ASSESSMENT
OF SEXUAL FUNCTION IN PATIENTS UNDERGOING VASECTOMY USING THE INTERNATIONAL
INDEX OF ERECTILE FUNCTION
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EDUARDO BERTERO,
JORGE HALLAK, CELSO GROMATZKY, ANTONIO M. LUCON, SAMI ARAP
General Hospital,
School of Medicine, University of Sao Paulo, USP, Sao Paulo, SP, Brazil
ABSTRACT
Introduction:
The present study aims to prospectively compare the sexual function in
males before and after vasectomy surgery using the international index
of erectile function (IIEF).
Materials and Methods: From October to December
2002, sixty-four patients who were candidates for male sterilization in
the vasectomy program of the Urology Section at the General Hospital of
the University of São Paulo were included. The same investigator
applied the IIEF before and 90 days after the surgery. The mean scores
obtained on pre and postoperative visits for all domains of sexual function
were analyzed and compared with the Wilcoxon test.
Results: The mean patient age was 35 years
(range from 25 to 48 years) and the mean number of children per man was
3. The total mean score of the IIEF was 64.06 before surgery and 65.64
after the procedure, with this difference considered statistically significant
(p < 0.001). Sixty-seven per cent of the patients improved their scores,
versus 17% and 16% who showed worsening or no change at all in IIEF scores
following surgery, respectively. Of the 5 sexual function domains, desire
and sexual satisfaction presented statistically significant improvement.
Conclusion: This study showed that vasectomy
caused a positive impact on sexual function, especially on desire and
sexual satisfaction, in the majority of men undergoing surgery. There
was no case of surgery-related erectile dysfunction.
Key
words: vasectomy; sexual activity; questionnaires; IIEF
Int Braz J Urol. 2005; 31: 452-8
INTRODUCTION
Currently,
voluntary male sterilization through vasectomy is a very common procedure,
which presents low complication rates (1-4). Post-vasectomy sexual dysfunction
has been reported in the literature and is defined as a psychological
complication of the surgery (5-7). Though many papers have reported post-vasectomy
complications, only a few deal with psychological or sexual issues (7,8).
In general, the incidence of psychological or sexual problems following
vasectomy has been reported at between 1 and 3% (8). However, none of
these studies used the international index of erectile function (IIEF)
for assessing post-vasectomy erectile function.
The IIEF is a questionnaire developed in
1997, for assessing the efficacy of sildenafil in patients treated for
erectile dysfunction (9). Since then, it has been used as the gold-standard
tool for assessing efficacy in results from several clinical trials regardless
of the type of treatment or population under study. Recently, an extensive
review of IIEF application in several subpopulations was published, although
it did not include vasectomized patients (10). The questionnaire consisted
of 15 items that should be answered by the patient himself with no interference
from third parties. In 1999, through the “First Consultation on
Erectile Dysfunction,” the World Health Organization adopted the
IIEF as the main tool for assessing efficacy in clinical studies (11).
The IIEF has been already validated in 32 languages, including Portuguese
(12).
The object of this study is to prospectively
assess through the IIEF the change in sexual function following voluntary
vasectomy.
MATERIALS
AND METHODS
We
selected 65 patients from October to December 2002 who had appointments
scheduled for the vasectomy program of the Urology Section at the General
Hospital of the University of São Paulo. Ages ranged from 25 to
48 years (35 ± 6).
On average, patients had 3 living children
(± 1) ranging from 1 to 6 years of age. The mean age of the youngest
child was 18 months (± 20 months), ranging from 4 months to 12
years (Figure-1).
This study was approved by the Institutional
Medical Ethics Committee, and all couples signed the informed consent
form in order to participate in the research. On the day of the first
interview, both the patient and his partner signed the responsibility
form in accordance with Law 9.263 from January 12, 1996 regarding the
regulation of family planning (13).
We included patients who were candidates
for vasectomy who were in accordance with the aforementioned law, and
who complied with the following requirements: 1) two living children or,
2) older than 25 years. Additionally, the aforementioned law states that
a minimum period of 60 days should be observed between the manifestation
of will and the surgical act. During this period, the interested individual
will be provided with access to a fertility regulation service, including
counseling by a multidisciplinary team aiming to discourage early sterilization
(13,14). All couples that were interviewed and participated in this study
have respected this period. One patient was excluded because he had abstained
from sexual intercourse during the 4 weeks preceding the application of
the questionnaire at the first interview. Therefore, the study group was
composed of 64 men.
