin
dergone partial amputation,8 and a Brazilian study has not been described as a complication; keeping
showed that sexual interest, sexual function, and fre- it may give the postpenectomy phallus an appear-

1294 UROLOGY 66 (6), 2005

ance of a short uncircumcised, but normal, penis. follow-up with a multidisciplinary team and cor-
However, when the excessive skin disturbs the rection of surgical complications may improve sex-
functional aspect of the penis, it should be consid- ual function after partial penectomy. However, it
ered and treated as a complication. Both complica- remains to be demonstrated.
tions can be corrected as an outpatient procedure,
but ideally they are best avoided. Whisnant and
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