The study design involved applying the IIEF
with 15 questions (IIEF-15) on a first occasion before surgery, which
was called visit 1, and then a second time, called visit 2, on average
93 days following vasectomy (70 to 126 days). Patients completed the questionnaire
during visit 1 on the same day that the social worker conducted the interview
and requested the signature of the informed consent and responsibility
term. Thus, the patients would have to comply with the 60-day period and
would be able to discuss with their partners other commercially available
contraceptive methods. The same physician (EB) always performed both visits.
The IIEF-15 was fully applied to the patient
according to the Portuguese-validated version (12). The questions are
divided into 5 sexual function domains: erectile function (questions 1
to 5 and 15), sexual satisfaction (questions 6, 7 and 8), orgasm (questions
9 and 10), sexual desire (questions 11 and 12) and overall satisfaction
(questions 13 and 14). Each question has a value ranging numerically from
0 to 5, with the lowest value presenting the poorer sexual response. Therefore,
the total possible score is 75. The total score of items relative to erectile
function as adopted by the “1st International Consultation on Erectile
Dysfunction” are questions 1 to 5 and 15 (11). Based on this score,
the degree of erectile dysfunction is defined as normal (> 25), mild
(21 to 24), moderate (16 to 20) and severe (< 15).
On visit 2, the IIEF-15 was applied again
in the same way as on visit 1. This follow-up visit was performed on the
seventh postoperative day by the same physician that performed the surgery.
Also on visit 2, the patient was given the results of the seminal analysis,
which had been performed approximately 60 days following the vasectomy.
The vasectomy procedure was performed at
the hospital’s outpatient clinic using the traditional technique.
The quantitative variables were represented
by mean and standard deviation, and qualitative variables were absolute
and relative frequency. Non-parametric tests were used due to the nature
of quantitative data; discrete continuous variables. Comparison between
assessments on visits 1 and 2 in relation to the scores obtained on isolate
questions, the sum of questions in each domain, and the total score, was
performed by the Wilcoxon test for related samples. A significance level
of p < 0.05 was adopted.
RESULTS
In
relation to the 5 sexual function domains, statistically significant variations
were found for the domains of sexual desire and sexual satisfaction (p
= 0.05 and p = 0.003, respectively), with the score on visit 2 being significantly
higher than on visit 1 (Tables-1 and 2).
Concerning the erectile function domain,
we did not observe in any of the 64 studied patients a postoperative sum
lower than 26, thus indicating that there was no case of erectile dysfunction
related to vasectomy surgery in this study (Table-3).
No statistically significant variation was
found for scores in the domains of orgasm and overall satisfaction between
the visits, though an increase in the score sum was identified on visit
2 (Tables-4 and 5).
Table-6 presents the results for mean score
of the total score IIEF-15 between visits 1 and 2 where a statistically
significant variation was found between visits (p < 0.001), with the
score on visit 2 being significantly higher than on visit 1.
Figure-2 shows the distribution of the 64
patients relative to the comparison between total scores on visits 1 and
2.
COMMENTS
Voluntary
male sterilization or vasectomy has become the best contraceptive method
performed on males, primarily because of its simplicity, effectiveness,
and low complication rates (15). Approximately 100 million men have already
been vasectomized worldwide as a method of family planning (16). One great
concern for men who choose this sterilization method has always been the
capacity of maintaining a satisfactory sexual life following surgery (7).
Erectile dysfunction is considered to be
a serious psychological complication following a vasectomy surgery (7).
Though the procedure has been proven not to cause any damage to erection
or ejaculation mechanisms, 0.3 % of patients operated in one study have
complained of erectile dysfunction (1). According to this same author,
in one study with 1000 men undergoing vasectomy who were given questionnaires,
the results were as follows: 99% of the men and 95% of their wives were
happy with the surgical result; concerning their sexual life, 60% stated
that it was better, 2.5% worse and 37% reported that their sexual performance
had not changed at all.
In one of the largest series published on
vasectomy performed by the same surgeon totaling 6248 cases, post-vasectomy
sexual dysfunction was reported by 39 men (4). In this paper, no specific
validated tool or questionnaire was used to identify sexual or erectile
dysfunction, which could certainly lead to an inaccurate number of men
with this complaint.
Contrarily, in other publications the psychological
effects of vasectomy are uniformly positive, improving sexual intercourse,
harmony between the couple, libido and increasing sexual frequency (17-19).
One exception for the series of positive results is the anecdotal and
curious case published in 1980 where a man reported having changed his
sexual preference and becoming homosexual as a direct consequence of the
surgery (20).
In this study, the first one using the IIEF-15
as a tool for assessing sexual changes following vasectomy, the mean total
score before and after vasectomy was 64.06 and 65.64 respectively, out
of a total of 75 points. This difference, which is favorable to vasectomy,
was statistically significant. This data is strongly representative and
means an overall improvement in sexual function following surgery.
When considering the IIEF in the domain
of erectile function (questions 1 to 5 and 15), the mean score before
and after surgery was 26.80 and 27.05, respectively. Though the difference
was not statistically significant, it shows that the vasectomy did not
have any psychologically negative impact that could contribute to the
development of erectile dysfunction, as other studies have stressed.
Performance anxiety can be caused by several
factors, such as stress and fear, which culminate in a discharge of the
neurohormones, adrenaline and noradrenaline, with consequent contraction
in the cavernous smooth muscles and resulting detumescence and, thus,
inability to maintain an erection long enough to complete sexual intercourse.
Question 4 of the IIEF related to the ability to maintain an erect penis
inside the partner following penetration. In this study, this item had
a statistically higher score on visit 2, thus suggesting that men feel
more secure and self-assured during coitus following surgery.
Additionally, in relation to self-assurance,
when we analyze the statistical differences in the mean scores between
visits for question 15, which refers to the self-assurance of men in obtaining
and maintaining an erection, we stress the theory that following vasectomy
surgery male self-assurance can be increased during coitus. We believe
that male self-assurance increases as a consequence of his unconcern with
pregnancy following sterilization. When considering question 6 of the
IIEF, which refers to sexual frequency during the past 4 weeks, the mean
score on the pre-vasectomy visit was 3.14, which means sexual intercourse
5 to 6 times per month. Following surgery there was an increase in sexual
frequency represented by the increase in the score for this item to 3.61,
which was statistically significant. This data suggests that patients
have a greater frequency of sexual intercourse after undergoing sterilization,
mainly because they do not have to worry anymore about family planning
or an unwanted pregnancy.
Other relevant data taken from this study
was the finding that 67% of patients under study have improved their total
of IIEF items when comparing visits 1 and 2, which means a slight tendency
towards an improvement in sexual function following vasectomy surgery.
On the other hand, only 17% of operated men have decreased their IIEF
totals 90 days following surgery. It is worth stressing that even if these
patients have lower IEFF totals following surgery, no case was considered
as clinically significant. In other words, based on the IIEF no patient
was categorized as having ED following surgery.
Among the patients whose mean score had
worsened following vasectomy, we identified a statistically significant
difference in questions 1, 2 and 8 of the IIEF. Questions 1 and 2 refer
to erectile function itself. Question 8 concerns sexual satisfaction.
Though no case of ED has been diagnosed using the IIEF criteria in this
group of patients (n = 11), we attribute this decrease in score to several
reasons, including anxiety and expectation generated for the waiting time
until the sperm analysis result, use of condoms until being certain of
having achieved azoospermia and fear of pain during ejaculation.
An interesting finding was the significant
improvement seen in the domains of desire and sexual satisfaction, when
comparing pre and postoperative visits, once again confirming the influence
and positive impact that vasectomy can have on the sexual life of these
men. When considering other sexual function domains, such as orgasm and
overall satisfaction, there was no significant difference between the
score from the previous visit and that obtained 90 days following vasectomy.
CONCLUSION
We
observed an improvement in sexual function, especially in the domains
of desire and sexual satisfaction, in this group of patients undergoing
vasectomy. There was no case of surgery-related erectile dysfunction.
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____________________
Received: April 14, 2005
Accepted after revision: June 10, 2005
________________________
Correspondence address:
Dr. Eduardo Bertero
Rua Vieira de Moraes, 420 / 87
São Paulo, SP, 04617-000, Brazil
Fax: + 55 11 5542-9557
E-mail: urologia-sp@uol.com.br |